Estimation of the physiologic ability and surgical stress scoring system as a useful predictor of postoperative recurrence in patients with stage II colorectal cancer: a multicenter study.

PURPOSE: We determined the usefulness of the estimation of physiologic ability and surgical stress (E-PASS), initially reported as a predictive factor for postoperative morbidity and mortality, as a prognostic indicator in stage II colorectal cancer (CRC). METHODS: Overall, 739 patients who underwent proctocolectomy for CRC at Tottori University Hospital and affiliated hospitals and histologically diagnosed with stage II CRC were included in the current study. RESULTS: A receiver operating characteristic (ROC) analysis of the five-year recurrence-free survival indicated that the comprehensive risk score (CRS) of E-PASS predicted postoperative recurrence. A multivariate analysis revealed that the presence of preoperative perforation, T4, v ≥ 2, and CRSHigh (≥ 0.2267) were independent predictors of postoperative recurrence. Patients were assigned a score using these factors, as follows: the presence of perforation = 1, the absence of preoperative perforation = 0, T4 = 1, T3 = 0, v2/3 = 1, v0/1 = 0, CRSHigh = 1, and CRSLow = 0 (total score: 0-4). Accordingly, the respective 5-year relapse-free survival rates were 91.0%, 83.6%, 70.3%, and 52.0% among those with scores of 0, 1, 2, and both 3 and 4 (P < 0.001). CONCLUSIONS: The CRS predicts postoperative recurrence in patients with stage II CRC.

Risk factors for recurrence in elderly patients with stage II colorectal cancer: a multicenter retrospective study.

BACKGROUND: Adjuvant chemotherapy for stage II colorectal cancer (CRC) is considered appropriate for patients with risk factors for recurrence, rather than for all patients uniformly. However, the risk factors for recurrence remain controversial, and there is limited information, especially for elderly patients. The Geriatric Nutritional Risk Index (GNRI) is widely used as a simple nutritional screening tool in the elderly and is associated with cancer prognosis and recurrence. This study aimed to investigate the risk factors for recurrence in the elderly with stage II CRC, focusing on the GNRI. METHODS: We enrolled 348 elderly patients (≥ 75 years) with stage II CRC who underwent curative resection at the Department of Surgery, Tottori University and our 10 affiliated institutions. The patients were divided into GNRIhigh (≥ 93.465) and GNRIlow (< 93.465) groups. RESULTS: The GNRIlow group showed a significantly worse overall survival (OS), cancer-specific survival (CSS), and relapse-free survival (RFS) (P < 0.001, P < 0.001, and P < 0.001, respectively). In a multivariate analysis, GNRIlow (hazard ratio [HR]: 2.244, P < 0.001), pathologic T4 stage (HR: 1.658, P = 0.014), and moderate to severe lymphatic or venous invasion (HR: 1.460, P = 0.033) were independent factors affecting RFS. By using these three factors to score the risk of recurrence from 0 to 3 points, the prognosis was significantly stratified in terms of OS, CSS, and RFS (P < 0.001, P < 0.001, and P < 0.001, respectively). The recurrence rate for each score was as follows: 0 points, 9.8%; 1 point, 22.0%; 2 points, 37.3%; and 3 points, 61.9%. CONCLUSIONS: GNRIlow, pathologic T4 stage, and moderate to severe lymphatic or venous invasion are high-risk factors for recurrence in the elderly with stage II CRC. The scoring system using these three factors appropriately predicted their recurrence and outcome.

[A Case of Surgically Treated Primary Anorectal Malignant Melanoma Detected by Colorectal Cancer Screening].

