Impact of a Dual-Ring Wound Protector on Outcome After Elective Surgery for Colorectal Cancer.

BACKGROUND: The impact of dual-ring wound protectors (DRWPs) on the long-term outcomes of patients with colorectal cancer (CRC) undergoing elective surgery remains unclear. The aim of this cohort study was to compare short- and long-term outcomes after CRC resection with or without use of a DRWP. METHODS: This study enrolled 625 patients with stage I-III CRC undergoing curative resection and divided them into DRWP (n = 348) and control (n = 277) groups. Primary endpoints were postoperative short- and long-term complications. Secondary endpoints were oncological outcomes including wound recurrence, disease-free survival, and overall survival. RESULTS: Rates of postoperative complications (P = 0.004) and laparotomy wound infection (LWI) (P < 0.001) were markedly lower in the DRWP group. Operation quality, as per the number of lymph nodes harvested and rate of R0 resection, did not differ between the groups (all P > 0.05). The DRWP group exhibited significantly lower rates of incisional hernia occurrence (5.3% versus 9.5%, P = 0.045) compared with the control group. Multivariable analyses demonstrated an increased risk of LWI with no wound protector in colorectal surgery (odds ratio, 3.778; P = 0.001), and patients who developed LWI after surgery were more than 4 times more likely to develop an incisional hernia during outpatient follow-up (odds ratio, 4.333; P = 0.001). One patient in the control group (0.36%) had isolated wound recurrence at 12 mo postoperatively. CONCLUSIONS: Fewer postoperative and late complications, comparable oncological safety, and similar long-term clinical outcomes confirmed the benefits of DRWP use for patients with CRC undergoing elective surgery. Therefore, the use of DRWP may be considered in curative CRC resection.

Short- and long-term outcomes of laparoscopic-assisted surgery, mini-laparotomy and conventional laparotomy in patients with Stage I-III colorectal cancer.

BACKGROUND: Three operative techniques have been used for colorectal cancer (CRC) resection: Conventional laparotomy (CL) and the mini-invasive techniques (MITs)- laparoscopic-assisted surgery (LAS) and mini-laparotomy (ML). The aim of the study was to compare the short- and long-term outcomes of patients undergoing the three surgical approaches for Stage I-III CRC resection. PATIENTS AND METHODS: This study enrolled 688 patients with Stage I-III CRC undergoing curative resection. The primary endpoints were perioperative quality and outcomes. The secondary endpoints were oncological outcomes including disease-free survival (DFS), overall survival (OS) and local recurrence (LR). RESULTS: Patients undergoing LAS had significantly less blood loss (P < 0.001), earlier first flatus (P = 0.002) and earlier resumption of normal diet (P = 0.025). Although post-operative complication rates were remarkably higher in patients undergoing CL than in those undergoing MITs (P = 0.002), no difference was observed in the post-operative mortality rate (P = 0.099) or 60-day re-intervention rate (P = 0.062). The quality of operation as assessed by the number of lymph nodes harvested and rates of R0 resection did not differ among the groups (all P > 0.05). During a median follow-up of 5.42 years, no significant difference was observed among the treatment groups in the rates of 3-year late morbidity, 3-year LR, 5-year LR, 5-year OS or 5-year DFS (all P > 0.05). CONCLUSIONS: Patients undergoing CL had higher post-operative morbidities. Moreover, the study findings confirm the favourable short-term and comparable long-term outcomes of LAS and ML for curative CRC resection. Therefore, both MITs may be feasible and safe alternatives to CL for Stage I-III CRC resection.

Coexistence of perineural invasion and lymph node metastases is a poor prognostic factor in patients with locally advanced rectal cancer after preoperative chemoradiotherapy followed by radical resection and adjuvant chemotherapy.

