Analysis of the risk factors for osteoporosis and its prevalence after gastrectomy for gastric cancer in older patients: a prospective study.

PURPOSE: Osteoporosis leads to fragility fractures and is a major public health problem. We conducted this study to analyze the prevalence of and risk factors for osteoporosis after gastrectomy in older patients. METHODS: This multicenter prospective trial comprised older patients without recurrence of gastric cancer for > 3 years after curative surgery. The prevalence of osteoporosis was identified using the World Health Organization bone mineral density (BMD)-based definition. Univariate and multivariate analyses were performed to identify the risk factors for osteoporosis. RESULTS: BMD values were measured in 267 of the 271 enrolled patients. The prevalence of osteoporosis was 38.2% (men 24.0%; women 60%). Analysis using FRAX® revealed that 51.7% of patients were candidates for pharmacologic therapy. Female sex (odds ratio [OR] 5.16, 95% confidence interval [CI] 2.61-10.2), age (OR 1.06, 95% CI 1.00-1.12), low body mass index (< 19.0 kg/m2) after gastrectomy (OR 5.31, 95% CI 2.79-10.13), and history of fracture (OR 2.06, 95% CI 1.06-4.02) were independently associated with osteoporosis. CONCLUSIONS: The prevalence of osteoporosis in older patients after gastrectomy was 38.2%. Moreover, female sex, age, low body mass index after gastrectomy, and a history of fracture were risk factors significantly associated with osteoporosis. Thus, older patients undergoing gastrectomy should have proactive surveillance and receive treatment for osteoporosis.

Osteopontin Levels Are Persistently Elevated for 4 weeks Following Minimally Invasive Colorectal Cancer Resection.

INTRODUCTION: Osteopontin (OPN) is an integrin binding phosphorylated glycoprotein secreted by macrophages and leukocytes that is found in extracellular fluids and sites of inflammation; various forms of CD44 serve as receptors. Osteopontin, expressed by numerous cancers, enhances tumor progression and angiogenesis via the PI3K/AKT and ERK mediated pathways in concert with Vascular Endothelial Growth Factor (VEGF); OPN also plays a role in wound healing. The impact of minimally invasive colorectal resection (MICR) for colorectal cancer (CRC) on plasma OPN levels is unknown. This study's goal was to assess blood levels during the first month after MICR. METHOD: Patients undergoing MICR for CRC who were enrolled in an IRB approved tissue/prospective data bank for whom preoperative, postop Day (POD) 1, POD 3, and at least 1 late postop plasma sample (POD 7-34) were available were studied. Osteopontin levels were determined in duplicate via enzyme linked immunosorbent assay (ELISA) (results reported as mean ± SD). The Wilcoxon signed rank test was used for analysis (significance P < .05). RESULTS: A total of 101 CRC patients (63% colon and 37% rectal) met study criteria. The mean preop OPN level was 89.2 ± 36.8 (ng/ml) for the entire group. Significantly elevated (P < .001) mean plasma levels were detected, vs preop, on POD1 (198.0 ± 67.4; n = 101), POD 3 (186.0 ± 72.6, n = 101), POD 7-13 (154.1 ± 70.2, n = 70), POD14-20 (146.7 ± 53.4, n=32), and POD 21-27 (123.0 ± 56.9, n = 25). No difference was noted at the POD 27-34 timepoint (P > .05). CONCLUSION: Plasma OPN levels are significantly elevated over baseline for a month after MICR for CRC. The early rise in OPN levels may be related to the postop acute inflammatory response. The persistent elevation noted in weeks 2-4, however, may be a manifestation of wound healing in which OPN plays a role. Similar persistent plasma elevations of VEGF, angiopoietin 2 (ANG 2), and 11 other proangiogenic proteins have been noted and, collectively, may promote angiogenesis in residual tumors.

[A Case of Advanced Gastric Cancer in Which Tumor Relapse Was Observed after Discontinuation of Nivolumab Due to Complete Response, and for Which Re-Administration Was Initiated].

