A long-term survival case of Sister Mary Joseph's nodule caused by colon cancer and treated with a multidisciplinary approach.

Umbilical metastasis from intra-abdominal or pelvic malignancy, which is called Sister Mary Joseph's nodule (SMJN), is rare, and it has a poor prognosis. Its most common primary sites are the stomach and ovaries. SMJN caused by colon cancer is uncommon. A 42-year-old woman visited local clinics with complaints of an umbilical mass. After a detailed examination, she was diagnosed with peritoneal and umbilical metastasis caused by colon cancer. A radical surgery was performed after 12 months of chemotherapy. 6 months later, local recurrence and ovarian metastasis were suspected. Further radical surgery was performed, and 14 months after that (50 months after starting treatment), no recurrences have been observed. We experienced a long-term survival case of SMJN caused by colon cancer and treated with a multidisciplinary approach.

HNRNPLL stabilizes mRNA for DNA replication proteins and promotes cell cycle progression in colorectal cancer cells.

Heterogeneous nuclear ribonucleoprotein L-like (HNRNPLL), an RNA-binding protein that regulates alternative splicing of pre-mRNA, has been shown to regulate differentiation of lymphocytes, as well as metastasis of colorectal cancer cells. Here, we show that HNRNPLL promotes cell cycle progression and, hence, proliferation of colorectal cancer cells. Functional annotation analysis of those genes whose expression levels were changed threefold or more in RNA sequencing analysis between SW480 cells overexpressing HNRNPLL and those knocked down for HNRNPLL revealed enrichment of DNA replication-related genes by HNRNPLL overexpression. Among 13 genes detected in the DNA replication pathway, PCNA, RFC3 and FEN1 showed reproducible upregulation by HNRNPLL overexpression both at mRNA and at protein levels in SW480 and HT29 cells. Importantly, knockdown of any of these genes alone suppressed the proliferation-promoting effect induced by HNRNPLL overexpression. RNA-immunoprecipitation assay presented a binding of FLAG-tagged HNRNPLL to mRNA of these genes, and HNRNPLL overexpression significantly suppressed the downregulation of these genes during 12 h of actinomycin D treatment, suggesting a role of HNRNPLL in mRNA stability. Finally, analysis of a public RNA sequencing dataset of clinical samples suggested a link between overexpression of HNRNPLL and that of PCNA, RFC3 and FEN1. This link was further supported by immunohistochemistry of colorectal cancer clinical samples, whereas expression of CDKN1A, which is known to inhibit the cooperative function of PCNA, RFC3 and FEN1, was negatively associated with HNRNPLL expression. These results indicate that HNRNPLL stabilizes mRNA encoding regulators of DNA replication and promotes colorectal cancer cell proliferation.

Survival Benefit of Japanese Extended Lymphadenectomy for Clinically Node-Negative and Node-Positive Colorectal Cancers.

BACKGROUND: The impact of extended lymphadenectomy for colorectal cancer is still not sufficiently clear. OBJECTIVE: The aim of the present study was to evaluate the survival benefit of extended lymphadenectomy compared with nonextended lymphadenectomy for clinically node-negative and node-positive colorectal cancers. DESIGN: The present study was a retrospective cohort study that used prospectively collected data and a propensity score matching method. SETTINGS: The present study was conducted at a single specialized colorectal surgery department. PATIENTS: Of the 1314 patients who underwent radical resection with nonextended or extended lymphadenectomy between 1988 and 2007, we included 711 and 603 patients in the cN0 and cN1/2 series. Propensity score matching was applied, and 141 and 63 pairs were extracted from the cN0 and cN1/2 series. MAIN OUTCOME MEASURES: Disease-free survival, cancer-specific survival, and overall survival of the 2 groups were calculated and compared. RESULTS: In the cN0 series, no differences were observed in the long-term outcomes between the nonextended and extended groups. In the cN1/2 series, the disease-free survival, cancer-specific survival and overall survival were significantly higher (log rank, p = 0.04, p = 0.02, and p = 0.01, respectively), and the frequency of local recurrence was significantly lower (p = 0.04) in the extended group. LIMITATIONS: The present study was limited by its nonrandomized retrospective design. CONCLUSIONS: Extended lymphadenectomy demonstrated a good inhibitory effect on the local recurrence rate and led to improved disease-free survival, cancer-specific survival, and overall survival of patients in the cN1/2 series. See Video Abstract at http://links.lww.com/DCR/A517.