OBJECTIVE: To determine the role of lymph node metastases (ypN) and perineural invasion (PNI) in patients with locally advanced rectal cancer (LARC). SUBJECTS AND METHODS: Eighty-eight LARC patients receiving preoperative chemoradiotherapy from April 2006 to November 2011 were enrolled in this study. Univariate and multivariate analyses were conducted to determine the association between clinicopathologic features and clinical outcome. RESULTS: The presence of ypN (p = 0.011) and PNI (p = 0.032) was a significant adverse prognostic factor for disease-free survival (DFS). High histologic grade (p = 0.015), PNI+ (p = 0.043) and ypN+ (p = 0.041) were adverse prognostic factors for overall survival (OS). Positive PNI was significantly associated with a higher risk of distant failure (odds ratio = 6.09; 95% CI: 1.57-27.05; p = 0.008). Moreover, patients with a coexistence of ypN+ and PNI+ had the significantly worst DFS (p < 0.001) and OS rates (p < 0.001) compared with other phenotypes. CONCLUSIONS: The presence of either PNI or ypN was a significant prognostic factor for predicting poor survival rates in LARC patients, especially those with a coexistence of both factors. Accordingly, we recommend an intensive follow-up and therapeutic programs for LARC patients with simultaneous PNI+ and ypN+.

Helical tomotherapy combined with capecitabine in the preoperative treatment of locally advanced rectal cancer.

The aim of this study was to evaluate the efficacy of helical tomotherapy plus capecitabine as a preoperative chemoradiotherapy (CRT) in patients with locally advanced rectal cancer (LARC). Thirty-six LARC patients receiving preoperative CRT were analyzed. Radiotherapy (RT) consisted of 45 Gy to the regional lymph nodes and simultaneous-integrated boost (SIB) 50.4 Gy to the tumor, 5 days/week for 5 weeks. Chemotherapy consisted of capecitabine 850 mg/m(2), twice daily, during the RT days. Patients underwent surgery 6-8 weeks after completion of CRT. Information was collected for patient characteristics, treatment response, and acute and late toxicities. Grade 3/4 (G3+) toxicities occurred in 11.1% of patients (4/36). Sphincter preservation rate was 85.2% (23/27). Five patients (14.3%) achieved pathological complete response. Tumor, nodal, and ypT0-2N0 downstaging were noted in 60% (21/35), 69.6% (16/23), and 57.1% (20/35). Tumor regression grade 2~4 was achieved in 28 patients (80%). After a median follow-up time of 35 months, the most common G3+ late morbidity was ileus and fistula (5.7%, 2/35). The study showed that capecitabine plus helical tomotherapy with an SIB is feasible in treatment of LARC. The treatment modality can achieve a very encouraging sphincter preservation rate and a favorable ypT0-2N0 downstaging rate without excessive toxicity.

FOLFIRI combined with bevacizumab as first-line treatment for metastatic colorectal cancer patients with hyperbilirubinemia after UGT1A1 genotyping.

OBJECTIVE: To report a metastatic colorectal cancer patient with hyperbilirubinemia treated with a combination of bevacizumab and FOLFIRI (5-fluorouracil, leucovorin, and irinotecan) using uridine diphosphate glucuronosyl transferase (UGT1A1) genotyping. CLINICAL PRESENTATION AND INTERVENTION: A 46-year-old male was diagnosed with rectosigmoid colon cancer with liver metastases and hyperbilirubinemia presenting with severe jaundice. UGT1A1 genotyping was used before therapy to ascertain whether genotype-adjusted dosages of irinotecan plus bevacizumab could alleviate the toxicity. Then, the patient was treated with FOLFIRI. CONCLUSION: The FOLFIRI regimen was successfully used in this patient without concerns regarding toxicity.

Predictive value of vascular endothelial growth factor overexpression in early relapse of colorectal cancer patients after curative resection.

