Effective dissection for rectal cancer with lateral lymph node metastasis based on prognostic factors and recurrence type.

PURPOSE: There are no reports showing the significance and effective range of dissection for patients with lateral lymph node metastasis (LLNM). This study aimed to investigate the indications for lateral lymph node dissection (LLND) in patients with LLNM based on prognostic factors and recurrence types. METHODS: We reviewed 379 patients with advanced rectal cancer who were treated with total mesorectal excision plus LLND. We analyzed background factors and survival times of patients who had LLNM to determine prognostic factors and recurrence types. RESULTS: Pathological LLNM occurred in 44 (11.6%). Among patients with LLNM, the predictors of poor prognoses, according to univariate analysis, were > 3 node metastases, the presence of node metastasis on both sides, and spreading beyond the internal iliac lymph nodes. Moreover, LLNM beyond the internal iliac region was found to be an independent prognostic risk factor. Twenty-eight of the 44 patients with lateral lymph node metastasis (64%) relapsed, 22 of whom had distant metastases and 11 of whom experienced local recurrences. Among the latter group, nine (20%) and two (5%) had recurrences in the central and lateral pelvis, respectively. CONCLUSION: The therapeutic benefit of resection was high, especially in patients with ≤ 3 positive lateral lymph nodes, one-sided bilateral lymph node areas, and positive nodes localized near the internal iliac artery.

[Significance of Neoadjuvant Chemotherapy before Colorectomy and Hepatectomy].

BACKGROUND: We discuss the significance of neoadjuvant chemotherapy for resectable simultaneous liver metastases in our department. SUBJECT: We examined 73 cases of resectable simultaneous colorectal liver metastases surgeries occurred in our department from 2000 to 2019. RESULTS: There were 13 patients in the chemotherapy before colorectomy group(before colorectomy group), 24 patients in the chemotherapy before hepatectomy group(before hepatectomy group), and 36 patients in the no chemotherapy group(no chemo group). Five-year overall survival in Grade A/B was 77.8%/100% in the before colorectomy group, 50.0%/42.4% in the before hepatectomy group and 45.6%/66.2% in the no chemo group. Three-year progression-free survival in Grade A/B was 51.9%/50.0% in the before colorectomy group, 16.7%/40.4% in the before hepatectomy group and 46.5%/55.6% in the no chemo group. Six patients in the before colorectomy group had no local recurrence, lymph node recurrence, or peritoneal dissemination. CONCLUSION: Patients in the before colorectomy group were expected to have prolonged survival. There was no local recurrence, lymph node recurrence, or peritoneal dissemination in the before colorectomy group, suggesting the possibility of controlling them.

[The Validity of a Stent-Independent Strategy for Left-Sided Stenotic Colon Cancer].

In recent years, stenting and stoma creation as a bridge to surgery for obstructive left-sided colon cancer have been attracting attention. Our team has a stent-independent strategy and performs primary resection after stoma construction and preoperative chemotherapy with cT4 patients. In this study, we investigated both its validity and issues. Sixty-five cases of scope-impassable left-sided colon cancer surgeries from November 2015 to September 2020 were included. The short- and long-term results were examined in Stage Ⅱ-Ⅲ and Ⅳ. The median time from admission to surgery was 6 days and 8 days, respectively; postoperative morbidity was 9.5% and 17.4%, respectively; anastomotic leakage was 4.8% and 17.4%, respectively; permanent stoma was 26.2% and 21.7%, respectively; and postoperative death was zero in both groups. In group Ⅱ-Ⅲ, the 3-year overall survival rate was 77.0%, 3-year disease-free survival rate was 72.7%, and in group Ⅳ, the 3-year overall survival rate was 36.0%. Local recurrence was observed in 2(16.7%)of 12 patients with cT3-4N+ rectosigmoid cancer who did not receive neoadjuvant chemotherapy. The stent-independent strategy was safe with low morbidity, and the permanent stoma rate was reasonable.

