Prospective observational study comparing the perioperative outcomes of laparoscopic colectomy with or without epidural anesthesia: the Kanagawa Yokohama Colorectal Cancer Study Group (KYCC) 1806.

PURPOSE: There have been no adequate comparisons of the efficacy, safety, and efficiency of analgesia after laparoscopic colorectal resection (LAC), with and without epidural anesthesia (EDA). METHODS: This was a multicenter prospective observational study of patients undergoing LAC. The primary end point was the mean visual analog scale (VAS) score on postoperative days (PODs) 1-7. The secondary end points were the highest VAS, complication rate, days to first ambulation and fatigue, length of hospital stay, and time to commencement of surgery. RESULTS: We compared an EDA group (Group E, n = 48) and a no-EDA group (Group O, n = 48) after matching. The mean VAS was not significantly different between the groups (28.7 vs. 30.1, p = 0.288). On assessing the secondary end points, the highest VAS was not significantly different between the groups. In fact, the VAS was lower in Group E only on POD 2. There was no difference in the incidence of complications, the time to first postoperative evacuation was shorter in Group E, and postoperative hospitalization was similar. The time to surgery was shorter in Group O. CONCLUSION: These results suggest that LAC without EDA is a feasible option, but with the early and regular use of adjunctive measures to provide more stable analgesia.

Primary omental smooth muscle tumor in an adult male: a diagnostic dilemma for leiomyoma: a case report.

BACKGROUND: The greater omentum comprises peritoneal, adipose, vascular, and lymphoid tissues. Most omental malignancies are metastatic tumors, and the incidence of primary tumors is rare. We report on a prior omental smooth muscle tumor case in an adult male patient. CASE PRESENTATION: A 54-year-old Japanese male patient with no relevant medical history was diagnosed with an abdominal mass during a routine medical checkup. Subsequent contrast-enhanced computed tomography revealed a mass of approximately 3 cm in size in the greater omentum, and a laparotomy was performed. A 27 × 25 × 20 mm raised lesion was found in the omentum. Microscopically, spindle cells were observed and arranged in whorls and fascicles. Individual tumor cells had short spindle-shaped nuclei with slightly increased chromatin and were characterized by a slightly eosinophilic, spindle-shaped cytoplasm. The mitotic count was less than 1 per 50 high-power fields. The tumor cells showed positive immunoreactivity for α smooth muscle actin, HHF35, and desmin on immunohistochemical examination. The Ki-67 labeling index using the average method was 1.76% (261/14806). No immunoreactivity was observed for any of the other tested markers. We considered leiomyoma owing to a lack of malignant findings. However, primary omental leiomyoma has rarely been reported, and it can be difficult to completely rule out the malignant potential of smooth muscle tumors in soft tissues. Our patient was decisively diagnosed with a primary omental smooth muscle tumor considering leiomyoma. Consequently, the patient did not undergo additional adjuvant therapy and was followed up. The patient was satisfied with treatment and showed neither recurrence nor metastasis at the 13-month postoperative follow-up. DISCUSSION AND CONCLUSION: We encountered a primary smooth muscle tumor of the greater omentum with no histological findings suggestive of malignancy in an adult male patient. However, omental smooth muscle tumors are extremely difficult to define as benign, requiring careful diagnosis. Further case reports with long-term follow-up and case series are required to determine whether a true omental benign smooth muscle tumor (leiomyoma) exists. In addition, proper interpretation of the Ki-67 labeling index should be established. This case study is a foundation for future research.

A Case of Colon Cancer with Extramural Tumor Deposits in the Main Lymph Node Area: A Case Report.

