Emergency surgery for hemorrhagic shock caused by a gastrointestinal stromal tumor of the ileum: A case report.

In this report, a case of hemorrhagic shock caused by a gastrointestinal stromal tumor (GIST) of the ileum, which was successfully treated by emergency surgery, is presented. A 67-year-old male patient presented to the Ibaraki Medical Center, Tokyo Medical University (Ami, Japan) in July 18, 2014, with dizziness and blood in the stool. Upper endoscopy and colonoscopy failed to reveal the source of the hemorrhage, although abdominal contrast-enhanced computed tomography revealed extravasation of the contrast medium into the small intestine. The patient developed hemorrhagic shock; thus, double-balloon enteroscopy (DBE) was performed, which revealed a Meckel's diverticulum and a submucosal tumor with excessive bleeding at 60 and 100 cm proximal to the ileocecal valve, respectively. Subsequent emergency partial resection of the ileum, including the tumor and the Meckel's diverticulum, was performed in July 20, 2014. Histological examination of the excised tumor revealed proliferation of spindle-shaped cells, and immunohistochemical staining of the tumor was positive for CD34, KIT and α-smooth muscle actin, but negative for S-100 protein. These immunohistological results supported the diagnosis of GIST of the ileum. The patient had an uneventful recovery and has been monitored at our outpatient clinic for 14 months after surgery. This case demonstrated the efficacy of DBE for the diagnosis of small intestinal bleeding, and immediate emergency surgery should be considered for cases of small intestinal GISTs with excessive bleeding.

Synchronous ovarian metastasis from colorectal cancer: A report of two cases.

Ovarian metastasis of colorectal cancer is relatively rare. The present study reports two cases of synchronous ovarian metastasis from colorectal cancer, which were managed by cytoreductive surgery. In case one, a 60-year-old female patient presented with a multilocular pelvic tumor and ascites. Virtual colonoscopy revealed a mass in the sigmoid colon; however, no tumor cells were identified on histological examination. Ovarian metastasis from sigmoid colon cancer was suspected and adnexectomy was subsequently performed. Histological examination of the excised tumor revealed adenocarcinoma. Immunohistochemical analysis of the resected tumor revealed positive staining for cytokeratin (CK)20 and caudal-type homeobox 2 (CDX2), and negative staining for CK7, estrogen receptor, progesterone receptor and inhibin. The immunohistological results supported the diagnosis of ovarian metastasis from sigmoid colon cancer. In case two, a 56-year-old female patient presented with a multilocular pelvic tumor and ascites. Colonoscopy identified a rectal tumor, and histological examination revealed moderately-differentiated adenocarcinoma, which was confirmed by cytological analysis of ascites. Subsequently, ovarian metastasis from rectal cancer with peritoneal dissemination was diagnosed, and left ovariectomy and transverse colostomy were performed. Histological examination of the excised tumor revealed moderately-differentiated adenocarcinoma, and immunohistochemical investigation revealed positive staining for CK20 and CDX2, but negative staining for CK7. These immunohistological results indicated ovarian metastasis from rectal cancer. Both patients recovered well and are currently undergoing regular follow-up examinations. The observations from the two cases indicate that ovarian metastases of primary colorectal cancer may present as pelvic tumors and, thus, preoperative examination of the gastrointestinal tract is required. Furthermore, even in cases of widespread colorectal cancer metastases, excision of the ovarian tumor is required to establish a histological diagnosis for the selection of appropriate treatments.

Pre-operative granulocyte/lymphocyte ratio as a predictive marker of post-operative complications in patients with colorectal cancer.