BACKGROUND: Preclinical and clinical studies have indicated that vascular endothelial growth factor (VEGF) is the predominant angiogenic factor. Recently, there was a consistent trend of poorer survival rates in colorectal cancer (CRC) patients of earlier relapse. The purpose of this study was to investigate novel predictors of early relapse in stage I-III CRC and further to determine their correlation with disease outcomes. MATERIALS AND METHODS: We retrospectively analyzed clinicopathological features and VEGF expression by immunohistochemical staining in 100 stage I-III CRC patients undergoing curative resection to identify predictors of postoperative early relapse. RESULTS: Among 100 patients, 40 patients were classified into early relapse group, and 60 patients were categorized into non-early relapse group. A multivariate logistic regression analysis showed that vascular invasion (P = 0.048), perineural invasion (P = 0.042), VEGF overexpression (P = 0.023), and high postoperative carcinoembryonic antigen (CEA) levels (P = 0.004) were independent predictors of early relapse. Additionally, we found that with more predictors such as the combined incidence of vascular invasion, perineural invasion, VEGF overexpression, and postoperative CEA levels are involved, the incidence of early postoperative relapse increases. Moreover, VEGF overexpression predicted not only early postoperative relapse but also disease-free survival (P < 0.001) and overall survival (P = 0.002). CONCLUSIONS: This study suggests that VEGF overexpression is an important predictor of early postoperative relapse in patients with stage I-III CRC and may help identify patients who would benefit from intensive follow-up and therapeutic programs.

Osteoporosis self-assessment tool for Asians as a simple risk index of identifying a poor prognosis in women surgically treated for colorectal cancer.

BACKGROUND: Osteoporosis and colorectal cancer (CRC) in older women are considered enormous public health burdens. The effects of osteoporosis on the oncologic outcome of CRC surgery are poorly understood. We evaluated the use of the Osteoporosis Self-assessment Tool for Asians (OSTA) for predicting postoperative outcome in older women after receiving surgical treatment of CRC. MATERIALS AND METHODS: The present single-institution retrospective study analyzed patients who had undergone surgery for CRC in 2002-2008. To characterize the major population of women with osteoporosis, which consists of postmenopausal women, only patients aged 50 years and older were analyzed. Their OSTA scores were evaluated for correlations with cancer-specific survival after surgery for CRC by performing univariate, multivariate, and survival analyses. RESULTS: During a 7-year period, 440 women were studied. The cancer-specific mortality and overall mortality rate was 28.4% and 33.4%, respectively. The univariate analyses revealed that significant predictors of cancer-specific mortality after CRC surgery were the International Union Against Cancer (UICC) stage, OSTA category, histologic grading, lymph node metastases, and tumor invasion depth. After risk adjustment, the UICC stage and OSTA risk index were independent predictors of mortality. A comparison of OSTA risk index among patients with different UICC stages showed that the accuracy of the index in predicting cancer-specific survival after CRC surgery was greatest for patients with stage II and III disease. CONCLUSIONS: The UICC stage and OSTA risk status showed independent positive associations with postoperative mortality in aged female patients with CRC. Moreover, the OSTA index had a particularly strong association with cancer-specific mortality in patients with UICC stage II and III.

DPYD, TYMS, TYMP, TK1, and TK2 genetic expressions as response markers in locally advanced rectal cancer patients treated with fluoropyrimidine-based chemoradiotherapy.

This study is to investigate multiple chemotherapeutic agent- and radiation-related genetic biomarkers in locally advanced rectal cancer (LARC) patients following fluoropyrimidine-based concurrent chemoradiotherapy (CCRT) for response prediction. We initially selected 6 fluoropyrimidine metabolism-related genes (DPYD, ORPT, TYMS, TYMP, TK1, and TK2) and 3 radiotherapy response-related genes (GLUT1, HIF-1α, and HIF-2α) as targets for gene expression identification in 60 LARC cancer specimens. Subsequently, a high-sensitivity weighted enzymatic chip array was designed and constructed to predict responses following CCRT. After CCRT, 39 of 60 (65%) LARC patients were classified as responders (pathological tumor regression grade 2 ~ 4). Using a panel of multiple genetic biomarkers (chip), including DPYD, TYMS, TYMP, TK1, and TK2, at a cutoff value for 3 positive genes, a sensitivity of 89.7% and a specificity of 81% were obtained (AUC: 0.915; 95% CI: 0.840-0.991). Negative chip results were significantly correlated to poor CCRT responses (TRG 0-1) (P = 0.014, hazard ratio: 22.704, 95% CI: 3.055-235.448 in multivariate analysis). Disease-free survival analysis showed significantly better survival rate in patients with positive chip results (P = 0.0001). We suggest that a chip including DPYD, TYMS, TYMP, TK1, and TK2 genes is a potential tool to predict response in LARC following fluoropyrimidine-based CCRT.

