Heita Ozawa

Retrospective, matched case-control study comparing the oncologic outcomes between laparoscopic surgery and open surgery in patients with right-sided colon cancer

PurposeThe short- and long-term outcomes of laparoscopic surgery for right-sided colon cancer remain largely uninvestigated. This study was undertaken to compare the morbidity and mortality after either a laparoscopic right hemicolectomy (LRHC) or an open right hemicolectomy (ORHC) for this type of tumor.MethodsThe study group included 100 patients who underwent an LRHC and 100 patients who underwent an ORHC for right-sided colon cancer from 1990 through 2004. The two groups were retrospectively well matched with respect to sex, age (±5 years), and pathological tumor-node-metastasis (TNM) stage.ResultsThe median follow-up period was 83 months in the LRHC group and 105 months in the ORHC group. The LRHC group had a lower volume of intraoperative bleeding (P < 0.001), a lower rate of wound infection (P = 0.019) or postoperative intestinal obstruction (P = 0.013), and a shorter hospital stay (P < 0.001) than the ORHC group. The rate of recurrence did not differ significantly between the LRHC group (19%) and the ORHC group (22%). In patients with TNM stage I or II, the disease-free survival (DFS) rate (94.9% vs 95.1%) and overall survival (OS) rate (95.8% vs 95.0%) did not differ significantly between the two groups. A similar tendency was observed in patients with stage III with the rates for DFS (71.3% vs 60.4%) and OS (73.6% vs 64.1%), respectively.ConclusionsAn LRHC for right-sided colon cancer has the advantage over an ORHC of better short-term outcomes, and both groups have similar long-term oncologic outcomes. An LRHC is thus an acceptable alternative to an ORHC for the treatment of this type cancer.

A Phase II Trial of Neoadjuvant Preoperative Chemoradiotherapy With S-1 Plus Irinotecan and Radiation in Patients With Locally Advanced Rectal Cancer: Clinical Feasibility and Response Rate

PURPOSE We aimed to validate our hypothesis that a preoperative chemoradiotherapy regimen with S-1 plus irinotecan is feasible, safe, and active for the management of locally advanced rectal cancer in a single-arm Phase II setting. METHODS AND MATERIALS Eligible patients had previously untreated, locally advanced rectal adenocarcinoma. Radiotherapy was administered in fractions of 1.8 Gy/d for 25 days. S-1 was administered orally in a fixed daily dose of 80 mg/m2 on Days 1 to 5, 8 to 12, 22 to 26, and 29 to 33. Irinotecan (80 mg/m2) was infused on Days 1, 8, 22, and 29. Four or more weeks after the completion of the treatment, total mesorectal excision with lateral lymph node dissection was performed. The primary endpoint was the rate of completing treatment in terms of feasibility. The secondary endpoints were the response rate and safety. RESULTS We enrolled 43 men and 24 women in the study. The number of patients who completed treatment was 58 (86.6%). Overall, 46 patients (68.7%) responded to treatment and 24 (34.7%) had a complete histopathologic response. Three patients had Grade 3 leukopenia, and another three patients had Grade 3 neutropenia. Diarrhea was the most common type of nonhematologic toxicity: 3 patients had Grade 3 diarrhea. CONCLUSIONS A preoperative regimen of S-1, irinotecan, and radiotherapy to the rectum was feasible, and it appeared safe and effective in this nonrandomized Phase II setting. It exhibited a low incidence of adverse events, a high rate of completion of treatment, and an extremely high rate of pathologic complete response.

Prognostic significance of peritoneal tumour cells identified at surgery for colorectal cancer

The prognostic significance of intraperitoneal tumour cells (IPCs) in colorectal cancer is not clear. This study aimed to determine whether detection of IPCs could be used a prognostic marker for selecting patients at high risk of recurrence.

Successful laparoscopic resection of a sacrococcygeal teratoma in an adult: report of a case.

