Large Cell Neuroendocrine Carcinoma of the Colon With Carcinomatosis Peritonei

Colorectal large-cell neuroendocrine carcinomas (NECs) are extremely rare and have very poor prognosis compared to adenocarcinomas. A 74-year-old man presented with abdominal pain, diarrhea and hematochezia. The histopathologic report of colonoscopic biopsy performed at a local clinic was a poorly differentiated carcinoma. An abdominopelvic computed scan revealed irregularly enhanced wall thickening at the sigmoid colon with regional fat stranding and lymphnode enlargement. He underwent a laparoscopic high anterior resection with selective peritonectomy for peritoneal carcinomatosis, intraoperative peritoneal irrigation chemotherapy, and early postoperative intraperitoneal chemotherapy for 5 days. The tumor had a high proliferation rate (mitotic count > 50/10 HPFs and 90% of the Ki-67 index) and lymph-node metastases had occurred. On immunohistochemistry, the tumor cells expressed CD56 and synaptophysin. Large-cell NEC was confirmed. Systemic chemotherapy with cisplatin/etoposide was done. The patient is still alive after 3 years with no evidence of recurrence.

Diagnostic and prognostic value of preoperative ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography for colorectal cancer: comparison with conventional computed tomography

BACKGROUND/AIMS: ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) has been used for preoperative staging of colorectal cancer (CRC). However, the diagnostic accuracy of FDG-PET/CT for detection of lymph node or distant metastasis and its prognostic role have not been well established. We therefore evaluated the diagnostic and prognostic value of FDG-PET/CT in comparison with conventional CT for CRC. METHODS: We investigated 220 patients who underwent preoperative FDG-PET/CT and CT, followed by curative surgery for CRC. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of FDG-PET/CT and CT for detection of lymph node metastasis and distant metastasis were evaluated. In addition, we assessed the findings of FDG-PET/CT and CT according to outcomes, including cancer recurrence and cancer-related death, for evaluation of prognostic value. RESULTS: For detection of lymph node metastasis, FDG-PET/CT had a sensitivity of 44%, a specificity of 84%, and an accuracy of 67%, compared with 59%, 65%, and 62%, respectively, for CT (P=0.029, P=0.000, and P=0.022). For distant metastasis, FDG-PET/CT had a sensitivity of 79%, a specificity of 94%, and an accuracy of 93%, compared with 79%, 87%, and 86%, respectively, for CT (P=1.000, P=0.004, and P=0.037). In addition, positive findings of lymph node metastasis and distant metastasis on FDG-PET/CT were associated significantly with cancer recurrence or cancer-related death (P=0.009, P=0.001, respectively). CONCLUSIONS: Preoperative FDG-PET/CT had a higher specificity and accuracy compared to CT for detection of lymph node metastasis and distant metastasis of CRC. In addition, FDG-PET/CT could be a valuable prognostic tool for CRC.

Quality of life changes during adjuvant chemotherapy in patients with colon cancer

PURPOSE: The survival of advanced colon cancer patients has increased due to the development of surgical techniques and adjuvant chemotherapy. The administration of adjuvant chemotherapy after curative resection is generally accepted as a standard of care. The primary endpoint of chemotherapy should include not only tumor response and survival, but also impact on the quality of life (QoL). We evaluated changes in QoL during adjuvant chemotherapy in patients with colon cancer.METHODS: Between October 2009 and February 2012, 56 patients with stage II and III colon cancer received the combination adjuvant chemotherapy 5-flurouracil/folinic acid with oxaliplatin (FOLFOX). Patients were asked to complete the QoL questionnaire QLQ-C30 version 3 before and after 6 cycles of adjuvant chemotherapy.RESULTS: There was no significant difference in the QoL between the start of chemotherapy and after the completion of 6 cycles. After completion of 6 cycles, global QoL was worse in patients >70 years of age. The functional scale score was low in patients with chemotherapy schedules delayed more than 2 times due to adverse events. Patients with body weight increases greater than 5% scored lower on symptom scales. Interestingly, patients with peripheral neuropathy scored higher on symptom scales.CONCLUSION: QoL changes during adjuvant chemotherapy did not show significant differences. After the sixth chemotherapy, QoL was affected by age, body weight gain, delay of the scheduled chemotherapy, and peripheral neuropathy. Therefore, the proper attitude of physicians focused on reassurance and education of patients is very important during chemotherapy.

