Risk factors of recurrence in TNM stage I colorectal cancer.

Purpose: TNM stage I colorectal cancer (CRC) can recur, although the recurrence rate is low. Few studies have evaluated the risk factors for TNM stage I CRC recurrence. This study aimed to evaluate the TNM stage I CRC recurrence rate, as well as risk factors for recurrence. Methods: In this retrospective study, we reviewed the database of patients who had undergone surgery for TNM stage I CRC between November 2008 and December 2014 without receiving neoadjuvant therapy or transanal excision for rectal cancer. Our analysis included 173 patients. Primary lesions were found in the colon of 133 patients and in the rectum of 40 patients. Results: The CRC recurrence rate was 2.9% (5 out of 173 patients). For colon cancer patients, tumor size was not associated with higher recurrence risk (P = 0.098). However, for rectal cancer patients, both tumor size (≥3 cm) and T stage were associated with higher recurrence risk (P = 0.046 and P = 0.046, respectively). Of the 5 recurrent cases, 1 patient exhibited disease progression despite treatment, 1 patient maintained stable disease status after recurrence treatment, and 3 patients had no evidence of a tumor after recurrence treatment. Conclusion: Our findings suggest that tumor size and T stage are predictors of stage I rectal cancer recurrence, and careful monitoring and follow-up of patients with larger tumors may be warranted.

Expression Profiles of Immune Cells after Propofol or Sevoflurane Anesthesia for Colorectal Cancer Surgery: A Prospective Double-blind Randomized Trial.

BACKGROUND: The antitumor effects of natural killer cells, helper T cells, and cytotoxic T cells after cancer surgery were reported previously. This study hypothesized that propofol-based anesthesia would have fewer harmful effects on immune cells than volatile anesthetics-based anesthesia during colorectal cancer surgery. METHODS: In total, 153 patients undergoing colorectal cancer surgery were randomized and included in the analysis. The primary outcome was the fraction of circulating natural killer cells over time in the propofol and sevoflurane groups. The fractions of circulating natural killer, type 1, type 17 helper T cells, and cytotoxic T cells were investigated. The fractions of CD39 and CD73 expressions on circulating regulatory T cells were investigated, along with the proportions of circulating neutrophils, lymphocytes, and monocytes. RESULTS: The fraction of circulating natural killer cells was not significantly different between the propofol and sevoflurane groups until 24 h postoperatively (20.4 ± 13.4% vs. 20.8 ± 11.3%, 17.9 ± 12.7% vs. 20.7 ± 11.9%, and 18.6 ± 11.6% vs. 21.3 ± 10.8% before anesthesia and after 1 and 24 h after anesthesia, respectively; difference [95% CI], -0.3 [-4.3 to 3.6], -2.8 [-6.8 to 1.1], and -2.6 [-6.2 to 1.0]; P = 0.863, P = 0.136, and P = 0.151 before anesthesia and after 1 and 24 h, respectively). The fractions of circulating type 1 and type 17 helper T cells, cytotoxic T cells, and CD39+ and CD73+ circulating regulatory T cells were not significantly different between the two groups. The neutrophil to lymphocyte ratio in both groups remained within the normal range and was not different between the groups. CONCLUSIONS: Propofol-based anesthesia was not superior to sevoflurane-based anesthesia in terms of alleviating suppression of immune cells including natural killer cells and T lymphocytes during colorectal cancer surgery.

Adjuvant oxaliplatin-based chemotherapy effect after treatment of colorectal hepatic metastasis.

