Conversion surgery only for highly selected patients with unresectable pancreatic cancer: a satisfactory outcome in exchange for a lower resection rate.

PURPOSE: The purpose of this study is to clarify the resection rate, safety, and significance of conversion surgery for highly selected patients with unresectable pancreatic cancer (URPca). METHODS: We studied 434 URPca patients. Conversion surgery was permitted only for patients who met following requirements: responders to first-line therapy, showing sufficient reduction of the local tumor to enable complete resection, at least 6 months of disease control, and no metastatic lesions detected on radiological examinations (for patients with metastatic disease). The overall survival (OS) was compared between patients who underwent surgery and those who did not. Furthermore, a multivariate analysis was performed to identify possible predictive factors for both total patients with URPca and responders. RESULTS: Conversion surgery was performed in 18 patients (4.1%). The pathologically complete resection rate was 88.9% (16/18). The median operative time, blood loss, and hospitalization duration were 450 min, 780 ml, and 29 days, respectively. The OS was significantly better in patients who underwent surgery than in those who did not. In a multivariate analysis, conversion surgery was shown to be significantly correlated with the OS both in total patients and responders. CONCLUSIONS: A satisfactory outcome was achieved for highly selected patients with URPca in exchange for a lower resection rate (4.1%).

Prognostic predictions based on pathological findings of peritoneal dissemination in patients with stage IV colorectal cancer without residual disease (R0 status).

PURPOSE: This study aimed to clarify the prognosis of patients after resection of stage IV colorectal cancer and synchronous peritoneal metastasis (no residual disease: R0 status) based on histopathologic findings. METHODS: The subjects of this study were 26 patients who underwent radical resection of synchronous peritoneal metastases of stage IV colorectal cancer. Only patients with one synchronous peritoneal metastasis were included in this study. The peritoneal lesions were initially classified into two categories based on the presence or absence of adenocarcinoma on their surface: RM-negative or RM-positive. The lesions were subsequently classified as being of massive or diffuse type and of small (< 6 mm) or large (≥ 6 mm) type according to the maximum metastatic tumor dimension. RESULTS: Multivariate analysis revealed that massive type metastatic tumors were associated with a better disease-free survival (DFS; p = 0.047) and overall survival (OS; p = 0.033), than diffuse type tumors. CONCLUSION: A detailed stratification of pathological findings could contribute remarkably to prognostic predictions for patients with synchronous peritoneal metastases.

A case of local recurrence of T1 rectal cancer 10 years after transanal excision.

We report a case of a patient with T1 rectal cancer, which recurred locally after 10 years from the primary operation. A 78-year-old woman was diagnosed with rectal cancer. Transanal excision (TAE) was performed in December 2006. The pathological findings revealed stage I rectal cancer [tub2>muc, pSM (2,510 µm), ly0, v0, pHM0, pVM0]. Because she did not opt for additional treatment, she received follow-up examination. After approximately 10 years from the primary operation, she presented to her physician, complaining of melena, and she was referred to our hospital again in November 2016. She was diagnosed with recurrent rectal cancer. Laparoscopic abdominoperineal resection was performed in December 2016. Pathological findings revealed stage IIIB rectal cancer (tub2>muc, pA, pN1). The reported postoperative local recurrence rate for T1 rectal cancer after TAE is high, but local recurrence after years from the primary operation is rare. In high-risk cases, local recurrence may be observed even after 10 years from the primary operation. Long-term and close postoperative follow-up is important to detect local recurrence early.

[The Case of a Patient with Gastric Cancer Who Showed No Neutropenia Only When Using the Generic S-1 Adjuvant Chemotherapy Formulation].

We report the case of a 72-year-old female who underwent laparoscopic total gastrectomy for gastric cancer. The pathological diagnosis was pT3, N1, M0, pStage II B. She received adjuvant chemotherapy with the TS-1®combination OD tablet, beginning 48 days after gastrectomy. The first course was stopped at day 7 because of neutropenia. The dose was decreased, a second course was started, and the patient completed her second course without neutropenia. After completion of the second course, we discovered that she had taken generic drugs(NKS-1®combination OD tablet)during the second course. She was enrolled in a clinical trial in which the administration of generic drugs was not permitted, as per the protocol. Beginning with the third course, we once again treated her with TS-1, and we observed a return of neutropenia in every subsequent course. We decreased the dose of TS-1 and changed the administration schedule each time. She exhibited no neutropenia only when using the generic S-1 formulation. It is possible that the anti-tumor effect of the generic S-1 formulation, and its associated adverse events, are not identical to the innovator formulation.