Mesh-Based Transperineal Repair of a Perineal Hernia After a Laparoscopic Abdominoperineal Resection

A perineal hernia (PH) is formed by a protrusion of intra-abdominal viscera through a defect in the pelvic floor. This is a rare complication after a conventional abdominoperineal resection (APR). However, the risk of a PH may be increased after a laparoscopic resection because this technique can cause fewer postoperative adhesions, predisposing the small bowel to sliding down toward the pelvis. However, only a few case reports describe the transperineal approach for the repair of a PH after a laparoscopic APR. We present a case of a PH after a laparoscopic APR; the PH was repaired with synthetic mesh by using a transperineal approach. A transperineal approach using a mesh to reconstruct the pelvic floor is less invasive and more effective. We suggest that this technique should probably be the first choice for treating an uncomplicated PH that occurs after a laparoscopic APR.

Podoplanin, alpha-Smooth Muscle Actin or S100A4 Expressing Cancer-Associated Fibroblasts Are Associated with Different Prognosis in Colorectal Cancers

The interactions between the tumor microenvironment and tumor cells determine the behavior of the primary tumors. Whether cancer-associated fibroblasts (CAF) have a tumor progressive or a protective role likely depends on the type of tumor cells and the CAF subpopulation. In the present study, we analyzed the prognostic significance of CAF subpopulations in colorectal cancer (CRC). CAF phenotypes were analyzed in 302 CRC patients by using antibodies against podoplanin (PDPN), alpha-smooth muscle actin (alpha-SMA), and S100A4. The relationship between the CAF phenotypes and 11 clinicopathological parameters were evaluated and their prognostic significance was analyzed from the disease-free and overall survival times. We observed that at the tumor invasive front, PDPN CAFs were present in 40% of the cases, and S100A4 or alpha-SMA CAFs were detected in all the cases. PDPN/S100A4 and alpha-SMA/S100A4 dual-stained CAFs were observed in 10% and 40% of the cases, respectively. The PDPN+ CAFs were associated with 6 favorable clinicopathological parameters and prolonged disease-free survival time. The PDPN-/alpha-SMA(high) CAFs were associated with 6 aggressive clinicopathological parameters and tended to exhibit shorter disease-free survival time. On the other hand, the PDPN-/S100A4(high) CAFs were associated with 2 tumor progression parameters, but not with disease prognosis. The PDPN+ CAF phenotype is distinct from the alpha-SMA or S100A4 CAFs in that it is associated with less aggressive tumors and a favorable prognosis, whereas the PDPN-/alpha-SMA(high) or PDPN-/S100A4(high) CAFs are associated with tumor progression in CRC. These findings suggest that CAFs can be a useful prognostic biomarker or potential targets of anti-cancer therapy in CRC.

Unusual Case of Solitary Perineal Subcutaneous Metastasis From Sigmoid Colon Cancer

Subcutaneous metastasis from colorectal cancer is an unusual presentation. Most perineal subcutaneous metastases are found in extensive involvements of multiorgan metastases or local recurrences of rectal cancer. Subcutaneous metastasis from colon cancer is considered as a distant metastasis with poor prognosis. We report an unusual case of solitary subcutaneous metastasis beneath the perineum without solid organ involvement after a curative anterior resection for sigmoid colon cancer. The patient underwent a perineal resection, and chemotherapy with the FOLFOX (fluorouracil, leucovorin, and oxaliplatin) regimen was instituted. Eight months later, multiple lung metastases were found, and chemotherapy was restarted with the FOLFIRI (fluorouracil, leucovorin, and irinotecan) regimen. However, lung metastases progressed, and new metastases appeared at the adrenal glands, the kidneys and the cerebellum. The patient died 30 months after the diagnosis of perineal subcutaneous metastasis. He lived relatively long in comparison with patients in previous reports.