A 72-year-old man with type 2 sub-circumferential tumors in the descending colon and two nodules around the pedicle of the inferior mesenteric artery (main lymph node area) underwent laparoscopic left hemicolectomy with D3 lymphadenectomy. Two lymph nodes around the inferior mesenteric artery pedicle were completely excised. Pathological examination revealed a moderately differentiated tubular adenocarcinoma. Nodules were only found in the main lymph node area, and no lymph node structures were observed in these nodules. These tumor deposits (TDs) may be extramural TDs without lymph node structure or lymph node skip metastasis. The presence of TDs in colorectal cancer is associated with an adverse prognosis, and the requirement of chemotherapy in such cases should be examined. Therefore, it is important to correctly recognize TDs and categorize the disease into a high- or low-risk group within stage III. We report this case because it is necessary to review the definition of TDs, and the assessment of extramural TDs remains controversial.

Automated non-invasive identification of pelvic autonomic nerves with a handheld Raman spectrometer and potential application to nerve-sparing colorectal surgery: a preliminary study in surgical specimens.

BACKGROUND: Although minimally invasive surgery for colorectal cancer, whether performed as standard laparoscopic or robotic surgery, has been established as an oncologically safe procedure, postoperative urinary dysfunction and sexual dysfunction remain matters of concern, even when so-called nerve-sparing surgery is performed. We have hypothesized that Raman spectroscopy can be used intraoperatively as a non-invasive label-free means of objective identification of the pelvic nerves, and we conducted a preliminary study by applying a newly developed handheld Raman spectrometer to surgical specimens. METHODS: Samples of nervous tissue, colon cancer tissue, and tissues from surrounding pelvic organs were obtained from 25 patients undergoing colectomy. Raman spectra were obtained by irradiation with the Progeny™ Raman spectrometer. We looked for characteristic Raman shifts to distinguish nervous tissue from cancer tissue. To improve discrimination between nervous tissue and other tissues, the spectral data were subjected to principal component analysis. RESULTS: We detected characteristic differences in the spectra at 1,309 cm-1, 1,442 cm-1, and 1,658 cm-1. A significant difference was detected at 1,442 cm-1, and accuracy of the modality for identification of nervous tissue was 75%. The addition of principle component analysis (4 components) yielded 100% sensitivity, 85% specificity, and 90%, notably increasing accuracy from 75% to 90% in discriminating between nervous tissue and cancer tissue. CONCLUSIONS: Raman spectroscopy holds promise for non-invasive intraoperative recognition of nervous tissue. We expect the modality to become a powerful clinical tool, compensating for the lack of tactile feedback intrinsic to minimally invasive colectomy and thus thwarting the risk of postoperative urinary and/or sexual dysfunction.

[A Case Survived Long Period after Repeated Operation against the Small Intestinal GIST with Perforation].

A patient was 60-year-old man. In March 2011, the small bowel tumor with perforation was found and the partial resection of small intestine was urgently performed. KIT of resected specimen was positive. Then, diagnosis as GIST was defined. Oral administration of imatinib was started, but it was finished in 5 months because of development of the systemic edema. In February 2013, the abdominal CT revealed a tumor of 20 cm in size in the pelvis. Upon laparotomy, we detected the GIST recurrence generated at the region of small intestine anastomosis where manipulated previously, then resected all of tumor and partially small intestine. Afterward, we diagnosed as a recurrence of GIST. In March 2014, the abdominal CT found 4 cm sized mesenteric tumor and 2 cm sized abdominal wall tumor. The laparotomy was performed and we found 5 disseminated nodules intraperitoneally. We confirmed that all of these disseminated nodules were successfully removed. We defined them as re-recurrence of GIST. Six years and 5 months have elapsed since the first operation was performed, but there is no sign of three times recurrence.

[Long-Term Survival after Resection for Repeated Abdominal Wall Recurrence of Gallbladder Cancer].

