Simplified and Optimized Immune Score for Colorectal Cancer Microenvironment.

BACKGROUND/AIM: Immunoscore (IS) is an important evaluation method for the tumor immune microenvironment (TIME); however, formal IS analysis requires designated reagents and a specific digital pathology software and image data analysis. This study aimed to investigate whether simplified IS (s-IS) can substitute formal IS upon modifying the location of the assessment of the numbers of immune cells and verify that the addition of T cell subset markers to s-IS can enhance the prognostic impact in patients with colorectal cancer (CRC). PATIENTS AND METHODS: A total of 82 CRC cases were included in this study. Immunohistochemical analysis was performed using CD3/CD8/CD45RO/FOXP3 on tissue specimens; the expression levels were calculated in the center and perimeter of the tumors using digital pathology. The clinical prognostic significance of the expression of these markers was investigated by concordance index comparison according to their location of assessment and combinations. RESULTS: In the univariate analysis, the CD3, CD8, and FOXP3 levels were significant prognostic factors. Moreover, for each T cell subset marker, the assessment of each T cell subset marker at the tumor perimeter had a stronger prognostic power than that in the tumor center. The modified s-IS (s-IS plus FOXP3 evaluation) was an independent prognostic factor for recurrence-free survival and overall survival through multivariate analysis and demonstrated the best prognostic power compared to other T subset marker combinations. CONCLUSION: In CRC, TIME evaluation could be simplified by assessing CD3- and CD8-positive T cells in the perimeter of the tumor, and additional FOXP3 evaluation would empower the ability of s-IS evaluation in prognostic assessment.

A Case of Immediate Anastomotic Leakage After Low Anterior Resection for Rectal Cancer.

A man in his seventies was referred to our hospital for radical therapy for advanced rectal cancer with multiple liver metastases. A colonic stent had already been placed in his rectum at the previous hospital because of malignant colorectal obstruction, so our therapeutic strategy was to perform systematic chemotherapy after resection of the primary tumor. Laparoscopic low anterior resection with a covering stoma was performed under general anesthesia. At about one hour after the surgery, the patient had sudden abdominal pain with watery diarrhea, and a similar discharge from his drainage tube. We suspected peritonitis caused by bowel perforation and emergency surgery was performed. The operative findings showed that his peritonitis was caused by anastomotic leakage from the rectum. Radical lavage of the abdominal space and reconstruction of colostomy was performed. The patient gradually recovered and we were able to start systematic chemotherapy at one month after the surgery. Anastomotic leakage immediately after anterior resection caused by watery diarrhea is rare, and it may be concerned with several issues. The covering stoma is intended to stop anastomotic leakage but it cannot prevent all cases of leakage especially when obstruction is present. We recommend that preventive measures be taken against anastomotic leakage, including intraoperative leakage tests or anal decompression tube placement.

Investigation of clinicopathological characters and gene expression features in colorectal signet-ring cell carcinoma utilizing CMS classification.

Signet ring cell carcinoma (SRCC) is a rare pathological type of colorectal cancer, of which the clinicopathological features and genetic background have not yet been fully investigated. Previous research has focused on the optimization of colorectal cancer treatment utilizing consensus molecular subtyping (CMS). However, it is not known what type of CMS would be designated to SRCC treatment. In the current study, of 1,350 patients diagnosed with colorectal cancer who underwent surgery, 14 were diagnosed with SRCC. The case-control cohort that fit the clinical background of the SRCC case was constructed. Statistical comparison between the SRCC group and the case-control cohort was performed among clinicopathological variables. SRCC and well to moderately adenocarcinoma case mRNA were submitted to microarray analysis and CMS analysis. Compared with the case-control cohort, the SRCC group was located more in the right-sided colon, the lymphatic invasion was more severe and the peritoneal dissemination was more frequent. The cancer-specific survival and the progression-free survival were significantly worse in the SRCC group compared with the case-control cohort. Microarray and CMS analysis identified that one SRCC case was significantly well assigned in the CMS 4 group and the other case was assigned in the CMS 1 group. Gene set analysis revealed the upregulation of EMT related genes and the downregulation of fatty acid, glycolysis, differentiation, MYC, HNF4A, DNA repair genes. In conclusion, the clinical characteristics of SRCC are severe but there is a possibility of the presence of different phenotypes according to CMS analysis.