Transcatheter retrieval of an Amplatzer Vascular Plug.

INTRODUCTION: An Amplatzer Vascular Plug (AVP), which was designed as a permanent occluding device derived from the Amplatzer Septal Occluder and Amplatzer Duct Occluder, is a useful embolic device that can be precisely deployed in medium to large vessels with high resistance to migration. However, migration of these Amplatzer devices has been reported as a relatively rare but major complication. CASE REPORT: A 59-year-old woman was referred for the treatment of advanced pancreatic body cancer; after systemic chemotherapy, distal pancreatectomy with en bloc celiac axis resection (DP-CAR) was planned as curative treatment. Therefore, preoperative embolisation of the common hepatic artery (CHA) for arterial redistribution was performed. Although a 6-mm AVP II was deployed at the mid-portion of the CHA, the AVP migrated to the proper hepatic artery. Although migrated AVP retrieval using a goose neck snare was attempted, it was impossible to retrieve it into the 5-F guiding sheath. Therefore, the AVP was delivered to the splenic artery, which was planned to be resected in DP-CAR. Finally, a 10-mm AVP II was redeployed at the proximal portion of the CHA, and complete occlusion was achieved. CONCLUSIONS: When AVP retrieval is not possible, delivery to the other arteries having lesser influence might be an alternate technique.

Treatment of biliary strictures with fully covered self-expandable metal stents after pancreaticoduodenectomy.

Background and study aims Anastomotic stricture is a late complication after biliary reconstructive surgery, but standard treatments are currently lacking. We selected patients who had undergone pancreaticoduodenectomy and Child's procedure, and aimed to evaluate the safety and efficacy of temporary placement of fully covered self-expandable metal stents (FCSEMSs) to treat postoperative anastomotic stricture. Patients and methods This study retrospectively analyzed 13 patients who underwent treatment with FCSEMSs for anastomotic stricture between June 2011 and March 2016. We evaluated technical and clinical success, complications, duration of patency after FCSEMS removal, and re-stenosis. Results All of the anastomotic strictures were improved by FCSEMS placement and luminal patency was maintained throughout the follow-up period, with no complications. After 2 months, the FCSEMSs were removed endoscopically in nine patients, and in four patients the stent had been expelled spontaneously per rectum. Median duration of follow-up was 225 days (range 30 - 935 days). No re-stenosis occurred in any of the 13 cases following stent removal. Conclusion Deployment of FCSEMSs for anastomotic stricture offers a safe and promising treatment that may replace percutaneous transhepatic biliary drainage and deployment of multiple plastic stents as the first-line treatment.

A case of metachronous left ovarian metastasis 8 years after surgery for cecal cancer and right ovarian metastasis: Report of a case.

Metachronous ovarian metastasis of colorectal adenocarcinoma is mostly identified within 3 years. Here we present a case of a 64-year-old woman with cecal cancer who underwent right oophorectomy for ovarian metastasis. Imaging was performed because of abdominal bloating; it detected a swollen right ovary with ascites. On laparotomy, a right ovarian tumor and cecal cancer were identified. After right oophorectomy, a diagnosis of unilateral ovarian metastasis from colon cancer was made. One month later, right hemicolectomy was performed. Eight years after initial surgery, the patient presented with vaginal bleeding. A computed tomography (CT) scan revealed a pelvic mass approximately 10 cm in diameter, but no mass was evident on a CT image taken 6 months before. The patient was diagnosed with left ovarian metastasis from colon cancer. A third laparotomy revealed a left ovarian tumor, but there was no evidence of other metastases or peritoneal dissemination. Left oophorectomy was performed. Oophorectomy is considered to be associated with a survival benefit in ovarian metastasis without other extensive metastasis. However, ovarian metastasis is often bilateral. Although complete resection was achieved in the present case, the findings support performing prophylactic bilateral oophorectomy if metastasis is identified in a unilateral ovary.

Histopathologic risk stratification of stage IIB colorectal cancer.

