Lateral node metastasis in low rectal cancer as a hallmark to predict recurrence patterns.

BACKGROUND: Lateral node metastasis confers a poor prognosis in rectal cancer. Several multidisciplinary treatments have been proposed with favorable outcomes. However, appropriate neoadjuvant/adjuvant treatments or follow-up plans based on information about the probable recurrence site have not been specified. We aimed to clarify the distinctive features of recurrence patterns for lateral node-positive low rectal cancer according to the lateral and mesorectal lymph node status. METHODS: We retrospectively analyzed 508 patients with stage III low rectal cancer who underwent lateral node dissection. We investigated the impact of lateral and mesorectal lymph node status on site-specific recurrence rates and patient survival. RESULTS: Analyses for relapse-free survival revealed the prognostic impact of lateral node positivity in stage III low rectal cancer (p < 0.0001). Lateral node-positive patients exhibited higher risk of overall recurrence, local recurrence, and recurrence in extra-regional nodes than lateral node-negative patients (p < 0.0001, p = 0.001, and p < 0.0001, respectively). However, lateral node positivity was not statistically associated with a hematogenous recurrence rate. In lateral node-positive patients, both tumor-node-metastasis (TNM)-N status and number of lateral nodes involved were revealed as significant prognostic factors (p < 0.0001, both). In addition, the number of lateral nodes involved could be a discriminatory indicator of probabilities of local recurrence and recurrence in extra-regional nodes (p = 0.02, and p < 0.0001, respectively). CONCLUSIONS: Lateral node-positive low rectal cancer exhibits higher local recurrence and extra-regional node recurrence rates that correlate with the number of lateral nodes involved.

The technique for less infectious and earlier healing of stoma closure wound: negative pressure wound therapy with instillation and dwelling followed by primary closure.

BACKGROUND: Temporary stomas have been widely used to avoid the risk of complications such as anastomotic leakage after colorectal resection. Stoma closure is relatively easy; however, postoperative surgical site infection (SSI) may be a problem. Various methods have been used to reduce the incidence of SSI. We aimed to evaluate a new technique for stoma wound closure. METHODS: We enrolled patients who underwent stoma closure at our hospital between September 2019 and May 2020. We selected patients who lived far from our hospital and had difficulty visiting the hospital regularly and who agreed to undergo this surgical technique. We used negative pressure wound therapy with instillation and dwelling (NPWTi-d) and delayed primary closure for these patients. RESULTS: Four patients underwent NPWTi-d and delayed primary closure without the occurrence of SSI. The median postoperative hospital stay was 9 days (range: 7-14 days), and the median number of days to confirmation of epithelialization was 11.5 days (range: 10-16 days). CONCLUSION: The combined use of NPWTi-d and delayed primary closure for the stoma wound was very effective. This method may be a valuable new technique for wound management after stoma closure.

Cytotoxic T lymphocyte response to peptide vaccination predicts survival in stage III colorectal cancer.

We previously reported a phase I clinical trial of a peptide vaccine ring finger protein 43 (RNF43) and 34-kDa translocase of the outer mitochondrial membrane (TOMM34) combined with uracil-tegafur (UFT)/LV for patients with metastatic colorectal cancer (CRC), and demonstrated the safety and immunological responsiveness of this combination therapy. In this study, we evaluated vaccination-induced immune responses to clarify the survival benefit of the combination therapy as adjuvant treatment. We enrolled 44 patients initially in an HLA-masked fashion. After the disclosure of HLA, 28 patients were in the HLA-A*2402-matched and 16 were in the unmatched group. In the HLA-matched group, 14 patients had positive CTL responses specific for the RNF43 and/or TOMM34 peptides after 2 cycles of treatment and 9 had negative responses; in the HLA-unmatched group, 10 CTL responses were positive and 2 negative. In the HLA-matched group, 3-year relapse-free survival (RFS) was significantly better in the positive CTL subgroup than in the negative-response subgroup. Patients with negative vaccination-induced CTL responses showed a significant trend towards shorter RFS than those with positive responses. Moreover, in the HLA-unmatched group, the positive CTL response subgroup showed an equally good 3-year RFS as in the HLA-matched group. In conclusion, vaccination-induced CTL response to peptide vaccination could predict survival in the adjuvant setting for stage III CRC.