A observational study of the efficacy and safety of capecitabine versus bolus infusional 5-fluorouracil in pre-operative chemoradiotherapy for locally advanced rectal cancer.

BACKGROUND AND OBJECTIVES: This study is to evaluate the safety and efficacy of preoperative radiotherapy (RT) combined with bolus infusional 5-fluorouracil (5-FU) or oral capecitabine in patients with locally advanced rectal cancer (LARC). MATERIALS AND METHODS: Seventy-four patients were retrospectively analyzed. Twenty-seven patients were treated with 5-FU (350 mg/m(2) i.v. bolus) and leucovorin (20 mg/m(2) i.v. bolus) for 5 days/week during week 1 and 5 of RT. Forty-seven patients were treated with capecitabine (850 mg/m(2), twice daily for 5 days/week). Both groups received the same RT course (45-50.4 Gy/25 fractions, 5 days/week, for 5 weeks). Patients underwent surgery in 6 weeks after completion of the chemoradiotherapy. Data of the observational study were collected. RESULTS: Grade 3 or 4 toxicities occurred in 40.7% (5-FU) and 19.1% (capecitabine) of the patients (P = 0.044). Six patients in the 5-FU group (22.2%) and six patients in the capecitabine group (14%) achieved complete response. Primary tumor (T) downstaging were achieved in 51.9% (5-FU) and 69.8% (capecitabine) of the patients. The pathological ypT0-2 stage was 40.7% (5-FU) and 67.4% (capecitabine) (P = 0.028). CONCLUSIONS: In consideration of the better ypT0-2 downstaging rate, less severe toxicities, and no need for indwelling intravenous device on oral capecitabine regimen, the administration of oral capecitabine with RT may be a more favorable option in the neoadjuvant treatment for LARC.

Multiple genetic polymorphisms in the prediction of clinical outcome of metastatic colorectal cancer patients treated with first-line FOLFOX-4 chemotherapy.

OBJECTIVES: The objective of the study is to investigate whether multiple chemotherapeutic agent-related genetic polymorphisms are associated with the clinical outcomes of Taiwanese metastatic colorectal cancers (mCRC) patients treated with the first-line FOLFOX-4 chemotherapy. METHODS: Consecutive mCRC patients were prospectively enrolled into this study. Peripheral blood samples were used for genotyping of polymorphisms in MTHFR, DPD, GSTP1, MDR1, TYMS, ERCC1, XRCC1, and ERCC2 genes by polymerase chain reaction-restriction fragment length polymorphism technique and DNA sequencing. The primary end point of the study was to investigate the association of each genetic polymorphism with progression-free survival and overall survival (OS). RESULTS: Favorable genotypes from polymorphisms in ERCC1 codon 118C/C [hazard ratio (HR)=0.061, 95% confidence interval (CI): 0.014-0.274, P<0.001] and XRCC1 codon 399G/G (HR=0.306, 95% CI: 0.103-0.905, P=0.032) that are associated with progression-free survival were identified. Furthermore, ERCC1 codon 118C/C (HR=0.065, 95% CI: 0.011-0.377, P=0.002) and XRCC1 codon 399G/G (HR=0.152, 95% CI: 0.041-0.568, P=0.005) were significantly associated with favorable OS. Combining ERCC1 and XRCC1 genetic polymorphisms, patients with both favorable genotypes of ERCC1 codon 118C/C and XRCC1 codon 399G/G were associated with the better OS than those with one or without any favorable genotypes (P<0.001). CONCLUSION: The genetic polymorphisms of ERCC1 and XRCC1 may be useful in predicting clinical outcome in Taiwanese mCRC patients treated with FOLFOX-4. However, further prospective studies will be needed for the potential clinical implication.