PURPOSE: We aimed to investigate whether adjuvant oxaliplatin-based chemotherapy after treatment for hepatic metastasis affects recurrence or survival and to determine the risk factors for recurrence or survival. METHODS: Forty-six patients who underwent curative treatment for hepatic metastasis from colorectal cancer between July 2009 and December 2017 were included from a retrospectively collected patient database. Curative resection included hepatic resection, radiofrequency ablation (RFA), or a combination of both, followed by adjuvant chemotherapy with oxaliplatin-based chemotherapy. RESULTS: Thirty-seven patients (80.4%) had colon cancer and 9 (19.6%) had rectal cancer. Twenty-six patients (56.5%) underwent hepatic resection, 7 (15.2%) RFA, and 13 (28.3%) hepatic resection and RFA. Thirty-two patients (69.6%) underwent chemotherapy after hepatic treatment. The recurrence incidence was 50% in the non-chemotherapy group and 46.9% in the chemotherapy group (P > 0.999). The incidence of death was 7.1% in the non-chemotherapy group and 18.8% in the chemotherapy group (P = 0.657). The recurrence risk factors were N stage (N0 vs. N2; P = 0.013, P = 0.005) and bilobed hepatic metastasis (P = 0.027, P = 0.009) in the univariate and multivariate analyses, respectively. However, chemotherapy after hepatic treatment was not a risk factor for disease-free survival (DFS) or overall survival (OS) in the univariate and multivariate analyses (P = 0.656 and P = 0.414, respectively; P = 0.510 and P = 0.459, respectively). CONCLUSION: Oxaliplatin-based adjuvant chemotherapy after colorectal hepatic metastasis treatment did not affect the DFS or OS. The N stage of the primary tumor and bilobed hepatic metastasis are risk factors for recurrence and death.

High Concordance of Genomic Profiles between Primary and Metastatic Colorectal Cancer.

The comparison of the genetic profiles between primary and metastatic colorectal cancer (CRC) is needed to enable the discovery of useful therapeutic targets against metastatic CRCs. We performed the targeted next generation sequencing assay of 170 cancer-associated genes for 142 metastatic CRCs, including 95 pairs of primary and metastatic CRCs, to reveal their genomic characteristics and to assess the genetic heterogeneity. The most frequently mutated gene in primary and metastatic CRCs was APC (71% vs. 65%), TP53 (54% vs. 57%), KRAS (45% vs. 44%), PIK3CA (16% vs. 19%), SMAD4 (15% vs. 14%) and FBXW7 (11% vs. 11%). The concordance in the top six frequently mutated genes was 85%, on average. The overall mutation frequencies were consistent with two sets of public data (TCGA and MSKCC). To the author's knowledge, this is the first study to compare the genetic profiles of our cohort with that of the metastatic CRCs from MSKCC. Comparative sequencing analysis between primary and metastatic CRCs revealed a high degree of genetic concordance in the current clinically actionable genes. Therefore, the genetic investigation of archived primary tumor samples with the challenges of obtaining an adequate sample from metastatic sites appears to be sufficient for the application of cancer precision medicine in the metastatic setting.

Histology and its prognostic effect on KRAS-mutated colorectal carcinomas in Korea.

KRAS mutation is frequently identified in advanced colorectal carcinoma (CRC); however, its prognostic significance and the associated histological features have remained to be clarified. In the present study, the precise histological results and prognostic value of KRAS-mutated CRCs were investigated in patients from South Korea. A retrospective review of the results from KRAS mutation testing, as well as evaluation of the histology of 310 cases of CRC at various stages, were performed. Cross-tabulation and survival analysis were performed according to the KRAS status. Patients with KRAS mutation more frequently exhibited serrated and papillary architectures (P=0.009 and P=0.014, respectively). KRAS mutation was an independent unfavorable prognostic factor for overall survival (OS) according to multivariate analysis (P=0.001), whereas no association was observed with disease-free survival (DFS) (P=0.611). Of note, in the subgroup of KRAS-mutated carcinomas, the presence of a solid component on histology was associated with less favorable OS (P=0.032). Furthermore, among the wild type cases, patients with a micropapillary component had a worse OS than those who did not (P=0.018). However, no subgroup or specific histological features were associated with DFS. In summary, KRAS-mutated CRCs had a moderate association with particular histological features, and according to the KRAS mutational status, there was a certain degree of association between histology and prognosis.

Folate, alcohol, ADH1B and ALDH2 and colorectal cancer risk.