Mesocolic hernia following retroperitoneal laparoscopic radical nephrectomy: A case report.

INTRODUCTION: Small bowel obstruction (SBO) caused by an internal hernia through a mesocolon after retroperitoneal laparoscopic nephrectomy (RLN) is rare. PRESENTATION OF CASE: A 66-year-old man who had undergone RLN with bladder cuff excision for a left renal pelvic cancer. After the surgery, he experienced SBO repeatedly. Contrast-enhanced computed tomography (CT) and gastrografin contract radiography through a long tube showed an internal hernia through the mesocolon to the retroperitoneal space where the resected left kidney had been located. We performed a subsequent surgery for the internal hernia. Postoperative course was uneventful and currently he has no recurrence of herniation 6 months post-operatively. DISCUSSION: Mesenteric defects that cause an internal hernia can be created inadvertently during RLN when the colon is mobilized medially, and the kidney is being detached from retroperitoneum. The removal of a kidney leads to a potential retroperitoneal space to which small intestine can migrate. While there is no absolute necessity in mobilizing the colon during the retroperitoneal laparoscopic approach, there is still a risk of making mesocolic defects directly in the retroperitoneal space. CONCLUSION: We need to perform operations with sufficient anatomical knowledge of retroperitoneal fascia and careful surgical techniques. The critical thing to prevent an internal hernia following RLN is to close the mesenteric defects intraoperatively. It is also important to suspect an internal hernia and do proper examinations promptly when patients had the symptoms of SBO after nephrectomy.

Mixed ductal-acinar cell carcinoma of the pancreas: A case report.

Mixed carcinoma of the pancreas is defined as the concurrent existence of pancreatic ductal carcinoma, acinar cell carcinoma, and/or islet cell carcinoma within the same neoplasm. We herein report a rare case of mixed ductal-acinar cell carcinoma in a 74-year-old man who was undergoing treatment for hypertension and diabetes at another hospital. After an abrupt worsening of his blood glucose control, the patient was referred to our hospital for further evaluation. Abdominal contrast-enhanced computed tomography and magnetic resonance imaging revealed a tumor with a multilocular cystic lesion in the head of the pancreas. Endoscopic retrograde cholangiopancreatography revealed obstruction of the main pancreatic duct and dilation of the dorsal pancreatic duct; in addition, adenocarcinoma was detected in the pancreatic juice cytology. Based on the abovementioned findings, the patient was diagnosed with carcinoma of the pancreatic head and underwent subtotal stomach-preserving pancreaticoduodenectomy. Based on the histopathological and immunohistochemical findings, the patient was diagnosed with mixed ductal-acinar cell carcinoma. The patient was prescribed TS-1 as postoperative adjuvant chemotherapy upon discharge. However, treatment was discontinued 2 months later due to marked general malaise, and the patient succumbed to tumor recurrence in the residual pancreas 12 months after the surgery.

[Endocrine cell carcinoma of the esophagus without recurrence for more than 7 years after chemoradiotherapy].

We report a case of endocrine cell carcinoma (ECC) of the esophagus with long term survival after chemoradiotherapy. The patient had a complete response and remains without any recurrence. A 69-year-old woman visited our hospital because of progressive dysphagia. The patient was diagnosed by computed tomography and histology examination of biopsy specimens with small cell ECC of the esophagus, cT2N1M0, cStage II based on the Classification of Esophageal Carcinoma. She was treated with chemoradiotherapy comprising 45Gy of irradiation and four courses of cisplatin and etoposide chemotherapy. After completion of the treatment, she was found to have a complete response. She remains alive to date without evidence of any recurrence after 7 years. This case suggests that chemoradiotherapy is an effective treatment for ECC of the esophagus.