Anorectal malignant melanoma(AMM)is a relatively rare disease with an extremely poor prognosis. We experienced a case of this disease detected by colorectal cancer screening and report it here with a literature review. Our 67-year-old female patient was referred to the Department of Gastroenterology at our hospital for a thorough examination of the gastrointestinal tract after an abnormal fecal occult blood count(+/+ on 2 occasions)was noted during a colorectal cancer screening. Lower gastrointestinal endoscopy revealed a small easily bleeding lesion near the anal verge for which endoscopic mucosal resection was performed. A histopathological examination revealed a primary malignant melanoma of the rectum, and the patient underwent abdominoperineal rectal amputation. According to the rules for the treatment of T1b (1,200 µm), N0, P0, H0, M(-), StageⅠ, Cur A colorectal cancer. A histopathological examination of the resected specimen showed no remnant tumor cells. About 2 years have passed since the surgery, and the patient is still alive without recurrence. Considering its characteristics, patients with AMM will require further careful follow-up. Here we summarize our experience diagnosing and treating a case of early-stage AMM.

Preoperative white blood cell count predicts anastomotic leakage in patients with left-sided colorectal cancer.

To determine whether preoperative white blood cell (WBC) counts reflect risk of anastomotic leak (AL) for patients with colorectal cancer (CRC), we retrospectively examined data from records of 208 consecutive patients who had undergone resections for left-sided CRC, including their clinicopathological parameters and preoperative laboratory data. The diagnostic value of WBC count for AL was evaluated and compared with those of neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, lymphocyte-monocyte ratio and platelet count × C-reactive protein level multiplier (P-CRP) value; optimal cut-off values were derived from receiver operating characteristic curves. AL was observed in 11 of the 208 patients (5.3%). Compared with the no-AL group, the AL group had a significantly higher mean WBC count and smoking rate. In multivariate analysis, WBC count and smoking were independent risk factors for AL. Compared with the other tested inflammatory indicators, the cut-off value for WBC (6,200/µL) had the highest sensitivity (81.8%) and negative predictive value (98.4%), as well as the lowest likelihood ratio (0.289). Preoperative WBC count could therefore be a convenient predictor of AL in patients with left-sided CRC.

Evaluation of Blood Supply with Indocyanine Green Fluorescence in Resection for Concurrent Gastric and Pancreatic Cancer: A Case Report.

We present a rare case of concurrent resection of pancreatic and gastric cancer in which indocyanine green (ICG) fluorescence was used to evaluate the remnant stomach. An 80-year-old man was referred with a tumor in the distal pancreas. Computed tomography showed a 25-mm mass in the pancreatic tail; endoscopic ultrasound-guided fine-needle aspiration revealed adenocarcinoma. Upper gastrointestinal endoscopy and subsequent upper gastrointestinal series revealed advanced gastric cancer in the mid-stomach. Concurrent resection of the pancreatic and gastric tumors was performed. After distal pancreatectomy and distal gastrectomy, ICG evaluation of the stomach showed fluorescence extending only 3 cm distal from the cardia. To avoid ischemic change at the remnant stomach, total gastrectomy was performed. Since remnant gastric necrosis and anastomotic leak following ischemia can lead to fatal outcomes, the use of ICG to evaluate blood supply at anastomotic sites can help determine the extent of safe resection in such cases.

Xp11.2 translocation renal cell carcinoma with TFE3 gene fusion in the elderly: case report and literature review.

A 68-year-old man was followed up with chronic kidney disease. Follow-up CT incidentally detected a tumor at the left kidney and multiple small nodular shadows in the lungs bilaterally. The patient underwent needle biopsy and was diagnosed with Xp11.2 translocation renal cell carcinoma (RCC) pathologically. Hence, laparoscopic nephrectomy was performed. Fluorescence in situ hybridization analysis revealed a break-apart of the transcription factor E3 (TFE3) genes in the left tumor. After 2 months postoperatively, nivolumab and ipilimumab were administered thrice intravenously, considering the intermediate risk by the IMDC risk classification. However, pleural effusion occurred but was removed adequately. Lung metastasis decreased, but new metastasis occurred at the left iliopsoas muscle. Target therapy was performed with axitinib. Unfortunately, he died 6 months later postoperatively. These tumors commonly occur in children than in adults, and very rare in elderly patients. Xp11.2 translocation RCC in the elderly has a poorer prognosis than that in children. To date, no effective treatment for Xp11.2 translocation RCC has been established.

Primary tumor of the ureteral stump after a radical nephrectomy for renal cell carcinoma: case report and literature review.