OBJECTIVE: There is limited evidence on the interaction by alcohol dehydrogenase 2 (ADH1B) (rs1229984) and aldehyde dehydrogenase 2 (ALDH2) (rs671) regarding the associations of alcohol and a methyl diet (low folate and high alcohol intake) with cancer risk, partly because of rare polymorphisms in Western populations. DESIGN: In a case-control study, we estimated the ORs and 95 % CIs to evaluate the associations of ADH1B and ALDH2 genotypes with colorectal cancer (CRC) and the joint association between methyl diets and ADH1B and ALDH2 polymorphisms with CRC risk using logistic regression models. SETTING: A hospital-based case-control study. PARTICIPANTS: In total, 1001 CRC cases and 899 cancer-free controls admitted to two university hospitals. RESULTS: We found that alcohol intake increased the risk of CRC; OR (95 % CI) was 2·02 (1·41, 2·87) for ≥60 g/d drinkers compared with non-drinkers (Ptrend < 0·001). The associations for two polymorphisms with CRC were not statistically significant. However, we found a potential interaction of ALDH2 with methyl diets and CRC. We observed a 9·08-fold (95 % CI 1·93, 42·60) higher risk of CRC for low-methyl diets compared with high-methyl diets among individuals with an A allele of ALDH2, but the association was not apparent among those with ALDH2 GG (Pinteraction = 0·02). CONCLUSIONS: Our data support the evidence that gene-methyl diet interactions may be involved in CRC risk in East Asian populations, showing that a low-methyl diet increased the risk of CRC among individuals with an A allele of ALDH2.

Tannic Acid Promotes TRAIL-Induced Extrinsic Apoptosis by Regulating Mitochondrial ROS in Human Embryonic Carcinoma Cells.

: Human embryonic carcinoma (EC; NCCIT) cells have self-renewal ability and pluripotency. Cancer stem cell markers are highly expressed in NCCIT cells, imparting them with the pluripotent nature to differentiate into other cancer types, including breast cancer. As one of the main cancer stem cell pathways, Wnt/ß-catenin is also overexpressed in NCCIT cells. Thus, inhibition of these pathways defines the ability of a drug to target cancer stem cells. Tannic acid (TA) is a natural polyphenol present in foods, fruits, and vegetables that has anti-cancer activity. Through Western blotting and PCR, we demonstrate that TA inhibits cancer stem cell markers and the Wnt/ß-catenin signaling pathway in NCCIT cells and through a fluorescence-activated cell sorting analysis we demonstrated that TA induces sub-G1 cell cycle arrest and apoptosis. The mechanism underlying this is the induction of mitochondrial reactive oxygen species (ROS) (mROS), which then induce the tumor necrosis factor-related apoptosis-inducing ligand (TRAIL)-mediated extrinsic apoptosis pathway instead of intrinsic mitochondrial apoptosis pathway. Moreover, ribonucleic acid sequencing data with TA in NCCIT cells show an elevation in TRAIL-induced extrinsic apoptosis, which we confirm by Western blotting and real-time PCR. The induction of human TRAIL also proves that TA can induce extrinsic apoptosis in NCCIT cells by regulating mROS.

Case report of periorbital metastasis from rectal cancer.

INTRODUCTION: Periorbital metastasis of colorectal cancer is rare. Therefore, herein, we report a patient with rectal cancer who presented with periorbital metastasis without any systemic metastasis. PATIENT CONCERNS: The patient was a 57-year-old man who had a painless nodule on his left eyelid. DIAGNOSIS: The patient presented with loose and frequent stools and was diagnosed with rectal adenocarcinoma via colonoscopic biopsy at the local clinic. Curative resection (low anterior resection with temporary ileostomy formation) was performed 4 weeks after completing chemoradiotherapy. The final TNM stage was yp stage T2N0M0. Eight months after the diagnosis of rectal cancer, a protruding lesion was noticed on the patient's left eyelid. Histologic evaluation of the nodule revealed metastatic adenocarcinoma of rectal cancer. INTERVENTIONS: The patient received neoadjuvant chemoradiotherapy and curative resection for rectal cancer. After excision of the periorbital nodule, he received 5 cycles of chemotherapy. OUTCOMES: The patient underwent regular follow-up because he was not able to endure chemotherapy; no recurrence has been observed 21 months after the diagnosis of rectal cancer. Histologic examination revealed metastatic adenocarcinoma of rectal cancer on the patient's left eyelid. However, consecutive imaging studies revealed no other metastatic lesions. Finally, the patient was diagnosed with a solitary periorbital metastasis of rectal cancer. CONCLUSION: This case report helps in understanding the course of progression from rectal cancer to periorbital metastasis.