The aim of the present study was to assess the clinical relevance of the pre-operative granulocyte/lymphocyte (G/L) ratio as a predictive marker of post-operative complications in patients with colorectal cancer. In total, 85 patients (59 males and 26 females; mean age, 68.9 years) underwent surgery for colorectal cancer at the Department of Surgery, Ibraki Medical Center, Tokyo Medical University (Ami, Japan), and were divided into post-operative complication and non-complication groups. Clinical data, including age, gender, body mass index, tumor localization, tumor pathological type, cancer staging, surgery time, volume of surgical bleeding, pre-operative G/L ratio and further pre-operative laboratory data, including levels of albumin and C-reactive protein, Glasgow Prognostic Score, white blood cell count and levels of hemoglobin, creatine kinase, lactate dehydrogenase, carcinoembryonic antigen and carbohydrate antigen 19-9 were analyzed between these groups. The total post-operative complication rate was 18.8%. On univariate analysis, the amount of surgical bleeding and the pre-operative G/L ratio were significantly higher in the complication group than in the non-complication group (299.8±361.7 vs. 155.6±268.6 ml, P<0.05; and 6.73±10.38 vs. 3.49±2.78, P<0.05, respectively). Multivariate logistic regression analysis for the risk factors of post-operative complications, determined using univariate analysis, demonstrated that the amount of surgical bleeding and the pre-operative G/L ratio were independent risk factors of post-operative complications in patients with colorectal cancer. In conclusion, the G/L ratio may be a clinically relevant pre-operative predictive marker for post-operative complications.

Complete response of lung metastases from rectal cancer to combination first-line therapy of S-1 and irinotecan plus bevacizumab: A case report and review of the literature.

This report presents the case of a 72-year-old male who had undergone abdominoperineal resection following a diagnosis of lower rectal cancer with multiple lung metastases. Pathologically, the resected specimen exhibited advanced rectal cancer with regional lymphoid metastases and was classified as stage IV disease. S-1 and irinotecan (IRIS) plus bevacizumab combination therapy was used to treat the lung metastases following the surgery. S-1 (100 mg/body) was administered orally on days 1-14 of a 28-day cycle, and irinotecan (125 mg/m2) and bevacizumab (7.5 mg/kg) were administered by intravenous infusion on days 1 and 15. Computed tomography revealed a marked decrease in the size of the metastases following three therapeutic courses, and no lung metastases or new lesions were detected following nine therapeutic courses. The response was declared clinically complete. The patient refused additional treatment following nine therapeutic courses, and there was no recurrence 36 months after the final course of therapy. This case demonstrates the efficacy of IRIS plus bevacizumab as a first-line combination therapy against lung metastases of rectal cancer.

Removal of an intra-abdominal desmoplastic small round cell tumor by repetitive debulking surgery: A case report and literature review.

In the current study, a case of recurrent desmoplastic small round cell tumor (DSRCT) is presented, which was successfully treated by repetitive debulking surgery. In May 2010, a 39-year-old male, with a history of surgical resection of intra-abdominal DSRCT, visited the Ibaraki Medical Center, Tokyo Medical University Hospital (Ami, Japan) with severe lower abdominal discomfort. Abdominal computed tomography revealed a large tumor in the pouch of Douglas with a small number of nodules in the abdominal cavity. The recurrent DSRCT was diagnosed and removed via lower anterior resection; however, complete resection was impossible due to multiple peritoneal metastases. One year later, the patient developed pain in the right groin due to the growth of metastasized tumor cells in the groin lymph nodes. The affected lymph nodes were removed utilizing an extra-peritoneal approach. At the time of writing, the patient continues to survive without any symptoms 60 months since the initial surgery. In conclusion, surgical debulking is a significant procedure for relieving patient symptoms as well as improving the survival time of patients with metastatic and recurrent DSRCT.

Postoperative arterial blood lactate level as a mortality marker in patients with colorectal perforation.

