Risk factors of recurrence in TNM stage I colorectal cancer.

Purpose: TNM stage I colorectal cancer (CRC) can recur, although the recurrence rate is low. Few studies have evaluated the risk factors for TNM stage I CRC recurrence. This study aimed to evaluate the TNM stage I CRC recurrence rate, as well as risk factors for recurrence. Methods: In this retrospective study, we reviewed the database of patients who had undergone surgery for TNM stage I CRC between November 2008 and December 2014 without receiving neoadjuvant therapy or transanal excision for rectal cancer. Our analysis included 173 patients. Primary lesions were found in the colon of 133 patients and in the rectum of 40 patients. Results: The CRC recurrence rate was 2.9% (5 out of 173 patients). For colon cancer patients, tumor size was not associated with higher recurrence risk (P = 0.098). However, for rectal cancer patients, both tumor size (≥3 cm) and T stage were associated with higher recurrence risk (P = 0.046 and P = 0.046, respectively). Of the 5 recurrent cases, 1 patient exhibited disease progression despite treatment, 1 patient maintained stable disease status after recurrence treatment, and 3 patients had no evidence of a tumor after recurrence treatment. Conclusion: Our findings suggest that tumor size and T stage are predictors of stage I rectal cancer recurrence, and careful monitoring and follow-up of patients with larger tumors may be warranted.

Adjuvant oxaliplatin-based chemotherapy effect after treatment of colorectal hepatic metastasis.

PURPOSE: We aimed to investigate whether adjuvant oxaliplatin-based chemotherapy after treatment for hepatic metastasis affects recurrence or survival and to determine the risk factors for recurrence or survival. METHODS: Forty-six patients who underwent curative treatment for hepatic metastasis from colorectal cancer between July 2009 and December 2017 were included from a retrospectively collected patient database. Curative resection included hepatic resection, radiofrequency ablation (RFA), or a combination of both, followed by adjuvant chemotherapy with oxaliplatin-based chemotherapy. RESULTS: Thirty-seven patients (80.4%) had colon cancer and 9 (19.6%) had rectal cancer. Twenty-six patients (56.5%) underwent hepatic resection, 7 (15.2%) RFA, and 13 (28.3%) hepatic resection and RFA. Thirty-two patients (69.6%) underwent chemotherapy after hepatic treatment. The recurrence incidence was 50% in the non-chemotherapy group and 46.9% in the chemotherapy group (P > 0.999). The incidence of death was 7.1% in the non-chemotherapy group and 18.8% in the chemotherapy group (P = 0.657). The recurrence risk factors were N stage (N0 vs. N2; P = 0.013, P = 0.005) and bilobed hepatic metastasis (P = 0.027, P = 0.009) in the univariate and multivariate analyses, respectively. However, chemotherapy after hepatic treatment was not a risk factor for disease-free survival (DFS) or overall survival (OS) in the univariate and multivariate analyses (P = 0.656 and P = 0.414, respectively; P = 0.510 and P = 0.459, respectively). CONCLUSION: Oxaliplatin-based adjuvant chemotherapy after colorectal hepatic metastasis treatment did not affect the DFS or OS. The N stage of the primary tumor and bilobed hepatic metastasis are risk factors for recurrence and death.

Case report of periorbital metastasis from rectal cancer.