We report a case of ureteral stump carcinoma following a radical nephrectomy for renal cell carcinoma. A 76-year-old man was diagnosed as having ascending colon cancer and a right renal carcinoma. He was treated with partial colon resection and radical nephrectomy without lymphadenectomy. The histology was renal cell carcinoma. Three years after that surgery, he complained of intermittent macrohematuria. Abdominal computed tomography (CT) suggested a solid mass in the pelvis. We then performed a biopsy with CT guidance. An epithelial tumor was suspected by immunohistochemistry. A total excision of ureter was then performed. The histology showed the features of urothelial carcinoma, G3, v(+), pT3. He received adjuvant chemotherapy with gemcitabine and cisplatin. He was free of disease for the following 11 months.

Unusual case of tacrolimus vascular toxicity after deceased donor renal transplantation.

We report a case of tacrolimus vascular toxicity found on a protocol biopsy shortly after a deceased donor renal transplantation. The patient was immunologically high-risk and acute antibody-mediated rejection during post-transplant dialysis phase was suspected on the protocol biopsy. Although the patient was stable after treatment of rejection, a further examination showed a very rare but specific side-effect of tacrolimus. It is sometimes difficult to make a differential diagnosis during postoperative dialysis period among AMR, primary non-functioning, drug toxicity, infection or just prolonged recovery from the damage of a long agonal phase on the non-heart beating donor. Although the possibilities of coexistence of rejection or other causes such as infection have not been completely excluded, it is important to be aware of this unusual side effect of tacrolimus.

Biopsy findings on a stable recipient after secondary donor specific antibody (DSA) positive and ABO incompatible kidney transplantation.

Using desensitization protocol, we performed a secondary donor specific antibody (DSA) positive and ABO incompatible kidney transplantation. One-hour biopsy showed no C4d deposition. The protocol biopsy after 2 weeks showed diffuse C4d deposition with peritubulitis. After 12 weeks, however, the protocol biopsy showed disappearance of tubulitis in spite of remaining C4d deposition. The recipient was in stable condition with excellent graft function despite high titer of the DSA. Monitoring of protocol biopsy is critical while antibody titer and the interpretation of the histological findings correlating with clinical markers must be considered.

[A case of complete response of gemcitabine (GEM) monotherapy-refractive liver metastatic pancreatic cancer treated with GEM+S-1 combined chemotherapy].

A 75-year-old man with pancreatic body cancer underwent distal pancreatectomy and was treated with gemcitabine (GEM) as an adjuvant therapy. Multiple liver metastases appeared three months after the surgery. With GEM+S-1 combined chemotherapy, liver metastatic lesions became unidentifiable upon imaging 7 months later. Complete response status had continued as long as 13 months. Though grade 3 neutropenia appeared after 2 courses of the combined therapy, the patient well tolerated it after controlling the dosing schedule. The GEM+S-1 combined chemotherapy was expected to have synergistic effects for GEM monotherapy-refractive pancreatic cancer.

[Clinical outcome of totally implantable subcutaneous infusion port--comparison with home parenteral nutrition and chemotherapy].

We investigated long-term clinical findings in a total of 107 cases with a subcutaneous infusion port. Some 109 patients were implanted with a subcutaneous infusion port at our institution from 1994 to 2003. The patients' ages ranged from 1 to 93 years (average 58.1 years). Implantation failed in 2 patients because it was impossible to insert the guide wire into the central vein and because of mediastinal hematoma due to injury to the central vein from the dilator. 32 patients had complications after catheter system exchange, 17 suffered port infection, 9 had obstruction of the catheter system, and 3 developed ulcerations from the port system. Two cases were given subcutaneous injection due to port system breakage, and one case experienced pain from the port puncture needle. The use of a totally implantable subcutaneous infusion port is widespread for chemotherapy access or home parenteral nutrition in patients with malignancy or malnutrition. This catheter system is useful for improvement of patient's quality of life. However, once complications occur, patient's condition might become worse. Appropriate measures must be taken when complications occur.

Laparoscopy-assisted and open distal gastrectomies for early gastric cancer at a general hospital in Japan.