A New N Staging System for Colorectal Cancer in the Era of Extended Lymphadenectomy.

BACKGROUND: Complete mesocolic excision is becoming popular in colon cancer surgery in Western countries, and in the tumor-node-metastasis (TNM) classification of rectal cancer, a part of the lateral pelvic lymph nodes is classified as regional. However, the appropriateness of TNM staging according to the assessment of nodal status exclusively by extended lymphadenectomy remains unclear. PATIENTS AND METHODS: Using a nationwide multicenter database in Japan, we retrospectively analyzed 6866 patients with stage III colorectal cancer (CRC) treated with extended (D3) dissection. First, the best cutoff values for the number of metastatic nodes were explored. Second, the utility of the metastatic status of the main lymph nodes (i.e., at the origin of the feeding artery) and the lateral pelvic lymph nodes ("jN3" category in the Japanese staging system) as N staging criteria was evaluated. The modified N staging system that had the best risk stratification power was determined according to the Akaike information criterion (AIC). RESULTS: Excellent performance was noted when the number of metastatic nodes was categorized by cutoff values of "3/4" and "6/7." Categorization of nodal metastasis was proven the most clinically efficacious when classified as modified-N1 (N1 and jN3-negative), modified-N2a (N2a and jN3-negative), and modified-N2b (N2b and/or jN3-positive; AIC, 22,810.8), rather than the classification based on the TNM (AIC, 22,849.2) or Japanese staging system (AIC, 22,811.1). CONCLUSIONS: We structured a modified N staging system according to the number and extent of lymph node metastases. The modified system may be used in stage III cases for precise risk stratification.

Prominent Information of jN3 Positive in Stage III Colorectal Cancer Removed by D3 Dissection: Retrospective Analysis of 6866 Patients From a Multi-institutional Database in Japan.

BACKGROUND: The presence of main or lateral lymph node metastasis in colorectal cancer is classified as jN3 by the Japanese Society for Cancer of the Colon and Rectum. Whether information on jN3 status adds value to the TNM classification remains unclear. OBJECTIVE: We aimed to assess the prognostic relevance of colorectal cancer nodal staging through the Japanese jN3 categorization compared with that through TNM. DESIGN: This was a retrospective study. SETTING: The study used the multi-institutional database of the Japanese Society for Cancer of the Colon and Rectum. PATIENTS: Clinical and pathological data of 6866 patients with histologically proven stage III colorectal cancer who underwent curative surgery (R0) with D3 dissection between 1995 and 2006 were derived from the database. MAIN OUTCOME MEASURES: We investigated the prognostic significance of jN3 status in each TNM N class (N1/N2a/N2b) and stage (IIIA/IIIB/IIIC) based on cancer-specific survival. RESULTS: Comparison of cancer-specific survival rates revealed significant differences between jN3+ and jN3- colorectal cancer patient groups according to the TNM N status (5-year cancer-specific survival; N1, 70.4% (jN3+) vs 85.5% (jN3-), p < 0.001; N2a, 59.2% vs 77.0%, p < 0.001; N2b, 39.2% vs 68.7%, p < 0.001) and the TNM stage (stage IIIA, 72.5% vs 94.9%, p < 0.001; stage IIIB, 67.9% vs 84.0%, p < 0.001; stage IIIC, 42.4% vs 70.6%, p < 0.001). LIMITATIONS: This study was limited by its retrospective nature. CONCLUSIONS: Assessment and inclusion of jN3 status are of clinical importance for patients with stage III colorectal cancer with D3 dissection, because it contributes to improved understanding of recurrence risk and subsequent decision-making for follow-up procedures and adjuvant therapy. See Video Abstract at http://links.lww.com/DCR/A506.

