Prognostic factors for patients with advanced colorectal cancer and symptomatic brain metastases.

BACKGROUND: Increased rates of long-term survival after CRC diagnosis are accompanied by increases in the incidence of BMs. Here, we retrospectively evaluated the outcomes of patients with BMs from CRC. MATERIALS AND METHODS: We reviewed the records of 1364 patients with CRC treated between January 1999 and December 2010 at Kinki University Hospital in Japan. Twenty-five of these patients developed BMs. Log-rank tests and Cox regression analyses were used to assess potential prognostic factors for survival. RESULTS: Among the patients with BMs, BMs developed a median of 25.3 (range, 11.4-111) months after primary CRC surgery. There was a median of 2 BMs per patient. Eleven patients had solitary BMs. Concomitant extracerebral metastases, particularly lung metastases, were found in 23 patients. Twenty-three patients were receiving systemic chemotherapy at the time of diagnosis with BMs. After the development of BMs, the median survival time (MST) was 2.8 months. The MST was 4.8 months among patients who underwent neurosurgical resection (n = 6) or stereotactic surgery (n = 9, including combined therapy in 2 patients) and 1.5 months among patients who underwent whole-brain radiotherapy only or best supportive care (n = 12). In multivariate analysis, single BMs and additional systemic chemotherapy after BMs diagnosis were significantly associated with overall survival (P = .022 and .023, respectively). CONCLUSION: Our results suggest that advancements in continuing systemic chemotherapy prolong survival among patients with BMs from CRC. Clinicians should be especially aware of BMs in patients with lung metastases.

[A case of complete response after treatment with UFT and leucovorin for synchronous multiple liver metastases of rectal cancer].

The patient was a 55-year-old female who had multiple liver metastases of rectal cancer. This patient underwent hepatic arterial infusion chemotherapy after low anterior resection for rectal cancer. Hepatic arterial infusion was discontinued due to severe diarrhea, and the administration of UFT (300 mg/day) and LV(75 mg/day) was then begun. The carcinoembryonic antigen (CEA) level was normalized immediately after the start of this administration. One year later, liver metastases disappeared on computed tomography (CT) and a complete response (CR) was achieved. No adverse events were noted, and CR was maintained for 2 years. This therapy can serve as one of the chemotherapies for advanced colorectal cancer.

Depth of mesorectal invasion has prognostic significance in T3N0 low rectal cancer.

BACKGROUND/AIMS: To investigate mesorectal fat invasion as a prognostic factor for T3N0 low rectal adenocarcinoma following sharp mesorectal excision. METHODOLOGY: Subjects consisted of 26 patients who had a potential curative excision of a T3N0 low rectal adenocarcinoma without neoadjuvant therapy between August 1988 and April 2003. Histological preparations were used to measure depth of mesorectal invasion, which was analyzed for associations with disease-free survival and recurrence. RESULTS: Five-year overall survival and disease-free survival were 64.8% and 57.1%, respectively. Ten patients developed recurrent disease; 3 had local recurrence, 3 had distant metastasis, and 4 had both local and distant recurrence. Rectal cancers were stratified by depth of mesorectal invasion using 4 cutoff values (2, 3, 4, 5 mm), and examined by Cox proportional hazard model. At a cutoff of 3 mm, multivariate analyses confirmed depth of mesorectal invasion to be an independent prognostic factor for 5-year disease-free survival (< 3mm, 90.9%; > or = 3mm, 32.0%; p = 0.023). Distant metastasis differed significantly (< 3mm, 0%; > or = 3mm, 46.7%; p = 0.01), but local recurrence did not (< 3 mm, 9.1%; > or = 3mm, 40%; p = 0.17). CONCLUSIONS: Patients with advanced low T3N0 rectal cancer are at high risk of distant metastases. Depth of mesorectal invasion may be valuable in decisions regarding intensive adjuvant therapy.

Long-term functional changes after low anterior resection for rectal cancer compared between a colonic J-pouch and a straight anastomosis.

BACKGROUND/AIMS: We prospectively compared changes in function between colonic J-pouch and straight anastomoses from 1 to 5 years after low anterior resection for rectal cancer. METHODOLOGY: At 1, 3, and 5 years after surgery, functional outcome was compared between 48 patients with J-pouch reconstruction (J group) and 51 with straight anastomosis (S group), using a 17-item questionnaire (overall best, 0; overall worst, 26). Reservoir function was evaluated manovolumetrically. RESULTS: At 5 years, patients with ultralow anastomoses (< or =4 cm from anal verge) had fewer bowel movements during day or night, and less urgency and soiling in the J than S group. At that time, patients with low anastomoses (5 to 8 cm above the verge), had fewer bowel movements at night and less urgency in the J than S group. Manovolumetric results were better in the J than S group for both anastomotic levels. Functional scores improved significantly over time for both anastomotic levels, especially in the S group. Mean scores with ultralow anastomoses were J-group, 5.6 at 1 year vs. 5.3 at 3 years (P = 0.0304) vs. 3.7 at 5 years (P < 0.0001); and S group, 10.2 at 1 year vs. 9.6 at 3 years (P = 0.0063) vs. 7.3 at 5 years (P < 0.0001). Mean scores with low anastomoses were J group, 3.4 at 1 year vs. 3.1 at 3 years (P = 0.0052) vs. 2.1 at 5 years (P = 0.0003); and S group, 5.2 at 1 year vs. 3.8 at 3 years (P < 0.0001) vs. 2.7 at 5 years (P < 0.0001). Manovolumetric results improved overtime in both groups. CONCLUSIONS: Functional outcome improved in the J and especially the S group over 5 years. However, function was better in the J than S group at all time points.