A 61-year-old male was diagnosed with unresectable advanced gastric cancer(cT4b[SI; panc], N+, M0, cStage ⅣA). However he was administered S-1 plus oxaliplatin as a primary treatment and ramucirumab plus paclitaxel as a secondary treatment, the primary tumor and lymph nodes were enlarged. We judged PD and switched to the third-line treatment with nivolumab. After starting nivolumab, both the primary tumor and the lymph nodes shrank, and the PET-CT scan after 24 courses showed no FDG accumulation in the primary tumor or lymph nodes, so we judged the response as CR. The patient requested discontinuation of nivolumab, and nivolumab administration was stopped. Twenty months later after nivolumab administration was discontinued, CT scan showed re-growth of the primary tumor, and nivolumab administration was resumed. After resumption, he received 22 courses of nivolumab for 10 months with maintenance of SD.

Impact of antithrombotic agents on short-term outcomes following minimally invasive colorectal cancer surgery: a propensity score-matched analysis.

BACKGROUND: It remains unclear whether minimally invasive colorectal cancer (CRC) surgery under the suitable management of perioperative antithrombotic therapy (ATT) is safe and feasible in patients treated with chronic ATT. The present study aimed to assess the impact of ATT on short-term outcomes following minimally invasive CRC surgery. METHODS: We retrospectively analyzed 1495 consecutive patients who underwent elective minimally invasive CRC surgery between 2011 and 2021, using propensity score-matched analysis. RESULTS: Overall, 230 patients had chronically received ATT. After propensity score matching, we enrolled 412 patients (n = 206 in each group). Before matching, significant group-dependent differences were observed in terms of sex (p < 0.01), age (p < 0.01), American Society of Anesthesiologists' physical status (p < 0.01), body mass index (p < 0.01), and pathological N classification (p = 0.03). The frequencies of overall postoperative complications, bleeding events, and thromboembolic events were significantly higher in the ATT group than in the Non-ATT group (p < 0.01). After matching, no significant differences were found between the groups in terms of clinical or surgical characteristics, or in terms of the frequency of overall postoperative complications, bleeding events, thromboembolic events, length of postoperative stay, or any other postoperative complication. Multivariate analysis identified no significant risk factors for postoperative bleeding events or severe postoperative complications associated with ATT. CONCLUSIONS: Patients treated with chronic ATT showed acceptable short-term outcomes for minimally invasive CRC surgery compared with those not receiving ATT. Minimally invasive CRC surgery appears safe and feasible under the suitable management of perioperative ATT regardless of whether the patient has a history of ATT.

Impact of prior abdominal surgery on short-term outcomes following laparoscopic colorectal cancer surgery: a propensity score-matched analysis.

BACKGROUND: Whether laparoscopic surgery after prior abdominal surgery (PAS) is safe and feasible for colorectal cancer (CRC) remains controversial. The present study aimed to evaluate the impact of PAS on short-term outcomes following laparoscopic CRC surgery. METHODS: We performed retrospective analysis used propensity score-matched analysis to reduce the possibility of selection bias. Participants comprised 1284 consecutive patients who underwent elective laparoscopic CRC surgery between 2010 and 2020. Patients were divided into two groups according to PAS. Patients with PAS were then matched to patients without these conditions. Short-term outcomes were evaluated between groups in the overall cohort and matched cohort, and risk factors for conversion to laparotomy and severe postoperative complications were analyzed. RESULTS: After propensity score matching, we enrolled 762 patients (n = 381 in each group). Before matching, significant group-dependent differences were observed in sex, age, primary tumor site, pathological (p) T stage, and type of procedure. No significant difference was found between groups in terms of rate of conversion to laparotomy, estimated blood loss, rate of extended resection, length of postoperative stay, and postoperative complications. After matching, estimated operative time was significantly longer in the PAS group (p = 0.01). Significant differences were found between groups in terms of reason for conversion to laparotomy. Multivariate analyses identified significant risk factors for conversion to laparotomy as pT stage ≥ 3 (odds ratio [OR] 2.36; 95% confidence interval [CI] 1.05-5.26) and body mass index ≥ 25 kg/m2 (OR 3.56; 95% CI 1.07-11.7). Multivariate analyses identified rectum in the primary tumor site as the only significant risk factor for severe postoperative complications (OR 2.37; 95% CI 1.08-5.20). CONCLUSIONS: Laparoscopic CRC surgery after PAS showed acceptable short-term outcomes compared to Non-PAS. The laparoscopic approach appears safe and feasible for CRC regardless of whether the patient has a history of PAS.