Treatment of a Recurrent Rectourethral Fistula by Using Transanal Rectal Flap Advancement and Fibrin Glue: A Case Report

Rectourethral fistulas (RUFs) in adults are rare and could result from complicated trauma, and prostatic or rectal surgery. RUFs have been treated initially by using primary repair and omental interposition with or without a colostomy during surgery. Recurrent RUFs require complex surgery, such as a low rectal resection and coloanal anastomosis, an interposition flap of the datos muscle or gracilis muscle, and others. Recently, transanal rectal flap advancement and fibrin glue injection have provided an effective occlusion of RUFs. However, no reports about this technique exist for cases of recurrent RUFs. We report a case of a recurrent RUF successfully repaired by using transanal rectal flap advancement combined with fibrin glue injection into the fistula tract. The postoperative course was uneventful without complications. At the 1-year follow-up, no complications such as urethral stricture or recurrence existed, and voiding was normal without anal incontinence.

A Case of Colovesical Fistula Induced by Sigmoid Diverticulitis

Colonic diverticulosis has continuously increased, noticeably left-sided diseases, in Korea. A colovesical fistula is an uncommon complication of diverticulitis, and its most common cause is diverticular disease. Confirmation of its presence generally depends on clinical findings, such as pneumaturia and fecaluria. The primary aim of a diagnostic workup is not to observe the fistular tract itself but to find the etiology of the disease so that an appropriate therapy can be initiated. We present here the case of a 79-year-old man complaining of pneumaturia and fecaluria. On abdomen and pelvis CT, the patient was diagnosed as having a colovesical fistula due to sigmoid diverticulitis. After division of the adhesion between the sigmoid colon and the bladder, the defect of the bladder wall was repaired by simple closure. The colonic defect was treated with a segmental resection, including the rectosigmoid junction. The patient is doing well at 6 months after the operation and shows no evidence of recurrence of the fistula.

Muscle Regeneration: Research for the Treatment of Fecal Incontinence

Fecal incontinence remains a socially isolating condition, which can have a profound impact on all aspects of quality of life. It affects 2% to 17% of people living in the community and is an iatrogenic disease that develops after a restorative proctectomy for rectal cancer. Conservative management, such as biofeedback and medication, or surgical therapy may be ineffective, the symptomatic benefit being disappointing. In a few recent reports, autologous myoblasts injected into the urinary or anal sphincter were used successfully for the treatment of incontinence, and these cells improved the muscle function. These autologous cell therapies can avoid adverse events, such as tumor formation, compared to the use of embryonic stem cells. However, the limited regenerative capacity of cell therapy has prompted the development of replacing dysfunctional muscle tissue. Regenerative medicine for functioning muscles may be a therapeutic tool for fecal incontinence in the future. Now, many challenges remain to be overcome prior to reaching the ultimate goal of a fully functional 3-D vascularized engineered muscle: These include development of highly organized 3-D scaffolds, development of scaffolds that specifically direct cellular differentiation, development of co-culture systems of multiple cell types on smart surfaces, development of vascularized constructs, reduction of serum dependence, and innervation into constructed muscle. The successful generation of functional muscle tissues requires an in-depth knowledge of both muscle tissue physiology and advanced engineering practices. The recent advances in tissue engineering technique and cell biology suggest that artificially-derived muscle constructs may be used in clinical settings in the near future.

Experiences on Obturator Hernia and Review of Korean Cases

PURPOSE: We performed this study to share experiences in the management of obturator hernia, which is a very rare disease among elderly women, because rarity of this disease will not approve an expert institute or surgeon and because the aging society, Korea, can increase the incidence. METHODS: Patient characteristics, clinical manifestations and treatment results were retrospectively collected from the 12 obturator hernia patients since 2000 in the three hospitals of the authors. Twenty-one obturator hernia cases reported in the Korean literatures were reviewed. In addition, we analyzed clinical features and treatment results of the total 33 patients, collectively. RESULTS: Most of the patients were elderly women except one young, poorly nourished, male patient with pulmonary tuberculosis. Their mean age was 79.6 years. Sixty-four percent (21/33) of the patients had preoperative morbidity. Symptoms from the compression of the obturator nerve, which is an important clue to the diagnosis, were observed in 67% (22/33). Interestingly, spontaneous or suspicious-spontaneous reductions were reported in 7 (21%) patients. Abdominal CT scan was the major tool for diagnosis. Abdominal approach alone could successfully manage most cases, though 84% (27/32) needed anastomosis of the bowel. Operative mortality was 2 of the 32 cases but morbidity was 44% of the 32 patients and the mean hospital period after operation was 21 days. CONCLUSION: Management of patients with obturator hernJd surgical management and proper peri-operative care as well as appropriate managing the families is essential for improved results.