Sacrococcygeal teratoma is a relatively rare congenital retroperitoneal tumor in adults. The standard treatment is a complete tumor resection. This report describes the successful laparoscopic resection of a sacrococcygeal teratoma. The patient was a 27-year-old woman with a well-demarcated cystic mass, 6 cm in diameter, in the retroperitoneum overlying the anterior surface of the sacrum. The mass was resected laparoscopically. A histopathological examination showed a mature teratoma. The magnifying function of the laparoscope allowed an en bloc resection in the narrow pelvic cavity, without damaging the tumor. The aesthetic outcome was excellent. The patient remains relapse-free at 1 year 6 months after surgery.

Gastrointestinal Stromal Tumor of the Rectum Resected by Laparoscopic Surgery: Report of a Case

A 53-year-old man visited our hospital with the chief complaint of pain on urination. On digital rectal examination, a rigid immobile tumor mass with a smooth surface was palpated on the anterior wall on the right side of the rectum near the anal canal. Computed tomography (CT) and magnetic resonance imaging (MRI) of the pelvis revealed a heterogeneous tumor mass measuring 6.5 cm in diameter, which occupied the cavity of the lesser pelvis. This rectal tumor was diagnosed to be a gastrointestinal stromal tumor (GIST) based on the results of a transrectal needle biopsy. A laparoscopic abdominoperineal resection of the rectum was performed to remove the mass. The intraoperative findings showed an ambiguous boundary between the tumor and the rectum but clear boundaries between the tumor and the peripheral organs, and the use of a laparoscope allowed for a good separation by providing a good visual field. The bleeding volume was approximately 80 ml and the operative time was 320 min. The macroscopic findings of excised specimens of the mass showed the tumor, measuring 6.5 × 5.5 × 5.0 cm, to be growing extrinsically from the anterior wall on the right side of the rectum. A histological examination of the excised specimens revealed at most 5 mitoses per 50 high-power fields (×400). The tumor mass was diagnosed to be a GIST of low-grade malignancy based on these findings. The postoperative course was favorable, and there were no postoperative complications. The patient was discharged on the 8th hospital day. Laparoscopic surgery is a minimally invasive surgical procedure for rectal GIST, which is excellent in terms of esthetics. Laparoscopic surgery is therefore considered to be useful for a resection of the rectum, because the magnifying effect allows surgical maneuvers with a favorable visual field within the pelvis.

Paired-like homeodomain protein ESXR1 possesses a cleavable C-terminal region that inhibits cyclin degradation.

The eukaryotic cell cycle is regulated by sequential activation and inactivation of cyclin–cyclin-dependent kinase (Cdk) complexes. In this work, we screened human cDNAs that can rescue yeast Saccharomyces cerevisiae from lethality caused by ectopic expression of human cyclin E and isolated a cDNA encoding ESXR1, a paired-like homeodomain-containing protein with a unique C-terminal proline-rich repeat region. In adult tissues, ESXR1 is primarily expressed in the testis. We demonstrate that ESXR1 prevents degradation of ubiquitinated cyclins in human cells. Accordingly, elevation of ESXR1 level results in accumulation of cyclin A and cyclin B1 and thereby provokes M-phase arrest. In human cells, the 65-kDa full-length ESXR1 protein is capable of proteolytically processing into N-terminal 45-kDa and C-terminal 20-kDa fragments. The C-terminal fragment, containing a proline-rich repeat region, is localized to the cytoplasm and displays the ability to inhibit cyclin degradation. In contrast, the N-terminal fragment, containing a paired-like homeodomain, is localized exclusively in the nucleus, suggesting that it plays a role in transcription. Our results indicate that proteolytic processing of ESXR1 plays a role in concerted regulation of the cell cycle and transcription in human cells.

Benefits of a straight laparoscopic restorative proctocolectomy with ileal pouch anal anastomosis for ulcerative colitis: a retrospective case-matched study.

