Prognoses and treatment strategies for synchronous peritoneal dissemination of colorectal carcinoma.

PURPOSE: We devised a simple dichotomous classification system and showed sufficient reproducibility to indicate treatment strategies for peritoneal metastasis of colorectal cancer. METHODS: We included 67 patients with peritoneal metastasis of colorectal cancer and classified them according to the largest lesion size, number of lesions and number of regional peritoneal metastases. The oncological data were recorded and compared. RESULTS: According to the univariate analyses, the prognoses were significantly better in patients with ≤3 disseminated lesions than in those with ≥4, and in patients with disseminated lesions in only one region than in those with ≥2 lesions. A multivariate analysis showed that primary tumor resection and the presence of peritoneal metastases in only one region were favorable factors for the patient survival. Patients with disseminated lesions in only one region (localized group) and those with nonlocalized lesions had three-year survival rates of 45.6 and 12.2 %, respectively. Finally, primary tumor resection improved the prognoses in both the localized and nonlocalized groups. CONCLUSIONS: Colorectal cancer patients were categorized into localized and nonlocalized groups according to the number of regions with peritoneal metastasis, and significant prognostic associations were demonstrated. Subsequent analyses of the oncological data suggested that primary tumor resection contributes to an improved prognosis in all patients with synchronous peritoneal metastases.

[Clinical Significance of Lateral Lymph Node Dissection for Stage â £ Low Rectal Cancer].

We reviewed the clinical records of 81 patients with stage Ⅳ low rectal carcinoma (LRC) (25 Cur B surgeries and 56 Cur C surgeries) to evaluate the effectiveness of lateral lymph node dissection (LLND) by comparing the treatment outcomes with those of patients with stage Ⅲ LRC. Mesenteric lymph node metastasis was a risk factor for local recurrence in a multivariate analysis. There were no significant differences in the frequency of lateral node metastasis, local recurrence rate, or prognosis between Cur B and stage Ⅲ LRC patients. We suggest that LLND effectively improves prognosis as well as local control in Cur B patients. In Cur C patients, prognosis was poor regardless of lateral node metastasis. However, in patients with lateral node metastasis, there were no significant differences in between the Cur C (25.0%), Cur B, and stage Ⅲ groups, suggesting that LLND improves local control in Cur C patients with lateral node metastasis. Although the local recurrence rate was high (71.4%) in Cur C patients without lateral node metastasis, fewer lateral lymph nodes were harvested in these patients than in those with lateral node metastasis. Our results indicate that further examination of the local control effects of LLND in Cur C patients is necessary.

Endoscopic mucosal resection of a rectal malakoplakia in a healthy adult.

Malakoplakia in the gastrointestinal tract is rare in healthy young people without underlying disease. Sufficient tissue is required for accurate diagnosis. We describe a malakoplakia that developed in a healthy young woman and was treated by endoscopic mucosal resection (EMR). A 40-year-old woman with a history of taking oral contraceptives until one year earlier was referred to our hospital with anal bleeding and constipation. A colonoscopy carried out at our another hospital 18 months earlier disclosed no abnormal findings. Colonoscopy at presentation revealed a yellowish-white tumor, 5 mm in diameter, in the rectum. The lesion was slightly protruded and had a smooth flat surface, without erosion or ulceration. EMR was carried out for a definitive diagnosis. Histopathological examination showed that the tumor contained granular histiocytes, positive for CD68 and negative forcytokeratin (AE1/AE3). Several histiocytes contained intracytoplasmic round bodies (Michaelis-Gutmann bodies), which reacted positively with periodic acid-Schiff and calcium (Von Kossa) stains. Intracytoplasmic Escherichia coli (von Hansemann bodies) were identified by Giemsa staining. Based on these results, the tumor in the rectum was diagnosed as a malakoplakia. Following EMR, the patient did not receive further treatment for malakoplakia because she had no symptoms associated with malakoplakia. She has been well for more than 9 months, with no symptoms of disease. Awareness of colorectal malakoplakia is important in patients taking steroids, including oral contraceptives.

[Treatment outcome in nine cases of anal squamous cell carcinoma].