[A Resected Case of the Sigmoid Colon Cancer after the Endovascular Aneurysm Repair in Which Intraoperative Indocyanine Green Fluorescence Method Was Useful for Evaluating the Blood Flow in the Colon].

A man in his 70s underwent an endovascular aneurysm repair(EVAR)for abdominal aortic aneurysm. Blood test revealed an anemia and an increased tumor marker. Enhanced computed tomography revealed the wall thickening in the sigmoid colon and the Type Ⅱ endoleak after EVAR. Colonoscopy showed the wall thickening in the sigmoid colon, and biopsy indicated a diagnosis of adenocarcinoma. We performed open sigmoid colectomy with D3 lymph node dissection and ileostomy. We performed intraoperative indocyanine green (ICG) fluorescence method for evaluating the blood flow in the colon before the high ligation of the inferior mesenteric artery and the creation of the anastomosis, and perfusion of the colon was visualized. He was discharged postoperative day 14, and was performed closure of ileostomy 5 months later. Intraoperative ICG fluorescence method was safety and useful for evaluating the blood flow in the colon.

[A Case of Synchronous Secondary Lymph Node Metastasis in the Mesentery of the Ileum with cCR Achievement after Surgery for Sigmoid Colon Cancer].

A 71-year-old woman was hospitalized with loose stools and lightheadedness. She was subsequently diagnosed with sigmoid colon cancer for which we performed a laparoscopic sigmoid colectomy, small intestine partial resection, partial bladder resection, and open conversion. The intraoperative findings and histopathological analysis showed secondary lymph node metastasis in the mesentery of the ileum, and the surgery resulted in R2 resection. Chemotherapy(CAPOX plus Bev) was initiated thereafter, and the L-OHP and Bev were discontinued over time. A complete response was achieved at 1 year postoperative. Capecitabine alone was continued, and no signs of recurrence were noted at 2 years postoperative.

[Outcome of Hepatectomies for Non-Colorectal Liver Metastases].

We performed 16 cases of non-colorectal liver metastasis resection(19 resections)between January 2011 and December 2021. Among the 16 cases, the primary lesions were as follows: gastric cancer in 7 cases; GIST in 2 cases; and neuroendocrine tumor, renal cancer, pancreatic cancer(acinic cell carcinoma), cholangiocarcinoma, breast cancer, ovarian cancer, and leiomyosarcoma in 1 case each. The median time from primary lesion resection to the diagnosis of liver metastasis was 20.6 months. In cases of neuroendocrine tumors and renal cancer, hepatectomy was performed with a preoperative diagnosis of hepatocellular carcinoma. Four cases underwent laparoscopic hepatectomy, and 10 cases underwent anatomical liver resection. Postoperative chemotherapy was performed in 8 cases. Recurrence of liver metastasis was observed in 7 cases. One case of gastric cancer and 1 case of neuroendocrine tumor underwent repeat hepatectomy. The median relapse-free survival was 13.8 months, and the median overall survival was 55.7 months.

[A Case of Resection of Sigmoid Colon Metastasis from Pancreatic Cancer].

A 73-year-old man underwent distal pancreatectomy for invasive pancreatic ductal carcinoma in 2018. He showed stenosis of sigmoid colon due to recurrence of pancreatic cancer and received transverse colostomy in 2020. One year after initiation of gemcitabine monotherapy, he complained of abdominal pain. CT images and colonoscopy revealed accumulation of mucus in sigmoid colon due to stenotic lesions. Because conservative treatment using antibiotics was not effective, we performed sigmoidectomy. Histological examination revealed that tubular adenocarcinoma located mainly in the muscularis propria invaded into the colonic mucosa. Immunohistochemical analysis showed positive staining for CK7, and negative for CK20. We diagnosed sigmoid colon metastases of pancreatic cancer.

[Metachronous Ovarian Metastasis of Colorectal Cancer at Our Hospital].