Mina53 nuclear localization is an important indicator of prognosis in patients with colorectal cancer after adjuvant chemotherapy.

The aim of this study was to investigate the status of the c­Myc­related molecule Mina53 and the clinical impact of Mina53 nuclear localization in patients with stage II and III colorectal cancer (CRC). Patients (n=250) who underwent complete resection of CRC at our department were enrolled in this study, and tissue microarray samples were constructed from resected specimens. Mina53 expression in the nuclei of tumor cells was analyzed using immunohistochemistry (IHC). Patients were classified into Mina53 nuclear localization­-positive and ­negative groups, and statistical correlations with clinicopathological factors were investigated. Relapse­free survival (RFS) was compared using the Kaplan­Meier method and the Cox proportional hazard model. Tumor recurrence was significantly higher in the Mina53­positive group than in the Mina53­negative group. Moreover, in RFS analysis, patients in the Mina53­positive group exhibited significantly poorer prognosis than patients in the Mina53­negative group. In the univariate analysis, histological type, adjuvant chemotherapy status, carcinoembryonic antigen (CEA) status, and Mina53 status were prognostic factors for RFS. Furthermore, in the subgroup analysis, patients in the Mina53­positive group with stage III disease treated with adjuvant chemotherapy exhibited significantly poorer prognosis in RFS than patients in the Mina53­negative group. In the univariate and multivariate analyses, histological type and Mina53 status were significantly associated with RFS. Thus, our findings revealed that Mina53 was an important indicator of prognosis in patients with stage III CRC treated with adjuvant chemotherapy.

Nuclear Y-Box-binding Protein-1 Expression Predicts Poor Clinical Outcome in Stage III Colorectal Cancer.

BACKGROUND/AIM: Y-Box-binding protein-1 (YB-1), a DNA/RNA-binding protein, is an important oncogenic transcription and translation factor. We aimed to evaluate the relationships between nuclear YB-1 expression, epidermal growth factor receptor (EGFR) status, and poor clinical outcomes in patients with colorectal cancer (CRC). MATERIALS AND METHODS: Nuclear YB-1 expression was immunohistochemically analyzed in CRC tissues obtained from 124 patients who underwent curative resection between 2005 and 2008. Correlations between nuclear YB-1 expression, various clinicopathological characteristics, EGFR status, and prognostic factors were evaluated. RESULTS: High-grade nuclear YB-1 expression was detected in 62.9% of cases and was found to be an independent predictor of poorer overall survival (p<0.001) and relapse-free survival (p<0.001). A trend was also observed towards a positive correlation between nuclear YB-1 expression and EGFR status (p=0.051). CONCLUSION: Nuclear YB-1 expression is a useful prognostic biomarker that correlates with EGFR status in patients with CRC.

A High RORγT/CD3 Ratio is a Strong Prognostic Factor for Postoperative Survival in Advanced Colorectal Cancer: Analysis of Helper T Cell Lymphocytes (Th1, Th2, Th17 and Regulatory T Cells).

BACKGROUND: Tumor-infiltrating lymphocytes (TILs), part of the host immune response, have been widely reported as influential factors in the tumor microenvironment for the clinical outcome of colorectal cancer (CRC). However, the network of helper T cells is very complex, and which T-cell subtypes affect the progression of CRC and postoperative prognosis remains unclear. This study investigated the expression of several subtypes of TILs including T helper type 1 (Th1), Th2, Th17, and regulatory T (Treg) cells to determine their correlation with clinicopathologic features and postoperative prognosis. METHODS: The study investigated the expression of TILs using immunohistochemistry of tissue microarray samples for 199 CRC patients. The number of each T-cell subtype infiltrating tumors was counted using ImageJ software. The relationship between TIL marker expression, clinicopathologic features, and prognosis was analyzed. RESULTS: A high RORγT/CD3 ratio (Th17 ratio) was significantly correlated with lymph node metastasis (p = 0.002), and a high of Foxp3/CD3 ratio (Treg ratio) was correlated with tumor location in the colon (p = 0.04), as shown by the Chi square test. In multivariate analysis, a high RORγT/CD3 ratio was the only independent prognostic factor for overall survival (p = 0.04; hazard ratio [HR], 1.84; 95% confidence interval [CI] 1.02-3.45). CONCLUSIONS: This study confirmed a high RORγT/CD3 ratio as a strong prognostic marker for postoperative survival. The immunohistochemistry results suggest that Th17 may affect lymph node metastasis in CRC. If new immunotherapies reducing Th17 expression are established, they may improve the efficiency of cancer treatment and prolong the survival of patients with CRC.