Red meat intake, CYP2E1 and PPARγ polymorphisms, and colorectal cancer risk.

The association between red meat intake and colorectal cancer (CRC) may be modulated by genetic polymorphisms of cytochrome P450 2E1 (CYP2E1), a key enzyme in the metabolism of nitrosamines, and peroxisome proliferator-activated receptor gamma (PPARγ), a transcription factor involved in adipogenesis and lipid and glucose metabolism. We conducted a case-control study of 971 patients with CRC and 658 controls who were admitted to two university hospitals between 1995 and 2004 in Seoul, Korea. Participants were asked about red meat intake by using a validated food frequency questionnaire. Polymorphisms of CYP2E1 (rs3813867) and PPARγ (rs1801282 or rs3856806) were identified using the TaqMan assay. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) using multivariable logistic regression models. We found that the association between red meat and CRC varied by CYP2E1 polymorphisms; ORs (95% CIs) for at least five or more vs. less than one time/week of red meat intake were 2.77 (1.23-6.25) among individuals with C alleles of CYP2E1 and 0.89 (0.51-1.54) among individuals with the GG allele (Pinteraction=0.05). Compared with those individuals with the CC allele, increasing risk of CRC with increasing red meat intake was more pronounced among individuals with T alleles of PPARγC161T (rs3856806), but the association was not significant. Our data provide evidence that East Asians with the variant type of CYP2E1 may have high susceptibility to development of CRC risk.

Brain metastasis from colorectal cancer: a single center experience.

PURPOSE: The detection rate of brain metastasis (BM) from colorectal cancer (CRC) is increasing. This study was designed to analyze the clinical features of BM and prognosis according to the therapeutic modalities. METHODS: A total of 19 cases were collected in this study between November 2008 and December 2015. We reviewed the patients' demographic data and the clinical features of BM retrospectively and investigated their prognostic significance. RESULTS: Nineteen patients included 8 male and 11 female patients. The median age at diagnosis of BM was 62.4 years (range, 32-83 years). The median interval between diagnosis of CRC and BM was 39 months (range, 0-98 months). Eighteen patients (94.7%) had extracranial metastasis at the diagnosis of BM. Lung was the most common site of extracranial metastasis in 14 patients (73.7%). Synchronous BMs were found at the diagnosis of primary CRC in 2 patients (10.5%). The location of primary CRC was the colon in 6 patients (31.6%) and the rectum in 13 patients (68.4%). At the diagnosis of BM, 10 patients (52.6%) had a solitary BM. The common neurologic symptoms were headache in 8 cases (42.1%) and ataxia in 6 cases (31.6%). The median survival after the diagnosis of BM was 3 months (range, 1-10 months). The patients who underwent surgery plus stereotactic radiosurgery (SRS) had an improved survival (range, 3-10 months) than the other patients (range, 1-6 months) (P = 0.016). CONCLUSION: In patients with BM from CRC, surgical resection plus SRS might improve survival.

Clinical Significance of Preoperative Virtual Colonoscopy for Evaluation of the Proximal Colon in Patient With Obstructive Colorectal Cancer.