Definitive chemoradiotherapy for anal canal cancer: single-center experience.

BACKGROUND: Chemoradiotherapy (CRT) is a standard treatment for anal canal cancer although many patients with anal canal cancer undergo surgery in Japan. The efficacy of CRT for anal canal cancer was evaluated retrospectively. METHODS: Medical charts of 13 patients with anal canal cancer treated by definitive CRT from October 2004 to May 2016 were reviewed. Twelve patients had squamous cell carcinoma and one had adeno-squamous carcinoma. PET/CT simulation was performed in nine patients. The median total dose was 59.4 Gy (range 57.6-63.4 Gy) with fractions of 1.8-2.0 Gy. Ten patients received chemotherapy with mitomycin C (10 mg/m2) and fluorouracil (5-FU) (800 mg/m2 over 4 days) in weeks 1 and 5, while two patients were treated with cisplatin (40 mg) and 5-FU (750 mg over 5 days) in weeks 1 and 5. One elderly patient received radiotherapy (RT) alone. RESULTS: All 13 patients were alive after a median follow-up period of 102 months (range 16-121 months). Local failure only occurred in the patient with adeno-squamous cell carcinoma, while there was no loco-regional recurrence or distant metastasis in the other 12 patients. The 5-year loco-regional control rate (LRC) and 5-year overall survival rate (OS) were 92% and 100%, respectively. Acute toxicities of ≥ grade 3 were observed in six patients (46%), mainly being dermatitis around the anal verge, and late toxicity of ≥ grade 3 occurred in one patient. CONCLUSION: CRT for squamous cell carcinoma of the anal canal achieved good LRC and OS with acceptable toxicities.

Prediction of lateral pelvic lymph node metastasis from lower rectal cancer using magnetic resonance imaging and risk factors for metastasis: Multicenter study of the Lymph Node Committee of the Japanese Society for Cancer of the Colon and Rectum.

PURPOSE: The goal of the study was to examine prediction of lateral pelvic lymph node (LPLN) metastasis from lower rectal cancer using a logistic model including risk factors for LPLN metastasis and magnetic resonance imaging (MRI) clinical LPLN (cLPLN) status, compared to prediction based on MRI alone. METHODS: The subjects were 272 patients with lower rectal cancer who underwent MRI prior to mesorectal excision combined with LPLN dissection (LPLD) at six institutes. No patients received neoadjuvant therapy. Prediction models for right and left pathological LPLN (pLPLN) metastasis were developed using cLPLN status, histopathological grade, and perirectal lymph node (PRLN) status. For evaluation, data for patients with left LPLD were substituted into the right-side equation and vice versa. RESULTS: Left LPLN metastasis was predicted using the right-side model with accuracy of 86.5%, sensitivity 56.4%, specificity 92.7%, positive predictive value (PPV) 61.1%, and negative predictive value (NPV) 91.2%, while these data using MRI cLPLN status alone were 80.4, 76.9, 81.2, 45.5, and 94.5%, respectively. Similarly, right LPLN metastasis was predicted using the left-side equation with accuracy of 83.8%, sensitivity 57.8%, specificity 90.4%, PPV 60.5%, and NPV 89.4%, and the equivalent data using MRI alone were 78.4, 68.9, 80.8, 47.7, and 91.1%, respectively. The AUCs for the right- and left-side equations were significantly higher than the equivalent AUCs for MRI cLPLN status alone. CONCLUSIONS: A logistic model including risk factors for LPLN metastasis and MRI findings had significantly better performance for prediction of LPLN metastasis compared with a model based on MRI findings alone.

Selection of Lymph Node-Positive Cases Based on Perirectal and Lateral Pelvic Lymph Nodes Using Magnetic Resonance Imaging: Study of the Japanese Society for Cancer of the Colon and Rectum.