Long-term functional outcome of colonic J-pouch reconstruction after low anterior resection for rectal cancer.

PURPOSE: To evaluate the long-term functional outcome of colonic J-pouch reconstruction after low anterior resection (LAR) for rectal cancer in a prospective study. METHODS: We compared the functional outcome of 46 patients who underwent J-pouch reconstruction (J-group) and 49 patients who underwent straight anastomosis (S-group) after LAR for rectal cancer. We evaluated clinical function using a 17-item questionnaire about different aspects of bowel function. Physiologic reservoir function was evaluated by manovolumetry. RESULTS: Among the patients with an ultralow anastomosis (

[Intracellular glutathione (GSH) of monocytes (Mo) directs the development of peritumoral stroma in patients with colon carcinoma].

BACKGROUND: One of the unresolved issues related to immunotherapy for cancers is how to predict the degree of growth of tumor stroma at the periphery of the tumor. We examined the feasibility of predicting stromal growth by measuring the glutathione (GSH) level in monocytes as an indicator of the local redox state of cancer, reflecting anti-tumor immune responses. METHODS: Blood was drawn preoperatively from 21 patients with colorectal cancer. Monocytes were isolated from each blood sample and observed under a fluorescent microscope after fluorescent dye staining. The chromatic responses were rated on a three-grade scale: strongly positive, moderately positive and weakly positive. The monocytes were counted in each grade, and the GSH score was calculated. After surgery, pathology specimens of resected tissue were observed under a microscope to measure the percentage of the surface area of stroma in a given visual field at a magnification of x200. The percentage of stromal surface area was measured for three visual fields (near the deepest area of the tumor) to calculate the stroma score. RESULTS: The mean GSH score was 290.2. The mean stroma score was 60.8. There was a significant correlation between the GSH score and the stroma score (r = 0.421, p < 0.05). CONCLUSION: The monocyte GSH level may serve as a predictor of stromal growth.

Optimal ligation level of the primary feeding artery and bowel resection margin in colon cancer surgery: the influence of the site of the primary feeding artery.

PURPOSE: In colon cancer surgery, it is recommended that en bloc resection involving extended lymphadenectomy, characterized as a hemicolectomy, be performed by ligating the primary feeding artery at a high position and resecting proximal and distal with 5-cm to 10-cm bowel margins. However, there is little evidence to unequivocally support such extensive lymphovascular resection. METHODS: The distribution of nodal metastases was obtained by the clearing method in 164 patients with colon cancer. RESULTS: For pericolic spread, for pT1 tumors, the distance from the primary tumor to a diseased node was 2.5 cm; for pT2, the distance was less than 5 cm; for 97.0 percent of pT3 tumors and 93.3 percent of pT4 tumors with nodes involved, the distance was less than 7 cm. For central spread, for pT1 tumors, the rate of spread to central nodes was 0 percent; for pT2, the rate of spread was 20.0 percent to intermediate nodes (for tumors more than 5 cm from the feeding artery, the rate for central nodes was 0 percent); for pT3, the rate was 30.6 percent to intermediate nodes and 15.3 percent to main nodes; for pT4, the rate was 44.4 percent to intermediate nodes and 22.2 percent to main nodes. For curative resection cases with pT3 tumors more than 7 cm from the feeding artery, the rate to central nodes was 0 percent. CONCLUSIONS: In T1 tumors, central node dissection is not required, but resection with proximal and distal 3-cm margins are required; in T2, central node dissection that includes the intermediate node should be performed in addition to resection with proximal and distal 5-cm margins. In T3 and T4, central node dissection that includes the main node should be performed in addition to resection with proximal and distal 7-cm margins. However, for T2 more than 5 cm from the primary feeding artery, and for T3 more than 7 cm from the primary feeding artery, proximal and distal resection alone may be adequate.

Number versus distribution in classifying regional lymph node metastases from colon cancer.

BACKGROUND: Metastasis to regional lymph nodes from colon cancer is an important prognostic factor. In the TNM classification, node metastases are classified into three grades based on the number of metastatic nodes. In the Japanese General Rules for Clinical and Pathologic Studies on Cancer of the Colon, Rectum, and Anus (JGR), node metastases are classified into four grades based on the distribution of metastatic nodes. STUDY DESIGN: Based on the findings of node metastases in 164 patients with colon cancer obtained by the clearing method, node classifications by the JGR and TNM classifications were compared. RESULTS: The case distribution by the JGR grading was 41.5% in n (-), 29.3% in n1 (+), 18.3% in n2 (+), and 11.0% in n3 (+) disease. In the TNM classification, the distribution was 23.8% in pN1 and 34.8% in pN2 disease. The 5-year survival rate by the JGR was 98.4% in n (-), 74.3% in n1 (+), 51.2% in n2 (+), and 30.0% in n3 (+) disease; in TNM classification, this rate was 76.0% in pN1 and 45.0% in pN2 disease. CONCLUSIONS: In the classification of regional node metastases from colon cancer, the JGR classification showed a wider range in distribution and 5-year survival rate compared with the TNM system.

