Nomogram Development and External Validation for Predicting the Risk of Lymph Node Metastasis in T1 Colorectal Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Predicting lymph node metastasis (LNM) risk is crucial in determining further treatment strategies following endoscopic resection of T1 colorectal cancer (CRC). This study aimed to establish a new prediction model for the risk of LNM in T1 CRC patients. MATERIALS AND METHODS: The development set included 833 patients with T1 CRC who had undergone endoscopic (n=154) or surgical (n=679) resection at the National Cancer Center. The validation set included 722 T1 CRC patients who had undergone endoscopic (n=249) or surgical (n=473) resection at Daehang Hospital. A logistic regression model was used to construct the prediction model. To assess the performance of prediction model, discrimination was evaluated using the receiver operating characteristic (ROC) curves with area under the ROC curve (AUC), and calibration was assessed using the Hosmer-Lemeshow (HL) goodness-of-fit test. RESULTS: Five independent risk factors were determined in the multivariable model, including vascular invasion, high-grade histology, submucosal invasion, budding, and background adenoma. In final prediction model, the performance of the model was good that the AUC was 0.812 (95% confidence interval [CI], 0.770 to 0.855) and the HL chi-squared test statistic was 1.266 (p=0.737). In external validation, the performance was still good that the AUC was 0.771 (95% CI, 0.708 to 0.834) and the p-value of the HL chi-squared test was 0.040. We constructed the nomogram with the final prediction model. CONCLUSION: We presented an externally validated new prediction model for LNM risk in T1 CRC patients, guiding decision making in determining whether additional surgery is required after endoscopic resection of T1 CRC.

Persistent Bleeding Following a Stapled Hemorrhoidopexy

A stapled hemorrhoidopexy (SH) is widely used for treatment of patients with grades III and IV hemorrhoids. The SH is easy to perform, is associated with less pain and allows early return to normal activities. However, complications, whether severe or not, have been reported. Here, we present the case of a female patient with persistent bleeding after a SH. The bleeding was caused by the formation of granulation tissue at the stapler line, diagnosed with sigmoidoscopy, and successfully treated via transanal excision (TAE) under spinal anesthesia. The biopsy showed inflammatory granulation tissue. After the TAE, her symptom was completely gone.

Preemptive Analgesia in Single-Incision Laparoscopic Surgery

No abstract available.

The Pathological and Clinical Effects of Preoperative Chemoradiation in Rectal Cancer / 대한방사선종양학회지

PURPOSE: To evaluate the pathological and clinical effects of preoperative chemoradiation (CCRT) in cases of locally advanced rectal cancer and to determine the predictive factors for tumor downstaging. MATERIALS AND METHODS: From March 2004 to August 2008, 33 patients with locally advanced rectal cancer were treated with preoperative CCRT. Twenty-eight patients (84.8%) were treated using a concomitant boost technique while five (15.2%) patients were treated using a cone down boost technique. All patients received 50.4 Gy of irradiation and concurrent chemotherapy with 5-fluorouracil. The median follow-up duration was 24.2 months (range, 9.8 to 64.7 months). RESULTS: Thirty-one (93.9%) patients underwent surgery. Twenty-four patients (72.7%) underwent anal sphincter-preserving surgery. The 3-year disease free survival (DFS) and overall survival rates were 63.4% and 78.8%, respectively. Post-operative factors were more important for DFS. Pathologic N stage, margin status, and pathologic differentiation were significant prognostic factors (p=0.001, 0.029, 0.030). Tumor size and lymphovascular invasion were also associated with marginal significance (p=0.081, 0.073). However, only pre-treatment T stage was a significant pre-operative factor (p=0.018). The complete pathological response rate was 9.1%. T-downstaging was observed in ten (30.3%) patients, whereas N-downstaging was found in 24 (72.7%) patients. Pre-treatment T stage and the interval between CCRT and operation were the predictive factors for downstaging in a univariate analysis (p=0.029, 0.027). Pre-treatment carcinoembryogenic antigen was also associated with marginal significance (p=0.068). CONCLUSION: The survival of rectal cancer patients can be better determined based on post-operative findings. Therefore, pre-operative CCRT for downstaging of the tumor seems to be important. Pre-treatment T stage and the interval between CCRT and operation can be used to predict downstaging.

Results of Screening Colonoscopy in Asymptomatic Average-risk Koreans at a Community-based Secondary Hospital / 대한소화기내시경학회지

BACKGROUND/AIMS: Colonoscopy has emerged as the dominant colorectal cancer screening strategy, yet the data on the results of performing screening colonoscopy in asymptomatic average risk Koreans is limited. The aim of this study is to determine the results of screening colonoscopy at a community-based single center in Korea. METHODS: A total of 13,743 individuals (5,935 males and 7,808 females, age: 50.6+/-11.8 years) who underwent screening colonoscopy at a community based hospital from April 2006 to March 2008 were analyzed. RESULTS: Of the 13,743 subjects, neoplasia, advanced neoplasia and early colon cancer were detected in 3,270 subjects (23.8%), 315 subjects (2.3%) and 60 subjects (0.5%), respectively. The prevalence of neoplasia and advanced neoplasia increased with age (p<0.001), and this was higher among males as compared to that of females (p<0.001). Of the 3,666 subjects with neoplasia, 1,440 subjects (38.3%) had multiple neoplasia. Old age and male gender were associated with multiple neoplasia. CONCLUSIONS: The overall prevalence of colorectal neoplasia in asymptomatic average-risk Koreans at a community based hospital is comparable with that in a health care setting or university hospitals. Old age and male gender are associated with a higher risk of colorectal neoplasia and having multiple neoplasia.