PURPOSE: To investigate the optimum cutoff for lymph node size to identify cases positive for perirectal lymph node (PRLN) and lateral lymph node (LPLN) metastasis of lower rectal cancer on magnetic resonance imaging (MRI). METHODS: The subjects were 449 patients who underwent preoperative MRI. Mesorectal excision was performed in all patients (combined with lateral pelvic lymph node [LN] dissection in 324) between 2004 and 2013 at 6 institutes. Cases were classified as cN positive and cN negative on the basis of the short axis of the largest LN being greater than or equal to a cutoff or less than a cutoff, respectively. PRLN and LPLN diagnoses using 5 and 10 mm cutoffs were compared with histologic diagnoses. Of the 449 patients, 55 received preoperative chemoradiotherapy. MRI was only performed after this therapy in all of these patients. RESULTS: For PRLNs, 5 and 10 mm cutoffs gave area under the curve (AUC) values of 0.6364 and 0.5794, respectively. The 5 mm cutoff gave a significantly higher AUC value (P = 0.0152), with an accuracy of 63.7 %, sensitivity of 72.6 %, and specificity of 54.7 %. For right LPLNs, the respective AUC values were 0.7418 and 0.6326 (P = 0.0034), and the variables (5 mm cutoff) were 77.6, 68.6, and 79.7 %. For left LPLNs, AUC values were 0.7593 and 0.6559, respectively (P = 0.0057), and the variables (5 mm cutoff) were 79.3, 70.8, and 81.0 %. CONCLUSIONS: Identification of LN-positive cases on the basis of PRLN and LPLN sizes was superior at a short-axis 5 mm cutoff. Size-based diagnosis of LN metastasis is simple and useful, but further investigation is needed to clarify whether it is superior to diagnosis based on morphology, such as shape, border, and signal intensity.

The important risk factor for lateral pelvic lymph node metastasis of lower rectal cancer is node-positive status on magnetic resonance imaging: study of the Lymph Node Committee of Japanese Society for Cancer of the Colon and Rectum.

PURPOSE: This study seeks to evaluate lateral pelvic lymph node (LPLN) and perirectal lymph node (PRLN) status on magnetic resonance imaging (MRI) as potential risk factors for lymph node metastasis. METHODS: The subjects were 394 patients with lower rectal cancer who underwent MRI prior to mesorectal excision (combined with lateral pelvic lymph node dissection in 272 patients) at 6 institutes. No patients received neoadjuvant therapy. Cases were classified as cN(+) and cN(-) based on the short axis of the largest lymph node ≥5 and <5 mm, respectively. LPLN and PRLN status and other clinicopathologic factors were analyzed by multivariate logistic regression. The importance of identified risk factors for lymph node metastasis was examined using the area under the curve (AUC). RESULTS: Independent risk factors for right LPLN metastasis included histopathological grade (G3 + G4), pPRLN(+), M1, cLPLN(+) [odds ratio (OR) 10.73, 95 % confidence interval (CI) 4.59-27.1], and those for left LPLN metastasis were age (<64), histopathological grade (G3 + G4), pPRLN(+), and cLPLN(+) (OR 24.53, 95 % CI 9.16-77.7). ORs for cLPLN(+) were highest. The AUCs for right and left cLPLN status of 0.7484 (95 % CI 0.6672-0.8153) and 0.7904 (95 % CI 0.7088-0.8538), respectively, were significantly higher than those for other risk factors. In contrast, the ORs for cPRLN(+) and cPRLN status of 2.46 (95 % CI 1.47-4.18) and 0.6396 (95 % CI 0.5917-0.6848) were not much higher than for other factors. CONCLUSIONS: An LPLN-positive status with a short axis ≥5 mm on MRI is an important predictor of LPLN metastasis, but PRLN status is not a strong predictor of PRLN metastasis.