[Treatment for Laterally Invasive Rectal Cancer with Robot-Assisted Surgery after Preoperative Treatment].

The patient is a 40-year-old male. He was referred to our department because, after a thorough examination, he was diagnosed with rectal cancer. Preoperative imaging showed a tumor in the rectum at the level of the seminal vesicles, and left lateral invasion was suspected. In addition, lymph node metastases in the left lateral area were suspected. We performed a robot-assisted low anterior resection plus bilateral lateral dissection plus covering ileostomy for this patient after neoadjuvant chemotherapy. The operation time was 495 minutes, and the blood loss was 50 g. The histopathological diagnosis was pT3, N3(#263), M0, pStage Ⅲc, PM0, DM0, RM0, R0, Cur A. In Japan, robotic-assisted surgery for rectal cancer has been covered by insurance since April 2018, and in our department, robotic surgery is the first option for any stage or type of surgery for rectal cancer. We believe that the greatest advantages of robotic surgery for rectal cancer are in lateral dissection, ie, the better understanding of how blood vessels and nerves travel around the internal iliac vessels and the associated anatomy of pelvic organs that comes from reliable lateral dissection. We have experienced a case of safe robotic-assisted radical resection of laterally invasive rectal cancer, which is considered to be relatively difficult, and we hereby report the usefulness of the robotic-assisted modality.

[A Case of Two Stage taTME for Perforated Rectal Cancer during Chemotherapy].

The patient was a 57-year-old male. He was diagnosed with locally advanced rectal cancer infiltrating the left levator ani muscle. Chemotherapy(S-1 plus L-OHP plus bevacizumab regimen)was started for the purpose of obtaining a negative circumferential radial margin. After the second course, he presented with perforation of the sigmoid colon for which an emergency operation was performed. The perforation was located 5 centimeters above the tumor in the sigmoid colon. We performed partial resection of the sigmoid colon to repair the perforation and create a sigmoid colostomy. CT, after the initial S-1 plus L-OHP plus bevacizumab chemotherapy regimen, revealed tumor shrinkage. Following 2 more courses of chemotherapy( S-1 plus L-OHP regimen), we performed transanal total mesenteric excision(taTME)as curative surgery. R0 resection was achieved. The combined transanal and laparoscopic approach was highly effective for a patient with pan-peritonitis.

[Improvement of QOL by Surgery in Two Patients for Brain Metastasis from Esophageal Carcinoma with Paralysis-A Report of Two Cases].

Brain metastasis from esophageal cancer is rare. Symptoms such as paralysis caused a decline in quality of life(QOL)and activity of daily life(ADL)and required emergency treatment. We report 2 cases in which QOL was improved by emergency resection for brain metastasis from esophageal carcinoma with paralysis. Case 1: A 50's male was diagnosed esophageal carcinoma and underwent esophagectomy(pT3N2M0, Stage Ⅲ). Brain metastasis was detected owing to development of left hemiparesis. Craniotomy and tumorectomy were performed, left hemiparesis was improved. He died 10 months after diagnosis of brain metastasis due to progression of other metastatic lesions. Case 2: A 61-year-old female was diagnosed esophageal carcinoma and underwent esophagectomy(pT3N1M0, Stage Ⅲ). She developed right hemiparesis 5 months after esophagectomy, admitted to our hospital. Brain and lung metastases were detected, craniotomy and tumorectomy and were performed, right hemiparesis was improved. Although systemic chemotherapy was administered, she died 10 months after diagnosis of brain metastasis due to progression of lung metastasis. Conclusion: Aggressive surgical treatments for brain metastasis were one good treatment option to maintain QOL and ADL.

[Evaluation of the Therapeutic Effect of Using Dual-Energy CT for Rectal Cancer after Neoadjuvant Chemotherapy].

