Impact of subdivision of pathological stage I colorectal cancer.

AIM: Stage II-IV colorectal cancers are subdivided according to TNM categories. However, stage I cases are a single category, despite the inclusion of both T1 and T2 cases, which may have different outcomes. The aim of this study was to evaluate the usefulness of subdividing stage I colorectal cancers by T category. METHODS: From 1984 to 2015, 844 patients with stage I colorectal cancer (T1: 446, T2: 398) underwent colorectal resection with lymph node dissection at three hospitals. The long-term survival and recurrence rates were compared between T1 and T2. A Cox regression analysis was used to evaluate the risk factors associated with cancer recurrence. RESULTS: A comparison of the T1 and T2 groups revealed significant differences in 5-year overall (95.9% vs 91.4%, P = .008), recurrence-free (94.8% vs 87.1%, P = .0007), and cancer-specific survival (97.6% vs 93.6%, P = .004), and in the overall (2.5% vs 6.8%, P = .003), local (0.2% vs 1.5%, P = .04), and lymph node recurrence rates (0.2% vs 1.5%, P = .04). All local and lymph node recurrences were associated with lower rectal cancer, and this difference was significant. The Cox multivariate analysis identified male sex (P = .01, hazard ratio: 4.00, 95% confidence interval: 1.38-11.55), T2 (P = .02, hazard ratio: 2.98, 95% confidence interval: 1.17-7.60), and venous invasion (P = .03, hazard ratio: 2.38, 95% confidence interval: 1.12-5.10) as risk factors for recurrence. CONCLUSIONS: The subdivision of stage I colorectal cancer according to T category clearly reflected the long-term outcomes.

[Two cases of unresectable advanced gastric cancer treated with S-1, CDDP and trastuzumab].

We report two cases of unresectable advanced gastric cancer treated with S-1, CDDP and trastuzumab. A significant reduction of tumors was observed in these cases. A 77-year-old man was diagnosed as unresectable gastric cancer. The pathological diagnosis was tub2 and human epidermal growth factor receptor 2(HER2)positive(3+IHC method). We started chemotherapy(S-1+CDDP+trastuzumab). After 2 courses of S-1+CDDP, the findings of upper gastrointestinal endoscopy and CT were much improved to PR. But after 6 courses of S-1+CDDP, they worsened to PD. The regimen of chemotherapy was changed to weekly paclitaxel. The other patient, a 68-year-old woman, was diagnosed as far advanced gastric cancer. The pathological diagnosis was tub2=por2 and HER2 positive(3+IHC method). We started chemotherapy(S- 1+CDDP+trastuzumab). After 3 courses of S-1+CDDP, the tumor reduced significantly to PR. We continued this regimen. From the result of the ToGA trial, addition of trastuzumab to chemotherapy(capecitabine+CDDP or fluorouracil+CDDP) has been recommended as a new standard first-line regimen for HER2-positive advanced gastric cancer. But there is no evidence that trastuzumab added to the other regimen improved survival in patients with advanced gastric cancer. It is necessary to conduct a clinical trial to evaluate the treatment effect of this chemotherapy.

Large-scale investigation into dumping syndrome after gastrectomy for gastric cancer.

BACKGROUND: The aim of this study was to investigate early and late dumping syndromes in a large number of patients after gastrectomy for gastric cancer. STUDY DESIGN: Responses to questions on a visual analogue scale survey completed by 1,153 gastrectomy patients were analyzed for associations between clinical factors and occurrence of dumping syndrome. Types of gastrectomy included distal gastrectomy with Billroth I or with Roux-Y reconstruction, pylorus preserving gastrectomy, proximal gastrectomy, and total gastrectomy. RESULTS: Based on the visual analogue scale rating of symptomatic discomfort, patients were categorized into 1 of 2 groups: symptom-free or symptomatic. Incidences of early or late dumping syndrome in all patients were 67.6% and 38.4%, respectively. Patients in whom early dumping syndrome developed were significantly more likely to experience late dumping syndrome than those in whom it did not develop (p < 0.001). According to multivariate analyses, factors that decreased the risk for developing early dumping syndrome were reduced weight loss (p < 0.01), old age (p < 0.01), pylorus preserving gastrectomy (p < 0.01), distal gastrectomy with Roux-Y reconstruction (p < 0.01), and distal gastrectomy with Billroth I (p = 0.019). In addition, factors that decreased the risk of developing late dumping syndrome were reduced weight loss (p = 0.03), being male (p < 0.01), pylorus preserving gastrectomy (p < 0.01), and distal gastrectomy with Roux-Y reconstruction (p < 0.01). No other clinical factors (lymph node dissection, vagal nerve preservation, and postoperative period) showed a substantial association with the occurrence of dumping syndrome in multivariate analyses. CONCLUSIONS: Substantially more patients suffered from early dumping syndrome than late dumping syndrome after gastrectomy. Two clinical factors, surgical procedures and amount of body weight loss, associated significantly with the occurrence of both early and late dumping syndrome.