PURPOSE: Virtual colonoscopy is the most recently developed tool for detecting colorectal cancers and polyps, but its effectiveness is limited. In our study, we compared the result of preoperative virtual colonoscopy to result of preoperative and postoperative colonoscopy. We evaluated also the accuracy of preoperative virtual colonoscopy in patients who had obstructive colorectal cancer that did not allow passage of a colonoscope. METHODS: A total of 164 patients who had undergone preoperative virtual colonoscopy and curative surgery after the diagnosis of a colorectal adenocarcinoma between November 2008 and August 2013 were pooled. We compared the result of conventional colonoscopy with that of virtual colonoscopy in the nonobstructive group and the results of preoperative virtual colonoscopy with that of postoperative colonoscopy performed at 6 months after surgery in the obstructive group. RESULTS: Of the 164 patients, 108 were male and 56 were female patients. The mean age was 62.7 years. The average sensitivity, specificity, and accuracy of virtual colonoscopy for all patients were 31.0%, 67.2%, and 43.8%, respectively. In the nonobstructive group, the average sensitivity, specificity, and accuracy were 36.6%, 66.2%, and 48.0%, respectively, whereas in the obstructive group, they were 2%, 72.4%, and 25.4%. Synchronous cancer was detected via virtual colonoscopy in 4 of the 164 patients. CONCLUSION: Virtual colonoscopy may not be an effective method for the detection of proximal colon polyps, but it can be helpful in determining the therapeutic plan when its results are correlated with the results of other studies.

Impact Of Circulating T Helper 1 And 17 Cells in the Blood on Regional Lymph Node Invasion in Colorectal Cancer.

We hypothesised that the blood levels of immune cells would be related to the progression of colorectal cancer and regional lymph node metastasis. We investigated the association between the blood levels of immune cells and regional lymph node metastasis in colorectal cancer patients. Patients with American Joint Committee on Cancer (AJCC) stages 1 and 2 colorectal cancer were assigned to Early stage group and those with AJCC stages 3 and 4 were assigned to Late stage group. Blood levels of circulating immune cells, such as cluster of differentiation (CD)4+ including T helper 1 (Th1) and 17 (Th17) cells, regulatory T (Treg) cells, CD8+ T cells, and natural killer (NK) cells were assessed using fluorescence-activated cell sorting (FACS). The blood levels of CD4+ T, Treg, CD8+ T, and NK cells did not significantly differ between the two groups. However, the blood levels of Th1 and Th17 cells did significantly differ between the groups. Specifically, Late stage group had higher levels of Th1 and Th17 cells than Early stage group (Th1, 11.14±1.22% vs. 16.25±1.57%, p = 0.015; Th17, 3.32±0.05% vs. 1.11±0.15%, p < 0.01). In conclusion, the blood levels of Th1 and Th17 cells significantly increased as the N stage increased. The blood levels of Th1 and Th17 cells might be useful as predictive markers of lymph node invasion in colorectal cancer.

BRAF-Mutated Colorectal Cancer Exhibits Distinct Clinicopathological Features from Wild-Type BRAF-Expressing Cancer Independent of the Microsatellite Instability Status.

In patients with colorectal cancer (CRC), the BRAF V600E mutation has been reported to be associated with several clinicopathological features and poor survival. However, the prognostic implications of BRAF V600E mutation and the associated clinicopathological characteristics in CRCs remain controversial. Therefore, we reviewed various clinicopathological features, including BRAF status, in 349 primary CRCs and analyzed the relationship between BRAF status and various clinicopathological factors, including overall survival. Similar to previous studies conducted in Eastern countries, the incidence of the BRAF V600E mutation in the current study was relatively low (5.7%). BRAF-mutated CRC exhibits distinct clinicopathological features from wild-type BRAF-expressing cancer independent of the microsatellite instability (MSI) status. This mutation was significantly associated with a proximal tumor location (P = 0.002); mucinous, signet ring cell, and serrated tumor components (P < 0.001, P = 0.003, and P = 0.008, respectively); lymphovascular invasion (P = 0.004); a peritumoral lymphoid reaction (P = 0.009); tumor budding (P = 0.046); and peritoneal seeding (P = 0.012). In conclusion, the incidence of the BRAF V600E mutation was relatively low in this study. BRAF-mutated CRCs exhibited some clinicopathological features which were also frequently observed in MSI-H CRCs, such as a proximal location; mucinous, signet ring cell, and serrated components; and marked peritumoral lymphoid reactions.

Inverse Correlation between Cancer Size and Abdominal Obesity in Colorectal Cancer Cases.