HNRNPLL, a newly identified colorectal cancer metastasis suppressor, modulates alternative splicing of CD44 during epithelial-mesenchymal transition.

OBJECTIVE: Despite the recent advances in treatment of colon cancer, the prognosis is unfavourable for patients with distant metastases. The aim of this study was to identify targets for prevention and/or therapy of colon cancer metastasis. DESIGN: CMT93 cells, a murine rectal cancer cell line with poor metastasising activity, were transduced with lentiviral shRNA library and transplanted into the rectum of syngeneic C57BL/6 mice. Genomic DNA was collected from metastatic lesions, and the integrated shRNA were retrieved by PCR for sequencing, followed by identification of the candidate genes targeted by the shRNA. RESULTS: The genome-wide shRNA library screen identified Hnrnpll (heterogeneous nuclear ribonucleoprotein L-like) encoding a pre-mRNA splicing factor as a candidate metastasis suppressor gene. Knockdown of Hnrnpll enhanced matrigel invasion activity of colon cancer cells in vitro, as well as their metastatic ability in vivo. An RNA-immunoprecipitation analysis showed Hnrnpll-binding to Cd44 pre-mRNAs, and the level of Cd44 variable exon 6 (Cd44v6), a poor prognosis marker of colorectal cancer, was increased by knocking down Hnrnpll. A neutralising Cd44v6 antibody suppressed the matrigel invasion ability induced by Hnrnpll knockdown. HNRNPLL expression was downregulated when colon cancer cells were induced to undergo epithelial-mesenchymal transition (EMT). Immunohistochemistry of clinical samples indicated that colorectal cancer cells with low E-cadherin expression at the invasion front exhibited decreased HNRNPLL expression. CONCLUSIONS: HNRNPLL is a novel metastasis suppressor of colorectal cancer, and modulates alternative splicing of CD44 during EMT.

Solitary distant peritoneal metastasis of cecal cancer after laparoscopic colectomy: a case report.

A 77-year-old Japanese female underwent laparoscopic ileocecal resection and lymph node dissection for cecal cancer by a previous doctor. Two years and 9 months after previous operation, contrast-enhanced computed tomography and magnetic resonance imaging with gadolinium ethoxybenzyl-L-diethylenetriamine pentaacetic acid revealed an intraperitoneal tumor at the right subphrenic fossa. 18F-fluorodeoxyglucose position emission tomography showed fluorodeoxyglucose accumulation in the tumor, and we suspected the tumor to be solitary distant peritoneal metastasis of the previous cecal cancer to the right diaphragm. We performed partial diaphragmectomy and direct closure, and pathological examination revealed moderately differentiated tubular adenocarcinoma resembling the previous cecal cancer, which seemed to be disseminated metastasis in the pathological features. Based on the intraoperative findings, we assumed the tumor to be solitary distant peritoneal metastasis caused by procedures during the previous laparoscopic operation. The present report suggests the importance of paying close attention to procedures during laparoscopic colorectal resection to prevent peritoneal seeding. J. Med. Invest. 64: 288-290, August, 2017.

Recovery from Choriocarcinoma Syndrome Associated with a Metastatic Extragonadal Germ Cell Tumor Hemorrhage.

A germ cell tumor is the most common form of malignancy in early male life, and can be classified as either seminomatous or nonseminomatous. Choriocarcinoma, comprised of nonseminomatous germ cells, is the most aggressive type of germ cell tumor and characteristically metastasizes to the retroperitoneal lymph nodes and less frequently to the lungs, liver, bone or brain [Shibuya et al., 2009;48: 551-554]. A 56-year-old man was admitted to another hospital complaining of abdominal distension. Symptoms included anorexia, vomiting, and diarrhea. The patient was diagnosed with an extragonadal germ cell tumor and referred to our hospital to receive chemotherapy. The day after admission, the patient's abdominal distension gradually worsened. An emergency operation revealed venous hemorrhage from the surface of a metastatic extragonadal germ cell tumor between the ligament of Treitz and the inferior mesenteric vein in a horizontal position. Hemostatic treatment was performed with 4-0 proline thread attached to a medicated cotton sponge, rather than using a simple proline thread, and the closure area was manually compressed. Chemotherapy was initiated on postoperative day 10. A metastatic extragonadal germ cell tumor that causes massive hemorrhage and gastrointestinal hemorrhage is very rare, and represents a life-threatening emergency. If the patient's condition carries a substantial risk of bleeding to death, it may be worthwhile to attempt abdominal operations.