Clinical, radiologic and pathologic characteristics of the Carney triad: a case report and literature review.

This report describes a patient with a gastrointestinal stromal tumor (GIST) and upper gastrointestinal hemorrhage as initial presentations of the Carney triad, a synchronous or metachronous condition involving gastric leiomyosarcoma, extra-adrenal paraganglioma and pulmonary chondroma. A 26-year-old woman presented with dizziness and several episodes of melena over 3 days. Physical examination revealed pale conjunctiva but normal hemodynamic status. Gastroendoscopy showed one antral submucosal tumor with evidence of an associated bleeder (the bleeder over the mucosal surface of the gastric tumor). An abdominal computed tomography scan showed an antral submucosal tumor, two secondary lesions over segment II/V of the liver and a retroperitoneal tumor. Surgical removal of the tumor and subsequent recovery were uneventful. The gastric GIST with liver metastasis and retroperitoneal paraganglioma were confirmed by pathologic study. The patient was treated with imatinib mesylate for the GIST with liver metastasis, and continued follow-up treatment at our hospital. An abdominal computed tomography scan at 32 months after surgery showed no change in the liver metastatic lesions and no evidence of local recurrence. Another follow-up visit at 33 months after surgery confirmed the stable condition. Of nearly 100 cases reported in the literature, this case is the first to be reported in Taiwan. This case highlights the possibility of this rare syndrome occurring in young female patients with one of the three components of the triad and the need for further diagnostic studies for early identification of tumors when curative surgery is still possible.

Adult intussusception secondary to lymphangioma of the cecum: a case report.

We report the case of a patient with ileocolic intussusception caused by cecal lymphangioma. A 45-year-old man visited our hospital with a 2-month history of frequent episodes of watery diarrhea (>/= 5 times/day) and intermittent abdominal pain. A cecal submucosal tumor with mucosal ulceration and partial obstruction of the colonic lumen was identified by colonoscopy. He was admitted to our hospital 2 days later due to aggravation of his abdominal pain. Physical examination revealed tenderness over the right abdomen with no peritoneal signs. A double-contrast lower gastrointestinal series showed a right-side colonic lesion with indentation and a peripheral, beak-like sign. Abdominal computed tomography scanning revealed an intra-abdominal mass with the characteristic sausage sign, highly suggestive of intussusception. The patient subsequently underwent right hemicolectomy. The final diagnosis was ileocolic intussusception with cecal lymphangioma, which was confirmed by histopathology. He had an uneventful recovery with follow-up in our hospital. This case highlights the possibility of colonic lymphangioma as the leading point of adult intussusception, and this should be taken into consideration as a possible diagnosis in this uncommon clinical condition.

Occult colon cancer in a patient with diabetes and recurrent Klebsiella pneumoniae liver abscess.

Klebsiella pneumoniae (Kp) is a well-known leading cause of liver abscess in patients with diabetes, but recurrent Kp liver abscess in such patients within a period of time is seldom seen. Here, we report a patient with diabetes who experienced three episodes of Kp liver abscess within 1 year. The patient was subsequently diagnosed to have an occult sigmoid cancer. The liver abscess did not recur after resection of the colonic tumor. Occult sigmoid colonic cancer may have played an important role in the recurrent Kp liver abscess in our case. Therefore, further investigation of gastrointestinal malignancies, particularly of the colonic tract, is necessary in patients with diabetes and Kp liver abscess.

Predicting factors of postoperative relapse in T2-4N0M0 colorectal cancer patients via harvesting a minimum of 12 lymph nodes.