BACKGROUND: Correlation between colorectal cancer (CRC) and abdominal obesity has been established, but there is a paucity of data on non-obese CRC patients. The aim of this study was to establish the characteristics of CRCs that occur in such patients. MATERIALS AND METHODS: Consecutive CRC patients without cachexia were included. Unintended body weight loss, T4- or M1-staged CRCs, extensive lymph node involvement, or synchronous malignancy were classified as cachectic conditions. Abdominal fat volumes were measured using a multidetector CT unit with software (Rapidia, INFINITT, Seoul, Korea). RESULTS: Of the newly-diagnosed CRC patients, 258 non-cachectic and 88 cachectic patients were analyzed. The cancer size (p<0.001) and T stage (p<0.001) were inversely correlated with body mass index (BMI), visceral fat and subcutaneous fat volumes. Cancer size was the only independent factor related to BMI (p=0.016), visceral fat volume (p=0.002), and subcutaneous fat volume (p=0.027). In non-cachectic patients, a significant inverse correlation was found only between the cancer size and visceral fat volume (p=0.017). CONCLUSIONS: Non-obese CRC patients tend to have larger CRC lesions than their obese counterparts even under non-cachectic conditions. Such an inverse correlation between cancer size and visceral fat volume suggests that considerable CRCs are not correlated with abdominal obesity.

Undetermined Margins After Colonoscopic Polypectomy for Malignant Polyps: The Need for Radical Resection.

AIM: The aim of the present study was to analyze the clinicopathological features of patients with colorectal cancer (CRC) who underwent radical operation after malignant polyp removal by colonoscopic procedure. PATIENTS AND METHODS: Between 2009 and 2013, radical colorectal resection was performed in 50 patients with CRC after colonoscopic polypectomy. RESULTS: Nine cases (18%) had residual cancer. Lymph node (LN) metastasis was found in three cases (6.0%) and tumor deposit without LN metastasis (N1c) was found in two cases (4.0%). The indications for radical operation were an undetermined resection margin (23 cases), positive lateral margin (15 cases). Out of the nine cases with residual cancer, five cases had LN metastasis or tumor deposit without residual tumor in the main lesion. One-fourth of cases with an undetermined margin had residual cancer (six out of 23 cases), three of whom had stage III disease. CONCLUSION: Undetermined margins may be considered as an indication for additional radical operation.

Detection of Polyps After Resection of Colorectal Cancer.

PURPOSE: Because colonoscopy after colorectal cancer surgery is important for detecting synchronous or metachronous colorectal neoplasms, we designed this study to investigate, by using postoperative colonoscopy, the miss rate for and the location of polyps remaining after colorectal cancer surgery. METHODS: In a prospectively-collected patient database, 264 patients were shown to have undergone a colorectal cancer resection between May 2012 and June 2013. Of these, 116 who had received a complete colonoscopy preoperatively and postoperatively were included in this study. RESULTS: Of these 116 patients, 68 were males and 48 were females; their mean age was 63 years. The mean time after surgery at which postoperative colonoscopy was performed was 7.1 months (range, 3-15 months). On postoperative colonoscopy, a total of 125 polyps were detected. Of these, there were no cancerous lesions; 46 (36.8%) were neoplastic polyps, and 79 (63.2%) were nonneoplastic polyps. Fifty-nine polyps (47.2%) and 15 polyps (12%) were located in the proximal and the distal parts of the anastomosis, respectively. The miss rates for the total numbers of polyps and of neoplastic polyps remaining after surgery were 37.4% and 24.2%, respectively. The incidence of neoplastic polyps increased during postoperative colonoscopy as it had during preoperative colonoscopy (r = 0.164, P = 0.048). CONCLUSION: Colonoscopic surveillance after colorectal cancer resection results in the detection of pathologic polyps in one-fourth of the cases. During postoperative colonoscopy, careful examination of the proximal colon is necessary. Patients in whom multiple neoplastic polyps had been detected during preoperative colonoscopy require careful and thorough follow-up.

Intraductal papillary mucinous neoplasm of the ileal heterotopic pancreas in a patient with hereditary non-polyposis colorectal cancer: A case report.