Necessary circumferential resection margins to prevent rectal cancer relapse after abdomino-peranal (intersphincteric) resection.

PURPOSE: The purpose of this study was to determine the adequate circumferential resection margin (CRM) for abdomino-peranal (intersphincteric) resection (ISR) that would prevent the relapse of rectal cancers. METHODS: The records of 41 cases that underwent curative ISR for rectal cancer were retrospectively reviewed. The relapse-free survival rates and overall survival rates were evaluated and correlated with the maximum depth of the inner muscularis layer reached during ISR (i.e., the radial margin [RM] and distal margin [DM]). Cases were divided into three groups based on the sizes of the RM and DM: (1) group A (RM >2 mm and DM >1.5 cm), (2) group B (RM >2 mm or DM >1.5 cm but not both), and (3) group C (RM <2 mm and DM <1.5 cm). RESULTS: The relapse-free survival rates of the cases in group C were lower than those in the cases of group A or group B (p = 0.002 and 0.037, respectively). The resection margins required to prevent rectal cancer relapse were >2 mm for the RM and >1.5 cm for the DM. For these margins, the intersphincteric space had to be entered (i.e., between the internal and external anal sphincters). CONCLUSION: It is critical to enter the intersphincteric space to ensure an adequate CRM (RM >2 mm and DM >1.5 cm) for preventing rectal cancer recurrence after ISR.

Adequate Margins to Prevent Local Re-recurrence of Rectal Cancer: Viewpoint of Pathological Findings.

BACKGROUND: A sufficient surgical margin is critical for preventing re-recurrence and achieving R0 status after resection of a local recurrence of rectal cancer (LRRC). PATIENTS AND METHODS: Re-recurrence-free survival was analyzed in 110 cases of LRRC according to histological type of primary lesion. The circumferential resection margin (CRM) was classified as 'R1' (x=0 µm), 'R0 shortness' (0 µm 2,000 µm during resection of LRRC is more likely to prevent re-recurrence. Cases with poorly differentiated carcinoma from the primary lesion to the recurrent lesion tend to have poor prognoses.

A delayed-onset rectourethral fistula after intersphincteric resection for very low rectal cancer: a case report and literature review.

Rectourethral fistula is one of the complications that can occur after prostatectomy in the urologic discipline. However, a delayed-onset rectourethral fistula after intersphincteric resection (ISR) for low rectal cancer is extremely rare. Here, we report one such case in a 57-year-old man. After ISR for low rectal cancer with a diverting stoma (DS), the DS was closed. After approximately 1 year, frequent pneumaturia and right orchitis were observed. Results of contrast enemas and abdominal computed tomography examinations revealed a rectourethral fistula from an anastomosis to the urethra. The colonoscopic appearance revealed a pinhole fistula on the anastomotic line, with thick pus. We performed a transverse colostomy, and the pneumaturia and right orchitis were no longer observed. Two months later, colonoscopy, contrast enemas, and cystoscopy revealed no rectourethral fistula. To the best of our knowledge, our case is the first report of a delayed-onset rectourethral fistula after ISR.

A Case of Gastric Cancer with Residual Tumor Only in the Para-Aortic Lymph Nodes after Systemic Chemotherapy followed by Conversion Surgery.

