Tumor Budding and Recurrence in Submucosal Invasive Colorectal Cancers of Favorable Histology: Case Reports of Two Early Colorectal Cancers with Advanced Recurrences

Complete resection of submucosal invasive colorectal cancer (SICC) showing favorable histology is regarded as curative. We report on two cases of SICC showing recurrence within 5 years despite complete resection. The first patient was a 68-year-old woman with well differentiated rectal adenocarcinoma invading the superficial submucosa, which recurred after 4.7 years. The second patient was a 53-year-old man with pT1N0 moderately differentiated colonic adenocarcinoma. He developed widespread tumor recurrence after 3.9 years. Retrospective pathologic review of the original tumors showed multiple foci of tumor budding at the invasive front. Immunohistochemical staining for D2-40 of deeper levels of the paraffin blocks showed rare foci of small lymphatic invasion. Tumor budding at the invasive front may be an important indicator for SICC aggressiveness or may reflect early lymphatic invasion. More aggressive pathologic examination and follow-up is required for patients with SICC showing tumor budding, even in the absence of unfavorable histologic findings.

Tumor Budding and Recurrence in Submucosal Invasive Colorectal Cancers of Favorable Histology: Case Reports of Two Early Colorectal Cancers with Advanced Recurrences

Complete resection of submucosal invasive colorectal cancer (SICC) showing favorable histology is regarded as curative. We report on two cases of SICC showing recurrence within 5 years despite complete resection. The first patient was a 68-year-old woman with well differentiated rectal adenocarcinoma invading the superficial submucosa, which recurred after 4.7 years. The second patient was a 53-year-old man with pT1N0 moderately differentiated colonic adenocarcinoma. He developed widespread tumor recurrence after 3.9 years. Retrospective pathologic review of the original tumors showed multiple foci of tumor budding at the invasive front. Immunohistochemical staining for D2-40 of deeper levels of the paraffin blocks showed rare foci of small lymphatic invasion. Tumor budding at the invasive front may be an important indicator for SICC aggressiveness or may reflect early lymphatic invasion. More aggressive pathologic examination and follow-up is required for patients with SICC showing tumor budding, even in the absence of unfavorable histologic findings.

Comparison of Conventional Transanal Resection with Transanal Endoscopic Microsurgery in Patients with Rectal Neoplasm / 대한내시경복강경외과학회지

PURPOSE: Compared to traditionally used abdominoperineal resection and low anterior resection for the treatment of rectal neoplasm, transanal excision (TAE) has several benefits such as a lower complication rate, a shorter average hospital stay and improved quality of life. Transanal endoscopic microsurgery (TEM) was recently introduced for resecting rectal neoplasm. The aim of this study was to compare the therapeutic results between TAE and TEM in patients with rectal neoplasm. METHODS: From October 2000 to December 2008, 115 patients underwent TEM or TAE at the NCC. Among the patient with rectal neoplasm, the patients with recurred rectal cancer and pathologic T2 or T3 stage were excluded. Thirty four and 33 patients were included for this study in the TAE and TEM groups, respectively. The locations of the lesion, the average number of fragmented specimens, the resection margin, postoperative complications and recurrence were retrospectively compared between the TEM and TAE groups. For the patients with T1 cancer, the disease-free survival rates were compared between the TAE and TEM groups. RESULTS: The median distance of lesions from the anal verge in the TEM group was higher than that in the TAE group: (mean distance: 6.75 cm, range: 3~15 cm) for TEM group and (mean distance: 3.13 (range: 1~8 cm) for the TAE group, p<0.001). The TAE group had more fragmented specimens than the TEM group (mean for the TAE: 1.44 (range: 1~4), mean for the TEM group: 1.06 (range: 1~2), p=0.031). For the patients with T1 cancer, the 3 year disease-free survival rate was not significantly different between the two groups (83.9% for the TAE group and 91.7% for the TEM group p=0.734). CONCLUSION: TEM can remove higher located rectal neoplasm and a less fragmented specimen was aquired that that in TAE. TEM seems to have similar oncologic outcomes as compared with TAE.