Distal dissection in total mesorectal excision, and preoperative chemoradiotherapy and lateral lymph node dissection for rectal cancer.

The local recurrence rate after total mesorectal excision (TME) appears to be markedly lower than that after conventional operations. We reviewed all relevant articles identified from the MEDLINE databases and clarified the rationale for TME. It is clear that distal intramural spread is rare. Even when present, such spread is not likely to extend beyond 2 cm. Data with attention to mesorectal cancer deposits suggest that mesorectal clearance of at least 4-5 cm distal to the tumor should be sufficient. TME should be performed for most tumors of the mid- and lower rectum. This does not mean that the gut tube needs to be divided at the same level in every case. Dissection of the distal mesorectum off the gut tube can be performed, so the distal line of division of the bowel wall can be made at a minimum of 2 cm below the tumor if such a maneuver would ensure that the sphincters are preserved. In cases with cancer in the upper third of the rectum, the mesorectum and gut tube can safely be divided 5 cm below the tumor without jeopardizing the recurrence rates. Our findings indicate that TME is an essential treatment approach for rectal cancer, and lateral lymph node dissection and preoperative chemoradiotherapy are additional therapies that should be considered for advanced rectal cancer.

Endometrioid adenocarcinoma arising from inguinal endometriosis during follow-up for gastric cancer surgery: a case report and literature review.

Malignant transformation of inguinal endometriosis is rare. A 56-year-old woman underwent surgery for advanced gastric cancer 5 years ago and received postoperative adjuvant chemotherapy. She had no recurrence since then. However, 5 years after surgery, contrast-enhanced computed tomography (CT) showed a mass in the right inguinal region suspected to be a hydrocele of the canal of Nuck, with a blood test showing a slightly elevated CA19-9 level (63.0 U/mL). Six months later, CT showed an enlarged mass in the right inguinal region and inflammation in the surrounding area. In addition, both inguinal lymph nodes and those in the right iliac artery area were enlarged, suggesting the possibility of malignancy. For diagnostic purposes, a right inguinal mass was excised. Histopathological examination revealed that it was endometrioid adenocarcinoma with ectopic endometriois as the origin. The differential diagnoses for inguinal masses in women include an inguinal hernia, hydrocele of the canal of Nuck, ectopic endometriosis, lymphoma, and metastatic malignancy. The presence of a primary malignancy in the inguinal region is sporadic but must be differentiated. This is the first case of malignant transformation of inguinal endometriosis developed during postoperative follow-up of another cancer.

Analysis of the clinical factors associated with anal function after intersphincteric resection for very low rectal cancer.

BACKGROUND: Intersphincteric resection (ISR) has been used to avoid permanent colostomy in very low rectal cancer patients. This study aimed to assess the surgical safety and oncologic and functional outcomes of ISR. METHODS: The records of 30 consecutive very low rectal cancer patients who underwent ISR without neoadjuvant therapy were retrospectively analyzed; survival and locoregional recurrence rates were calculated by the Kaplan-Meier method. Incontinence was assessed by a functionality questionnaire and the Wexner score. RESULTS: The median distance between the distal margin of the dentate line was 10 mm. A total of 12, 4, and 14 patients underwent partial ISR, subtotal ISR, and total ISR, respectively. The mean distal resection margin was negative in all cases, and circumferential resection margin was positive in two cases. Morbidity was 33.3%: anastomotic stricture in seven patients, colonic J-pouch prolapse in two patients, and an anovaginal fistula in one patient. During the median, 56.2-month follow-up period, local, distant, and combined recurrences occurred in four, three, and two patients, respectively. The 5-year overall and disease-free survival rates were 76.5% and 68.4%, respectively. Local recurrence rates were 5.2% for the patients with Tis-T2 tumors as compared with 45.5% for those with T3 tumors (P = 0.008). The mean Wexner scores and stool frequencies, 12 months after stoma closure in 19 patients, were 11.5 and 6.6 per 24 h, respectively. Significant differences were not seen in the Wexner scores between partial ISR and subtotal/total ISR (11.8 ± 2.6 and 9.1 ± 5.6). Stool frequency (P = 0.02), urgency (P = 0.04), and fragmentation (P = 0.015) were worse in patients with anastomotic stricture than in those without; there was no symptom improvement in patients with anastomotic stricture. CONCLUSIONS: The anastomotic strictures in patients undergoing ISR may have negatively affected anal function. For total ISR patients, at least, informed consent stating the possibility of a permanent colostomy is necessary.