BACKGROUND/AIMS: At general hospitals in Japan, laparoscopic surgery for early gastric cancer is not yet popular. The benefits and feasibility of this procedure remain to be established. The aim of this study was to evaluate the surgical outcome of laparoscopy-assisted distal gastrectomy (LADG) in comparison with open distal gastrectomy (ODG) in a general hospital. METHODOLOGY: We performed LADG in 20 patients with early gastric cancer between 2000 and 2001. Clinicopathologic data, blood analyses, clinical course and financial cost of treating patients with LADG were compared with 22 patients treated with ODG between 1998 and 1999. RESULTS: All patients were treated successfully by LADG. Neither reduced operative curability nor increased complications were found with this procedure. Although LADG required a significantly longer operation time than ODG, blood loss was lower in LADG than in ODG. The leukocyte count on day 1 and day 3, and serum C-reactive protein levels on day 1 were significantly lower after LADG than after ODG. There was no significant difference between LADG and ODG in the period and volume of analgesics required. High body temperature continued longer after ODG than after LADG. The first walking, passage of flatus and oral diet initiation were significantly earlier in patients with LADG than in those with ODG. LADG required a significantly shorter hospital stay and less total hospital charge than ODG. CONCLUSIONS: Laparoscopy-assisted distal gastrectomy offered faster recovery of gastrointestinal function, a shorter hospital stay, and consequently less financial cost when compared with open surgery. Therefore, LADG may be a safe and recommendable procedure for patients with early gastric cancer at general hospitals in Japan.

[A case of advanced gastric cancer with peritoneal metastases responding to bi-weekly paclitaxel therapy].

A 68-year-old man underwent bypass operation for gastric cancer, because the tumor was judged to be unresectable due to peritoneal dissemination. After the operation, the patient was treated with daily oral administration of 100 mg TS-1 for two weeks followed by one week rest as one cycle. However, symptoms such as anemia, ascites and edema became worse and the TS-1 resulted in progressive disease. Bi-weekly paclitaxel therapy (80 mg/m2/2 weeks) was then chosen as second line chemotherapy. Anemia and edema were reduced and computed tomography showed shrinkage in the size of lymph nodes and disappearance of ascites. Only grade 1 alopecia was observed as an adverse event during the therapy. Bi-weekly paclitaxel therapy could be safe and useful as the second line therapy.

Effects of tumor necrosis factor-related apoptosis-inducing ligand alone and in combination with chemotherapeutic agents on patients' colon tumors grown in SCID mice.

Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) has been reported to induce apoptosis in a variety of malignant cell lines, but it shows little or no toxicity in most normal cells. We examined the response of three human colon tumors to TRAIL alone and in combination with chemotherapy, using SCID mice engrafted with intact patient surgical specimens. These tumors, taken from fresh surgical specimens, contained the heterogeneous tumor cell population characteristic of patient tumors and showed differential sensitivity to TRAIL alone. We also investigated the effect of TRAIL in combination with chemotherapy, using one tumor that showed moderate sensitivity to TRAIL alone. Combining TRAIL with either 5-fluorouracil (5-FU) or CPT-11 (irinotecan hydrochloride) produced a greatly enhanced antitumor effect over that of either agent alone, with 50% of the animals achieving complete tumor regression with a combination of TRAIL and CPT-11. By histological analysis, tumors treated with TRAIL plus either 5-FU or CPT-11 were seen to consist mainly of connective tissue and fibrotic areas with only a few scattered tumor cells encapsulated in the connective tissue. Several markers were assessed to investigate the basis for the observed therapeutic effect, and significant induction of apoptosis was observed in tumors treated with curative combinations. Cytoplasmic and cell surface expression of the TRAIL receptors DR4 and DR5 was observed in this patient's tumor by immunohistochemistry. Tumors treated with CPT-11 showed increased membrane expression of DR5, suggesting that CPT-11 may increase sensitivity to TRAIL by up-regulation of DR5. These results obtained in a relevant preclinical model support the idea that the use of TRAIL in combination with either 5-FU or CPT-11 may be an effective strategy in controlling human colon cancer.