Prognostic Significance of Synchronous Colorectal Adenocarcinoma: A Matched-Pair Analysis.

OBJECTIVE: To determine the prognostic significance of the synchronous colorectal cancer (S-CRC) on survival and recurrence rate. METHODS: Authors conducted an analysis of 90 colorectal adenocarcinoma patients who received a curative (R0) resection with a full course of standard adjuvant treatment. A total of 45 patients diagnosed with S-CRC at the time of initial presentation were individually matched to a group of 45 solitary CRC patients in pair at a ratio of 1:1. The case-matched criteria included age (± 5 years), gender, tumor location, and tumor stage. For S-CRC, the most advanced pathologic lesion was defined as the index lesion, and the matching cancer stage was categorized according to the index lesion. The N-stage was determined based on all lymph nodes. RESULT: There were a higher number of retrieved nodes in patients with S-CRC than those with solitary CRC. The median (min, max) of the total number of retrieved nodes for S-CRC was 18 (3, 53) nodes, compared to 14 (4, 45) nodes for solitary CRC (p < 0.01). All patients were without distant metastasis (stage I to III). The total accumulative number of patients experiencing tumor recurrence was 9 (20%) amongst the solitary CRC patients and 18 (40%) amongst the S-CRC patients at the 15-year surveillance period (p<0.05). The disease-free survival (DFS) (mean + SD) was 147.6 + 9.3 months in the solitary CRC group, compared to 110.5 + 11.7 months in the S-CRC group (p<0.05). Amongst S-CRC patients, those having primary and synchronous tumors located across anatomical segments had poorer DFS (70.5 months) and higher 15-year tumor recurrence rate (17.8%) than those with all tumors in the same or contiguous anatomical segments. In addition, the S-CRC patients with all tumors located in contiguous segment had a longer DFS (123.7 months) than the other types of anatomical correlation. CONCLUSION: Patients with S-CRC had worse prognosis than those with solitary CRC. For S-CRC, the anatomical correlation between the primary and the synchronous tumors may influence DFS and recurrence rate.

Tissue Microvessel Density as a Potential Predictive Marker for Vascular Invasion in Colorectal Cancer.

OBJECTIVE: This study aimed to determine whether microvessel density (MVD) in the tumor tissues could be a potential predictive marker for vascular invasion (VI). METHODS: Surgical specimens of 73 patients with colorectal adenocarcinoma in Phramongkutklao Hospital were analyzed. Tissues of patients receiving preoperative radiation or prior anti-angiogenic therapy were excluded. Tumor MVD was determined using the average number of counted CD34-stained endothelial cells from two selected fields at 200x magnification in each slide. The presence of VI was defined by tumor involvement of endothelial cell-lined spaces. The optimal cut-off value of MVD to predict VI was examined using receiver operating characteristic analysis to assess the area under the curve and accuracy. RESULT: VI was detected in 17 of 73 specimens (23.3%). Colorectal cancer (CRC) specimens were classified according to MVD as low (61 specimens, 83.6%) and high density (12 specimens, 16.4%). Average MVD was slightly higher in specimens with VI (81.3±9.3) than those without VI (76.3±7.6), but without statistical significance (p = 0.736). The MVD's cut-off value of 60 vessels/200x field provided 88% sensitivity, 40% specificity, and 57.5% accuracy, with the area under the ROC curve of 0.5788. Patients with CRC having MVD of > 60 vessels/200x field were at significantly higher risk of VI than those with CRC having MVD of <60 vessels/200x field (P=0.009, Fisher's exact test). Univariate analysis revealed that MVD, nodal involvement and AJCC tumor stage were associated with the presence of VI (p <0.05). Further multivariate analysis of these three potential variables demonstrated MVD (OR, 11.994; 95% CI, 2.197 to 65.483; p <0.01) and nodal involvement (OR, 10.767; 95% CI, 1.973 to 58.748; p <0.05) as independent prognostic factors associated with VI. CONCLUSION: Based on our study, MVD immunostaining was an angiogenic marker that potentially be a predictive marker for VI.

Pretreatment Microvessel Density for Predicting of Tumor Responsiveness to Neoadjuvant Chemoradiotherapy of Locally Advanced Rectal Cancer.