A Prospective, Multicenter, Randomized Trial for Duration of the Prophylactic Antibiotics after Elective Colorectal Surgery: 3 Days versus 5 Days

PURPOSE: The use of prophylactic antibiotics in elective colorectal surgery is essential. Although postoperative prophylactic antibiotics are recommended within 24 hr, the optimal duration of the use of prophylactic antibiotics after colorectal surgery has not yet been fully proven in Korea. The aim of this study was to compare infectious outcomes in elective colorectal cancer surgery between postoperative 3-day antibiotic therapy and 5-day therapy. METHODS: We conducted a multicenter, randomized trial of a 3-day use vs. a 5-day use of the second-generation cephalosporin cefotetan after elective colorectal surgery. The main outcome measures were the incidences of surgical site infection and all other infectious complications within 21 days after surgery. RESULTS: A total of 306 patients were enrolled. Fifty-one patients were excluded because they received additional surgery or dropped out during the study. Two-hundred fifty-five patients were analyzed in this study. The two groups were similar in terms of demographics, ASA score, tumor location, tumor stage, surgical approach (conventional open vs. laparoscopy-assisted vs. robotic-assisted), and type of operation. The incidences of surgical site infection were not significantly different between the 3-day use group (4/130 or 3.1%) and the 5-day use group (3/125 or 2.4%) (P=1.000). Incidences of overall infectious diseases did not differ significantly between the two groups. Postoperatively, both groups had similar values in their white blood cell count, absolute neutrophil count, and C-reactive protein levels. However, the number of patients is small to draw a definite conclusion in this study. CONCLUSION: Three-day cefotetan administration may be not inferior in preventing surgical site infection compared to 5-day antibiotic administration. However, further studies with a large number of patients are needed before a definite conclusion can be drawn.

Cefotetan versus Conventional Triple Antibiotic Prophylaxis in Elective Colorectal Cancer Surgery

This study examined infectious outcomes in elective colorectal cancer surgery between cefotetan alone or conventional triple antibiotics. From January to December 2007, 461 consecutive primary colorectal cancer patients underwent elective surgery. Group A contained 225 patients who received conventional triple antibiotics (cephalosporin, aminoglycoside and metronidazole) for prophylaxis, and group B contained 236 patients who received cefotetan alone for prophylaxis. Treatment failure was defined as the presence of postoperative infection including surgical-site infection (SSI), anastomotic leakage, and pneumonia or urinary tract infection. The two groups were similar in terms of demographics, American Society of Anesthesiologists (ASA) score, tumour location, stage, surgical approach (conventional open vs. laparoscopy-assisted), and type of operation. The treatment failure rates were 3.1% in Group A and 3.4% in Group B (absolute difference, -0.3%; 95% confidence interval [CI], 0.39 to 3.07, P=0.866), with SSI being the most common reason for failure in both groups (2.7% in Group A and 3.0% in Group B [absolute difference, -0.3%; 95% CI, 0.37 to 3.37, P=0.846]). Cefotetan alone is as effective as triple antibiotics for prophylaxis in primary colorectal cancer patients undergoing elective surgery.

The Prophylactic Impact of Low Molecular Weight Heparin on Occurrence of Venous Thromboembolism after Colorectal Cancer Resection

PURPOSE: In western society, prophylaxis for venous thromboembolism (VTE) is the standard treatment under colorectal surgery for colorectal cancer. However, the incidence of VTE after colorectal surgery and the effect of prophylactic methods are not well known in Korea. The aim of this study is to evaluate the incidence of VTE and assess the efficacy and safety of low molecular weight heparin (enoxaparin) after major colorectal surgery in Korean patients with compression stockings. METHODS: From Jan. 2006 to Dec. 2008, 1,727 consecutive patients underwent major colorectal surgery. Thirty-six were excluded due to the therapeutic use of enoxaparin. A final number of 1,691 patients were included. Graduated compression stockings were used in all patients and 654 were perioperatively given enoxaparin. Only compression stocking group (group A) and compression stocking with enoxaparin group (group B) were compared in terms of VTE. The event of VTE within 6 months after surgery was counted by clinical symptoms, then imaging findings were used for confirmation. RESULTS: Total VTE developed in 10 patients (0.6%). Three with deep vein thrombosis had pulmonary embolism. Two had only pulmonary embolism. The rates of VTE were not different between group A and B (0.8% vs. 0.3%, P=0.333). Also, postoperative major bleeding was not significantly different. However, postoperative transfusion was higher in group B (P<0.001). CONCLUSION: The incidence of VTE was very low after colorectal surgery in Korean patients with compression stockings. The additional use of enoxaparin for colorectal cancer patients with compression stockings seems to have little benefit for VTE prophylaxis.