Analysis of Wnt and ß-catenin Expression in Advanced Colorectal Cancer.

BACKGROUND: Wnt/ß-catenin signaling plays an important role in colorectal cancer (CRC). Wnt has many sub-types and it is uncertain which of them affect progression of CRC. PATIENTS AND METHODS: We analysed 201 patients who underwent curative surgery for CRC. We investigated the relationship between the expression of Wnt and ß-catenin proteins and prognosis using immunohistochemistry. RESULTS: The high expression of Wnt1 correlated with high expression of nuclear and cytoplasmic ß-catenin (p=0.0004, p=0.02). The high expression of Wnt5a also correlated with high expression of membrane ß-catenin (p=0.03). In multivariate analysis, lymph node metastasis (p=0.046) and high expression of nuclear ß-catenin (p=0.04) were independent prognostic factors for survival. CONCLUSION: The expression of nuclear ß-catenin is a useful predictive marker in CRC. It is suggested that Wnt1 may be the main activator of the ß-catenin signaling pathway and that Wnt5a may stabilize adherens junctions, thereby suppressing the epithelial-mesenchymal transition.

Fecoflowmetric analysis of anorectal motor function in postoperative anal-preserving surgery patients with low rectal cancer comparison with the wexner score and anorectal manometry.

The aim of this study was to elucidate whether fecoflowmetry (FFM) could evaluate more detailed evacuative function than anorectal manometry by comparing between FFM or anorectal manometric findings and the clinical questionnaires and the types of surgical procedure in the patients who received anal-preserving surgery. Fifty-three patients who underwent anal-preserving surgery for low rectal cancer were enrolled. The relationships between FFM or the manometric findings and the clinical questionnaires and the types of procedure of anal-preserving surgery were evaluated. There were significant differences between FFM markers and the clinical questionnaire and the types of the surgical procedure, whereas no significant relationship was observed between the manometric findings and the clinical questionnaire and the types of the surgical procedure. FFM might be feasible and useful for the objective assessment of evacuative function and may be superior to manometry for patients undergoing anal-preserving surgery.

Minichromosome maintenance protein 7 is a risk factor for recurrence in patients with Dukes C colorectal cancer.

BACKGROUND: It has been hypothesized that minichromosome maintenance (MCM) proteins, which are replicative control factors, can be used to detect tumor proliferation. The aim of the present study was to investigate the expression of MCM in colorectal cancer tissues and correlate it to clinical outcomes. PATIENTS AND METHODS: The study included 145 patients with colorectal cancer who underwent curative surgery, from January 2002 until December 2004, at the Kurume University Hospital in Fukuoka, Japan. The median follow-up duration was 87 months. The expression of MCM7 in tissues was studied by immuno-histochemical staining. The labeling index (LI) of MCM7 was calculated by dividing the number of positively-stained cells by the total number of cells counted. We divided samples into two groups: positive (MCM7 LI 76% or higher) and negative (MCM7 LI less than 76%). RESULTS: In patients with Dukes A and B, there were no significant differences in either overall survival (OS) or recurrence-free survival (RFS) between patents with MCM7-positive and those with MCM7-negative disease. On the other hand, in patients with Dukes C, there was significantly worse OS and RFS for patients with MCM7-positive compared to those with MCM7-negative disease. CONCLUSION: We found that the expression of MCM7 is an independent risk factor for RFS in patients with Dukes C colorectal cancer. Further studies are required to investigate the validity of MCM7 protein expression for its potential clinical use in colorectal cancer therapy and prognosis.