INTRODUCTION: Periorbital metastasis of colorectal cancer is rare. Therefore, herein, we report a patient with rectal cancer who presented with periorbital metastasis without any systemic metastasis. PATIENT CONCERNS: The patient was a 57-year-old man who had a painless nodule on his left eyelid. DIAGNOSIS: The patient presented with loose and frequent stools and was diagnosed with rectal adenocarcinoma via colonoscopic biopsy at the local clinic. Curative resection (low anterior resection with temporary ileostomy formation) was performed 4 weeks after completing chemoradiotherapy. The final TNM stage was yp stage T2N0M0. Eight months after the diagnosis of rectal cancer, a protruding lesion was noticed on the patient's left eyelid. Histologic evaluation of the nodule revealed metastatic adenocarcinoma of rectal cancer. INTERVENTIONS: The patient received neoadjuvant chemoradiotherapy and curative resection for rectal cancer. After excision of the periorbital nodule, he received 5 cycles of chemotherapy. OUTCOMES: The patient underwent regular follow-up because he was not able to endure chemotherapy; no recurrence has been observed 21 months after the diagnosis of rectal cancer. Histologic examination revealed metastatic adenocarcinoma of rectal cancer on the patient's left eyelid. However, consecutive imaging studies revealed no other metastatic lesions. Finally, the patient was diagnosed with a solitary periorbital metastasis of rectal cancer. CONCLUSION: This case report helps in understanding the course of progression from rectal cancer to periorbital metastasis.

Brain metastasis from colorectal cancer: a single center experience.

PURPOSE: The detection rate of brain metastasis (BM) from colorectal cancer (CRC) is increasing. This study was designed to analyze the clinical features of BM and prognosis according to the therapeutic modalities. METHODS: A total of 19 cases were collected in this study between November 2008 and December 2015. We reviewed the patients' demographic data and the clinical features of BM retrospectively and investigated their prognostic significance. RESULTS: Nineteen patients included 8 male and 11 female patients. The median age at diagnosis of BM was 62.4 years (range, 32-83 years). The median interval between diagnosis of CRC and BM was 39 months (range, 0-98 months). Eighteen patients (94.7%) had extracranial metastasis at the diagnosis of BM. Lung was the most common site of extracranial metastasis in 14 patients (73.7%). Synchronous BMs were found at the diagnosis of primary CRC in 2 patients (10.5%). The location of primary CRC was the colon in 6 patients (31.6%) and the rectum in 13 patients (68.4%). At the diagnosis of BM, 10 patients (52.6%) had a solitary BM. The common neurologic symptoms were headache in 8 cases (42.1%) and ataxia in 6 cases (31.6%). The median survival after the diagnosis of BM was 3 months (range, 1-10 months). The patients who underwent surgery plus stereotactic radiosurgery (SRS) had an improved survival (range, 3-10 months) than the other patients (range, 1-6 months) (P = 0.016). CONCLUSION: In patients with BM from CRC, surgical resection plus SRS might improve survival.

Clinical Significance of Preoperative Virtual Colonoscopy for Evaluation of the Proximal Colon in Patient With Obstructive Colorectal Cancer.

PURPOSE: Virtual colonoscopy is the most recently developed tool for detecting colorectal cancers and polyps, but its effectiveness is limited. In our study, we compared the result of preoperative virtual colonoscopy to result of preoperative and postoperative colonoscopy. We evaluated also the accuracy of preoperative virtual colonoscopy in patients who had obstructive colorectal cancer that did not allow passage of a colonoscope. METHODS: A total of 164 patients who had undergone preoperative virtual colonoscopy and curative surgery after the diagnosis of a colorectal adenocarcinoma between November 2008 and August 2013 were pooled. We compared the result of conventional colonoscopy with that of virtual colonoscopy in the nonobstructive group and the results of preoperative virtual colonoscopy with that of postoperative colonoscopy performed at 6 months after surgery in the obstructive group. RESULTS: Of the 164 patients, 108 were male and 56 were female patients. The mean age was 62.7 years. The average sensitivity, specificity, and accuracy of virtual colonoscopy for all patients were 31.0%, 67.2%, and 43.8%, respectively. In the nonobstructive group, the average sensitivity, specificity, and accuracy were 36.6%, 66.2%, and 48.0%, respectively, whereas in the obstructive group, they were 2%, 72.4%, and 25.4%. Synchronous cancer was detected via virtual colonoscopy in 4 of the 164 patients. CONCLUSION: Virtual colonoscopy may not be an effective method for the detection of proximal colon polyps, but it can be helpful in determining the therapeutic plan when its results are correlated with the results of other studies.