We reviewed the clinical records of 9 patients with anal squamous cell carcinoma (SCC) chiefly to evaluate the effectiveness of chemoradiotherapy (CRT). Surgery was performed in 1 patient; radiotherapy (RT), in 2; and CRT, in 6. RT consisted of 40 Gy delivered to the pelvic and bilateral inguinal lesions, and a perianal booster dose of 20 Gy in fractions of 2.0 Gy/day, 5 days a week. 5-fluorouraci (l 750 mg/m², administered through a 24-h continuous infusion for 5 days) and mitomycin C (10 mg/m², administered as a single bolus infusion)were administered 3 times every 4 weeks as standard chemotherapy. One patient with a T3 tumor received oral TS-1 during RT because of advanced age. In the CRT group, 1 patient had a T1 tumor, another had a T3 tumor, and the others had a T2 tumor. Grade 2 adverse effects occurred in 3 patients, and grade 3 adverse effects occurred in 1 patient. Nevertheless, CRT was completed in all of the 6 patients. All the patients had complete response after CRT for the anal lesion. Two patients, one of whom had a T3 tumor treated with oral S-1, had recurrence of the anal lesion. The 2 patients (T2 and T3) who underwent RT and needed surgery because of residual tumor died of recurrent disease. The patient with a T4 tumor who underwent abdominoperineal resection also died of recurrent disease. CRT is considered a safe and effective treatment option to improve prognosis in anal SCC.

[Outcomes of preoperative chemoradiotherapy for rectal cancer with invasion to the adjacent organs].

We reviewed the clinical records of 13 patients who received preoperative chemoradiotherapy(CRT)to evaluate the clinical effectiveness of CRT for T4b rectal cancer. Preoperative radiotherapy consisted of 40-50 Gy delivered in fractions of 1.8-2.0 Gy per day, 5 days per week. Treatment with intravenous 5-fluorouracil, oral tegafur-uracil(UFT-E)with l-leucovorin, oral S-1, or intravenous irinotecan(CPT-11)with oral S-1 was administered during radiotherapy. At 63 days after CRT, 1 patient died because of pelvic abscess. Complete response(CR)or partial response(PR)was observed in 7 patients, 1 month after CRT. Curative surgery was performed in 9 patients. Among 10 patients who underwent surgery 70 days after CRT, 5 who showed PR 1 month after CRT underwent curative surgery; both urinary and anal function were preserved in 4 of these patients. Histological invasion to the adjacent organs was not observed in 6 patients, and 1 patient achieved histological CR. Of the 9 patients who underwent curative surgery, recurrence was observed in 2; however, the other patients survived without recurrence. Preoperative CRT was considered to be effective in improving the resection rate and prognosis in patients with T4b rectal cancer. However, careful attention should be paid to the severe toxicities associated with CRT, such as pelvic abscess.

[HAI chemotherapy for liver metastases of colorectal cancer].

We evaluated the effect of hepatic arterial infusion(HAI)chemotherapy for liver metastases from colorectal cancer. A total of 65 patients received HAI chemotherapy. The chemotherapy regimen consisted of weekly 5-FU (1, 500 mg/body) or 5-FU (400 mg/mm2) and l-LV (200mg/mm2). The survival and response rates were assessed according to RECIST. Median survival time with HAI chemotherapy was 13. 5 months, 5-year survival rate 8% and response rates 55%. There was no evidence of myelosuppression, and HAI could be continued for a long time even for poor PS patients. There were no differences in survival time between synchronous, metachronous and postoperative metachronous liver metastases. In the patients who underwent curative hepatectomy after HAI chemotherapy, the 5-year survival rate was 21%, which was better than in patients with HAI chemotherapy alone. HAI chemotherapy could thus be an option for unresectable liver metastases, which could be well tolerated.

[Our experiences of preoperative chemoradiotherapy for rectal cancer with invasion to adjacent organs].

We reviewed clinical records of 10 cases with preoperative chemoradiotherapy to evaluate the clinical effectiveness of the chemoradiotherapy for T4 rectal cancer. The preoperative radiation therapy consisted of 40-50 Gy delivered in fractions of 1.8-2.0 Gy per day for five days per week. A treatment of 5-fluorouracil (500 mg/body) per day intravenously, or oral UFT-E (300 mg/m2) with l-leucovorin (75 mg/body) per day, or oral S-1 (80 mg/m2) per day for five days per week, was given during radiotherapy. Grade 1 or 2 adverse effects occurred in 3 patients during chemoradiotherapy, but a completion of chemoradiotherpy was achieved in all of the 10 patients. Invasive findings to the adjacent organs identified by CT and MRI disappeared in 6 cases with complete or partial response 1 month after chemoradiotherapy. Although the adjacent organs were also removed during surgery in 7 patients, curative surgery was performed in 7 patients. There was no histological invasion to the adjacent organs in 4 patients, and one patient had a histological complete disappearance of tumor. Although complications after surgery were found in all of the patients, they were improved by conservative treatment. Two of 7 patients with curative surgery had recurrence, but the rest of them survived without recurrence. Preoperative chemoradiotherapy was expected to be a safe and effective treatment to improve the resection rate and prognosis for T4 rectal cancer.