Clinical outcome of neoadjuvant chemoradiation in rectal cancer treatment.

ABSTRACT: To determine the clinical and pathological outcome of locally advanced rectal cancer patients treated with neoadjuvant chemoradiation (chemoradiotherapy [CRT]) followed by curative surgery and to identify predictive factors of pathological complete response (pCR).Locally advanced rectal cancer patients undergoing CRT followed by curative surgery from January 2012 to December 2017 were included. Patient's demographic data, pretreatment tumor characteristics, type of CRT regimens, type of surgery, postoperative complications, pathological reports and follow up records were analyzed. Univariate and multivariate analyses were applied to identify predictive factors for pCR. Five-year disease free and overall survival were estimated by Kaplan-Meier method and compared between pCR and non-pCR groups.A total of 85 patients were analyzed. Eighteen patients (21.1%) achieved pCR. The sphincter-saving surgery rate was 57.6%. After univariate analyses, tumor length >4 cm (P = .007) and positive lymph nodes (P = .040) were significantly associated with decreased rate of pCR. Complete clinical response was significantly associated with higher rate of pCR (P = .015). Multivariate analyses demonstrated that tumor length >4 cm (P = .010) was significantly associated with decreased rate of pCR. After a median follow-up of 65 months (IQR 34-79), the calculated 5-year overall survival and disease-free survival rates were 81.4% and 69.7%, respectively. Patients who achieved pCR tend to had longer 5-year disease-free survival (P = .355) and overall survival (P = .361) than those who did not.Tumor length >4 cm was associated with decreased rate of pCR in locally advanced rectal cancer who had CRT followed by surgery. Longer waiting time or more intense adjuvant treatment may be considered to improved pCR and oncological outcomes.

Left Paraduodenal Hernia As a Rare Cause of Small Bowel Obstruction in Elderly: A Case Report and Review of Literature.

The authors presented a case of left paraduodenal hernia as a cause of closed loop small bowel obstruction in an elderly patient. Internal hernias are a rare cause of intestinal obstruction. Paraduodenal hernias are the most frequent especially left sided, which are believed to be the result of malrotation of the midgut during embryonic period. The clinical presentations varied, ranging from asymptomatic, chronic abdominal pain, or acute abdominal pain as acute abdomen. Most of the patients usually have early presentation in adult life with average age of 38.5 years at time of diagnosis. Late presentation in elderly patient (> 70 years) is very rare due to its congenital in origin. This clinical entity is a diagnostic challenge, which happened in our case. When the diagnosis is late, the complication develops and may contribute to afatal outcome if left untreated Herein, the authors reported our case of left paraduodenal hernia with late presentation at age of 80, and reviewed literature.

Upper gastrointestinal bleeding from gastric splenosis; A case report and literature review.

Splenosis is a common condition found in a case that has a history of splenic trauma or splenectomy. It is usually a non-significant condition in clinical practice. However, splenosis can give rise to some complications including gastrointestinal hemorrhage as in the present case. The authors report here a case of gastric splenosis presenting with active upper gastrointestinal hemorrhage that was eventually managed with surgical resection, and the literature regarding splenosis was reviewed.

Human epidermal growth-factor receptor 2 overexpression in gastric carcinoma in Thai patients.

OBJECTIVE: To determine human epidermal growth-factor receptor 2 (HER2) protein-overexpression frequency and the concordance rate between immunohistochemistry and fluorescence in situ hybridization techniques in gastric carcinoma. MATERIAL AND METHOD: A retrospective analysis of gastric adenocarcinomas obtained from 224 adult patients between January 2000 and December 2008 were performed. The paraffin-embedded tissues were sliced into 4-microm-thick sections and analyzed for HER2 protein expression levels by immunohistochemistry (IHC) using an automated slide-staining IHC system. Breast carcinoma tissues were included in every staining batch as positive control. In order to detect and quantify amplification of the HER2, the authors performed fluorescence in situ hybridization (FISH) using PathVysion HER2 DNA Probe Kit. The IHC results were independently recorded by two pathologists using the standard HER2 scoring system for gastric carcinoma. FISH results were interpreted using standard guideline as employed in breast carcinoma. The two-tailed-Fisher's exact test was used to assess the concordance between IHC and FISH results. RESULTS: HER2 protein overexpression level was identified in 9% (20 in 224 cases) of the gastric tumors; 80% of which were well or moderately differentiated and of the intestinal or mixed type. However HER2-overexpressing tumors comprised only 16% of the intestinal/mixed-type or well/moderately differentiated tumors. There was no signal obtained from 29 specimens from FISH studies. Thus, the overall results of IHC and FISH methods were concordant in 88% (171 out of 195, p < 0.001). CONCLUSION: There is a significant concordance rate between IHC and FISH in gastric carcinoma. The present study is the first HER2 study of such carcinoma in Thai patients.