PURPOSE: This study aims to assess the clinical relevance of postoperative arterial blood lactate (LAC) level as a prognostic factor in patients with colorectal perforation. METHODS: Forty-two patients (22 males, 20 females; mean age, 70.8 years) underwent emergency surgery for colorectal perforation. The patients were divided into mortality and survivor groups. As a prognostic scoring system, Acute Physiological and Chronic Health Evaluation II (APACHE-II), Sequential Organ Failure Assessment (SOFA), and Systemic Inflammatory Response Syndrome criteria were calculated. These scores, postoperative LAC level, and other data, including site and etiology of perforation, elapsed time from onset to surgery (eTIME), preoperative white blood cell (WBC) and platelet counts, preoperative C-reactive protein (CRP), and preoperative arterial blood base excess were assessed between the groups. RESULTS: The total mortality rate was 33.3 %. On univariate analysis, the APACHE-II and SOFA scores were significantly higher, and eTIME was significantly longer in the mortality group than in the survivor group. The postoperative LAC level was significantly higher in the mortality group (43.1 ± 14.1 mg/dl) than in the survivor group (23.8 ± 12.7 mg/dl; p < 0.001), and the preoperative WBC was significantly lower in the mortality group than in the survivor group. Multivariate logistic regression analysis using the mortality risk factors determined by univariate analysis (eTIME, APACHE-II score, SOFA score, preoperative WBC count, and postoperative LAC) demonstrated that postoperative LAC level was an independent risk factor for mortality. CONCLUSIONS: High postoperative LAC level was a useful factor for predicting high mortality rate in patients with colorectal perforation.

In patients with colorectal cancer, preoperative serum interleukin-6 level and granulocyte/lymphocyte ratio are clinically relevant biomarkers of long-term cancer progression.

OBJECTIVE: To investigate the clinical significance of the serum inflammatory cytokines and the blood granulocytes/lymphocytes (G/L) ratio in patients with colorectal cancer. METHODS: Forty-six patients underwent surgery for colorectal cancer. The G/L ratio and serum inflammatory cytokines including interleukin (IL)-1ß, IL-6, IL-8, tumour necrosis factor-α (TNF-α), granulocyte colony-stimulating factor and macrophage colony-stimulating factor (M-CSF) were measured before surgery and correlated with the Tumour Node Metastasis classification and overall survival. RESULTS: Serum IL-6 in T3-4, N1-2, M1 cases and cancer stages III-IV sub-groups was significantly higher than in Tis-2, N0, M0 and cancer stages 0-II sub-groups. The G/L ratio, serum M-CSF and TNF-α in T3-4 cases were significantly higher than in Tis-2 cases. Furthermore, the G/L ratio and serum IL-6 showed a significant inverse correlation with the overall survival, while the G/L ratio showed a significant positive correlation with serum IL-6, TNF-α and M-CSF. Multivariate analysis showed that the serum IL-6 level and G/L ratio were independent risk factors for poor prognosis. CONCLUSIONS: In this investigation, a pre-operative high level of serum IL-6 and the G/L ratio appeared to be significant predictive factors for cancer progression and poor prognosis. Accordingly, these variables might be clinically relevant biomarkers in patients with colorectal cancer.

Prognostic significance of immunohistochemically detected blood and lymphatic vessel invasion in colorectal carcinoma: its impact on prognosis.

BACKGROUND: The prognostic significance of blood vessel invasion (BVI) and lymphatic vessel invasion (LVI) is unclear. Because of the absence of specific markers for venous and lymphatic vessels, earlier studies could not reliably distinguish between BVI and LVI. METHODS: By immunostaining for podoplanin and CD34 antigen, we retrospectively investigated LVI and BVI in 419 tissue specimens of colorectal carcinoma. We performed univariate and multivariate analysis of the clinicopathologic features, frequency of recurrence, and outcome of patients with or without LVI and BVI. RESULTS: The use of hematoxylin and eosin (H&E) staining to identify BVI and LVI yielded a false positive rate of 9.1% and false negative rate of 12.6%. The incidence of BVI was significantly higher among tumors with LVI than tumors without LVI (P <.001). In logistic multivariate analysis, only LVI (P < .001) was associated with lymph node metastasis and BVI (P = .015) was associated with distant recurrence. Calculating the prognostic relevance, both two invasion types correlated with decreased survival in univariate analysis (both P <.001). In multivariate analysis, BVI (P =.024), lymph node status (P =.003) and tumor stage (P <.001) remained statistically significant factors for survival. CONCLUSIONS: Our results suggest that immunohistologic evaluation of BVI and LVI could be useful in colorectal carcinoma indicating the risk of lymph node metastasis and recurrence, thereby contributing to prognostic evaluation.