Endoscopic Submucosal Dissection for Colorectal Neoplasia: Early Outcomes After 260 Cases

PURPOSE: Endoscopic submucosal dissection (ESD), a recently introduced endoscopic technique, makes it possible to perform an en-bloc resection of a lesion regardless of its size. The aim of this study was to report early experiences with colorectal ESD performed in our hospital. METHODS: Between October 2006 and December 2008, we performed an ESD for 260 consecutive cases of colorectal neoplasia in 255 patients. We evaluated the clinical outcomes, except for two failure cases of bowel perforation. RESULTS: The mean resected tumor size was 24.2+/-9.8 (5-60) mm. Our overall endoscopic en-bloc resection rate was 93.0% (240/258). and the pathologically margin free rate was 91.5% (236/258). Perforation occurred in 7.7% (20/260) of the cases. In 17 patients, perforation was managed by endoscopic clipping without salvage surgery; the other three patients underwent a laparoscopic operation. Pathological examination showed an adenocarcinoma in 35.4% of the cases (92/260). We recommended additional radical surgery in 13 cases (submucosal invasion less than 1 mm with unfavorable pathology: 1 case; unknown depth of submucosal invasion: 1 case; submucosal invasion > or =1 mm: 9 cases; invasion to proper muscle: 2 cases). We were able to check the recurrence rate through colonoscopy for 125 patients. During the mean follow-up period of 8.0+/-4.3 (3-21) mo, there were no recurrences. CONCLUSION: ESD was technically difficult, had a substantial risk of perforation, and needed a long procedure time. However, ESD enabled en-bloc resection of large colorectal tumors. As experience with the technique increases, ESD might gradually replace piecemeal endoscopic mucosal resection (EMR) and radical colon resection in the treatment of colorectal tumors.

Anastomotic Leakage after Laparoscopic versus Open Resection for Rectal Cancer: A Retrospective Study

PURPOSE: This study is to compare the rate and pattern of anastomotic leakage (AL) for rectal cancer after laparoscopic vs. conventional open surgery at high and low rectal anastomosis and to evaluate whether the number of linear staples used for distal rectal resection is related to AL in laparoscopic group. RESULTS: One hundred ninety-seven patients who underwent a curative resection for rectal cancer between March 2002 and February 2006 were studied retrospectively (107 laparoscopic, 90 open). The proportions of patients with anastomosis above vs. below 5 cm from AV were not different between the laparoscopic and the open groups; (above/below: 54/53 and 41/49, respectively, P=0.57). The protective stoma rate, the overall rate of AL, the rate of AL according to the height of the anastomosis, and the number of distal linear staples were evaluated for both groups. RESULTS: Clinical AL occurred in 11 of 107 patients (10.3%) for the laparoscopic group and in 5 of 90 patients (5.6%) for the open group. The rates of AL in patients without protective stoma were not significantly different for high rectal anastomosis (6.0% for laparoscopic vs. 2.6% for open, P= 0.63) and for low rectal anastomosis (25.8% for laparoscopic vs. 12.1% for open, P=0.21). The risk of AL was 4.9 times higher when 3 linear staples were used than when 2 linear staples were used in the laparoscopic group. CONCLUSIONS: There was no statistical difference in AL between the laparoscopic group and the open group. The rate of AL could be reduced by using fewer linear staples for distal rectal resection in the laparoscopic group.

Pulmonary Resection for Lung Metastases from Colorectal Cancer

Isolated lung metastasis occurs in about 1% of all colorectal cancer cases. As in the case of isolated liver metastasis, resection of isolated lung metastasis results in 5 year survival rate of about 30%. PURPOSE: This study was performed to evaluate the survival benefit after pulmonary resection for metastatic colorectal cancer. METHODS: Between January, 1992 and March, 1998, twelve patients underwent lung metastatectomy from colorectal cancer at the Seoul National University Hospital. We evaluated the clinical characteristics of patients and analyzed the follow-up results in 10 patients whose medical records were available. Indications for resection of pulmonary metastasis were complete resection of the primary tumor, no other organ involvement except lung, completely resectable lung lesion, and tolerable general condition of patient for lung resection. RESULTS: Two patients had their primary tumors located in colon and 8 in rectum. Synchronous lung metastases were observed in 3 patients, and 7 patients had metachronous metastases developing 9 to 121 months (median; 33 months) after primary tumor resection. Eight patients had solitary metastatic nodule in lung, while two patients had multiple lesions confined to unilateral lung. Five patients underwent wedge resections, 4 underwent pulmonary lobectomies, and one patient had both wedge resection and lobectomy in unilateral lung. Three patients were lost during the follow-up, but remaining 7 patients are alive after median follow-up of period of 32 months and 6 of these patients have no postoperative recurrence. In addition, four of these 7 patients are alive for more than 3 years after lung metastatectomy. CONCLUSION: Pulmonary metastasis from colorectal cancer without other organ involvement may be a candidate for lung resection. However, further studies are needed to determine the survival benefits after pulmonary resection.