Colon interposition after esophagectomy with extended lymphadenectomy for esophageal cancer.

BACKGROUND: The purpose of this retrospective study was to investigate the feasibility of colon interposition procedures after esophagectomy with extended lymphadenectomy. METHODS: Between 1990 and 2008, 95 consecutive patients underwent colon interposition after esophagectomy with extended lymphadenectomy for esophageal cancer in our Institution. We reviewed clinical data and long-term survival, and also investigated the association between anastomotic leakage and clinicopathologic findings. RESULTS: We applied three-field lymphadenectomy to 71 patients and two-field to 24 patients, by a right thoracotomy. Ninety-two patients underwent reconstruction by a retrosternal route, and a posterior mediastinal route was applied to only three patients. We performed hand-sewn anastomosis in the neck in all cases. Three patients required microvascular surgery. Sixty-one patients (64%) experienced postoperative morbidity, most commonly pulmonary complications. Anastomotic leakage occurred in 12 patients (13%). No colon conduit necrosis was detected. Overall mortality, including hospital mortality, was 5.3%. Dysphagia (39%) and diarrhea (38%) were common and stricture was low (6%) after discharge. The overall 5-year survival rate was 43%. During the latter period (1998 to 2008), when ileocolon grafts evolved as the primary choice for interposition, the rate of leakage decreased from 17% (1990 to 1997) to 5.4%. No mortality was recorded during the latter period. CONCLUSIONS: Results from this study demonstrate that colon interposition after esophagectomy with extended lymphadenectomy is feasible and can have a favorable outcome.

[A case of advanced esophageal cancer with liver metastases: efficacy of combination therapy of docetaxel/cisplatin/5-FU].

The combination chemotherapy with docetaxel/CDDP/5-FU(DCF)for head and neck squamous carcinoma(SCC) has been widely accepted. It seems quite natural that DCF therapy is expected to be equally effective against esophageal SCC because of their histological similarity. In this report, we present a case of unresectable advanced esophageal SCC with multiple liver metastases which showed remarkable regression by DCF therapy, with relatively slight adverse effects. The patient was a 46-year-old female, who underwent upper gastrointestinal fiber-optic endoscopy for dysphasia and was diagnosed to have upper middle thoracic esophageal SCC. Abdominal CT scan showed multiple liver metastases with para-aortic lymph node involvement. The clinical stage diagnosis was T3N4M1, Stage IVB, obviously non-resectable far-advanced esophageal SCC. Systemic chemotherapy with DCF was started as the initial treatment. The chemotherapy regimen was as follows. 5-FU 500 mg/m(2) was administered as continuous intravenous infusion through day 1 to 5, while docetaxl 60 mg/m(2) and cisplatin 50 mg/m(2) were given intravenously on day 2. Each course was followed by a 23-day drug-free period, and the entire course was repeated every 28 days. Ten cycles of this DCF chemotherapy were carried out. After 4 cycles, primary lesion was judged as complete response(CR)by endoscopy. After 8 cycles, the liver metastases were judged as CR and para-aortic lymph nodes showed a partial response(PR)by CT scan. After 10 cycles, all we could detect was a small local recurrence of the primary tumor, which was then treated with chemoradiotherapy at the outpatient clinic. Until this writing, we added 2 more cycles of DCF therapy for the recurrent para-aortic and inguinal lymph node metastasis. Three years have passed from her first visit, and the patient is still in a stable disease state. The adverse effects were grade 3 at most in both hematological and non-hematological toxicity. We conclude that DCF therapy is potentially very effective for advanced esophageal SCC.

[Modified FOLFOX6 in a patient on hemodialysis with metastatic colorectal cancer].