Virchow lymph node metastatic recurrence of sigmoid colon cancer with severe lymph node metastases successfully treated using systemic chemotherapy combined with radiotherapy.

Metastatic recurrence of colon cancer in the left supraclavicular lymph node (Virchow lymph node) is rare, and to date there are no reports on radiotherapy as treatment. We report on a case of metastatic recurrence of sigmoid colon cancer in the Virchow lymph node with severe lymph node metastases successfully treated with a combined modality therapy of systemic chemotherapy and radiotherapy. The case is of a 58-year-old man, who underwent sigmoid excision and lymph node excision, and subsequently received systemic chemotherapy. After left supraclavicular lymph node recurrence appeared he later received radiotherapy. Complete response was achieved, and there has been no further recurrence, to date, 10 months after the radiotherapy. Radiotherapy was effective as a local treatment, and local control of distant metastasis of colonic cancer may lead to a good prognosis.

Prognostic impact of lymphatic invasion of colorectal cancer: a single-center analysis of 1,616 patients over 24 years.

BACKGROUND: The degree of lymph node metastasis represents an important prognostic factor for cancer. Lymphovascular invasion is a traditional tool for estimating the aggressiveness of colorectal cancer. AIM: To determine correlations between lymphatic invasion and lymph node metastasis or disease stage, and clarify the prognostic impact of lymphatic invasion. PATIENTS AND METHODS: Patients (N=1,616) who underwent curative resection of primary colorectal adenocarcinoma at the Kurume University Hospital were included. Lymphatic invasion was calculated as an average and the degree was also determined (Ly0-3). Clinicopathological factors including lymphatic invasion were assessed by uni- and multivariate analyses to determine factors affecting survival. Survival was compared between different degrees of lymphatic invasion and lymph node metastasis. RESULTS: Lymphatic invasion was absent (Ly0) in 806 patients (50%), and lymph node metastasis was absent (N0) in 1,085 patients (67%). Ninety-one percent of N0 patients were Ly0-1, 72% of N1 were Ly0-1, and 54% of N2 were Ly2-3. All patients with stage 0 disease (100%) were Ly0, 95% of stage I were Ly0-1, 46% of stage II were Ly1-2, and 36% of stage III were Ly2-3. Five- and 10-year survival rates were 83% and 68% in Ly0, 73% and 56% in Ly1, 66% and 49% in Ly2, 63% and 48% in Ly3, 81% and 67% in N0, 69% and 57% in N1, and 60% and 52% in N2, respectively (p<0.0001 each). CONCLUSION: Lymphatic invasion in colorectal cancer correlates well with the status of lymph node metastasis and disease stage, representing an independent prognostic factor after curative resection. Lymphatic invasion can be used for evaluating tumor aggressiveness and estimating patient survival, irrespective of the actual number of positive lymph nodes found.

Amphiregulin is a prognostic factor in colorectal cancer.

Amphiregulin is an epidermal growth factor (EGF) which is a ligand of epidermal growth factor receptor (EGFR). Amphiregulin is the most enhanced EGFR ligand in colon cancer. Here we report on the expression of Amphiregulin using immunohistochemical staining in primary colorectal cancer, and the correlations between prognosis and various clinicopathological factors. We examined 174 consecutive patients who underwent curative resection of colorectal cancer, from January 2002 to December 2004. Amphiregulin was positive in 156 (90%) patients. Amphiregulin was found to be an independent predictor of overall survival [hazard ratio=6.25 (95% confidence interval=1.3-111.5; p=0.0144)] and relapse-free survival [hazard ratio=6.94 (95% confidence interval=1.5-123.2; p=0.0075)]. We conclude that the expression of Amphiregulin in a primary colorectal tumor is useful as an indicator of prognosis and as a predictor of recurrence.