PURPOSE: To stratify stage IIB (pT4a PN0) colorectal cancer in terms of histopathologic findings. METHODS: We reviewed the medical records of 80 patients who underwent surgery for stage IIB colorectal cancer. The disease-free survival (DFS) and overall survival (OS) rates were evaluated and correlated with the presence or absence of "Tumor Necrosis", "Crohn's-like lymphoid reaction", and "Perineural Invasion". RESULTS: Patients with "Tumor Necrosis" had significantly lower DFS rates (p < 0.0001), those with "Crohn's-like lymphoid reaction" had significantly higher DFS rates (p = 0.037), and those with "Perineural Invasion" had significantly lower DFS rates (p < 0.0001). Patients with "Tumor Necrosis" had significantly lower OS rates (p = 0.016), those with "Crohn's-like lymphoid reaction" had significantly higher OS rates (p = 0.022), and those with "Perineural Invasion" had significantly lower OS rates (p = 0.003). CONCLUSIONS: Since stage IIB colorectal cancers accompanied by the pathological findings of "Tumor Necrosis" and "Perineural Invasion", but with the absence of "Crohn's-like lymphoid reaction" carried a poor prognosis, the efficacy of adjuvant chemoradiation must be considered for these patients.

Post-adjuvant chemotherapy CA19-9 levels predict prognosis in patients with pancreatic ductal adenocarcinoma: A retrospective cohort study.

BACKGROUND: Carbohydrate antigen 19-9 (CA19-9) is a widely used tumor marker for pancreatic ductal adenocarcinoma (PDAC). In addition, several studies have reported the utility of both pre- and postoperative CA19-9 levels as prognostic factors in resectable PDAC. However, little is known about the implications of post-adjuvant chemotherapy (AC) CA19-9 levels. The purpose of this study was to examine the utility of the post-AC CA19-9 level as a prognostic marker for relapse-free survival (RFS) in resectable PDAC. METHODS: A total of 119 patients who completed AC were analyzed (normal post-AC CA19-9, n = 79; high post-AC CA19-9, n = 40). The upper limit of the normal (ULN) serum level of CA19-9 was 37 U/mL. RESULTS: Median RFS was significantly shorter for patients with high post-AC CA19-9 levels than for those with normal post-AC CA19-9 (10.4 months vs. 29.6 months, respectively; p < 0.001). After adjustment, high post-AC CA19-9 level was an independent predictive factor for short RFS (hazard ratio for RFS, 2.72). Median overall survival was significantly shorter in patients with high post-AC CA19-9 levels than in those with normal postoperative CA19-9 levels (24.7 months vs. 92.1 months, respectively; p < 0.001). The optimal cutoff value of post-AC CA19-9 levels for prediction of early recurrence was >1.5 × UNL (55.5 U/mL), with a 74.2% positive predictive value. CONCLUSIONS: The present results show that high post-AC CA19-9 level is an independent prognostic factor for short RFS in patients with resected PDAC. In addition, it may be useful for predicting early recurrence.

Necessary circumferential resection margins to prevent rectal cancer relapse after abdomino-peranal (intersphincteric) resection.

PURPOSE: The purpose of this study was to determine the adequate circumferential resection margin (CRM) for abdomino-peranal (intersphincteric) resection (ISR) that would prevent the relapse of rectal cancers. METHODS: The records of 41 cases that underwent curative ISR for rectal cancer were retrospectively reviewed. The relapse-free survival rates and overall survival rates were evaluated and correlated with the maximum depth of the inner muscularis layer reached during ISR (i.e., the radial margin [RM] and distal margin [DM]). Cases were divided into three groups based on the sizes of the RM and DM: (1) group A (RM >2 mm and DM >1.5 cm), (2) group B (RM >2 mm or DM >1.5 cm but not both), and (3) group C (RM <2 mm and DM <1.5 cm). RESULTS: The relapse-free survival rates of the cases in group C were lower than those in the cases of group A or group B (p = 0.002 and 0.037, respectively). The resection margins required to prevent rectal cancer relapse were >2 mm for the RM and >1.5 cm for the DM. For these margins, the intersphincteric space had to be entered (i.e., between the internal and external anal sphincters). CONCLUSION: It is critical to enter the intersphincteric space to ensure an adequate CRM (RM >2 mm and DM >1.5 cm) for preventing rectal cancer recurrence after ISR.