It is difficult to know the effects of preoperative treatment on advanced rectal cancer even if using a variety of diagnostic imaging modalities. We report the efficacy of evaluating the therapeutic effect of using dual-energy CT(DECT)against rectal cancer after neoadjuvant chemotherapy(NAC). The subject sample consisted of1 1 patients who underwent rectal cancer surgery after NAC from September 2015 to January 2016. The pathological effective grade was higher if the after/before ratio ofcontrast enhancement on DECT was small(Grade 1a: 1.4, Grade 1b: 0.8, Grade 2: 0.4, Grade 3: 0.3). Therefore, a successful response rate occurred if blood flow was reduced after NAC. In this study, it was possible to predict the pathological response grade for rectal cancer via contrast enhancement using DECT.

[Laparoscopic Lateral Lymph Node Dissection for Rectal Cancer with Lateral Lymph Node Metastasis - A Case Report].

BACKGROUND: Lateral lymph node dissection(LLND)for locally advanced lower rectal cancer is the standard treatment procedure in Japan. We performed LLND with an extraperitoneal approach. Recently, we introduced laparoscopic surgery for locally advanced rectal cancer and laparoscopic LLND. We performed laparoscopic LLND in a patient havinglower rectal cancer with lateral lymph node metastasis that was detected via preoperative imaging. CASE PRESENTATION: The patient was a woman in her 50s who experienced melena and visited a physician. Colonoscopy revealed a tumor in the lower rectum and computed tomography showed lateral lymph node swelling and liver metastasis. The patient was referred to our institution and she was diagnosed with lower rectal cancer having lateral lymph node and synchronous liver metastases. We performed laparoscopic abdominoperineal resection and laparoscopic LLND. The operatingtime was 260 min, and the blood loss was 60g. CONCLUSION: The magnification of laparoscopy enables precision in the surgical operation of the narrow pelvis during lymph node dissection, allowingautonomic nerve preservation. Therefore, laparoscopic LLND is a helpful procedure in the treatment of locally advanced rectal cancer with a lateral lymph node metastasis.

[A Case of Laparoscopic Surgery for Rectal Cancer with Synchronous Lung Metastases after Chemotherapy].

A woman in her 70's presented with the predominant complaint of bloody stools. She was diagnosed with rectal cancer, and bilateral lymph node and pulmonary metastases were detected on computed tomography(CT). The patient was diagnosed with cT3N3M1a, cStage IV disease. After undergoing a colostomy, the patient was treated with S-1 plus oxaliplatin (SOX), and bevacizumab(Bev). A second CT scan obtained after completion of 7 courses of chemotherapy revealed that the lung metastases had significantly reduced or disappeared. Approximately 7 months after initial treatment, the patient underwent a laparoscopic Hartmann procedure to remove the tumor. The patient is currently under observation while being administered postoperative adjuvant chemotherapy as an outpatient in our department. There is currently no evidence of the safety of laparoscopic-assisted rectal cancer surgery for first-time Stage IV cases. However, when tumor regression has been achieved with chemotherapy, it may be an effective option.

[A Case of Pathological Complete Response after Neoadjuvant Chemotherapy(S-1 plus Oxaliplatin)and Laparoscopic Low Anterior Resection for Rectal Cancer].

We report a case of pathological complete response after neoadjuvant chemotherapy(NAC)(S-1 plus oxaliplatin)for rectal cancer. The patient was a 50-year-old man who had type 3 circumferential rectal cancer. An abdominal CT scan revealed locally advanced rectal cancer(cT3N2H0P0M0, cStage III b)with severe stenosis and oral-side intestinal dilatation. The patient was treated with NAC after loop-ileostomy. After 3 courses of chemotherapy, a CT scan revealed significant tumor reduction. Laparoscopic low anterior resection and bilateral lymph node dissection were performed 5 weeks after the last course of chemotherapy. The pathological diagnosis was a pathological complete response(no residual cancer cells). This case suggests that laparoscopic low anterior resection after NAC with S-1 plus oxaliplatin for locally advanced rectal cancer is a potentially effective procedure.