We report the case of a 79-year-old woman with repeated abdominal wall recurrence of gallbladder cancer. The original diagnosis was gallbladder carcinoma. She underwent open liver bed dissection and lymph node dissection. Postoperative pathological examination indicated T2N1M0, Stage III disease. She received 6 courses of postoperative chemotherapy with gemcitabine. Two years and 2 months after the surgery, we detected a 13 mm mass under the abdominal wall scar on CT, and we resected this tumor. Pathological findings indicated adenocarcinoma, which was found to be metastasis of the gallbladder cancer. She was treated with S-1 for 8 courses postoperatively. However, 3 years 4 months after the first surgery, a tumor of 22mm was detected in the abdominal wall on the caudal side away from the previous tumor excision site. We resected the abdominal wall including the tumor. The pathological examination revealed adenocarcinoma, which was again metastasis from gallbladder cancer. The increase of CA19-9 was confirmed around 4 years and 7months after the first operation. An abdominal wall tumor of 45mm was detected in contact with the iliac bone near the last excision site and it proved to be a recurrence of gallbladder carcinoma. We performed abdominal wall tumor resection, again identifying adenocarcinoma, which was the third recurrence of gallbladder cancer. Despite continued abdominal wall recurrence, she is alive and well without metastasis for more than 5 years.

[The Outcomes of Laparoscopy-Assisted Surgery in Elderly Patients with Colorectal Carcinoma].

AIM: To evaluate short-term outcomes of laparoscopy-assisted colectomy (LAC) in elderly patients with colorectal carcinoma. METHODS: A total of 289 colorectal cancer patients underwent LAC between 2008 and 2013. They were divided into an elderly group (<80 years of age, group E), and a younger group (<80 years of age, group Y). The treatment results, including the surgery-related factors, the perioperative course, and the pre- and postoperative complications, were retrospectively analyzed. RESULTS: There were 49 patients in group E, and 240 patients in group Y. There was no significant difference between the 2 groups considering the operative time, blood loss, rate of transfusion, post-operative hospital stay, rate of conversion to open surgery, or rate of complications, except for the number of patients with an ASA classification of greater than Grade 2 and the degree of lymph node dissection. CONCLUSIONS: LAC in elderly patients was found to be relatively safe because it was associated with a reduction in damage to the abdominal wall, and with an early recovery from surgery. These results suggest that the indications of LAC could be expanded for elderly patients.

[Outcomes of laparoscopic surgery after preoperative metallic stent placement for obstructive colorectal cancer].

AIM: To assess the outcomes of preoperative colonic stent placement for obstructive colorectal cancer. PATIENTS AND METHODS: A total of 30 patients with colorectal cancer were treated after preoperative colonic metallic stent placement between July 2012 and March 2014. We reviewed their medical records to assess the usefulness of stent placement and the clinical course. The effects of various clinicopathological variables on post-operative complications were analyzed statistically. RESULTS: Stent insertion was effective in 93% of the 30 patients with obstructive colorectal cancer. Preoperative colonoscopy or enema for proximal colonic survey was possible in 70% of the patients after stent placement; colonic lesions requiring simultaneous resection were noted in 5 patients (24%). The mean interval between stent insertion and operation was 19 days, and 23%of the patients underwent laparoscopic surgery. Statistical analysis revealed that the occurrence of complications was associated with laparoscopic surgery and the amount of operative blood loss. CONCLUSION: Preoperative stent placement in patients with obstructive colorectal cancer is feasible and laparoscopic surgery can be selected after stent placement.

Risk factors for 6-month continuation of S-1 adjuvant chemotherapy for gastric cancer.