Aggressive resection of frequent peritoneal recurrences in colorectal cancer contributes to long-term survival.

We report a long-term survivor of colorectal cancer who underwent aggressive, frequent resection for peritoneal recurrences. A 58-year-old woman was diagnosed with descending colon cancer. Resection of the descending colon along with lymph node dissection was performed in September 2006. The pathological findings revealed Stage IIA colorectal cancer. The following peritoneal recurrences were removed: two in July 2007, two in the omental fat and two in the pouch of Douglas in June 2008 resected by low anterior resection of the rectum, one in the uterus and right ovarian recurrence resected via bilateral adnexectomy and Hartmann's procedure in May 2011, and one in the ascending colon by partial resection of the colon wall in December 2011. Postoperative adjuvant chemotherapy (uracil and tegafur/leucovorin, fluorouracil/levofolinate/oxaliplatin/bevacizumab, 5-fluorouracil/leucovorin/bevacizumab, irinotecan/bevacizumab, and irinotecan/panitumumab) was administered. The patient did not desire postoperative adjuvant chemotherapy after the fourth operation. The long-term survival was 6 years and 7 months.

Poor prognosis of common-type invasive ductal carcinomas that originate in the branching pancreatic duct.

PURPOSE: To clarify the incidence, clinicopathological features and prognosis of pancreatic invasive ductal carcinomas (IDCs) with different tumor origin sites in the pancreatic duct. METHODS: Based on the relationship between the invasive cancer area (ICA) and the main pancreatic duct (MPD), IDCs less than 2 cm in diameter were classified into two groups: type I, in which the ICA and MPD were separated, and type II, in which the MPD passed through the ICA. The clinicopathological findings and prognosis of each type were compared in a total of 37 patients. RESULTS: The incidences of IDC types I and II were 18.9 and 81.1 %, respectively. Although there was no difference in local invasion, both node involvement and venous invasion tended to occur more frequently in type I IDC, and the three-year survival rate was significantly lower for type I (28.6 %) than type II (71.8 %) IDC. CONCLUSIONS: The prognosis of IDCs that originated in the branching pancreatic duct (BPD) distant from the MPD (type I) was worse than the prognosis of IDCs that originated in either the MPD or the BPD close to the MPD (type II). These data suggest that the progression and degree of malignancy of IDCs may vary depending on the site of tumor origin in the pancreatic duct.

[Long-term survival of a patient with sigmoid colon cancer showing multiple liver metastases treated by performing partial hepatectomy, five years after achieving a complete response via hepatic arterial infusion chemotherapy].

Although systemic multidrug chemotherapy is the first-line therapy for unresectable colorectal cancer, hepatic arterial infusion chemotherapy(HAI)may be a potential alternative treatment for patients with unresectable colorectal liver metastasis. A 65-year-old man underwent sigmoidectomy for sigmoid colon cancer with bilobar, multiple liver metastases. Postoperatively, an HAI regimen of 5-fluorouracil(5-FU, 1,000mg/m²/5 h/every week)was administered for 26 weeks; the total dose of 5-FU administered was 52 g. Complete response(CR)was achieved, according to an imaging diagnosis technique. Thereafter, the patient was followed-up in an outpatient setting, without any further anti-cancer treatment. A solitary liver metastasis was identified by using magnetic resonance imaging(MRI), 6 years 6 months after achieving CR. The patient underwent partial liver resection for the recurrent liver metastasis. Histological diagnosis revealed an adenocarcinoma, consistent with the findings for metastatic sigmoid colon cancer. The patient's postoperative recovery was uneventful, and he remains alive 5 years after liver resection, without any evidence of tumor recurrence. Further long-term follow-up might be advisable considering the slow-growing nature of this tumor.

Detailed stratification of TNM stage III rectal cancer based on the presence/absence of extracapsular invasion of the metastatic lymph nodes.