OBJECTIVE: This study aimed to assess whether pretreatment tumor tissue microvessel density (MVD) could be a potential predictive marker for Mandard response in LARC treated with nCRT. METHODS: A retrospective analysis was performed in pretreatment paraffin-embedded specimens of 31 pathologically confirmed rectal adenocarcinoma. All patients received nCRT and subsequent total mesorectal resection. Tumor MVD was determined by an average number of counted CD34-stained endothelial cells from two selected fields at 200x magnification in each slide and categorized into two groups: low MVD ( 60). The tumor response was determined using the Mandard tumor regression grading system. The subjects were grouped according to their TRG into responder (TRG 1-3) and non-responder (TRG 4-5). RESULT: Twenty out of thirty-one patients (64.5%) were defined as responders. Eleven patients (35.5%) were defined as non-responders. MVD was significantly associated with tumor responsiveness to nCRT (p < 0.05). High MVD was shown to be an independent risk factor associated with tumor resistance to nCRT (OR, 22.58; 95% CI, 1.943-262.34; p = 0.013). A strong correlation was found between MVD and TRG (correlation coefficient value of 0.642, p <0.01), between MVD and vascular invasion (correlation coefficient value of 0.618, p <0.01), and between nodal involvement and vascular invasion (correlation coefficient value of 0.521, p <0.01). A moderate correlation was found between nodal involvement and vascular invasion (correlation coefficient value of 0.406, p <0.05). CONCLUSION: High MVD in pretreatment tumor tissue was significantly associated with the tumor resistance to nCRT.

Synchronous Advanced Colorectal Neoplasia: Clinicopathologic Features and Prognostic Significance.

OBJECTIVE: This study aimed to compare the clinico-pathologic features, recurrence rate and disease-free survival between colorectal cancers (CRCs) with synchronous advanced colorectal neoplasia (SCN) and solitary CRCs to determine the prognostic significance of SCN. METHODS: A retrospective review of prospectively collected data of patients with CRCs was conducted in Phramongkutklao Hospital from January 2009 to December 2014. Patients were categorized in 3 groups: 1) solitary CRCs, 2) CRCs with advanced colorectal adenomas (ACAs) but having no another cancer and 3) synchronous colorectal cancers (S-CRCs) with or without ACAs. Patients undergoing curative resection and complete standard adjuvant treatment were recruited to evaluate the prognostic significance of SCN.  Clinicopathologic features, recurrence rate and disease-free survival were analyzed to compare among different groups.  Result: Among 328 recruited patients, 282 were classified as solitary CRCs (86%), 23 as CRCs with ACAs (7%) and 23 as S-CRCs (7%). Patients with CRCs with SCN (groups 2 and 3) were significantly older than patients with solitary CRCs (p <0.01), and SCN was found more commonly among males (15.2%) than females (12.3%) (p=0.045). In all, 288 patients achieved a curative resection and accomplished complete standard postoperative adjuvant treatment. Of these, the accumulative number of patients experiencing tumor recurrence was 11.8, 21.2, 24.6, 26.4 and 26.7% at the 1-, 3-, 5-, 7- and 10-year surveillance period, respectively. The disease-free survival of the groups with SCN was marginally higher than that of solitary CRCs groups (p=0.72) (solitary CRCs, 120.7±4.4 months; CRCs/ACAs, 127.4±13.9 months and S-CRCs: 126.2±13.6 months). CONCLUSION: CRCs with SCN were found at a more advanced age than those with solitary CRCs. SCN was found more often among males than females. After achieving curative resection and complete adjuvant treatment, the recurrence rate and disease-free survival of CRCs with SCN did not significantly differ from those of solitary CRCs.

Anorectal malformation with didelphys uterus: Extremely rare anomaly and successful neoanal sphincter reconstruction with gracilis muscle flap.

Anorectal malformation or imperforate anus is a congenital anomaly of rectum and anus. Mullerian duct anomalies are abnormal development of uterus, cervix, and vagina. Imperforate anus with double uterus is extremely rare and cannot explain by normal embryologic development. Moreover, guideline in treatment is inconclusive. We report an extremely rare case of a young adult female who presented with recurrent pelvic inflammatory disease caused by rectovaginal fistula in congenital imperforate anus and didelphys uterus, and successfully neoanal reconstruction with gracilis muscle flap. Aims for treatment are closed rectovaginal fistula, and anal sphincter reconstruction. To our best knowledge, the imperforate anus with double uterus is extremely rare anomaly. Furthermore, successfully anal sphincter reconstruction with functional gracilis muscle in the imperforate anus with double uterus has never been reported in English literature.