Among the cases that underwent primary tumor resection(PTR)of colorectal cancer at our hospital between January 2010 and December 2020, we examined 6 cases that involved ovarian metastasis(OM)surgery. The period from PTR to recurrence of OM was 2-28 months. Bilateral oophorectomy or bilateral salpingo-oophorectomy was performed in 5 cases, and unilateral oophorectomy was performed in 1. The reasons for surgery were symptom development and progressive disease. The period from recurrence of OM to OM surgery was short, that of 0-6 months. In 5 cases, peritoneal dissemination and other distant metastases were observed during OM surgery; R0 resection was performed in 2 cases. Postoperative complications associated with OM surgery were not observed. The median time required from the day of OM surgery to the resumption of chemotherapy was 33 days, and it was possible to resume chemotherapy early. The median survival time after OM surgery was approximately 11 months, which is considered to be owing to the influence of complications of peritoneal dissemination and other distant metastases.

Evaluation of short- and long-term outcomes following laparoscopic surgery for colorectal cancer in elderly patients aged over 80 years old: a propensity score-matched analysis.

PURPOSE: It remains controversial whether the advantages of laparoscopic surgery for colorectal cancer (CRC) are beneficial in elderly patients (EP, age ≥ 80 years). The present study aimed to evaluate whether age itself is an independent risk factor for laparoscopic surgery by comparing short- and long-term outcomes between non-EP and EP groups. METHODS: We retrospectively analyzed 730 consecutive patients with stage I-III CRC who had undergone elective surgery between 2010 and 2017, using propensity score-matched analysis. RESULTS: Median follow-up was 49 months. After matching, we enrolled 228 patients. In the matched cohort, estimated operative time, estimated blood loss, lymph node dissection ≥ D3, number of lymph nodes harvested < 12, conversion rate, multivisceral resection rate, postoperative complication rate, and length of postsurgical stay were similar between the two groups. Before matching, compared with the non-EP group, the EP group had significantly shorter overall survival (OS) (p < 0.01), cancer-specific survival (CSS) (p < 0.01), recurrence-free survival (RFS) (p < 0.01), and higher frequency of local recurrence (LR) (p = 0.01); however, there was no significant difference in terms of incidence of LR or CSS between the two groups in the matched cohort. Prior to matching, multivariate analysis identified age ≥ 80 years as an independent prognostic factor for OS (p < 0.01), CSS (p < 0.01), and RFS (p = 0.01); however, after matching, age ≥ 80 years was not an independent poor prognostic factor for OS or CCS. CONCLUSIONS: Laparoscopic surgery offers a safe, effective option for CRC in EP aged ≥ 80 years.

An observational study on nutrition status in gastric cancer patients receiving ramucirumab plus taxane: BALAST study.

Limited data are available regarding the efficacy of nutrition support in advanced gastric cancer (AGC) patients receiving a standard second-line combination chemotherapy. The BALAST study is conducted as a prospective, multicenter observational study to evaluate the efficacy of nutrition support for patients with AGC treated with ramucirumab plus taxane as second-line treatment. As part of the routine care, patients who are malnourished or at risk of malnutrition will receive nutrition support from dietitians. We will enroll a total of 26 patients to estimate weight control rate at 12 weeks as primary end point. This study will generate valuable data reinforcing the role of nutrition support therapy for AGC patients receiving second-line chemotherapy.

Lay abstract Various guidelines recommend that nutrition support therapy should be considered if cancer patients are malnourished or at risk of malnutrition. Several studies have revealed that body weight loss, which is an important factor in determining the nutrition status, may predict survival during second-line standard chemotherapy with ramucirumab and a taxane for advanced gastric cancer (AGC) patients. However, limited data are available regarding the efficacy of nutrition support in AGC patients receiving ramucirumab and a taxane. This study is conducted as a prospective, multicenter observational study to evaluate the efficacy of nutrition support for Japanese patients with AGC treated with ramucirumab and a taxane. This study will generate valuable data reinforcing the role of nutrition support therapy for AGC patients in second-line treatment. Clinical trial registration: UMIN000037867.

Oncological outcomes following laparoscopic surgery for pathological T4 colon cancer: a propensity score-matched analysis.

