Prognostic factors of patients with left-sided obstructive colorectal cancer: post hoc analysis of a retrospective multicenter study by the Japan Colonic Stent Safe Procedure Research Group.

BACKGROUND: There are many reports on the choice of treatment for and prognosis of left-sided obstructive colorectal cancer; however, few studies have focused on the prognostic factors of left-sided obstructive colorectal cancer. Therefore, we analyzed the prognostic factors using a post hoc analysis of a retrospective multicenter study in Japan. METHODS: A total of 301 patients were enrolled in this study to investigate the prognostic factors for relapse-free survival. The relationships between sex, age, decompression for bridge to surgery, depth of invasion, lymph node metastasis, postoperative complications, adjuvant chemotherapy, carcinoembryonic antigen, carbohydrate antigen 19-9, neutrophil-to-lymphocyte ratio, and relapse-free survival were examined. RESULTS: No change in the decompression method, T3 cancer, negative postoperative complications (grades 0-1 of Clavien-Dindo classification), and adjuvant chemotherapy during Stage III indicated a significantly better prognosis in a Cox univariate analysis. Lymph node metastasis was not selected as a prognostic factor. Excluding patients with <12 harvested lymph nodes (possible stage migration), lymph node metastasis was determined as a prognostic factor. In a Cox multivariate analysis, change in the decompression method, depth of invasion, lymph node metastasis (excluding N0 cases with <12 harvested lymph nodes), and adjuvant chemotherapy were prognostic factors. CONCLUSIONS: Similar to those in nonobstructive colorectal cancer, depth of invasion and lymph node metastasis were prognostic factors in left-sided obstructive colorectal cancer, and patients with <12 dissected lymph nodes experienced stage migration. Stage migration may result in disadvantages, such as not being able to receive adjuvant chemotherapy.

[A Case of Successful Stomach-Preserving Pancreaticoduodenectomy with Celiac Artery Resection after Neoadjuvant Chemoradiation Therapy for Pancreatic Cancer with Hepatic Arterial Variation].

Here we report a case of successful stomach-preserving pancreaticoduodenectomy with celiac artery resection for pancreatic cancer with hepatic arterial variation. A 70-year-old woman was referred to our hospital for examination and treatment of pancreatic cancer. A CT scan showed a tumor with suspected portal vein invasion at the body and head of the pancreas, in contact with the common hepatic artery and the splenic artery with 360°involvement. Contact with the celiac artery and left gastric artery was less than1 80°. CT and angiography revealed hepatic arterial variation in which the right hepatic artery and the left hepatic artery arose from the superior mesenteric artery and the left gastric artery, respectively. Resectability status was considered as borderline resectable. After neoadjuvant chemoradiation therapy, the levels of the serum tumor markers declined remarkably and a CT scan showed SD(RECIST). Subtotal stomach-preserving pancreaticoduodenectomy with celiac artery resection(SSPPD-CAR)was performed without resectionof the left gastric artery and a pathological R0 resectionwas achieved. The significance of performing combination resection and reconstruction of a major artery in pancreatic cancer is unclear. However, there may be cases with vascular variants that enable radical resection without reconstruction of the common hepatic artery. Therefore, it is important to preoperatively evaluate the configuration of the artery accurately and to select the optimal surgical procedures onthe basis of these variations.

[A long term survival case of hilar cholangiocarcinoma with multiple metastases treated with chemotherapy and operation].

A 40-year-old woman presenting with hilar cholangiocarcinoma and multiple liver metastases was admitted to our hospital. Initially, she underwent an extended right hepatectomy, 1 segmentectomy, and partial resection of the liver. After adjuvant chemotherapy with gemcitabine (1,000 mg/m² days 1, 8, and 15, of a 28-day cycle), multiple liver metastases (1 lesion in S2 and 2 lesions in S4) were detected by computed tomography (CT). As a result of the impaired response to gemcitabine, the chemotherapy regimen was changed to include combined chemotherapy with gemcitabine (1,000 mg/m² days 1 and 8, of a 21-day cycle), and S-1 (120 mg/body/day days 1 through 14). After 5 courses of combined chemotherapy, the liver metastases reduced in size; subsequently, a left internal sectionectomy and radiofrequency ablation were performed. Thereafter, the patient continued to receive adjuvant chemotherapy with S-1 for an additional 3 years; she is alive, without recurrence, 5 years after the initial operation. We propose that aggressive surgery should be considered for patients presenting with chemotherapy-responsive cholangiocarcinoma with multiple metastases.

[A 5-year survival case of locally advanced cancer of the pancreatic body treated by distal pancreatectomy with en bloc celiac axis resection after neoadjuvant chemoradiation therapy].

A 59-year-old man was diagnosed with locally advanced cancer of the pancreatic body, involving the nerve plexus around the celiac axis, the common hepatic artery, and the splenic artery. He was treated with a combination of irradiation (2 Gy/day, total 24 Gy) and 600 mg/m2 of gemcitabine(GEM)biweekly. The tumor size and the involved plexus area were not diminished, but CA19-9 was reduced by half. Distal pancreatectomy with en bloc celiac axis resection(DP-CAR)was performed. The histological findings indicated extensive invasion into the nerve plexus, including that adjacent to the stump of the pancreas, and thus the R classification was R1. After surgery, 1,000 mg/m2 of GEM was administered biweekly. The chemotherapy has been performed for 5 years to prevent local and systemic recurrence. No recurrence has been found 5 years after surgery. Multidisciplinary treatment, combined with neoadjuvant chemoradiation therapy, curative-intent resection, and postoperative chemotherapy is important for effective treatment of locally advanced pancreatic cancer.

[A case of distal cholangiocarcinoma with high sensitivity to neoadjuvant chemoradiation therapy].

We hypothesized that neoadjuvant chemoradiation therapy for cholangiocarcinoma (NACRAC) using gemcitabine would improve the prognosis of resected cases. Phase II trial of NACRAC is ongoing. We report a very effective case to NACRAC for distal cholangiocarcinoma, which markedly reduced the size and levels of the tumor markers. The patient was a 50- year-old man who presented jaundice. Serum tumor markers were clearly elevated, and abdominal CT scan revealed an enhanced mass in the lower bile duct, a dilatation of the intrahepatic to the middle bile duct and a swollen regional lymph node. After NACRAC, the tumor markers were decreased within a normal range. Also on CT scan, the main tumor was slightly detectable and the swollen node was reduced more than 30% in short diameter. Therefore, the effect of NACRAC was considered PR in RECIST guidelines (ver.1 .1). Pancreaticoduodenectomy was performed 2 weeks after NACRAC. No perioperative complications occurred. Pathological examination showed a good response, Grade 2b on Oboshi-Shimosato's classification. In this case, NACRAC had a good effect in imaging and pathological findings as well as in the tumor markers. Therefore, the neoadjuvant chemoradiation therapy has a potential to improve the prognosis for cholangiocarcinoma.