High ligation of the inferior mesenteric artery in rectal cancer surgery.

In rectal cancer surgery, it is unclear whether the inferior mesenteric artery (IMA) should be ligated as high as possible, at its origin, or low, below the origin of the left colic artery. We reviewed all relevant articles identified from MEDLINE databases and found that despite a trend of improved survival among patients who underwent high ligation, there is no conclusive evidence to support this. High ligation of the IMA is beneficial in that it allows for en bloc dissection of the node metastases at and around the origin of the IMA, while enabling anastomosis to be performed in the pelvis, without tension, at the time of low anterior resection. High ligation of the IMA does not represent a source of increased anastomotic leak in rectal cancer surgery and postoperative quality of life is improved by preserving the hypogastric nerve without compromising the radicality of the operation. More importantly, high ligation of the IMA improves node harvest, enabling accurate tumor staging. Although the prognosis of patients with node metastases at and around the origin of the IMA is poor, the survival rate of patients with rectal cancer may be improved by performing high ligation of the IMA combined with neoadjuvant and adjuvant therapy.

Spontaneous rupture of an undifferentiated carcinoma with osteoclast-like giant cells of the pancreas presenting as intra-abdominal bleeding: a case report.

BACKGROUND: Undifferentiated carcinoma is a very rare histologic subtype, representing only 0.8% to 5.7% of all pancreatic exocrine neoplasms. Additionally, spontaneous abdominal hemorrhage is a particularly rare, life-threatening cause. CASE PRESENTATION: A 68-year-old man was taken by ambulance to our hospital because of sudden-onset abdominal pain. Contrast-enhanced abdominal computed tomography revealed a huge mass measuring 99 × 70 mm in the pancreatic tail with enhanced rim staining in the peripheral area. Imaging also showed extravasation and fluid collection beside the tumor. Hence, spontaneous rupture of the pancreatic tumor and intra-abdominal bleeding were diagnosed. Emergency laparotomy was performed because of acute abdominal pain with peritoneal signs. With an intraoperative diagnosis of rupture of the pancreatic tumor, distal pancreatectomy was successfully performed. Histologically, hematoxylin and eosin staining showed round to spindle-shaped, highly pleomorphic mononuclear cells and multinucleated giant cells as well as a component of ductal adenocarcinoma. Immunohistochemical staining showed that the tumor cells were negative for AE1/AE3, whereas the non-neoplastic osteoclast-like giant cells were positive for CD68. Taken together, these results led to a diagnosis of undifferentiated carcinoma with osteoclast-like giant cells. The patient's postoperative course was uneventful. CONCLUSION: We experienced an extremely rare case of spontaneous rupture of an undifferentiated carcinoma with osteoclast-like giant cells presenting as intra-abdominal bleeding. Obtaining a correct preoperative diagnosis is quite difficult at the first evaluation. Undifferentiated carcinoma should be considered as a differential diagnosis in the case with spontaneous rupture of a pancreatic tumor.

Effectiveness of negative pressure wound therapy with instillation and dwelling after stoma closure: a retrospective and propensity score matching analysis.