Impact Of Circulating T Helper 1 And 17 Cells in the Blood on Regional Lymph Node Invasion in Colorectal Cancer.

We hypothesised that the blood levels of immune cells would be related to the progression of colorectal cancer and regional lymph node metastasis. We investigated the association between the blood levels of immune cells and regional lymph node metastasis in colorectal cancer patients. Patients with American Joint Committee on Cancer (AJCC) stages 1 and 2 colorectal cancer were assigned to Early stage group and those with AJCC stages 3 and 4 were assigned to Late stage group. Blood levels of circulating immune cells, such as cluster of differentiation (CD)4+ including T helper 1 (Th1) and 17 (Th17) cells, regulatory T (Treg) cells, CD8+ T cells, and natural killer (NK) cells were assessed using fluorescence-activated cell sorting (FACS). The blood levels of CD4+ T, Treg, CD8+ T, and NK cells did not significantly differ between the two groups. However, the blood levels of Th1 and Th17 cells did significantly differ between the groups. Specifically, Late stage group had higher levels of Th1 and Th17 cells than Early stage group (Th1, 11.14±1.22% vs. 16.25±1.57%, p = 0.015; Th17, 3.32±0.05% vs. 1.11±0.15%, p < 0.01). In conclusion, the blood levels of Th1 and Th17 cells significantly increased as the N stage increased. The blood levels of Th1 and Th17 cells might be useful as predictive markers of lymph node invasion in colorectal cancer.

Undetermined Margins After Colonoscopic Polypectomy for Malignant Polyps: The Need for Radical Resection.

AIM: The aim of the present study was to analyze the clinicopathological features of patients with colorectal cancer (CRC) who underwent radical operation after malignant polyp removal by colonoscopic procedure. PATIENTS AND METHODS: Between 2009 and 2013, radical colorectal resection was performed in 50 patients with CRC after colonoscopic polypectomy. RESULTS: Nine cases (18%) had residual cancer. Lymph node (LN) metastasis was found in three cases (6.0%) and tumor deposit without LN metastasis (N1c) was found in two cases (4.0%). The indications for radical operation were an undetermined resection margin (23 cases), positive lateral margin (15 cases). Out of the nine cases with residual cancer, five cases had LN metastasis or tumor deposit without residual tumor in the main lesion. One-fourth of cases with an undetermined margin had residual cancer (six out of 23 cases), three of whom had stage III disease. CONCLUSION: Undetermined margins may be considered as an indication for additional radical operation.

Detection of Polyps After Resection of Colorectal Cancer.

PURPOSE: Because colonoscopy after colorectal cancer surgery is important for detecting synchronous or metachronous colorectal neoplasms, we designed this study to investigate, by using postoperative colonoscopy, the miss rate for and the location of polyps remaining after colorectal cancer surgery. METHODS: In a prospectively-collected patient database, 264 patients were shown to have undergone a colorectal cancer resection between May 2012 and June 2013. Of these, 116 who had received a complete colonoscopy preoperatively and postoperatively were included in this study. RESULTS: Of these 116 patients, 68 were males and 48 were females; their mean age was 63 years. The mean time after surgery at which postoperative colonoscopy was performed was 7.1 months (range, 3-15 months). On postoperative colonoscopy, a total of 125 polyps were detected. Of these, there were no cancerous lesions; 46 (36.8%) were neoplastic polyps, and 79 (63.2%) were nonneoplastic polyps. Fifty-nine polyps (47.2%) and 15 polyps (12%) were located in the proximal and the distal parts of the anastomosis, respectively. The miss rates for the total numbers of polyps and of neoplastic polyps remaining after surgery were 37.4% and 24.2%, respectively. The incidence of neoplastic polyps increased during postoperative colonoscopy as it had during preoperative colonoscopy (r = 0.164, P = 0.048). CONCLUSION: Colonoscopic surveillance after colorectal cancer resection results in the detection of pathologic polyps in one-fourth of the cases. During postoperative colonoscopy, careful examination of the proximal colon is necessary. Patients in whom multiple neoplastic polyps had been detected during preoperative colonoscopy require careful and thorough follow-up.