Pretreatment Serum CEA as a Prognostic Factor for Rectal Cancer Treated with Preoperative Chemoradiotherapy

PURPOSE: Preoperative serum carcinoembryonic antigen (s-CEA) is well known to be a prognostic factor in patients with colorectal cancer. However, the prognostic effect of s-CEA in patients with rectal cancer treated with preoperative chemoradiotherapy (CRT) has not been well studied. The aim of this study is to evaluate the prognostic value of pretreatment s-CEA for rectal cancer treated with preoperative CRT. METHODS: This study analyzed the data of 436 patients who received preoperative CRT and underwent curative surgery for locally advanced rectal cancer from January 2002 to July 2007. Patients were categorized into two groups according to pretreatment CEA levels: 10 ng/mL. The disease-free survivals between the two groups were compared. RESULTS: The three-year disease-free survival rates of the CEA 10 ng/mL group were 80.4% and 67.3%, respectively (P=0.002). Multivariate analysis revealed the following independent risk factor for recurrence: pretreatment CEA >10 ng/mL (hazard ratio [HR] 1.616; 95% confidence interval [CI], 1.007 to 2.594; P=0.047), positive lymph node status (HR, 2.580; 95% CI, 1.625 to 4.094; P<0.001), and positive circumferential resection margin (HR, 1.889; 95% CI, 1.035 to 3.446; P=0.038). CONCLUSION: Pretreatment s-CEA (cutoff value 10 ng/mL) may be a prognostic factor for disease-free survival in rectal cancer patients treated with preoperative CRT and surgery.

Rectal Perforation after Anorectal Manometry Following Preoperative Chemoradiotherapy and Low Anterior Resection: Report of a Cases

Anorectal manometry is widely used to evaluate anorectal function. Few reports have described complications resulting from this procedure. A 47-year-old male underwent preoperative chemoradiotherapy and a low anterior resection for rectal cancer. The patient underwent anorectal manometry at postoperative 8 months. A rectal perforation was diagnosed shortly thereafter. The patient was initially managed conservatively using percutaneous drainage and parenteral antibiotics and then discharged on day 60 after the event. One month later, a colo-cutaneous fistula and expanding abdominal fasciitis developed. The patient underwent surgical exploration, drainage, resection of the rectum including the fistula, and redo-coloanal anastomosis with a diverting ileostomy. The patient discharged without complications on postoperative day 25. Anorectal manometry should be performed with particular care in patients who have undergone radiotherapy and anastomosis at the rectum.

A case of pelvic congestion syndrome diagnosed by venography / 대한산부인과학회지

Pelvic congestion syndrome (PCS), which is said to occur due to ovarian vein incompetence, is a recognized cause of chronic pelvic pain (CPP). It is difficult to diagnose PCS because of a variety of symptoms. In addition, it can be underestimated by Computed Tomographic or Magnetic Resonance Imaging. At this time, gonadal venography remains the definitive imaging modality to evaluate patients with PCS. Medical and surgical approaches are available to treat PCS. More recently, however, transcatheter embolotherapy (TCE) has been shown to be both safe and effective. We have experienced a case of pelvic congestion syndrome that was diagnosed by venography.

A case of fibroepithelial polyp of vulva / 대한산부인과학회지

Vulvar fibroepithelial polyp is a relatively uncommon benign polypoid tumor of the vulva commonly known as skin tag or occasionally acrochordon. In this case, a 18 years old girl complained of painless bulging mass at the right labium major. She has been suffering from slowly growing a vulva tumor for ten years. It was arising from the right labium major and measured 12 cm in its largest diameter. We have experienced an unusually large vulva mass that was surgically excised and histologically diagnosed as benign fibroepithelial polyp and presented this case with a brief review of literature.