Since pharmacokinetics in patients undergoing hemodialysis differs from that in patients with normal renal function, chemotherapy for a hemodialysis patient should be considered with due care. We administered chemotherapy of modified FOLFOX6 to a patient on hemodialysis with inoperable metastatic colorectal cancer, and measured his plasma concentration of total platinum and non-protein-bound platinum. Since there is no reported case of oxaliplatin use in patients on hemodialysis so far, we evaluated whether it could be safely used for such patients. We made a dose escalation study with 40, 50, 60, 70 and 85 mg of oxaliplatin, and evaluated the pharmacokinetics at each dose. AUC was 5.67-10.21 mg/L x h. The dialysis removal rate was 84.0%. Although this patient could accept it relatively safely without any severe side effect, the optimal dosage and the timing of hemodialysis for inoperable metastatic colorectal cancer patients should be determined by a further study using more cases.

[Value of postoperative surveillance of tumor recurrence after curative esophageactomy].

A study of 256 patients whose dates and patterns of first mode of recurrence after curative esophagectomy from 1984 to 2004 revealed the recent improvement in survival after the detection of tumor recurrence. This tendency was evident in lymphatic recurrence, particularly in the cervical area. Lung metastasis was another mode of recurrence that has shown recent improvement. In this series, 20 patients with lymph node metastases underwent reoperation for local or regional tumor control. The addition of systemic chemotherapy or chemoradiotherapy was our general rule. The 5-year survival rate after the detection of tumor recurrence in these 20 patients was 47.4%. Six with lung metastases in the group of patients whose esophagectomies were performed in the last 7 years underwent video-assisted pulmonary tumor resection. Five patients in this group are alive without signs of further recurrence for 92 to 1,437 days. The early detection of recurrent tumor, vigorous attempts to achieve locoregional control, and the addition of systemic chemotherapy are all important in achieving better results. We routinely perform conventional cervical and abdominal ultrasonography and computed tomography every 6 months until 6 years after surgery is performed.

[Operative technique aiming at en bloc dissection in esophageal surgery].

The lymph node metastases of esophageal cancer occur over a wide area. It is essential for radical surgery of such metastases to aim at en bloc dissection. Otherwise, it can easily become a combination of blunt esophagectomy and lymph node sampling through a right thoracotomy. In the intrathoracic procedure, all the nodes to be dissected can be harvested while attached to the esophagus together with the surrounding connective tissue, except for the pretracheal nodes in front of the cardiac branches of the right vagus nerve and the subaortic arch nodes. It is important to dissect the left paratracheal nodes en bloc, preserving the left recurrent laryngeal nerve. In the abdomen, nodes around the celiac axis and nodes on the common hepatic artery and proximal part of the splenic artery are all removed en bloc with the perigastric nodes in the left gastric arterial basin. The cervical paratracheal and paraesophageal nodes are removed separately from the resected esophagus, but the continuity of dissection can be ensured when the dissection from the neck meets the empty space made by the dissection along the bilateral recurrent laryngeal nerves through the thoracotomy. We believe that such en bloc dissection is the key to improving the long-term results of esophageal cancer surgery.

[Spontaneous epidural hematoma in a patient undergoing hemodialysis: a case report].

A 54-year-old male with chronic renal failure due to diabetic nephropathy suffered dysphagia and left facial spasm without head trauma during a hemodialysis session. CT scan revealed a right acute epidural hematoma. MRI and cerebral angiography did not reveal any abnormalities in the intracranial vasculature. The occurrence of intracranial spontaneous epidural hematoma in a haemodialysis patient has not been reported. During hemodialysis, the intracranial pressure transiently increases and rapidly recovers. It is assumed that the decreasing intracranial pressure caused epidural hematoma.

[A case of cervical pyogenic spondylitis difficult to differentiate from metastatic spinal tumor].

A 52-year-old man with medical complications of diabetic mellitus and alcoholic liver dysfunction, presented with weakness in the bilateral lower extremities. Cervical magnetic resonance images disclosed the lesion extended from retropharyngeal space and multiple vertebral bodies to epidural space of the spinal canal, which was enhanced by gadolinium. Not only fever elevation during clinical course but also inflammatory reaction on selologic examination were not identified, so we initially thought the lesion metastatic spinal tumor. In researching original foci, his clinical condition worsened with gate disturbance and urinary incontinence. Eleven days later after admission, laminectomy from C-5 to Th-1 and open biopsy of the lesion was performed. The vertebral bodies exposed via the right frontal approach were covered by thick whitish membrane. Small mount of pus emerged after incision of the membrane, so we diagnosed the lesion pyogenic spondylitis. After the operation, high dose antibiotic therapy for 6 weeks was performed. Follow-up cervical MR imaging 4 months after the operation found that the volume of the lesion and compression of the spinal cord were reduced. The gate disturbance and urinary incontinence gradually improved, he was able to walk with a cane 6 months later.