We report the case of a 60-year-old male who was diagnosed with gastric cancer. Upper gastrointestinal endoscopy indicated advanced cancer in the posterior wall of the gastric body. Biopsy revealed poorly differentiated adenocarcinoma. Abdominal computed tomography demonstrated thickening of the gastric wall and enlargement of the regional lymph nodes and of the para-aortic lymph nodes (PAN). The involvement of the PAN extended from the celiac axis to the caudal area of the inferior mesenteric artery [cT3N3aH0P0M1(LYM), stage IV]. Systemic chemotherapy was initiated. After 3 courses of S-1 plus cisplatin combination chemotherapy, the primary lesion and the enlarged lymph nodes revealed marked regression except for a minute residual lesion in the lymph nodes. Upon obtaining informed consent, open distal gastrectomy, D2 lymphadenectomy with PAN dissection, and Roux-en-Y reconstruction were performed. The patient was discharged from the hospital 35 days after the operation. Histopathological examination of the resected samples revealed malignant cells only in the PAN, not in the stomach or in the regional lymph nodes [ypT0N0M1(LYM), stage IV]. Currently, the patient is undergoing postoperative adjuvant chemotherapy with S-1 and has remained well without any recurrence after 6 months following surgery.

[A questionnaire survey on QOL and toxicity in colorectal cancer survivors who received adjuvant chemotherapy].

The relative risk of cancer recurrence with postoperative adjuvant FOLFOX/CapeOX therapy(Ox)for stage III colorectal cancer is reduced by approximately 20%when compared to that with fluorouracil plus Leucovorin. We performed a questionnaire survey to evaluate the quality of life(QOL)and extent of side effects in patients who received adjuvant chemotherapy. In order to evaluate the risks and benefits of oxaliplatin administration, we also examined the differences in awareness of oxaliplatin side effects between patients and medical staff. Responses were obtained from 147 patients, 54 doctors, and 84 nurses. Analysis of the patient responses showed higher current QOL scores regardless of the chemotherapy regimen, although patients in the Ox group had a high rate of residual sensory peripheral neuropathy. In the Ox group, 81% of patients responded that the side effects were moderate. In contrast, 40% of medical staff identified the side effects of oxaliplatin as severe, which differed from that reported by the patients. Considering that Ox adjuvant chemotherapy may reduce the risk of recurrence by approximately 20%, the risk/benefit balance is acceptable.

Differences in attitude toward adjuvant chemotherapy between colorectal cancer survivors and the medical staff of Japanese hospitals.

BACKGROUND: Adding oxaliplatin to fluorouracil-based chemotherapy can improve the survival of patients with stage III colorectal cancer by approximately 20 %. Reportedly, cancer patients are much more likely to prefer chemotherapy than medical professionals, although there is only a very small chance of achieving benefits from treatment. However, chronic neurotoxicity may be long lasting after the administration of oxaliplatin-based chemotherapy. This study aimed to evaluate potential side effects and differences in attitude between colorectal cancer patients and medical staff regarding the risk-benefit trade-offs of chemotherapy. METHODS: Relapse-free colorectal cancer patients who received adjuvant chemotherapy, doctors, and nurses were surveyed using a questionnaire regarding the side effects of chemotherapy and hypothetical clinical scenarios to quantify gains in the risk of relapse that were deemed necessary to make chemotherapy worthwhile. RESULTS: Responses were obtained from 147 patients, 54 doctors, and 84 nurses. Of these, 39 % of patients and 85 % of doctors replied that moderate side effects of adjuvant chemotherapy were worthwhile to achieve an absolute gain in the risk of relapse of 10 % from a baseline of 40 %. More severe side effects, as reported by colorectal cancer patients, were not associated with the larger gains necessary to make treatment worthwhile. Seven percent of patients treated with oxaliplatin, 40 % of doctors, and 43 % of nurses replied that side effects associated with oxaliplatin-based chemotherapy were severe. CONCLUSIONS: Doctors should consider potential heterogeneity in side effects and attitudes regarding the risk-benefit balance of adjuvant chemotherapy, and that patient perspectives should enhance shared decision-making.

The current status of emergency operations at a high-volume cancer center.