The State of Patient Satisfaction after Hernioplasty on an Ambulatory Basis

PURPOSE: There have been no studies employing a specific questionnaire relating to patient satisfaction following ambulatory hernioplasty. Via the production of a novel specific questionnaire, attempts were made to determine the factors associated with patient satisfaction following hernioplasty on an ambulatory basis. METHODS: Patient satisfaction was evaluated via cross-sectional telephone surveys administered 10.5 (range of 2~23) months after their operations, consisting of six questions, regarding; anesthetic technique, surgical method, necessity for admission, necessity for follow-up, intraoperative pain, and postoperative pain. Each of the questions was then scored using a 4-point scoring system, with global satisfaction determined via the addition of each score. Factors related to global satisfaction were determined among preoperative, intraoperative and postoperative factors. RESULTS: Telephone questionnaire interviews were conducted on all 131 consecutive patients. Four respondents (3.1%) expressed dissatisfaction with the ambulatory surgery. Twelve (9.2%) had been admitted overnight after the operation. Thirteen (9.9%) required analgesics for over 3 days. No patients required a re-operation, although 20 (15.3%) experienced minor postoperative complications. Significant factors for global dissatisfaction were analgesic requirement for over 3 days and the presence of surgical complication (P value <0.05). Time until return to work and required overnight admission were important factors for patient satisfaction, but these were not significant. CONCLUSION: Patient satisfaction was associated with postoperative pain and surgical complications. Therefore, a more appropriate method for pain control and prevention of minor surgical complication are suggested might serve to enhance patient satisfaction after hernioplasty on an ambulatory basis.

Ulcerofungating Rectal Mass Caused by Cytomegalovirus Infection in a Patient with AIDS

Cytomegalovirus infection is a common complication in patients suffering from advanced acquired immunodeficiency syndrome. Cytomegalovirus infections of the gastrointestinal tract in human immunodeficiency-virus-positive patients tend to manifest as ulcerative lesions rather than as mass lesions. In this study, we describe a case of a mass lesion identified as cytomegalovirus proctitis in a human immunodeficiency-virus-positive patient, which had initially been thought to have an adenocarcinoma or a lymphoma. A 60-year-old man had an ulcerofungating mass in the rectum, which was initially detected via palpation. Findings of computerized tomography indicated a malignant mass, which was enhanced in the contrast image. An additional colonoscopy and biopsy were conducted for purposes of diagnosis. The histological examination revealed characteristic inclusion bodies within the nuclei of vascular endothelial cells in the ulcer bed. Immunohistochemical staining with anti-cytomegalovirus antibody confirmed the diagnosis of cytomegalovirus infection. The patient's anorectal lesion had subsided after the initiation antiviral treatments. The diagnosis of cytomegalovirus infection in human immunodeficiency-virus- positive patients occasionally proves rather difficult. Cytomegalovirus infection had induce the formation of mass lesions in immunocompromised patients.

Assessment of Peritoneal Irrigation and Drainage Following Elective Gastric Cancer Surgery

PURPOSE: Peritoneal irrigation and drain insertion were traditionally performed following major abdominal surgery, as routine procedures The aim of this retrospective study was to evaluate the usefulness of peritoneal irrigation and drain insertion following elective gastric cancer surgery. METHODS: Between December 2000 and Feburary 2002, 184 patients having undergone surgery for gastric cancer were divided into two groups, a comparative group (86 patients with peritoneal irrigation and drainage) and an experimental group (98 patient without peritoneal irrigation and drainage). The demographics, histopathological classification, range of dissection, comorbid disease, first passage of flatus, start of soft diet, operation time, anesthesia time and operative complication were analyzed retrospectively in consecutive patients. The data were analyzed by student's t-tests with the level of significance set at P<0.05. RESULTS: No significance differences were found between the two groups in regard to demographics, range of dissection, comorbid disease or complications. However the mean length of hospitalization, operation time and anesthesia time and the first passage of flatus, and start of soft diet in the experimental group were significantly shorter than those in the comparative group. CONCLUSION: The result shows that routine peritoneal irrigation and drain insertion following elective gastric cancer surgery are ineffective in reducing postoperative complications. We think these procedures are unnecessary and offer no considerable advantages.