[Modified FOLFOX6 treatment for obstructive jaundice caused by hepatic lymph-node metastasis from liver metastases of rectal cancer--a case report].

Chemotherapy is potentially hazardous for patients with liver dysfunction. Although FOLFOX regimen is one of the standard chemotherapies for nonresectable liver metastases of colorectal cancer, the safety of this regimen has not been established yet in patients with obstructive jaundice associated with multiple liver metastases. We report a case of nonresectable liver metastases of rectal cancer treated by modified FOLFOX6 regimen after percutaneous transhepatic biliary drainage for obstructive jaundice, which was caused by hepatic lymph-node metastasis. Five days after giving a birth, a 32-year-old woman underwent Hartmann's procedure for perforation of rectal cancer associated with multiple liver metastases. She was admitted again to receive chemotherapy 35 days after surgery, but the level of total bilirubin was elevated (3.9 mg/dL). Since the total bilirubin level was not rapidly decreased after PTBD, the modified FOLFOX6 regimen was started with a 70% dose. After an introduction of mFOLFOX6 treatment, a biliary-stenting was successfully performed, and the mFOLFOX6 continued with a full dose starting from the 5th cycle. Although the therapeutic efficacy after an additional 8-cycle was classified as stable disease (SD), she did not show any sign of adverse effects except for grade 1 neurotoxicity.

[Hepatic lymph-node involvement in patients with synchronous liver metastasis from colorectal cancer-a correlation with the grading system for liver metastasis].

This retrospective study was performed to clarify the frequency and clinical significance of hepatic lymph-node metastasis in patients with synchronous liver metastasis from colorectal cancer, in relation to the grading system of liver metastasis classified by the 7th Edition of General Rules for Clinical and Pathological Studies on Cancer of the Colon, Rectum and Anus. Hepatic lymph-node metastasis was histologically examined in 61 patients with synchronous liver metastasis whose primary lesion was resected. The incidence of hepatic lymph-node metastasis for all patients was 26%. The frequency was 8% in Grade A (n=13), 20% in Grade B (n=15), and 36% in Grade C (n=33) (p=0.09). Among patients classified in Grade A/Grade B, the patients with hepatic lymph-node metastasis showed a shorter survival time than those without metastasis (p<0.01). Among patients in Grade C, there was no significant difference in survival times between the patients with hepatic lymph-node metastasis and those without metastasis (p=0.59). In conclusion, the incidence of hepatic lymph-node metastasis should be considered regardless of the Grade of liver metastasis from colorectal cancer.

[Prognosis of patients undergoing resection of both hepatic and pulmonary metastases from colorectal cancer].

This retrospective study evaluated the prognosis of patients undergoing resection of both hepatic and pulmonary metastases from colorectal cancer. The subjects were 14 patients who underwent resection of both hepatic and pulmonary metastases from colorectal cancer between January 1991 and January 2008. The range of patient age at first metastatectomy was 48- 73-years-old (median 59). The ratio of males to females was 4 to 3. Hepatic metastatectomy proceeded to pulmonary metastatectomy in 10 cases, while pulmonary metastatectomy was performed first in 4 cases. The median duration of relapse-free survival and overall survival after the second metastatectomy was 11.2 months and 20.4 months, respectively. The overall survival after the second metastatectomy tended to correlate with the relapse-free survival after the first metastatectomy (rs=0.55, p=0.08). In conclusion, relapse-free survival after the first metastatectomy should be considered when a second metastatectomy is scheduled in patients with both hepatic and pulmonary metastases from colorectal cancer.

[Problems involved in the resection of pulmonary metastasis from colorectal cancer in the era of new anticancer drugs].

BACKGROUND AND PURPOSE: Surgical resection has been the standard treatment recommended for respectable pulmonary metastasis from colorectal cancer. However, we should evaluate again the indication of bilateral thoracotomy and repeat resection of pulmonary metastatic lesions, because these surgical interventions may deteriorate the patients' quality of life. This retrospective study was performed to address this issue. PATIENTS AND METHODS: The subjects were 39 patients who underwent pulmonary metastatectomy of colorectal cancer between May 1990 and January 2007. The prognosis was evaluated according to the types of thoracotomy, bilateral thoracotomy (n=5), repeat pulmonectomy (n=6), and single thoracotomy (n=28). In addition, the impact of new anticancer drugs (5-fluorouracil+Leucovorin, S-1, irinotecan, and oxaliplatin) on survival after thoracotomy was examined. RESULTS: The patients undergoing bilateral thoracotomy showed a significantly shorter survival after the last thoracotomy than those in other groups (p=0.03). The survival time after the initial thoracotomy was not different between patients who received new anticancer drugs (n=11) and those without (n=28, p=0.58). CONCLUSIONS: Bilateral pulmonary metastatectomy from colorectal cancer appears to have little benefit on survival, while a repeat metastatectomy may cause a long-term survival. A further collection of cases is needed to conclude whether the new anticancer drugs would be useful for prolonging the patients' survival after pulmonary metastatectomy.