PURPOSES: Whether laparoscopic colectomy (LC) is safe and effective for patients with locally advanced T4 colon cancer remains controversial. This study aimed to compare the oncological outcomes of LC and open colectomy (OC) for patients with pathological (p) T4 colon cancer. METHODS: We retrospectively analyzed 151 consecutive patients with pT4M0 colon cancer who underwent curative surgery between 2010 and 2017 using a propensity score-matched analysis. RESULTS: After propensity score-matching, we enrolled 100 patients (n = 50 in each group). Median follow-up was 43.5 months. The conversion rate to laparotomy in this study was 5.5% for the entire patient cohort and 6.0% for the matched cohort. Compared to the OC group, the LC group showed reductions in estimated blood loss and length of postsurgical stay. Clavien-Dindo classification grade ≥ II and all-grade complication rates were significantly lower in the LC group than in the OC group. R0 resection was achieved in all patients with LC. No significant differences were found between the groups in terms of overall, cancer-specific, recurrence-free survival, or incidence of local recurrence among the entire patient cohort and matched cohort. CONCLUSIONS: The oncological outcomes were similar between the LC and OC groups. LC offers a safe, feasible option for patients with pT4 colon cancer.

[Medication Support and Adverse Events Monitoring System Using Medical Social Networking Service(SNS)].

PURPOSE: We introduced the medication support and adverse events monitoring system using medical social networking service (SNS). METHODS: Thirty-two gastric cancer patients who were treated with oral anticancer drugs were included in this study. Patients or their families input the status of medication and adverse events using the ICT terminal every day, and the pharmacist confirmed the input contents on the PC. If there was a serious adverse events, the nurse confirmed the status of patient by telephone. RESULTS: Of the 32 registered cases, 3 cases (9.3%) discontinued input within less than 2 months during treatment. We experienced a case whose adverse events could be dealt with during long vacations and a case whose treatment could be continued by sharing information with home-visit nursing stations. In the questionnaire survey, there were many opinions that it would lead to anxiety reduction. CONCLUSION: Medication support system using medical SNS can be a safe and useful tool.

[A Case Report of Gastric Cancer with Long-Term Prognosis by Multidisciplinary Treatment].

The patient was a 55-year-old man. For gastric cancer with peritoneal dissemination and pyloric stenosis, gastrojejunostomy was performed and S-1 plus paclitaxel combination therapy was started. After confirming tumor shrinkage and negative peritoneal dissemination, pyloric gastrectomy was performed. Paclitaxel therapy was performed for 1 year after surgery, and the patient was followed up without systemic chemotherapy. Since the CA19-9 level increased 1 year and 8 months after gastrectomy, ramucirumab plus paclitaxel therapy and followed S-1 plus oxaliplatin therapy were performed. Two years and 6 months after gastrectomy, solitary metastasis of the paraportal lymph nodes was observed, and radiation therapy was introduced. One year later after radiation, lymph node metastasis of near the left common iliac artery was detected, and nivolumab therapy was performed. Although nivolumab was discontinued due to hepatic dysfunction, he is alive without recurrence, 7 years after gastrectomy. It could be important to judge treatment decision based on the evaluation of radiographic assessment, tumor markers and clinical symptoms.

[A Case of Surgical Resection for Solitary Lymph Node Metastasis of Hepatocellular Carcinoma].

A 77-year-old man has undergone 5 times of transcatheter arterial chemoembolization(TACE)and 5 times of radiofrequency ablation(RFA)for hepatocellular carcinoma(HCC)since 2015. In February 2019, serum tumor marker levels extremely increased and CT scan showed a 40 mm mass in hepatoduodenal ligament. Imaging study revealed that intrahepatic lesions of HCC were well controlled and the mass was diagnosed as solitary lymph node metastasis of HCC. We performed surgical resection of the lymph node. The patient discharged 8 days after the surgery. Histopathologicaly, the tumor was diagnosed as lymph node metastasis of HCC. The patient remains free from recurrence 14 months after surgery.

[A Case of Cecal Cancer Directly Invading the Duodenum with a Mobile Cecum].

A 70-year-old man showing positive results for a fecal occult blood test was admitted to a local hospital. He was suspected of double cancer in the cecum and duodenum. While performing ileocolic and segmental duodenal resections, he was diagnosed with cecal cancer invading the duodenum, following which he underwent surgical intervention. The tumor directly invaded the duodenum because of the mobile cecum. This case of duodenal invasion by cecal cancer is atypical.