Increased density and diameter of lymphatic microvessels correlate with lymph node metastasis in early stage invasive colorectal carcinoma.

To determine whether lymphangiogenesis was associated with the development of colorectal carcinoma and whether the mean maximal diameter of lymphatic microvessels (LMMMD) or lymphatic microvessel density (LMVD) is associated with lymph node metastasis in early stage invasive colorectal carcinoma (T1 carcinoma), we used immunohistochemical staining with podoplanin to measure LMMMD and LMVD in intratumoral (LMMMDit, LMVDit) and peritumoral areas (LMMMDpt, LMVDpt) of T1 carcinomas (n=87). By comparing the LMMMD and LMVD in normal large intestine (n=10), adenoma (n=15), and Tis carcinoma (n=15), we found out that the LMVDpt in T1 carcinoma with lymphatic vessel invasion (LVI) was significantly high (P<0.001), and there was a significant decrease in LMMMDpt in T1 carcinoma (P=0.031). Both LMMMDpt and LMVDpt were significantly increased in the T1 carcinomas, with LVI compared with the T1 carcinomas without LVI (P=0.018, P=0.003). Multivariate analysis revealed that LVI and combined greater LMMMDpt and greater LMVDpt were associated with lymph node metastases (P=0.005, P=0.036). These results indicate that lymphangiogenesis might be induced in the surrounding tumor areas of the T1 colorectal carcinoma with LVI; thus, evaluation of the diameter and density of lymphatic microvessels is important in T1 colorectal carcinoma to predict lymph node metastases.

Myofibroblasts correlate with lymphatic microvessel density and lymph node metastasis in early-stage invasive colorectal carcinoma.

BACKGROUND: Recent studies have shown that the interactions between tumor cells and stromal cells are important in tumor development. A possible correlation between tumor-activated myofibroblasts, the main component cells of tumor stroma, and lymphatic microvessel density (LMVD) or other clinical parameters in carcinoma was investigated. MATERIALS AND METHODS: Immunohistochemical examination of alpha-smooth muscle actin and podoplanin were performed in 83 cases of early-stage invasive colorectal carcinoma. RESULTS: There was a good correlation between proliferation of myofibroblasts (PMpt) and LMVD (LMVDpt) in the peri-tumoral area (p = 0.0034). Increased PMpt was also associated with lymphatic invasion (p = 0.0051) and with lymph node metastasis (p = 0.011). However, proliferation of myofibroblasts in intra-tumoral (PMit) areas was not associated with these clinical parameters. CONCLUSION: Proliferation of myofibroblasts in peri-tumoral areas seem to play an important role in lymphangiogenesis, and is also associated with lymph node metastasis.

The use of autologous fibrin glue for the treatment of postoperative fecal fistula following an appendectomy: report of a case.

We herein report a case of postoperative fecal fistula following an appendectomy which was successfully treated by the use of autologous fibrin glue. An 82-year-old man had acute appendicitis and underwent an appendectomy. Later, a fecal fistula developed and he underwent drainage treatment twice. After 4 weeks of drainage and during the third recurrence, the remaining fistula was successfully treated using autologous fibrin glue, instead of surgery, due to potential complications and the risks of associated with advanced age. No recurrence has been observed for 5 months. In conclusion, autologous fibrin gluing for fecal fistula was found to be a safe, economical, and effective treatment. A search of Medline from 1980 until 2002 revealed no other report of this treatment for postoperative fecal fistula following an appendectomy.