[A Case of Strangulation Ileus with Hemorrhagic Shock Caused by an Internal Hernia of the Small Intestine].

PATIENT: An 81-year-old man. Past medical history: distal gastrectomy and Roux-en-Y reconstruction. CHIEF COMPLAINT: epigastric pain, nausea, and hematemesis. History of present illness: the man developed epigastric pain, nausea, and hematemesis the day before visiting our hospital. Upper gastrointestinal endoscopy revealed that the small intestinal mucosa was extensively congested, and a clinical condition due to the previous gastric surgery was suspected. Therefore, the man was admitted to our department. The patient was diagnosed with strangulation ileus by contrast-enhanced abdominal CT, and was referred for emergency surgery. At the time of entering the operating room 3 hours later, his abdomen was remarkably swollen. After anesthesia induction, his blood pressure dropped to 40-49 mmHg, and he was in a state of shock. Strangulation ileus was caused by an internal hernia of the small intestine through the gap between the mesenteric sutures of the Roux-en-Y reconstruction. The small intestinal wall was significantly discolored and remarkably expanded due to bleeding into the small intestine. We determined that mass resection of the small intestine posed high risk, and performed only reduction of the small intestinal hernia. Since strangulated ileus causing hemorrhagic shock is rare, we describe the case and review the literature on the topic.

[A Case of Solitary Brain Metastasis from Stage 0 Esophageal Carcinoma after Neoadjuvant Chemotherapy Followed by Surgery].

Esophageal carcinoma rarely metastasizes to the brain. We experienced a case of solitary brain metastasis from Stage 0 esophageal carcinoma after surgery. A 54-year-old man was diagnosed with esophageal carcinoma (clinical T3N2M0, cStage Ⅲ). He received neoadjuvant chemotherapy consisting of 5-fluorouracil plus cisplatin followed by subtotal esophagectomy with dissection of 3 regional lymph nodes. The pathological diagnosis was poorly differentiated squamous cell carcinoma, CTpT1a- EP (T2), pN0, sM0, fStage 0. The pathological response of neoadjuvant chemotherapy was Grade 2. Eight months after surgery, abnormality of the right frontal lobe was identified with positron emission tomography(PET). Brain magnetic resonance imaging (MRI) uncovered a solitary 25 mm lobular tumor at the right frontal lobe, although no evidence of local recurrence or other metastatic sites was found. Gamma knife therapy was performed for the brain metastasis.He has survived for 35 months after esophagectomy without other metastases.

[A case of pneumatosis cystoides intestinalis after neoadjuvant chemotherapy for esophageal cancer].

A man in his 60s was diagnosed with esophageal cancer (T3, N0, StageII) and treated with 5-fluorouracil and cisplatin as neoadjuvant chemotherapy (NAC). On day 18 of the second NAC course, the patient developed febrile neutropenia, and a computed tomography (CT) scan showed pneumatosis cystoides intestinalis (PCI) of the ascending and transverse colon, free air around the ascending colon, thickening of the gallbladder wall, pleural effusion, and ascites. Because there were no signs of peritoneal irritation and intestinal perforation was ruled out, conservative treatment was selected. Seven days after PCI was diagnosed, CT showed improvement in PCI and the free air had disappeared, and 26 days after the diagnosis, a subtotal esophagectomy was performed. Observation of the abdomen did not show a thickened wall or stenosis of the ascending or transverse colon. PCI could be treated conservatively, even with free air in the abdominal cavity, by comprehensively assessing not only the imaging but also the physical findings. We were able to perform radical resection of the esophageal cancer without excessive treatment for PCI.

[A case of malignant peritoneal mesothelioma without deletion of p16].