Clinicopathologic Features of Sporadic Colorectal Cancer with MLH1/MSH2 Loss of Expression - Reduced Likelihood of Metastases

PURPOSE: This study was designed to determine the frequency of MMR defective sporadic colorectal cancer (CRC) by using immunohistochemistry and to investigate the correlation between the MMR status and the metastatic potential. METHODS: The study included 249 patients with sporadic colorectal cancer who underwent surgical resection. The MMR status was determined by using an immunohistochemical analysis of MLH1 and MSH2 expression. RESULTS: Twenty seven (10.8%) carcinomas showed abnormal MMR protein expression (18 MLH1 negative and 9 MSH2 negative) and were classified as MMR defective tumors whereas 222 tumors demonstrated normal MLH1/MSH2 immunoreactivity (MMR intact tumor). MMR defective tumors developed at significantly higher frequencies in a proximal site (59.3% vs. 27.5%, P=0.001) and tended to be larger in size (6.3+/-2.4 cm vs. 5.1+/-2.1 cm, P=0.026). They showed significantly lower overall stage, N stage, and M stage at the time of diagnosis (P=0.002, P=0.014, P=0.010, respectively). In patients who had MMR defective tumors, lymphocytic infiltration (40.7% vs. 8.7%, P<0.001) and poor differentiation (22.2% vs. 11.7%, P=0.012) were more frequently observed. Less frequently MMR defective tumors displayed lymphatic invasion (40.7% vs. 67.1%, P=0.007) and infiltrative borders (22.2% vs. 51.8%, P=0.004). The MMR defect was strongly associated with a decreased likelihood of lymph node (odds ratio: 0.34, 95% CI: 0.13~0.95) and distant organ metastases at diagnosis (odds ratio: 0.09, 95% CI: 0.01~0.94), independent of the clinicopathologic features. CONCLUSIONS: mmunohistochemical analysis revealed that 10.8% of sporadic CRC cases showed no staining for MLH1 or MSH2. Lymphatic invasion and distant metastases were found at lower rates in these MMR defective tumors.

Spontaneous Jejunal Intussusception after a Colectomy: A Rare Cause of Postoperative Intestinal Obstruction: A Case Report

Intussusception is a rare cause of intestinal obstruction in adults and is most often due to a primary abnormality of the bowel, which serves as the leading point. Idiopathic intussusception in adults is distinctly uncommon, comprising 10% of diagnosed intussusceptions. We report a case of a spontaneous jejunal intussusception in a 48-year-old man that developed shortly after an open colectomy. The 48-year-old man, with no history of a laparotomy, underwent a left hemicolectomy and a left hemihepatectomy for descending colon cancer with liver metastasis. For 14 postoperative days, the patient complained of ileus, and conservative management with a long intestinal tube failed. When the patient underwent a laparotomy, intussusception of the mid jejunum was observed. The intussusception was resected, and no underlying bowel abnormality was identified. This report highlights the importance of considering this rare etiology in patients with ileus who have recently undergone a laparotomy.

Hypertriglyceridemia induced acute pancreatitis in pregnancy / 대한산부인과학회지

Hypertriglyceridemia is a rare cause of pancreatits. However the relationship between acute pancreatits and severe hypertrigyceridemia is well recognized. It can be a life- threatening complication if the degree of hypertrigyceridemia is severe enough. A serum triglyceride level of more than 1,000 to 2,000 mg/dL is the identifiable risk factor. The clinical course and management of hypertriglyceridemia induced acute pancreatitis is not different from other causes. The clinical course and management of hypertriglyceridemia induced acute pancreatitis during pregnancy are similar to the one during nonpregnant state. The prevalence of acute pancreatitis in pregnancy ranges between 1 in 1,000 to 1 in 3,000. Gestational hypertrigyceridemic pancreatits can be fatal, and maternal morbidity rate has an upward trend of 20%. We report a 31-year-old woman with coexistence of hypertrigyceridemia and acute pancreatits at 32 weeks gestation with a brief review of the literatures.

Uterine artery embolization for the management of uterine artery bleeding after transobturator tape operation: A case report / 대한산부인과학회지

Transobturator tape (TOT) operation for urinary stress incontinence is associated with less complication rate than Tension free vaginal tape (TVT). The two procedures yield similar rates of success. The TOT is lead through the obturator foramen, reducing the risk of bladder injury as well as damage of structures located in the Retzii cave, e.g. nerves and blood vessels. However the complications of TOT procedure may have several complications associated with obturator foramen. They are the injury of obturator nerve and vessels, abscess formation on th obturator foramen, vulvar hematoma, etc. There is no report the uterine artery injury after TOT procedure so far. Recently we experienced a case of successful control of bleeding of the uterine artery after TOT operation via uterine artery embolization. Therefore we report our case with brief review of the literatures.