Insertion of totally implantable central venous access devices by surgeons.

PURPOSE: The aim of this study is to evaluate the results for the insertion of totally implantable central venous access devices (TICVADs) by surgeons. METHODS: Total 397 patients, in whom TICVADs had been inserted for intravenous chemotherapy between September 2008 and June 2014, were pooled. This procedure was performed under local anesthesia in an operation room. The insertion site for the TICVAD was mainly in the right-side subclavian vein. In the case of breast cancer patients, the subclavian vein opposite the surgical site was used for insertion. RESULTS: The 397 patients included 73 males and 324 females. Primary malignant tumors were mainly colorectal and breast cancer. The mean operation time was 54 minutes (18-276 minutes). Operation-related complications occurred in 33 cases (8.3%). Early complications developed in 15 cases with catheter malposition and puncture failure. Late complications, which developed after 24 hours, included inflammation in 6 cases, skin necrosis in 6 cases, hematoma in 3 cases, port malfunction in 1 case, port migration in 1 case, and intractable pain at the port site in 1 case. CONCLUSION: Insertion of a TICVAD under local anesthesia by a surgeon is a relatively safe procedure. Meticulous undermining of the skin and carefully managing the TICVAD could minimize complications.

Indeterminate pulmonary nodules in colorectal cancer.

AIM: To investigate the clinicopathologic parameters of pulmonary metastasis in colorectal cancer (CRC) patients after lung operation of indeterminate pulmonary nodules (IPNs). METHODS: From a prospective database of CRC patients, 40 cases that underwent lung operation between November 2008 and December 2012 for suspicious metastatic pulmonary nodules on chest computed tomography (CT) were enrolled. The decision to perform a lung operation was made if the patient met the following criteria: (1) completely resected or resectable primary CRC; (2) completely resectable IPNs; (3) controlled or controllable extrapulmonary metastasis; and (4) adequate general condition and pulmonary function to tolerate pulmonary operation. Lung operation was performed by a thoracic surgeon without CT-guided biopsy for pathologic confirmation. RESULTS: A total of 40 cases of lung resection was performed in 29 patients. Five patients underwent repeated lung resection. The final pathology result showed metastasis from the CRC in 30 cases (75%) and benign pathology in 10 cases (25%). The primary tumor site was the rectum in 26/30 (86.6%) cases with pulmonary metastasis, but only 3/10 (30%) cases in the benign group had a primary rectal cancer (P = 0.001). Positron emission tomography (PET)-CT was performed for 22/30 (73.4%) patients in the lung metastasis group and for 6/10 (60.0%) patients in the benign group. PET-CT revealed hot uptake of (18)fluorine 2-fluoro-2-deoxy-D-glucose with all IPNs in both groups. The group with pulmonary metastasis had a higher incidence of primary rectal cancer (P = 0.001), a more advanced tumor stage (P = 0.011), and more frequent lymphatic invasion of tumor cells (P = 0.005). Six cases with previous liver metastasectomy were present in the lung metastasis group. Serum carcinoembryonic antigen levels before lung operation were not elevated in any of the patients. CONCLUSION: The stage and location of the primary tumor and tumor cell infiltration of lymphatics provide useful indicators for deciding on lung resection of IPNs in CRC.

Metachronous schwannoma in the colon with vestibular schwannoma.