We report a case of intraductal papillary mucinous neoplasm (IPMN) originating from the ileal heterotopic pancreas in a patient with hereditary non-polyposis colorectal cancer (HNPCC). A 49-year-old woman had a past history of total colectomy and total hysterectomy with bilateral salpingo-oophorectomy due to colonic adenocarcinoma and endometrial adenocarcinoma 11 years ago. Her parents died from colonic adenocarcinoma and her sister died from colonic adenocarcinoma and endometrial adenocarcinoma. The clinician found an ileal mass with necrotic change and the mass increased in size from 1.7 cm to 2.2 cm during the past 2 years on computed tomography. It was surgically resected. Microscopically, the ileal mass showed heterotopic pancreas with IPMN high grade dysplasia. Immunohistochemical staining revealed positive reactivity for MLH1/PMS2 and negative reactivity for MSH2/MSH6. This is the first report of IPMN originating from the ileal heterotopic pancreas in a patient with HNPCC in the English literature.

Insertion of totally implantable central venous access devices by surgeons.

PURPOSE: The aim of this study is to evaluate the results for the insertion of totally implantable central venous access devices (TICVADs) by surgeons. METHODS: Total 397 patients, in whom TICVADs had been inserted for intravenous chemotherapy between September 2008 and June 2014, were pooled. This procedure was performed under local anesthesia in an operation room. The insertion site for the TICVAD was mainly in the right-side subclavian vein. In the case of breast cancer patients, the subclavian vein opposite the surgical site was used for insertion. RESULTS: The 397 patients included 73 males and 324 females. Primary malignant tumors were mainly colorectal and breast cancer. The mean operation time was 54 minutes (18-276 minutes). Operation-related complications occurred in 33 cases (8.3%). Early complications developed in 15 cases with catheter malposition and puncture failure. Late complications, which developed after 24 hours, included inflammation in 6 cases, skin necrosis in 6 cases, hematoma in 3 cases, port malfunction in 1 case, port migration in 1 case, and intractable pain at the port site in 1 case. CONCLUSION: Insertion of a TICVAD under local anesthesia by a surgeon is a relatively safe procedure. Meticulous undermining of the skin and carefully managing the TICVAD could minimize complications.

Indeterminate pulmonary nodules in colorectal cancer.

AIM: To investigate the clinicopathologic parameters of pulmonary metastasis in colorectal cancer (CRC) patients after lung operation of indeterminate pulmonary nodules (IPNs). METHODS: From a prospective database of CRC patients, 40 cases that underwent lung operation between November 2008 and December 2012 for suspicious metastatic pulmonary nodules on chest computed tomography (CT) were enrolled. The decision to perform a lung operation was made if the patient met the following criteria: (1) completely resected or resectable primary CRC; (2) completely resectable IPNs; (3) controlled or controllable extrapulmonary metastasis; and (4) adequate general condition and pulmonary function to tolerate pulmonary operation. Lung operation was performed by a thoracic surgeon without CT-guided biopsy for pathologic confirmation. RESULTS: A total of 40 cases of lung resection was performed in 29 patients. Five patients underwent repeated lung resection. The final pathology result showed metastasis from the CRC in 30 cases (75%) and benign pathology in 10 cases (25%). The primary tumor site was the rectum in 26/30 (86.6%) cases with pulmonary metastasis, but only 3/10 (30%) cases in the benign group had a primary rectal cancer (P = 0.001). Positron emission tomography (PET)-CT was performed for 22/30 (73.4%) patients in the lung metastasis group and for 6/10 (60.0%) patients in the benign group. PET-CT revealed hot uptake of (18)fluorine 2-fluoro-2-deoxy-D-glucose with all IPNs in both groups. The group with pulmonary metastasis had a higher incidence of primary rectal cancer (P = 0.001), a more advanced tumor stage (P = 0.011), and more frequent lymphatic invasion of tumor cells (P = 0.005). Six cases with previous liver metastasectomy were present in the lung metastasis group. Serum carcinoembryonic antigen levels before lung operation were not elevated in any of the patients. CONCLUSION: The stage and location of the primary tumor and tumor cell infiltration of lymphatics provide useful indicators for deciding on lung resection of IPNs in CRC.