Prognostic impact of postoperative intra-abdominal infections after elective colorectal cancer resection on survival and local recurrence: a propensity score-matched analysis.

PURPOSE: Several authors have reported an association between anastomotic leak and/or intra-abdominal abscess and oncological survival and recurrence. However, no reports have investigated whether combining anastomotic leak/intra-abdominal abscess and positive drainage culture influences long-term oncological outcomes. Therefore, we defined these complications as postoperative intra-abdominal infections. The present study aimed to evaluate the prognostic impact of postoperative intra-abdominal infections on long-term oncological outcomes after curative stage I-III colorectal cancer surgery. METHODS: We performed a retrospective analysis of 755 consecutive patients with stage I-III colorectal cancer undergoing curative surgery between 2010 and 2015 by performing a propensity score-matched analysis to reduce selection bias. RESULTS: Of the 755 patients, 62 were matched for postoperative intra-abdominal infections analyses. The median follow-up was 48 months. Compared with the non-infections group, the postoperative intra-abdominal infections group had a significantly shorter local recurrence-free survival (P = 0.01 prior to matching, and P = 0.05 after matching). No significant difference was found between the groups in terms of overall, cancer-specific free, recurrence-free, or distant recurrence-free survival. However, multivariate analyses identified postoperative intra-abdominal infections as an independent prognostic factor for local recurrence-free survival (P = 0.04 prior to matching, and P = 0.03 after matching). CONCLUSIONS: In this matched-pair analysis comparing stage I-III colorectal cancer patients with and without postoperative intra-abdominal infections, postoperative intra-abdominal infections were associated with poor local recurrence-free survival, but not overall, cancer-specific free, recurrence-free, or distant recurrence-free survival.

[Two Cases of Esophagogastric Junction Cancer after Subtotal Stomach-Preserving Pancreaticoduodenectomy].

We report 2 cases with esophagogastric junction(EGJ)cancer who underwent remnant gastrectomy preserving Braun anastomosis after subtotal stomach-preserving pancreaticoduodenectomy(SSPPD)with modified Child's reconstruction. In case 1, a 73-year-old man was diagnosed with EGJ cancer 4 years after SSPPD for stenosis of lower bile duct. He underwent remnant gastrectomy with Roux-en-Y(R-Y)reconstruction preserving Braun anastomosis using linear stapler(overlap method). In case 2, a 77-year-old man, who underwent SSPPD for intraductal papillary mucinous neoplasm 1 year ago, was performed endoscopic submucosal dissection for EGJ cancer and planned additional gastrectomy, because of non-curative resection. He was performed remnant gastrectomy with R-Y reconstruction preserving Braun anastomosis using circular stapler. In both patients, the postoperative courses were favorable without complication. Remnant gastrectomy after PD is difficult because of anatomical changes due to adhesions and gastrointestinal reconstruction. R-Y reconstruction preserving Braun anastomosis may be a useful surgical procedure for remnant gastric cancer after SSPPD.

[A Case of Advanced Adenosquamous Carcinoma of Pancreas with Conversion Surgery after Chemoradiotherapy Followed by Systemic Chemotherapy].

A man in his 60s with upper abdominal discomfort was referred to our hospital. CT scan revealed the 40 mm tumor in the body and tail of pancreas invading stomach wall. Solid soft tissue contact was also observed around celiac artery(CA)and common hepatic artery(CHA). EUS-FNA from pancreatic mass showed suspicion of adenosquamous carcinoma. We diagnosed it as pancreatic adenosquamous carcinoma, cT4N0M0, cStage Ⅲ. The patient received radiotherapy(46.8 Gy/26 Fr in total)combined with S-1. Although the primary lesion showed shrinkage, solid soft tissue around CA and CHA deteriorated. We judged the tumor unresectable, and the patient received systemic chemotherapy using gemcitabine(GEM). After 6 courses of GEM, solid soft tissue around CA and CHA almost disappeared. Based on these results, we performed distal pancreatectomy and partial gastrectomy 8 months after the initiation of the treatment. Pathological results showed adenosquamous carcinoma of the pancreas with Grade 2 response to the preoperative treatment. Although the tumor invaded into the gastric wall, R0 resection was achieved. The patient is alive with no recurrence a year and 4 months after the initiation of treatment and 8 months after resection.