[Administration of polysaccharide K (PSK) for stage III colorectal cancer in clinical practice].

PURPOSE: This retrospective study was performed to evaluate the administration and effect of PSK in patients with stage III colorectal cancer in clinical practice. PATIENTS AND METHODS: The subjects were 55 patients with stage III colorectal cancer who received adjuvant chemotherapy, comprising UFT in 44, UFT/calcium folinate (Leucovorin) in 4 and 5-FU/levofolinate calcium (l-LV) in 7, between April 2000 and December 2006. The rate of administering PSK, disease-free survival time, and overall survival time were evaluated. RESULTS: The rate of administering PSK was 82%. There was no significant difference in disease-free survival and overall survival between patients who received PSK and those without. Among the patients in stage IIIa, the patients who received PSK tended to show a longer overall survival time than those without PSK (p =0.15). CONCLUSIONS: The rate of administering PSK is high in patients with stage III colorectal cancer. But further cases would be needed to evaluate the effect of PSK with 5-FU-based adjuvant chemotherapy.

[Efficacy and safety of modified FOLFOX6 regimen in aged patients with nonresectable colorectal cancer].

PURPOSE: This retrospective study was performed to clarify the efficacy and safety of FOLFOX regimen in aged patients with nonresectable colorectal cancer. PATIENTS AND METHODS: We had 92 patients with nonresectable colorectal cancer between December 2005 and March 2008. The rate of introducing modified FOLFOX6 (mFOLFOX6) regimen was compared among the patients aged 75 years or older (n = 22, aged group) and those aged 74 years or younger (n = 55, younger group). In addition, relative dose intensity (RDI), therapeutic efficacy, and adverse events in the patients who were given the regimen, we compared between the groups. RESULTS: The rate of introducing the regimen was significantly lower in the aged group (36%, n = 8) than in the younger group (79%, n = 55) (p<0.01). The RDI tended to be lower in the aged group (68.0% versus 79.9%, p=0.10). There were no significant differences in the response rate, disease-control rate, progression-free survival, and overall survival between the groups. The rate of adverse events ( > or = grade 3) was not different between the groups ( 50% versus 51%). CONCLUSION: Similar to younger patients the mFOLFOX6 regimen is feasible, safe and effective in the selected aged patients, although the dose reduction may be needed for such patients.

[The validity of full administration of 5-fluorouracil, irinotecan, and oxaliplatin to unresectable or recurrent colorectal cancer].

PURPOSE: This retrospective study was performed to evaluate a survival benefit of the full administration of 5-fluorouracil (5-FU), irinotecan (CPT-11), and oxaliplatin (L-OHP) to patients with unresectable or recurrent colorectal cancer. PATIENTS AND METHODS: The subjects are 145 patients with unresectable or recurrent colorectal cancer who were given CPT-11 and/or L-OHP in addition to 5-FU. The overall survival times of these patients were evaluated. RESULTS: The median survival time (MST) was significantly longer in patients treated with three drugs (n=72) than patients treated with two drugs (n =73) (31.6 months versus 18.4 months, p<0.01). When analysis was restricted to patients treated with three drugs, there was no significant difference in MST between patients who were given L-OHP followed by CPT-11 (n=18) and those treated with these two drugs in reverse order (n=54) (p=0.67). CONCLUSIONS: Compared with the use of 5-FU in combination with CPT-11 or L-OHP, a full administration of three drugs may have a more beneficial impact on patients' survival and irrespective of the order of administering CPT-11/L-OHP.

[Clinical significance of chemotherapy and chemo-radiotherapy in patients with metastatic esophageal cancer].