BACKGROUND: The factors that affect the 6-month continuation of adjuvant chemotherapy with S-1 have not been fully evaluated. The objective of this retrospective study was to clarify the risk factors for 6-month continuation of S-1 adjuvant chemotherapy. METHODS: The study selected patients who underwent curative D2 surgery for gastric cancer, were diagnosed with stage 2 or 3 disease, had a serum creatinine level of ≤ 1.2 mg/dl, and received adjuvant S-1 between June 2002 and March 2011. RESULTS: One hundred of these patients were eligible for the present study. A comparison of 6-month continuation of S-1 stratified by various clinical factors, using the log-rank test, revealed a marginally significant difference in creatinine clearance (CCr) between those patients who continued for 6 months and those who did not. A CCr of 60 ml/min was regarded as the critical point. Uni- and multivariate Cox's proportional hazard analyses demonstrated that CCr was the only significant independent factor for the prediction of 6-month continuation. The 6-month continuation rate was 72.9 % in the patients with CCr ≥ 60 ml/min, and 40.0 % in patients with CCr <60 ml/min (P = 0.015). Adverse events occurred more frequently and earlier in the patients with CCr <60 ml/min than in those with CCr ≥ 60 ml/min. CONCLUSIONS: CCr <60 ml/min was a significant risk factor for 6-month continuation of S-1 adjuvant chemotherapy, even though the renal function was judged as normal by the serum creatinine level. Careful attention is therefore required for S-1 continuation in patients with CCr <60 ml/min.

[Neoadjuvant chemotherapy for gastric cancer--evidence from the world and future strategy in Japan].

Adjuvant chemotherapy is aimed at eradicating residual micro-metastatic tumor cells existing at the distant site outside of the surgical field. From evidence gathered from around the world, several courses of intensive neoadjuvant chemotherapy are promising even in Japan, where D2 surgery is the standard for local control. The Japan Clinical Oncology Group (JCOG) plays a central role in the development of neoadjuvant chemotherapy in Japan. Two JCOG Phase II trials clarified that neoadjuvant chemotherapy was effective for bulky nodal disease. A JCOG Phase III is now on-going to confirm the efficacy of neoadjuvant chemotherapy of S-1+CDDP for cancer of the schirrhous type. In another group, two randomized Phase II trials are also ongoing to compare different regimens and courses of neoadjuvant chemotherapy. These studies will set the direction of neoadjuvant chemotherapy development in the future.

Risk factors for peritoneal recurrence in stage II/III gastric cancer patients who received S-1 adjuvant chemotherapy after D2 gastrectomy.

BACKGROUND: The peritoneum is still the most frequent site of recurrence in stage II/III gastric cancer patients, although the survival rate was improved by the introduction of S-1 adjuvant chemotherapy. The objective of this retrospective study was to clarify the risk factors for peritoneal recurrence in patients who received S-1 adjuvant chemotherapy. METHODS: Peritoneal recurrence-free survival was examined in 100 gastric cancer patients who underwent curative D2 surgery, which were diagnosed with stage II or III disease pathologically, and received adjuvant S-1 between June 2002 and March 2011. The univariate and multivariate analyses were performed to identify risk factors by a Cox proportional hazards analysis. RESULTS: The P-RFS was 64.3% at 3 years and 58.8% at 5 years. A total of 18 patients were diagnosed with peritoneal recurrence. The macroscopic tumor diameter, depth of tumor invasion, and lymph node metastasis were the significant factors identified by the univariate analysis, while the tumor diameter and lymph node metastasis were the only significant independent risk factors identified by the multivariate analysis. CONCLUSIONS: The macroscopic tumor diameter and presence of lymph node metastasis were the most important risk factors for peritoneal recurrence. When patients had these risk factors, S-1 was not sufficient to inhibit peritoneal recurrence. A novel adjuvant chemotherapeutic agent targeting peritoneal metastasis in these patients should be developed.

[S-1/krestin immunochemotherapy for patients with advanced gastric cancer].

BACKGROUND: S-1 mono-therapy for advanced gastric cancer is hard to continue in some patients due to adverse events. We retrospectively examined the patients who received S-1/Krestin( PSK) immunochemotherapy for advanced gastric cancer. METHODS: During September 2006 to August 2008, 3 patients had received S-1/PSK. S-1 was given for 6-week schedule or 3-week schedule, and PSK was for everyday during the S-1 treatment. RESULTS: Cases 1 and 2 had lymph node metastases after surgery. Case 3 had peritoneal metastasis. The median treatment duration was 112 days. The median overall survival was 552 days. All patients stopped the treatment due to progression of disease. There were no patients who stopped the treatment due to adverse events. CONCLUSIONS: PSK may increase the compliance of S-1.