We experienced a case of vestibular schwannoma and metachronous schwannoma in the colon. A 59-year-old female presented with a 1-month history of hematochezia. She had undergone suboccipital craniectomy resulting in radical subtotal resection, followed by gamma knife radiosurgery for a large left vestibular schwannoma 4 years prior to admission. On preoperative colonoscopy, a huge mass through which the colonoscope could not be passed was detected. CT scans showed colo-colonic intussusception with a 4.8-cm-sized mass in the descending colon. PET/CT revealed hypermetabolism of the descending colon tumor and pericolic lymph nodes. We performed left hemicolectomy under the preoperative impression of colon cancer with intussusception. A pathological diagnosis of benign schwannoma of the colon was made in this patient.

Short-term Outcomes of Hand-Assisted Laparoscopic Surgery vs. Open Surgery on Right Colon Cancer: A Case-Controlled Study.

PURPOSE: This study was designed to evaluate short-term clinical outcomes by comparing hand-assisted laparoscopic surgery with open surgery for right colon cancer. METHODS: Sixteen patients who underwent a hand-assisted laparoscopic right hemicolectomy (HAL-RHC group) and 33 patients who underwent a conventional open right hemicolectomy (open group) during the same period were enrolled in this study with a case-controlled design. RESULTS: The operation time was 217 minutes in the HAL-RHC group and 213 minutes in the open group (P = 0.389). The numbers of retrieved lymph nodes were similar between the two groups (31 in the HAL-RHC group and 36 in the open group, P = 0.737). Also, there were no significant difference in the incidence of immediate postoperative leukocytosis, the administration of additional pain killers, and the postoperative recovery parameters. First flatus was shown on postoperative days 3.5 in the HAL-RHC group and 3.4 in the open group (P = 0.486). Drinking water and soft diet were started on postoperative days 4.8 and 5.9, respectively, in the HAL-RHC group and similarly 4.6 and 5.6 in the open group (P = 0.402 and P = 0.551). The duration of hospital stay was shorter in the HAL-RHC group than in the open group (10.3 days vs. 13.5 days, P = 0.048). No significant difference in the complication rates was shown between the two groups, and no postoperative mortality was encountered in either group. CONCLUSION: The patients with right colon cancer in the HAL-RHC group had similar pathologic and postoperative recovery parameters to those of the patients in the open group. The patients in the HAL-RHC group had shorter hospital stays than those in the open group. Therefore, hand-assisted laparoscopic right hemicolectomy for right-sided colon cancer is feasible.

Feasibility of hand-assisted laparoscopic surgery as compared to open surgery for sigmoid colon cancer: a case-controlled study.

PURPOSE: The aim of this study was to evaluate short-term clinical outcomes by comparing hand-assisted laparoscopic surgery (HALS) with open surgery for sigmoid colon cancer. METHODS: Twenty-six patients who underwent a hand-assisted laparoscopic anterior resection (HAL-AR group) and 52 patients who underwent a conventional open anterior resection during the same period were enrolled (open group) in this study with a case-controlled design. RESULTS: Pathologic parameters were similar between the two groups. The incidences of immediate postoperative leukocytosis were 38.5% in the HAL-AR group and 69.2% in the open group (P = 0.009). There were no significant differences between the two groups as to leukocyte count, hemoglobin, and hematocrits (P = 0.758, P = 0.383, and P = 0.285, respectively). Of the postoperative recovery indicators, first flatus, sips of water and soft diet started on postoperative days 3, 5, 7 in the HALS group and on days 4, 5, 6 in the open group showed statistical significance (P = 0.021, P = 0.259, and P = 0.174, respectively). Administration of additional pain killers was needed for 1.2 days in the HAL-AR group and 2.4 days in the open group (P = 0.002). No significant differences in the durations of hospital stay and the rates of postoperative complications were noted, and no postoperative mortality was encountered in either group. CONCLUSION: The patients with sigmoid colon cancer who underwent a HAL-AR had a lower incidence of postoperative leukocytosis, less administration of pain killers, and faster first flatus than those who underwent open surgery. Clinical outcomes for patients' recovery and pathology status were similar between the two groups. Therefore, a HAL-AR for sigmoid colon cancer is feasible and has the same benefit as minimally invasive surgery.