The use of temporary diverting stoma has become more common in low colorectal anastomosis to reduce anastomotic complications. Surgical site infection (SSI) at the stoma closure site has been one of the most frequent postoperative complications. The aim of this study was to compare the short-term outcomes between conventional primary suture closure and negative pressure wound therapy with instillation and dwelling (NPWTi-d) therapy following purse-string suturing, using propensity score matching analysis. We retrospectively evaluated the medical records of 107 patients who underwent stoma closure between January 2016 and October 2020. The primary outcome was the proportion of SSI. The secondary outcome was the day of postoperative length of stay. Propensity score matching with one-to-one match was performed for reducing treatment selection bias. Of a total of 107 patients, 67 patients had been treated with conventional primary closure and 40 with NPWTi-d therapy. The propensity score matching derived 37 pairs. The respective SSI proportions were 0% and 16.2% in the groups with NPWTi-d and primary closure (P = 0.025). The respective median days of postoperative hospital stay were 9.0 and 10.0 in the groups with NPWTi-d and primary closure (P = 0.453). NPWTi-d therapy with purse-string suturing was effective in reducing SSI after stoma closure.

Optimizing nodal and staging classification in low rectal cancers with lateral node metastasis: multicentre retrospective cohort study.

BACKGROUND: Patients with lateral node metastasis in low rectal cancers have a poor prognosis. However, variability in patient survival in terms of lateral metastatic status has not been thoroughly investigated. This study was conducted to assess the prognostic value of lateral node involvement and to review nodal classification. METHODS: Patients with stage III low rectal cancers who underwent lateral node dissection were retrospectively reviewed. Two cohorts were set: the first one (1995-2006) was selected using a Japanese multi-institutional database and was used for development of a new nodal system, and the second (2007-2013) was collected from referral institutions for validation of findings. Variables correlated with poor prognosis were investigated. Next, a modified classification of lateral-positive nodal cancers was created. Finally, this new classification was compared with TNM and Japanese classification-based systems according to the Akaike information criterion (AIC) and concordance index (c-index). RESULTS: Overall, 742 and 508 patients were selected for cohorts 1 and 2, respectively. Based on the analyses on cohort 1, patients with two or more lateral metastatic nodes partially spreading into regions outside of internal iliac area exhibited poor prognosis; accordingly, a modified N classification was created, where TNM-N1 and N2a cancers with this feature were upgraded, respectively, to N2a and N2b. The modified N classification yielded the most favourable indices (AIC = 2661.08; c-index = 0.6477) compared with the TNM (AIC = 2662.36; c-index = 0.6457) and Japanese classification-based systems (AIC = 2684.06; c-index = 0.6302). All findings were confirmed by analysing cohort 2. CONCLUSION: A modified nodal system is proposed to account for the significance of lateral node metastasis.

Lymph node ratio is a powerful prognostic index in patients with stage III distal rectal cancer: a Japanese multicenter study.

PURPOSE: The present study aims to define the prognostic impact of the lymph node ratio (LNR) in patients with stage III distal rectal cancer. METHODS: We analyzed data from 501 patients who underwent curative resection (total mesorectal excision, TME) for stage III distal rectal cancer at 12 institutions between 1991 and 1998. Patients were divided into four groups according to quartiles based on LNR. RESULTS: Among the 501 patients, 381 underwent TME with pelvic sidewall dissection (PSD). The median numbers of lymph nodes retrieved with and without PSD were 45 and 17, respectively (P < 0.0001). Forty-nine patients with lymph node retrieved less than 12 were excluded from further analyses. Among various clinicopathological parameters, univariate analysis identified age (P = 0.0059), histological grade (P < 0.0001), depth of tumor invasion (P = 0.0003), and number of positive nodes (P < 0.0001) and LNR (P < 0.0001) as prognostic factors. The Cox proportional hazards model revealed that age (P = 0.014), histological grade (P < 0.0001), depth of tumor invasion (P = 0.0002), and LNR (group 3, P = 0.0012; group 4, P < 0.0001) were independent prognostic factors. When the American Joint Committee on Cancer (AJCC) seventh staging system was added as a covariate, both AJCC stage (P < 0.0001) and LNR (P < 0.0001) were independent prognostic factors. CONCLUSIONS: Adding the LNR concept to the AJCC cancer staging system will improve accuracy in evaluating the nodal status of distal rectal cancer.