Transpyloric prolapse of a pedunculated polypoid gastric carcinoma: a case report and review of the literature.

Gastroduodenal intussusception is not a common clinical condition. It is usually caused by transpyloric prolapse of a benign gastric lesion into the duodenum. In the present report, the authors present an extremely rare case of gastroduodenal intussusception in which gastric carcinoma served as the lending point. Pre-operative diagnosis was made from endoscopy and biopsy. The patient was treated successfully by subtotal gastrectomy with D2 lymph node dissection. The clinical presentation, diagnosis, and management of this entity were discussed and the literature was reviewed. Both the condition itself and the leading tumor, gastric carcinoma, are extremely rare and to the authors' knowledge. This is the first report in Thailand.

Outcomes and prognostic factors of primary gastric GIST following complete surgical resection: a single surgeon experience.

OBJECTIVE: To examine the surgical outcomes and to identify prognostic factors influencing tumor recurrence and survival after curative resection of primary gastric GIST as performed by one surgeon. MATERIAL AND METHOD: The medical records of patients with primary gastric GIST (c-kit or CD117-positive) who underwent curative resection by one surgeon between January 2001 and March 2009. The clinicopathological features, tumor recurrence, and recurrence-free survival were assessed. RESULTS: Twenty-two patients (10 males and 12females) with a median age of 66 years (range, 39-98 yrs) were reviewed. According to the NIH risk criteria, high-risk, intermediate-risk and low-risk GISTs were found in 12 (54.5%), one (4.5%), and nine (41%) patients, respectively. After a median follow-up of 42 months (range, 19-96 months), three patients (13.6%) developed tumor recurrence, all of whom had high-risk GIST. No patient died during this follow-up period The recurrence-free probability at 5 years was 88% (95% CI; 59%-97%). Univariable analysis showed that high mitotic count (> 5/50 HPF) was a significant predictor of tumor recurrence. CONCLUSION: Low and intermediate-risk gastric GIST have an excellent prognosis after complete surgical resection alone, while high-risk group are associated with increased disease recurrence despite complete surgical resection. Adjuvant therapy should be advocated for patients with high-risk gastric GISTs. High mitotic count is an important prognostic factor for recurrence after surgery.

Gastric schwannoma presenting with perforation and abscess formation: a case report and literature review.

Gastric schwannoma represent only 0.2% of all gastric tumors and 4% of all benign gastric neoplasms. They are usually asymptomatic but can present with variable symptoms. The authors report a case of a 29-year-old male patient who presented with fever and abdominal pain with epigastric mass. Pre-operative diagnosis was gastric lymphoma with perforation and an abscess formation. Hemigastrectomy with Billroth II anastomosis was performed The pathologic examination and immunohistochemical studies confirmed gastric schawannoma as the diagnosis. The post-operative course was uneventful. Gastric schwannoma are difficult if not impossible to diagnose preoperatively as endoscopic and radiologic findings are nonspecific. The treatment of choice is complete surgical resection because of diagnostic uncertainty and the long-term outcome is excellent. This is the first report of gastric schwannoma presenting with concealed perforation and an abscess formation. The literature was reviewed.

Surgical management of Brunner's gland hamartoma causing upper GI hemorrhage: report of two cases and literature review.

Brunner's gland hamartomas are uncommon benign tumor of the duodenum. Most lesions are small and asymptomatic. Occasionally, those lesions may be large and manifest as a rare cause of upper GI hemorrhage or duodenal obstruction. The authors report here two cases of Brunner's gland hamartoma presenting with upper GI hemorrhage that were not amenable to endoscopic polypectomy thus requiring surgical resection. The literature on Brunner's gland hamartoma was reviewed.

Transperineal repair of rectourethral fistula: surgical technique and a case report.

A 60-year old Thai male diagnosed as iatrogenic rectourethral fistula. Preoperative investigation with intravenous pyelogram revealed connection between urethra and rectum. Colonoscopy also revealed fistula opening at mid-rectum. He underwent surgery via transperineal approach. Intraoperative fistula localization was performed using Methylene blue injection via foley catheter. The fistula tract was identified and divided exposing blue-staining tract. Rectal opening and urethral opening were repaired Fecal and urthral diversion were performed Postoperative period was uneventful. The final pathologic report of fistula tract was fibrosis. The perineal and rectal wounds were healed without complication. The suprapubic cystostomy catheter was removed at the end of the second month together with the colostomy closure.