This study aimed to assess the pathogenic causes, clinical conditions, surgical procedures, in-hospital mortality, and operative death associated with emergency operations at a high-volume cancer center. Although many reports have described the contents, operative procedures, and prognosis of elective surgeries in high-volume cancer centers, emergency operations have not been studied in sufficient detail. We retrospectively enrolled 28 consecutive patients who underwent emergency surgery. Cases involving operative complications were excluded. The following surgical procedures were performed during emergency operations: closure in 3 cases (10.7%), diversion in 22 cases (78.6%), ileus treatment in 2 cases (7.1%), and hemostasis in 1 case (3.6%). Closure alone was performed only once for peritonitis. Diversion was performed in 17 cases (77.3%) of peritonitis, 4 cases (18.2%) of stenosis of the gastrointestinal tract, and 1 case (4.5%) of bleeding. There was a significant overall difference (P = 0.001). The frequency of emergency operations was very low at a high-volume cancer center. However, the recent shift in treatment approaches toward nonoperative techniques may enhance the status of emergency surgical procedures. The results presented in this study will help prepare for emergency situations and resolve them as quickly and efficiently as possible.

Sterile abdominal abscess resulting from remnant laparoscopic clips after sigmoidectomy: a case report and literature review.

The occurrence of intra-abdominal sterile abscesses due to remnant clips after laparoscopic sigmoidectomy is rare. Here, we report one such case in a 74-year-old woman. Two years after laparoscopic sigmoidectomy, abdominal CT indicated an area of fluid accumulation approximately 5 cm in diameter and located in the middle of the abdominal cavity that contained a cluster of clips. Fine-needle aspiration of the fluid was performed through the wall of the sigmoid colon. The luminal fluid was found not to contain cancer cells on histological examination. After 1 year, abdominal surgery was performed. The abscess was located in the mesorectum at the anastomosis site; it was incised and a significant quantity of ivory-white viscous solution containing a cluster of clips was extracted. This case emphasizes the importance of reducing the number of clips used in laparoscopic surgery.

Complications associated with postoperative adjuvant radiation therapy for advanced rectal cancer.

Preoperative management of advanced rectal cancer often includes chemoradiotherapy, but little is known about the late complications of radiotherapy. However, these are usually serious, making determination of the characteristics of late complications after radiation therapy critical. Accordingly, we investigated the complications occurring after adjuvant pelvic radiation therapy in patients with advanced rectal cancer. We enrolled 34 consecutive patients with TNM stage III rectal cancer who had undergone curative surgery with adjuvant pelvic radiation therapy. Data on the type of complication/organ involved, the number of complications, the phase of onset, and the treatments used were reviewed. Patients who experienced gut complications or edema were less likely to have their complications resolved than those with complications due to infection. Similarly, patients with multiple complications and late-onset complications were also less likely to have their complications resolved than those with single complications and those with early-onset complications, respectively. Adjuvant radiation therapy in patients with resected advanced rectal cancer was associated with various complications, characterized by late onset and impaired resolution. Therefore, patients indicated for radiation therapy should be selected with great caution.

Sex differences between cT4b and pT4b rectal cancers.

We retrospectively evaluated rectal cancer surgery cases in which resection had been performed for invasion of other organs in terms of pathologic findings from the viewpoint of sex differences. We enrolled 61 consecutive patients with rectal cancer who had undergone curative surgery with resection of invaded adjacent organs. We investigated invasion of adjacent organs in terms of pathologic findings according to sex differences. Among males, 4 cases (13.8%) had received combined radical resections of more than 2 organs, while the number of such female cases was 15 (46.9%). The difference between males and females was statistically significant (P = 0.006). Among male cases, histopathologic invasion was present in 4 (13.8%), while 9 female cases (28.1%) showed this feature. Nevertheless, there was not a statistically significant difference between males and females (P = 0.08); the rate in females was roughly twice that in males. No significant difference was recognized in the overall survival rates between males and females, but more females than males experienced local recurrence. In cases with rectal cancer invading neighboring organs, the effect of the invasion must be carefully determined, and the most appropriate operative approach selected accordingly.

D3 Lymph Node Dissection in Right Hemicolectomy with a No-touch Isolation Technique in Patients With Colon Cancer.