The patient was a man in his 60s with a history of 2 operations for the treatment of malignant neurogenic tumors. Partial resection of the stomach and liver was performed in December 2006, followed by chemotherapy with adriamycin and interferon; resection of a recurrent tumor in the left subphrenic space was performed in December 2007. In June 2011, recurrent tumors were detected in the lesser curvature of the stomach body and left inferior quadrant of the abdomen (12 mm [SUVmax 7.9] and 23 mm [SUVmax 10.5], respectively)by using 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET). The tumors resected in August 2011 were diagnosed as malignant peritoneal mesothelioma on immunohistochemical analysis. In February 2013, FDG-PETrevealed a 20-mm tumor of in the mesentery with a SUVmax of 7.6, and the tumor was resected. This secondary tumor had the same features of the previously resected malignant mesothelioma. Fluorescence in situ hybridization revealed no deletion of the p16 gene, and the patient had had no other recurrence during follow-up. Malignant peritoneal mesothelioma is a rare disease, accounting for 10% of all malignant mesothelioma cases, with low rates of p16 gene deletion compared with malignant pleural mesothelioma. Previous studies have reported that the lack of p16 deletion is associated with better prognosis in malignant pleural mesothelioma. Herein, we report of a patient diagnosed with malignant peritoneal mesothelioma, without deletion of the p16 gene, who survived for over 2 years and 10 months after initial diagnosis of malignant mesothelioma.

Skeletal muscle mass and quality before preoperative chemotherapy influence postoperative long-term outcomes in esophageal squamous cell carcinoma patients.

BACKGROUND: Previous reports have focused on muscle mass as a prognostic factor in esophageal cancer. AIM: To investigate how preoperative body type influences the prognosis of patients with esophageal squamous cell carcinoma who underwent neoadjuvant chemotherapy (NAC) and surgery. METHODS: The subjects were 131 patients with clinical stage II/III esophageal squamous cell carcinoma who underwent subtotal esophagectomy after NAC. Skeletal muscle mass and quality were calculated based on computed tomography images prior to NAC, and their statistical association with long-term outcomes was examined retrospectively in this case-control study. RESULTS: The disease-free survival rates in the low psoas muscle mass index (PMI) group vs the high PMI group were 41.3% vs 58.8% (P = 0.036), respectively. In the high intramuscular adipose tissue content (IMAC) group vs the low IMAC group, the disease-free survival rates were 28.5% vs 57.6% (P = 0.021), respectively. The overall survival (OS) rates for the low PMI group vs the high PMI group were 41.3% vs 64.5% (P = 0.008), respectively, and for the high IMAC group vs the low IMAC group, they were 29.9% vs 61.9% (P = 0.024), respectively. Analysis of the OS rate revealed significant differences in patients aged 60 years or older (P = 0.018), those with pT3 or above disease (P = 0.021), or those with lymph node metastasis (P = 0.006), aside from PMI and IMAC. Multivariate analysis demonstrated that pT3 or above [hazard ratio (HR): 1.966, 95% confidence interval (CI): 1.089-3.550, P = 0.025), lymph node metastasis (HR: 2.154, 95%CI: 1.118-4.148, P = 0.022), low PMI (HR: 2.266, 95%CI: 1.282-4.006, P = 0.005), and high IMAC (HR: 2.089, 95%CI: 1.036-4.214, P = 0.022) were significant prognostic factors for esophageal squamous cell carcinoma. CONCLUSION: Skeletal muscle mass and quality before NAC in patients with esophageal squamous cell carcinoma are significant prognostic factors for postoperative OS.

A case of serous cystic neoplasm with tumor growth acceleration leading to extrapancreatic invasion.