Endoscopic Balloon Dilatation for Anastomotic Stricture Developed after Surgery for Colorectal Cancer

PURPOSE: This study was to evaluate the safety and efficacy of endoscopic balloon dilatation for anastomotic strictures that developed after colorectal cancer (CRC) operations. METHODS: Between Jan. 2001 and Dec. 2006, 18 patients (12 men, 6 women) who underwent endoscopic balloon dilatation for anastomotic strictures that developed after CRC operation at the Center for Colorectal Cancer, National Cancer Center, were enrolled, and their medical records were reviewed retrospectively. The median distance from the anal verge to the stricture was 10 cm (range, 3~40 cm). Dilatations were performed using through-the-scope balloons with diameters of 18 to 20 mm on inflation. RESULTS: The overall success rate of endoscopic balloon dilatation was 94.4% (17 patients). The mean number of treatment sessions per patient was 1.9 (range, 1~7). Of the 17 patients treated successfully, 11 patients (64.7%) required only one dilatation, 4 patients (23.2%) required 2 dilatations, and two patients (11.8%) required 7 dilatations. Failure of balloon dilatation occurred in one patient. No complications occurred. CONCLUSIONS: Endoscopic balloon dilatation of anastomotic strictures after a CRC operation is safe and efficient.

Cost of Colorectal Cancer Care in Korea: A Prospective Group Study with a 2-year Follow-up

PURPOSE: The incidence of cancer incidence and the rate of mortality are increasing in Korea. Specifically, colorectal cancer in men is one of the most sharply increasing malignancies. The objective of this study was to assess the direct costs for colorectal cancer patients and to identify the factors that influence cancer costs. METHODS: The direct costs of colorectal cancer were examined with a prospective group study at a hospital. The direct costs were assessed every 3 months over a 24-month period through patient interviews, medical records, and claims data. We identified the major factors associated with the cost of colorectal cancer by using a general linear model for the log-transformed data. RESULTS: The group was comprised of 100 patients with colon cancer and 120 patients with rectal cancer. The average costs per patient during the first and the second years after diagnosis were 16,280,000 won and 5,786,000 won respectively. Medical costs accounted for about 68% (11,090,000 won) of the first year's total cost and about 62% (3,602,000 won) of the second year's total cost. National Health Insurance (NHI) paid approximately 50% of the total medical cost. The total cost of colorectal cancer was clearly associated with the stage of the disease at first diagnosis, the cancer site, therapeutic modalities, and recurrence. CONCLUSIONS: These results indicate that colorectal cancer has a heavy financial impact on cancer patients. The total cost of colorectal cancer is clearly associated with the stage of the disease at first diagnosis. Increased efforts in terms of prevention and early detection may assist in reducing the costs.

A case of right rudimentary uterus with ipsilateral renal agenesis misdiagnosed as an ovarian tumor / 대한산부인과학회지

Rudimentary uterus with ipsilateral renal agenesis is a very rare Mullerian duct malformation. The most common clinical presentation is pelvic pain and dysmenorrhea shortly after menarche, in associated with the finding of a vaginal or pelvic mass. An appropriate and prompt diagnosis and treatment will prevent unnecessary procedures and offer relief of symptoms. We report one case of rudimentary uterine horn with ipsilateral renal agenesis with a brief review of concerned literatures.

Treatment Patterns for Colorectal Cancer Patients at the National Cancer Center Korea in 2003