BACKGROUND: The role of lymph node dissection in the management of right-sided colon cancer remains controversial. OBJECTIVE: The aim of this study was to investigate the surgical treatment of curable right-sided colon cancer by using D3 lymphadenectomy with a no-touch isolation technique and to determine the extent of lymph node dissection optimal for the prognosis of right-sided colon cancer. DESIGN: This research is a retrospective cohort study from a prospectively collected database. SETTING: The investigation took place in a specialized colorectal surgery department. PATIENTS: : Data on 370 consecutive patients who underwent D3 lymph node dissection for right-sided colon cancer with a no-touch isolation technique were identified. MAIN OUTCOME MEASURES: The survival of patients with involvement of main nodes at the roots of colonic arterial trunks along superior mesenteric vessels through intermediate nodes in the right mesocolon was determined. RESULTS: The 5-year overall survival of patients with stage I (n = 73, 19.7%), II (n = 155, 41.9%), and III (n = 142, 38.4%) cancer were 94.5%, 87.6%, and 79.2%. The 5-year disease-specific survival of patients with stages I, II, and III cancer were 100.0%, 94.5%, and 85.0%. Eleven patients (3.0%) had metastatic involvement of main lymph nodes, whereas 49 (13.2%) had metastases to intermediate lymph nodes. The 5-year overall survival and disease-specific survival of patients with metastases to main lymph nodes were 36.4% for both, and 5-year overall survival and disease-specific survival of patients with metastases to intermediate lymph nodes were 77.6% and 83.5%. LIMITATIONS: This study was limited by its nonrandomized retrospective design. CONCLUSIONS: D3 lymphadenectomy with a no-touch isolation technique allows curative resection and long-term survival in a cohort of patients with cancer of the right colon.

Detailed stratification of TNM stage III rectal cancer based on the presence/absence of extracapsular invasion of the metastatic lymph nodes.

BACKGROUND: The presence/absence of extracapsular invasion in metastatic lymph nodes has been reported as being significantly correlated with the prognosis in a wide variety of cancers. However, the influence of extracapsular invasion in the metastatic lymph nodes on the prognosis in patients with stage III rectal cancer has not yet been investigated. OBJECTIVE: We investigated the presence/absence of extracapsular invasion in the metastatic nodes of the relevant main/lateral lymph node group in patients with rectal cancer to determine the usefulness of this parameter for stratifying the prognosis of patients with stage III rectal cancer. DESIGN: This was a single-institution study. SETTINGS: This study was conducted at a single institution. PATIENTS: We enrolled 101 consecutive patients with stage III rectal cancer who had undergone curative surgery with extended lymph node dissection and investigated the presence/absence of extracapsular invasion in the regional metastatic lymph nodes to determine the usefulness of such stratification for a more precise prediction of the patient prognosis. MAIN OUTCOME MEASURES: The main outcomes measured were the disease-free and overall survival rates. RESULTS: Univariate analysis revealed a significantly poorer prognosis, in terms of both the disease-free survival rate (p = 0.003) and overall survival rate (p = 0.008), of the pN3-extracapsular invasion-positive cases in comparison with the pN3-extracapsular invasion-negative cases. Multivariate analysis revealed the presence/absence of extracapsular invasion in the metastatic lymph nodes as the only variable that was statistically significantly associated with the disease-free survival rate (p = 0.011). LIMITATIONS: This was a retrospective study in a small number of patients from a single institution. There were no comparator groups. CONCLUSIONS: Detailed stratification of pN3 cases based on the presence/absence of extracapsular invasion in metastatic lymph nodes has the potential to contribute significantly to more available prediction of the prognosis of patients with stage III colorectal cancer.

Tumor necrosis in patients with TNM stage IV colorectal cancer without residual disease (R0 Status) is associated with a poor prognosis.

AIM: To examine the usefulness of the histopathological finding of tumor necrosis for stratifying TNM stage IV colorectal cancer in R0 status. PATIENTS AND METHODS: We enrolled 98 patients with stage IV colorectal cancer, without residual disease after resection. The extent of necrosis was assessed using published thresholds, the extent was graded as "absent", "moderate" (<30% of tumor area), or "severe" (≥30%) in each section. RESULTS: In multivariate analysis, the only significant difference in the disease-free survival rate was related to tumor necrosis (p=0.01) and the significant differences in the overall survival rates were related to the maximum tumor size and the degree of tumor necrosis (p=0.02 and p=0.001, respectively). CONCLUSION: Tumor necrosis is associated with a poor prognosis in colorectal cancer and may allow the stratification of TNM stage IV patients without residual disease after surgery.