[Pancreatic resection for metastatic tumors to the pancreas].

We report 3 cases of resectable pancreatic metastasis. CASE 1: A 76-year-old woman was followed after nephrectomy for renal cell carcinoma for 13 years. CT examination demonstrated a high vascular lesion in the pancreatic body and tail. We conducted distal pancreatectomy and diagnosed with metastatic tumor from renal cell carcinoma. She died of liver metastasis 8 years after pancreatic resection. CASE 2: A 64-year-old man, who had undergone right lower lobectomy for lung cancer a year ago, was found to have a mass in the pancreatic tail. We performed distal pancreatectomy and diagnosed with metastatic tumor from lung cancer. He died of lung metastasis 12 months after pancreatic resection. CASE 3: A 62- year-old woman, who had undergone left nephrectomy for renal cell carcinoma 3 years ago, was found to have a mass in the pancreatic body. With a diagnosis of metastatic pancreatic tumor from renal cell carcinoma, distal pancreatectomy was done. She died of liver and lung metastases 15 months after pancreatic resection. Long-term survival can be achieved in patients undergoing a pancreatic standard resection including lymphadenectomy for isolated metastasis from nonpancreatic sites.

[Assessment of the cost of laparoscopy-assisted gastrectomy].

BACKGROUND: The cost of laparoscopic gastrectomy (LG) has not been fully clarified yet. PATIENTS AND METHODS: The actual cost for the instruments used for surgery was examined between LG and conventional open gastrectomy( OG) by separating distant (l D-) and total (l T-) gastrectomy in a total of 20 patients(5 for each)during Oct 2010 and Feb 2011. The profit was defined as the difference of the actual cost and the operation fee including the instruments determined by the insurance and compared. RESULTS: The fee for D-OG, T-OG, D-LG, and T-LG were 708, 700 yen, 856 , 400 yen, 783 , 600 yen and 922 , 300 yen, respectively. The mean profits of D-OG, T-OG, D-LG, and T-LG were 408 , 297 yen, 475 , 812 yen, 308, 681 yen and 269 , 478 yen, respectively. CONCLUSION: Appropriate surgical and instrumental fees should be determined considering the actual cost.

[Prognosis and clinical course of gastric cancer with para-aortic lymph node metastasis after curative D2 gastrectomy and adjuvant chemotherapy with S-1].

BACKGROUND: Survival and clinical course were unknown in patients with recurrence of para-aortic lymph node after curative D2 gastrectomy and adjuvant S-1 chemotherapy. METHODS: The study examined clinical characteristics and prognosis of 3 patients who had para-aortic nodal recurrence after curative D2 gastrectomy and S-1 adjuvant chemotherapy. RESULTS: Initial stage was III C in all of the patients. Median treatment interval of S-1 was 8 . 8 months. Para-aortic nodal metastasis was single in 2 and multiple in 1 patient. Median survival time was 14 .3 months. Other recurrent sites than para- aortic node were not seen in all of the patients. CONCLUSIONS: In the times of S-1 adjuvant chemotherapy, it is valuable to know whether para-aortic node should be resected prophylactically, or be treated after recurrence, or be treated by locally or systemically.

[Adrenalectomy for solitary adrenal metastasis from colorectal cancer].

A 77-year-old man had sigmoidectomy for sigmoid colon cancer. Two years later, a right hepatectomy for a liver metastasis was performed. Two years thereafter, abdominal computed tomography scanning and FDG-PET showed the right adrenal mass. Right adrenalectomy was performed with a diagnosis of solitary adrenal metastasis from sigmoid colon cancer. On pathology, adrenal metastasis was confirmed. The patient underwent adjuvant chemotherapy (IRIS). There have been no signs of recurrence for 6 months after the operation. We conclude that patients with solitary adrenal metastasis from colorectal cancer may benefit from surgical resection.