Serous cystic neoplasm (SCN) is a potentially malignant and invasive disease. However, there are no established guidelines regarding the surgical management of SCN. Here, we report a case of SCN with jejunal invasion that ultimately required a distal pancreatectomy with partial resection of the jejunum. The patient was a 65-year-old female who was referred to our department after a diagnosis of SCN in the pancreatic tail. CT and MRI showed a 75-mm multifocal cystic mass with calcifications; the splenic vein and left adrenal vein were entrapped within the tumor. Furthermore, the tumor was in contact with the beginning of the jejunum. Finally, she underwent a posterior radical antegrade modular pancreatosplenectomy with a partial wedge-shaped resection of the jejunum. Histological findings indicated serous cystadenoma. In addition, the tumor cells were found to have infiltrated the jejunal muscularis propria in some areas, suggesting that the tumor had malignant potential. Currently, 14 months have passed since surgery and there is no evidence of metastasis or recurrence. Surveillance and the decision to perform surgical resection should be made based on tumor size and growth rate to avoid malignant transformation as well as to provide SCN patients with organ-sparing, less invasive surgery.

Short-term outcomes of robotic-assisted surgery following neoadjuvant chemotherapy for lower rectal cancer.

INTRODUCTION: There have been reports about robotic surgery for rectal cancer with chemoradiotherapy (CRT), but only a few studies have compared the use of robotic surgery with and without neoadjuvant chemotherapy (NAC). The aim of our study was to compare the perioperative outcomes of robotic surgery with and without NAC for lower rectal cancer and to examine the effects of NAC on robotic surgery. METHODS: From January 2016 to July 2021, we compared the short-term outcomes of 45 patients who did not undergo NAC and 55 patients who underwent NAC. RESULTS: The rate of sphincter-preserving surgeries was higher in the NAC group than in the non-NAC group (P = .024). The total operative time was significantly longer in the NAC group than in the non-NAC group (P < .001). The rate of lateral lymph node dissection was significantly higher in the NAC group than in the non-NAC group (P < .001). No significant differences were identified in the rate of incisional surgical site infections (SSI), organ/space SSI postoperative bleeding, small bowel obstruction, anastomotic leakage, urinary dysfunction, or urinary infections between the groups. There were eight incidences of lateral lymph node metastasis (15%) and two cases with positive resection margins (4.0%) in the NAC group. CONCLUSIONS: Robotic surgery after NAC has few complications and a higher sphincter-preserving rate that without NAC.

Necrotizing pancreatitis complicated by retroperitoneal emphysema: two case reports.

BACKGROUND: Emphysematous pancreatitis is acute pancreatitis associated with emphysema based on imaging studies and has been considered a subtype of necrotizing pancreatitis. Although some recent studies have reported the successful use of conservative treatment, it is still considered a serious condition. Computed tomography (CT) scan is useful in identifying emphysema associated with acute pancreatitis; however, whether the presence of emphysema correlates with the severity of pancreatitis remains controversial. In this study, we managed two cases of severe acute pancreatitis complicated with retroperitoneal emphysema successfully by treatment with lavage and drainage. CASE PRESENTATION: Case 1: A 76-year-old man was referred to our hospital after being diagnosed with acute pancreatitis. At post-admission, his abdominal symptoms worsened, and a repeat CT scan revealed increased retroperitoneal gas. Due to the high risk for gastrointestinal tract perforation, emergent laparotomy was performed. Fat necrosis was observed on the anterior surface of the pancreas, and a diagnosis of acute necrotizing pancreatitis with retroperitoneal emphysema was made. Thus, retroperitoneal drainage was performed. Case 2: A 50-year-old woman developed anaphylactic shock during the induction of general anesthesia for lumbar spine surgery, and peritoneal irritation symptoms and hypotension occurred on the same day. Contrast-enhanced CT scan showed necrotic changes in the pancreatic body and emphysema surrounding the pancreas. Therefore, she was diagnosed with acute necrotizing pancreatitis with retroperitoneal emphysema, and retroperitoneal cavity lavage and drainage were performed. In the second case, the intraperitoneal abscess occurred postoperatively, requiring time for drainage treatment. Both patients showed no significant postoperative course problems and were discharged on postoperative days 18 and 108, respectively. CONCLUSION: Acute pancreatitis with emphysema from the acute phase highly indicates severe necrotizing pancreatitis. Surgical drainage should be chosen without hesitation in necrotizing pancreatitis with emphysema from early onset.