BACKGROUND: The presence/absence of extracapsular invasion in metastatic lymph nodes has been reported as being significantly correlated with the prognosis in a wide variety of cancers. However, the influence of extracapsular invasion in the metastatic lymph nodes on the prognosis in patients with stage III rectal cancer has not yet been investigated. OBJECTIVE: We investigated the presence/absence of extracapsular invasion in the metastatic nodes of the relevant main/lateral lymph node group in patients with rectal cancer to determine the usefulness of this parameter for stratifying the prognosis of patients with stage III rectal cancer. DESIGN: This was a single-institution study. SETTINGS: This study was conducted at a single institution. PATIENTS: We enrolled 101 consecutive patients with stage III rectal cancer who had undergone curative surgery with extended lymph node dissection and investigated the presence/absence of extracapsular invasion in the regional metastatic lymph nodes to determine the usefulness of such stratification for a more precise prediction of the patient prognosis. MAIN OUTCOME MEASURES: The main outcomes measured were the disease-free and overall survival rates. RESULTS: Univariate analysis revealed a significantly poorer prognosis, in terms of both the disease-free survival rate (p = 0.003) and overall survival rate (p = 0.008), of the pN3-extracapsular invasion-positive cases in comparison with the pN3-extracapsular invasion-negative cases. Multivariate analysis revealed the presence/absence of extracapsular invasion in the metastatic lymph nodes as the only variable that was statistically significantly associated with the disease-free survival rate (p = 0.011). LIMITATIONS: This was a retrospective study in a small number of patients from a single institution. There were no comparator groups. CONCLUSIONS: Detailed stratification of pN3 cases based on the presence/absence of extracapsular invasion in metastatic lymph nodes has the potential to contribute significantly to more available prediction of the prognosis of patients with stage III colorectal cancer.

Outcomes after hepatic and pulmonary metastasectomies compared with pulmonary metastasectomy alone in patients with colorectal cancer metastasis to liver and lungs.

BACKGROUND: Surgical resection is the most effective treatment for colorectal cancer that has metastasized to the liver. Similarly, surgical resection improves survival for selected patients with pulmonary colorectal metastases. However, the indication for pulmonary metastasectomy is not clear in patients with both hepatic and pulmonary colorectal metastases. Therefore, we evaluated outcomes after pulmonary resection of colorectal metastases in patients with or without a history of curative hepatic metastasectomy. METHODS: We retrospectively analyzed 96 patients who underwent pulmonary metastasectomy from March 1999 to November 2009. Patients were grouped according to treatment: resection of pulmonary metastases alone (lung metastasectomy group) or resection of both hepatic and pulmonary metastases (liver and lung metastasectomy group). Overall survival (OS) and disease-free survival (DFS) were evaluated by Kaplan-Meier analysis. Survival curves were compared using the log-rank test. RESULTS: The 5-year OS for all patients was 61.3 %, and the 5-year DFS was 26.7 %. Group comparisons showed that the 5-year OS of the lung metastasectomy group was significantly better than that of the liver and lung metastasectomy group (69 vs. 43 %; p = 0.030). However, the 5-year DFS rates of the lung metastasectomy group (25.8 %) and liver and lung metastasectomy group (28.0 %) did not differ significantly. Recurrence was higher after resection of both hepatic and pulmonary metastases than after pulmonary metastases alone (79 vs. 45 %; p = 0.025). CONCLUSIONS: Resection of pulmonary colorectal metastases may increase survival. However, the combination of liver and lung metastasectomies had a worse prognosis than pulmonary metastasectomy alone. In selected patients, combined liver and lung metastasectomy can be beneficial and result in acceptable DFS.

Isolated caudate lobectomy with pancreatoduodenectomy for a bile duct cancer.

BACKGROUND: In patients with distal bile duct cancer involving the hepatic hilus, a major hepatectomy concomitant with pancreatoduodenectomy (HPD) is sometimes ideal to obtain a cancer-free resection margin. However, the surgical invasiveness of HPD is considerable. PATIENTS AND METHODS: We present our treatment option for patients with distal bile duct cancer showing mucosal spreading to the hepatic hilum associated with impaired liver function. To minimize resection volume of the liver, an isolated caudate lobectomy (CL) with pancreatoduodenectomy (PD) using an anterior liver splitting approach is presented. Liver transection lines and bile duct resection points correspond complete with our standard right and left hemihepatectomies with CL for perihilar cholangiocarcinoma. RESULTS: Total operation time was 765 min, and pedicle occlusion time was 124 min, respectively. Although the proximal mucosal cancer extension was identified at both the right and the left hepatic ducts, all resection margins were negative for cancer. CONCLUSIONS: Isolated CL with PD is an alternative radical treatment option for bile duct cancer patients with impaired liver function.