[Preliminary study of Peptide vaccine with UFT/LV as adjuvant setting for stage III colorectal cancer].

cDNA microarray technology has been used to identify HLA-A24-restricted epitope peptides as potential targets for cancer vaccination in metastatic colorectal cancer patients. We conducted a clinical trial of two novel cancer-specific peptides( RNF43, TOMM34) with UFT/LV for the treatment of recurrent colorectal cancer. Among 23 patients, 21 patients had completed the protocol. All patients were well tolerated with no severe toxicities. The median survival time was 24.4 months. Furthermore, we investigated the relationship between CTL response to both antigens and overall survival. The best long-term survival was observed in the group with CTL responses against both antigens, followed by the group showing CTL responses against only RNF43 or TOMM34. The patients with no response had the lowest survival. Based on the results, we started a randomized trial of the current protocol, as adjuvant immunochemotherapy in following curative resection of Stage III colorectal cancer patients.

Laparoscopic repair of diaphragmatic hernia after radiofrequency ablation for hepatocellular carcinoma: Case report.

INTRODUCTION AND IMPORTANCE: We describe the case of a patients with a diaphragmatic hernia associated with radiofrequency ablation for hepatocellular carcinoma who was treated by laparoscopic repair. CASE PRESENTATION: An 82-years-old man with history of HCC with hepatitis C virus-related liver cirrhosis (Child-Pugh B). The patient was treated RFA to HCC for segment 4, 5, 6, 8. After 16 months from latest RFA for segment 8, the patient was admitted to our hospital because of mild dyspnea. Computed tomography revealed a diaphragmatic herniation of bowel loops into the right thoracic cavity. The patients electively underwent laparoscopic repair of the diaphragmatic hernia. The patient was discharged from hospital without any post-operative complications. CLINICAL DISCUSSION: The only treatment to diaphragmatic hernia is surgery, but liver cirrhosis patients limits this possibility. For the surgical treatment of patients with severe cirrhosis, the operation should be carefully assessed. We believe that a laparoscopic approach should be used for repairing diaphragmatic hernia. In the present case, we considered that a laparoscopic approach was safer and more feasible than open laparotomy. CONCLUSION: Diaphragmatic hernia is a rare late-onset complication associated with RFA for HCC. And patients with HCC often have severe liver dysfunction and cirrhosis. A laparoscopic approach is safe and minimally invasive for sever cirrhosis patients.

Successful treatment of intractable chylous ascites after laparoscopic low anterior resection using lymphangiography and embolization with lipiodol: A case report.

INTRODUCTION AND IMPORTANCE: Chylous ascites (CA) is an infrequent, intractable complication that may arise after abdominal surgery. Although various attempts at treatment have been adopted, to date, none of them have been consistently effective. We describe the successful treatment of CA using lymphangiography and embolization with lipiodol. CASE PRESENTATION: A 79-year-old woman underwent laparoscopic surgery for rectum cancer at another hospital. She was discharged on postoperative day (POD) 9; however, she had to be treated and hospitalized for CA three times until POD 76. She visited our hospital to undergo treatment for CA on POD 90 because the previous conservative treatment had not improved her condition. The computed tomography (CT) scans revealed ascites effusion. We performed lymphangiography and embolization with lipiodol two times. Repeated CT on POD 134 showed that the ascites had not increased. CLINICAL DISCUSSION: Lymphangiography and embolization with lipiodol effectively resolved chylous leakage that occurred after abdominal surgery. Additionally, we compare the features of two groups of cases of CA: one group in which patients were treated by lymphatic intervention and the second in which patients were treated through surgical procedures. CONCLUSION: We were thus able to demonstrate the clinical effectiveness of lipiodol lymphangiography in treating CA.