BACKGROUND AND AIM: The aim of this retrospective study was to determine which clinicopathological factors influenced the incidence of postoperative relapse and overall survival rates after radical resection of T(2-4)N(0)M(0) colorectal cancer (CRC) patients via harvesting a minimum of 12 lymph nodes. MATERIALS AND METHODS: Between January 2001 and June 2006, a total of 342 T(2-4)N(0)M(0) CRC patients who underwent radical resection were retrospectively analyzed in Kaohsiung Medical University Hospital. Of these 342 patients, 155 were observed by harvesting a minimum of 12 lymph nodes. These 155 patients were followed up intensively, and their outcomes were investigated retrospectively. RESULTS: Of 155 patients, 83 were men (53.5%) and 72 (46.5%) were women. The mean age was 65.5 +/- 11.1 years (range, 24-89 years). The median follow-up period was 49 months (range, 19-80 months). The present data showed invasive depth (P = 0.012), vascular invasion (P < 0.001), and perineural invasion (P = 0.009) as significantly prognostic factors for postoperative 5-year relapse rate by Kaplan-Meier analysis. Likewise, invasive depth (P = 0.013), vascular invasion (P < 0.001), and perineural invasion (P = 0.008) were significant factors for postoperative 5-year survival rate. Meanwhile, using a Cox proportional hazards analysis, depth of tumor invasion (P = 0.026) and vascular invasion (P = 0.001) were the independent predictors for postoperative relapse. Furthermore, the presence of vascular invasion was considerably correlated to the higher postoperative relapse rate and the poorer overall survival rates by survival analyses (P < 0.0001). CONCLUSIONS: Besides the conventional depth of tumor invasion, this study highlights the potential for using vascular invasion as a means of identifying a subgroup of T(2-4)N(0)M(0) CRC patients with adequate lymph node harvest at higher risk who would potential benefit from adjuvant therapy after surgery.

Experience with adjuvant chemotherapy for pseudomyxoma peritonei secondary to mucinous adenocarcinoma of the appendix with oxaliplatin/fluorouracil/leucovorin (FOLFOX4).

BACKGROUND: Pseudomyxoma peritonei (PMP) is a rare condition characterized by mucinous tumors, disseminated intra-peritoneal implants, and mucinous ascites. So far its diagnosis remains challenging to most clinicians. CASE PRESENTATION: A 55-year-old male patient had suffered from acute onset of abdominal pain and abdominal distension for one day prior to his admission. Physical examination revealed tenderness over the right lower quadrant of the abdomen without diffuse muscle guarding. A large amount of ascites was identified by abdominal computed tomography (CT) scan. Paracentesis showed the appearance of sticky mucinous ascites. He underwent laparotomy under the impression of pseudomyxoma peritonei. There was a lot of mucinous ascites, one appendiceal tumor and multiple peritoneal implants disseminated from the subphrenic space to the recto-vesicle pouch. Pseudomyxoma Peritonei caused by mucinous adenocarcinoma of appendiceal origin, was confirmed by histopathology. We performed an excision of the appendiceal tumor combined with copious irrigation and debridement. After the operation, he received 10 cycles of systemic chemotherapy with FOLFOX4 regimen, without specific morbidity. Follow-up of abdominal CT and colonoscopy at post-operative 17 months showed excellent response without evidence of local recurrence or distal metastasis. He made an uneventful recovery (up to the present) for 21 months after the operation. CONCLUSION: This case report emphasizes the possible new role of systemic chemotherapy in the treatment of patients with this rare clinical syndrome.

Successful management of perforated duodenal diverticulitis with intra-abdominal drainage and feeding jejunostomy: a case report and literature review.

We report the clinical experience of one patient with perforated duodenal diverticulitis who was successfully treated by intra-abdominal drainage and feeding jejunostomy. A 53-year-old male patient visited our hospital due to acute onset of abdominal pain and distension. Physical examination revealed tenderness over the epigastric area and right-lower quadrant of the abdomen without obvious rebound tenderness or muscle guarding. Duodenal diverticulitis with a retroperitoneal abscess was identified by abdominal computed tomography scan. Surgical intervention was performed after the failure of conservative treatment. The operative findings were compatible with perforated duodenal diverticulitis, and intra-abdominal drainage of retroperitoneal abscess with simultaneous feeding jejunostomy was undertaken. The patient was doing well at the 4-month postoperative follow-up visit. We suggest the use of a conservative operative method, as opposed to conventional diverticulectomy and duodenorrhaphy, as an alternative approach for the management of this disorder, especially when conservative treatment has failed.