PURPOSE: We investigated the clinical significance of chemo-radiotherapy (CRT) and chemotherapy (CT) in patients with primary metastatic esophageal cancer. PATIENTS AND METHODS: Twenty-six patients with esophageal cancer received CRT (n =21) or CT alone (n=5) as a first treatment for para-aortic lymph node and/or hematogenous metastases. The therapeutic effect, duration of treatment, changes in performance status before and after treatment, and survival were analyzed retrospectively. RESULTS: The median duration of treatment was 2.9 months for CRT and 2.3 months for CT. The response rate was 76% in patients who underwent CRT and 20% in patients who underwent CT. In 18 patients (69%), the level of performance status showed no change after treatment in comparison with that before treatment. The median survival time was 5.6 months after CRT and 5.8 months after CT (p=0.91). CONCLUSION: These results suggest that the majority of patients with extremely advanced esophageal cancer can tolerate CRT or CT well without compromising their performance status within their limited life expectancy.

Clinical significance of plasma level of vascular endothelial growth factor-C in patients with colorectal cancer.

OBJECTIVE: Vascular endothelial growth factor (VEGF)-C is known to be associated with angiogenesis and lymphangiogenesis in various cancers. However, little is known about the clinical significance of determining the blood level of VEGF-C in patients with colorectal cancer. METHODS: Plasma levels of VEGF-C in patients with colorectal cancer (n = 127) and normal healthy volunteers (n = 23) were determined by the sandwich enzyme-linked immunosorbent assay. RESULTS: The plasma VEGF-C concentration did not significantly differ between patients with colorectal cancer and healthy controls (P = 0.53). However, subgroup analysis showed that deeper tumor invasion (P = 0.04), more severe lymphatic invasion (P = 0.03) and venous invasion (P < 0.01) were correlated with an elevated level of plasma VEGF-C. Among the patients (n = 109) who underwent potentially curative surgery, the plasma level of VEGF-C was higher in patients who developed recurrence (n = 35) than in those who did not (n = 74) (P = 0.04). In addition, disease-free (P = 0.02) and overall survival times (P = 0.02) were shorter in patients with a high level (>1840 pg/ml) of plasma VEGF-C than in those with a low level (< or =1840 pg/ml) when the cut-off value was determined on the basis of the median value in colorectal cancer patients. Multivariate analysis with the Cox proportional hazard model demonstrated that the plasma VEGF-C level along with Dukes' stage was an independent factor affecting overall survival (P = 0.03). CONCLUSION: These results suggest that determining the plasma level of VEGF-C would be useful for predicting lymphatic invasion, venous invasion and poor outcome of patients with colorectal cancer.

Localized small-bowel infarction caused by Aspergillus during chemotherapy for acute myeloid leukemia: report of a case.

Aspergillosis is a common fungal infection in immunocompromised patients undergoing chemotherapy. The incidence of invasive fungal infection in these patients has increased dramatically in recent years. We report a case of small-bowel infarction caused by Aspergillus in a 48-year-old man who was receiving chemotherapy for acute myeloid leukemia. On day 20 after the start of chemotherapy, right lower abdominal pain and rebound tenderness developed, with a high fever. A contrast-enhanced computed tomography scan showed a semicircular perfusion defect in the ileum. Thus, we performed partial resection of the ileum with primary anastomosis. Macroscopically, the ileum had mucosal ulcerations. Microscopically, there was transmural necrosis with microperforation and Aspergillus invading necrotic tissue and blood vessels. The patient had an uneventful postoperative course and was discharged 14 days after the procedure. Intestinal aspergillosis is rare and associated with high mortality. Thus, it should be considered in the differential diagnosis of neutropenic patients with sudden abdominal pain and fever.

Rupture of a pancreaticoduodenal artery aneurysm into the common bile duct resulting in fatal suppurative cholangitis: report of a case.

A 73-year-old man with a preoperative diagnosis of cholangitis underwent a laparotomy, which revealed a necrotized gallbladder and dilated common bile duct, both filled with foul-smelling clotted blood. We could not find the cause of hemobilia at this time. On postoperative day (POD) 11, an exsanguinating hemorrhage suddenly began pouring from the T-tube, suggesting the possibility of a ruptured gastroduodenal artery branch aneurysm into the biliary system. Immediate angiography confirmed multiple aneurysms of the gastroduodenal artery. Embolization was done and there was no further bleeding from the T-tube; however, the patient's condition was too critical for recovery and he died on POD 17. At autopsy, we found multiple aneurysms in the gastroduodenal artery. The posterior superior pancreaticoduodenal artery, diverging from one of the aneurysms of the gastroduodenal artery, formed another tiny aneurysm subjacent to the common bile duct wall. Rupture of this aneurysm into the biliary system caused fatal acute obstructive suppurative cholangitis.