PURPOSE: In Korea, colorectal cancer (CRC) is one of the most sharply-increasing malignancies, and the National Colorectal Cancer Screening Program for persons over 50 years of age began in 2004. To determine the effectiveness of the program, comparative data regarding CRCs treated prior to 2004 must be analyzed. The present study assessed CRC status at diagnosis and treatment patterns in 2003. METHODS: In 2003, 503 patients were newly diagnosed with CRC and were treated at the Center for Colorectal Cancer, National Cancer Center (NCC). Clinical data were retrospectively reviewed. RESULTS: The 503 patients included 256 colon and 247 rectal cancer patients. Of the 256 colon cancer patients, 5 (2.0%) were diagnosed during screening colonoscopies and were successfully treated using an endoscopic mucosal resection (EMR), and 17 (6.6%) received only palliative chemotherapy because of distant metastases. Forty patients (15.6%) were treated with palliative surgery and chemotherapy, and 194 (75.8%) with curative surgery with or without adjuvant chemotherapy. Of the 247 rectal cancer patients, 9 (3.6%) were treated with an EMR, 20 (8.1%) with palliative chemotherapy with or without radiotherapy, 19 (7.7%) with palliative surgery and chemoradiotherapy, and 199 (80.6%) with curative surgery with or without chemoradiotherapy. Treatment with curative intent was possible in 199 of 256 (77.7%) colon cancer patients and in 208 of 247 (84.2%) rectal cancer patients. CONCLUSIONS: Only 12.1% of colon and 8.5% of rectal cancer patients were diagnosed early and treated without adjuvant therapies at the NCC in Korea in 2003.

Safety and Efficacy of Colonoscopic Tattooing of a Colorectal Neoplasm Prior to a Laparoscopic Resection

PURPOSE: Accurate tumor localization prior to a laparoscopic surgical resection is the critical. India ink tattoos properly placed in the colorectum are long lasting and have been reported to probably remain constantly in previous studies. The present study was done to review the safety and reliability of colonoscopic tattooing prior to a laparoscopic resection of a colorectal neoplasm. METHODS: Between May 2003 and August 2004, 20 patients underwent colonoscopic tattooing of a colorectal neoplasm prior to laparoscopic surgery. The clinical data were retrospectively reviewed. RESULTS: Among the 20 patients, 14 (70%) had tumors located in the sigmoid colon, 4 (20%) had tumors in the rectosigmoid junction, and 1 had a tumor (5%) in the upper rectum and descending colon. In six patients (30%) who had received an endoscopic mucosal resection (EMR), an additional surgical resection was required to remove the tumor completely, and those 6 patients needed another preoperative colonoscopy for India ink tattooing. The median time between tattooing and resection was 2 days (range: 1 to 18 days). Tattoos were visualized intraoperatively and localized the tumor accurately in 15 patients (75%). Seven patients underwent intraoperative colonoscopy; five didn't have tattoos that could be visualized intraoperatively, and two patients with visible tattoos needed intraoperative colonoscopy to confirm the site of tumor. Only one patient (5%) had mild fever with abdominal discomfort, which were relieved by hydration and administration of intravenous antibiotics for one day. CONCLUSIONS: A colorectal neoplasm can be localized with an acceptable reliability by using preoperative colonoscopic tattooing. India ink tattooing at the time of the EMR may reduce unnecessary colonoscopies if we doubt a complete resection has been achieved by using an EMR. The complications following colonoscopic tattooing were minimal.

The Quality Evaluation of Information of Websites on Colorectal Cancer Using the DISCERN Instrument

PURPOSE: Many patients rely on the Internet for medical information. In Korea, there are many websites providing medical information, but the quality of these websites relating to colorectal cancer remains to be clarified. This study was performed to evaluate the quality of websites providing information on colorectal cancer. METHODS: Firstly, sites were identified using four major domestic search engines and were classified according to the administrator. Then, two surgical oncologists used the 'DISCERN' instrument to assess 12 sites (including 2 foreign sites) for the reliability and the quality of the information on treatment choice. RESULTS: Total 297 sites were identified using the search term 'colorectal cancer'. Excluding dead links or duplicated sites, 148 sites were identified. When the sites had been classified according to the administrator of the websites, 115 (77.7%) were identified as local clinic or hospital sites, 8 (5.4%) as medical school sites, 7 (4.7%) as institute or public health sites, 11 (7.4%) as commercial sites, and 7 (4.7%) as private sites. The results of the evaluations by the two examiners showed moderate inter-examiner reliability (K=0.41). The evaluations of the domestic sites by using DISCERN showed serious or important shortcomings in the quality of information on treatment choices and in reliability. Among these domestic websites, the quality of information provided at private or local hospital sites was poorer than that provided at institute or public health sites. CONCLUSIONS: About 80% of the websites providing medical information on colorectal cancer were identified as private or local hospital sites. Evaluations of the information provided at domestic sites showed serious or important shortcomings.