Efforts to advance surgical treatments for patients with familial adenomatous polyposis for 40 years in a cancer hospital.

BACKGROUND/AIMS: There have been numerous studies on surgical procedures for familial adenomatous polyposis (FAP), but the evolution in surgical treatments as they pertain to the major perioperative item, i.e., complications, as well as advantages and disadvantages of surgery, in only one institution have not been reported. We examined this surgical treatment evolution in FAP patients. METHODOLOGY: We enrolled 67 FAP patients who had undergone surgery and classified them into three groups, i.e., early phase (1965 to 1977), intermediate phase (1978 to 1987), and late phase (1988 to 2004). We assessed clinicopathological findings and outcomes in these three groups. RESULTS: With the passage of time, surgical techniques and therapeutic benefits improved, but the overall survival rates of early and late phase patients were significantly better than that of intermediate phase patients. CONCLUSION: As the surgical techniques improved, patient stress diminished but outcomes in the late period were not always better than in the early period. Surveillance has been enhanced by the increased prevalence of colonoscopy and genetic research has also contributed to better disease management. It is necessary to research the prognosis of FAP patients in the future.

A new option for laparoscopic spleen-preserving distal pancreatectomy: three cases with splenic artery preservation and resection of the splenic vein.

There are two techniques for a spleen-preserving distal pancreatectomy (SPDP): SPDP with splenic vessel preservation, and SPDP with splenic vessel resection. In some cases, although the splenic artery (SpA) can be preserved, the splenic vein (SpV) must be resected. We report the short- and long-term outcomes of three patients who underwent a new technique of laparoscopic SPDP with SpA preservation and SpV resection (SPDP-VRes). A grade B pancreatic fistula, which occurred in two patients, was successfully treated with drainage tube management. In all cases, the omental branches of the left gastroepiploic vein functioned as a drainage vein, and there was no splenomegaly, thrombocytopenia, or varix formation during the follow-up period (19 months to 5 years). Patients undergoing laparoscopic SPDP-VRes had no severe complications during the follow-up period; preserving the left omental branch is a key to this procedure. Laparoscopic SPDP-VRes might be a useful treatment option for patients undergoing SPDP.

Hepatolithiasis in the hepatic hilum mimicking hilar cholangiocarcinoma: report of a case.

We report a rare case of hepatolithiasis, which was diagnosed as hilar cholangiocarcinoma and treated with hepatectomy and extrahepatic bile duct resection. A 59-year-old woman presented to a local hospital with liver dysfunction. Diagnostic imaging revealed a biliary stricture at the hepatic hilum and middle bile duct. Hilar cholangiocarcinoma was diagnosed, and she was referred to our hospital for definitive surgical treatment. She underwent left hepatic trisectionectomy, total caudate lobectomy, and extrahepatic bile duct resection. Gross examination of the resected specimen revealed intrahepatic stones firmly adherent to the bile duct wall. Pathological examination revealed no malignant lesions. The epithelium of the bile duct was absent underneath the stone, and the boundary between the stone and bile duct wall was ill defined. To our knowledge, this is the first case report of hepatolithiasis with a biliary stricture caused by peculiar stone formation, mimicking hilar cholangiocarcinoma.

Pathology studies of combined radical resection of seminal vesicle in the treatment of rectal cancer.

To inhibit local recurrence of rectal cancer, it is very important to ensure that there is a sufficient circumferential resection margin. We evaluated pathology studies of combined radical resection of seminal vesicles in the treatment of rectal cancer. We analyzed data from 7 cases of combined radical resection of the seminal vesicle in the treatment of rectal cancer; we also analyzed data from 35 control cases without seminal vesicle resection. The circumferential resection margin averaged 5.97 mm for cases that had combined radical resection of the seminal vesicle, and this was significantly longer than for cases without resection (P < 0.001). Local recurrence was not seen in cases that had combined radical resection of the seminal vesicle, whereas 3 cases (5.9%) occurred in the group that did not undergo resection. Combined radical resection of the seminal vesicle in patients with rectal cancer ensures that the distance of the circumferential resection margin is sufficient to inhibit local recurrence.