Comparison of long-term functional results of colonic J-pouch and straight anastomosis after low anterior resection for rectal cancer: a five-year follow-up.

PURPOSE: Few reports on the long-term functional outcome of colonic J-pouch reconstruction have been published, and data comparing J-pouch and straight reconstruction are contradictory. This prospective study compares the functional outcome of colonic J-pouch and straight anastomosis five years after low anterior resection for rectal cancer. METHODS: Functional outcome was compared in 46 patients with J-pouch reconstruction (J-group) and 48 patients with straight anastomosis (S-group). Clinical status was evaluated with a 17-item questionnaire inquiring about different aspects of bowel function. Reservoir function was evaluated by manovolumetry. The Fisher's exact test and Wilcoxon's rank-sum test were used to compare categoric and quantitative data, respectively. RESULTS: Among patients with an ultralow anastomosis (< or = 4 cm from the anal verge), the number of bowel movements during the day (> or = 5, 4.3 vs. 29.2 percent; P = 0.028) and at night (> 1/week, 4.3 vs. 33.3 percent; P = 0.013) and urgency (4.3 vs. 33.3 percent; P = 0.013) and soiling (21.7 vs. 50.0 percent; P = 0.043) were less in the J-group than in the S-group. Among patients with a low anastomosis (5 to 8 cm from the verge), patients in the J-group had fewer bowel movements at night (> 1/week, 0 vs. 20.8 percent; P = 0.028) and less urgency (0 vs. 20.8 percent; P = 0.028). Reservoir function was better in the J-group than in the S-group in both the ultralow (maximum tolerable volume (mean), 101.7 vs. 76.3 ml; P = 0.004; threshold volume (mean), 46.5 vs. 30.4 ml; P < 0.001; compliance (mean), 4.9 vs. 2.5 ml/cm H2O; P < 0.001) and low-anastomosis (maximum tolerable volume, 120.4 vs. 97.9 ml; P < 0.001; threshold volume, 58.3 vs. 40.8 ml; P < 0.001; compliance, 5.2 vs. 3.1 ml/cm H2O; P < 0.001) groups. CONCLUSIONS: J-pouch reconstruction increased reservoir function and provided better functional outcome than straight anastomosis, even five years after surgery, especially in patients whose anastomosis is less than 4 cm from the anal verge.

Long-term functional outcome of low anterior resection with colonic J-pouch reconstruction for rectal cancer in the elderly.

PURPOSE: Bowel function after low anterior resection for rectal cancer with colonic J-pouch reconstruction is more normal than after conventional straight anastomosis. However, few reports have examined the function of colonic J-pouch reconstruction in the elderly. Good function would obviate the need for colostomy, which is sometimes performed because of concern about fecal incontinence, which increases with age. This study evaluated the function of colonic J-pouch reconstruction in elderly patients aged 75 years or older. METHODS: Functional outcome was compared in 20 patients aged 75 years or older (older group) and 27 patients aged 60 to 74 years (old group) and 60 patients aged 59 years or younger (young group), 3 years after colonic J-pouch reconstruction, using a functional scoring system with a 17-item questionnaire (score range, 0 (overall good) to 26 (overall poor)). RESULTS: The functional scores in the three age groups were satisfactory and similar. Among patients with anastomoses 1 cm to 4 cm from the anal verge, all 17 categories on the questionnaire in the three age groups were similar. Among patients with anastomoses 5 cm to 8 cm from the anal verge, only the use of laxatives or glycerine enemas was more common in the older group than in the old and young group (90 vs. 38.5 percent and 43.3 percent; P = 0.01). CONCLUSIONS: Low anterior resection with colonic J-pouch reconstruction provides excellent functional outcome, including continence, for elderly patients. Colonic J-pouch reconstruction is a highly preferable alternative to permanent colostomy in elderly patients undergoing low anterior resection.

[A patient with advanced gastric cancer that response remarkably to combination chemotherapy of TS-1 and biweekly paclitaxel (TXL)].

We treated a patient with inoperable advanced gastric cancer and malignant ascites by combination chemotherapy of TS-1 and biweekly paclitaxel (TXL). After two courses the ascites had disappeared and the primary tumor was reduced. TS-1 (80 mg/body/day) was administered for 21 days followed by 7 days rest and TXL (100 mg/body) was administered on days 1 and 14 as one course. The patient could not eat at the time of hospitalization, but at the time of the second course he could eat a full serving of rice porridge. Grade 2 anemia and leukopenia were the only adverse reactions observed; no major adverse reactions were observed. These results suggest that with TS-1 and TXL combination chemotherapy, patients with advanced gastric cancer can achieve a marked improvement in quality of life.