Randomized controlled trial of bisacodyl suppository versus placebo for postoperative ileus after elective colectomy for colon cancer.

OBJECTIVE: To compare the use of bisacodyl suppository with placebo in resolving postoperative ileus after elective colectomy in a randomized controlled trial. METHODS: Twenty elective colectomy patients were randomized to receive either bisacodyl or placebo suppository on the third postoperative day. Outcomes included time to first defaecation, length of hospital stay, and postoperative complications. Participants and the primary investigator were unaware of the treatment assignment. RESULTS: All 10 participants in the bisacodyl group defaecated on the third postoperative day, while participants in the placebo group defaecated on days 3 (2/10), 4 (5/10) and 5 (3/10) (p < 0.001). The average lengths of hospital stay for the bisacodyl and placebo groups were 8.5 +/- 2.7 days and 10.4 +/- 5.3 days, respectively (p = 0.325). No significant complications occurred in either group. CONCLUSION: Bisacodyl suppository seems to be effective and safe in resolving postoperative ileus after elective colectomy in colon cancer patients.

Prognostic significance of peritoneal washing cytology in Thai patients with gastric adenocarcinoma undergoing curative D2 gastrectomy.

BACKGROUND: The aim of the present study was to determine the prognostic significance of peritoneal washing cytology (PWC) among Thai patients with gastric adenocarcinoma. METHODS: Medical charts of 97 patients with gastric adenocarcinoma who underwent curative D2 gastrectomy between October 1995 and September 2005 were reviewed. RESULTS: A total of 22 patients (23%) had positive PWC. Factors significantly associated with positive PWC included tumor location, macroscopic findings, histology, depth of tumor invasion, nodal involvement, TNM stage, and angiolymphatic invasion. Positive PWC was found only in tumors invading the serosa. All patients with positive PWC developed peritoneal recurrence. The sensitivity and specificity of positive PWC in predicting peritoneal recurrence were 61% and 100%, respectively. The overall 5-year survival rates for patients with positive and negative PWC were 0% and 75%, respectively. CONCLUSION: Gastric adenocarcinoma with positive PWC should be considered stage IV disease. PWC should be included in the staging of gastric adenocarcinoma.

Results of D2 gastrectomy for gastric adenocarcinoma: 10-year experience in Thai patients.

BACKGROUND: The therapeutic value of D2 gastrectomy in the curative treatment of gastric adenocarcinoma is controversial outside Japan. MATERIAL AND METHOD: The authors retrospectively reviewed the medical records of 97 patients with gastric adenocarcinoma who underwent curative D2 gastrectomy between October 1995 and September 2005. RESULTS: Subtotal gastrectomy was performed in 42/97 patients (43%) and total gastrectomy in 55/97 patients (57%), with an average number of 38 lymph nodes (range, 22-82) and 48 lymph nodes (range, 24-126) removed, respectively. Overall morbidity rate was 17% (16/97). There was no hospital mortality. The 5-year overall and 5-year disease-free survival rates were 59% and 46%, respectively. The 5-year disease-free survival rate for each TNM stage was 100% for stages IA and IB, 75% for stage II, 78% for stage IIIA, 28% for stage IIIB and 4% for stage IV. Of the 43/97 patients (44%) who had metastasis to the level 2 (N2) lymph nodes, 14/ 43 patients (33%) survived more than 5 years. CONCLUSION: The D2 gastrectomy can be performed with low morbidity and mortality, and may increase the cure rate and survival of Thai gastric adenocarcinoma patients, at least in experienced centers.

Dysplastic nodules and small primary carcinoma of the liver: a study detecting the early morphological changes during hepatocarcinogenesis.

OBJECTIVE: Detect the early histological changes relating to human hepatocarcinogenesis in three nodular hepatocellular lesions. MATERIAL AND METHOD: Three cases of dysplastic nodules and one of small hepatocellular carcinoma were obtained from the authors' surgical-pathology file during 2000-2005 for a histopathological study in relevance to the early changes during hepatocarcinogenesis by employing hematoxylin and eosin stain, as well as some immunohistochemical staining. RESULTS: One nodular hepatocellular lesion, diagnosed as a complex lesion of focal nodular hyperplasia contained a microscopic focus (1.5 mm in diameter) of combined hepatocellular and cholangiocarcinoma. CONCLUSION: The small dysplastic hepatocytes subjected to neoplastic transformation combined hepatocellular and cholangiocarcinoma and are the precursorial cells of hepatocellular carcinoma. Chronic viral hepatitis B or C, aflatoxin B, and nitrosamine(s), as well as some nodular hepatocellular lesions share distinct roles in the complex process of hepatocarcinogenesis pertaining to this Southeast Asian country.