Purposes: The aim of this study was to evaluate the benefit of straight laparoscopic restorative proctocolectomy (sLRP) with ileal pouch anal anastomosis for ulcerative colitis (UC). Methods: Twenty patients underwent sLRP or open restorative proctocolectomy. The 2 groups were retrospectively well matched with respect to sex, body mass index, and American Society of Anesthesiologists’ score. Results: The median operative time was longer in the sLRP group (P=0.0003). The median operative blood loss was significantly less in the sLRP group (P=0.0054). The median analgesic drug usage during the first 7 days after surgery was lower in the sLRP group (P=0.038). There were no differences in morbidity rates and long-term functional outcome measures between the groups. Conclusions: An sLRP for UC has the advantage over an open restorative proctocolectomy of better short-term outcomes, and both groups have similar long-term outcomes. This procedure is acceptable for minimally invasive surgery in patients with UC.

FANCD2 mRNA Overexpression is a Bona Fide Indicator of Lymph Node Metastasis in Human Colorectal Cancer

BackgroundLymph node metastasis is widely accepted as one of the most important determinants of prognosis in colorectal cancer (CRC) patients. Therefore, there is an urgent need to identify molecular markers that can be used to predict lymph node metastasis.Materials and MethodsCandidate genes were found using LMD and cDNA microarrays in a large-scale study of CRC, followed by Penalized Canonical Correlation Analysis (PCCA). We focused on the Fanconi anemia, complementation group D2 (FANCD2) gene and evaluated FANCD2 mRNA expression in 133 CRC cases to determine the clinicopathological significance of FANCD2 expression.ResultsThe mean level of FANCD2 mRNA expression in tumor tissue specimens was significantly higher than in nontumor tissue. FANCD2 expression was found to be a significant factor affecting lymph node metastasis: the high FANCD2 expression group had a significantly poorer prognosis than the low expression group.ConclusionsThis study suggests that PCCA can be used to identify genes related to clinicopathological features. Furthermore, high FANCD2 expression was a significant independent factor for lymph node metastasis.

New technique of laparoscopic colectomy with the LAP DISC and a 5-mm flexible scope

PurposeWe devised a new method for the safe introduction of the first trocar and induction of pneumoperitoneum for laparoscopic excision of the large intestine.MethodsWith this method, a small laparotomy is first conducted according to the size of the exposed affected intestinal tract or tumor size, prior to the application of a LAP DISC (LD) to the wound and introduction of a 12-mm trocar for the establishment of pneumoperitoneum. The method is advantageous in that organ injury and vessel injury are avoided when the small laparotomy is conducted first, and prompt transition to a conventional laparotomy is possible. The diaphragm of the iris bulb can be controlled in a non-stepwise manner. In addition, trocars, the stapler, and other instruments, can be inserted under the pneumoperitoneum. Furthermore, the use of a 5-mm flexible scope allows surgical maneuvers, except for application of LD, to be conducted via 5-mm trocars. In addition, the 5-mm scope can be inserted through any trocar, allowing multidirectional avoidance of dead space and intraperitoneal observation. When only 5-mm trocars are used, it is not necessary for the sites of trocar puncture to be closed by sutures, and this minimizes the risk of adhesions and port-site herniation. The method is also considered to be excellent from the point of view of esthetics.ResultsWe employed this surgical approach in 50 patients with colorectal cancer at our hospital. None of the patients developed any traumatic complications associated with the insertion of trocars, and none of the patients, even those with a past history of abdominal operation, required conversion to conventional laparotomy.ConclusionsBased on these results, this method involving a small laparotomy prior to the application of an LD and introduction of a 12-mm trocar for establishing pneumoperitoneum, with the efficient use of a 5-mm flexible camera, is considered to be safe and useful for laparoscopic excision of the large intestine.

Metastasis to the penis from cecum carcinoma

Progression of cecal carcinoma occurs either by direct invasion or by metastasis through the hematogenous or lymphatic route. The most commonly involved organs are the liver and lymph nodes. However, metastasis to the penis is rare, with only 300 cases reported to date. The most common primary site of tumors that metastasize to the penis is the pelvic organs, and penile metastasis from tumors of the cecum or colon is particularly rare. This is the third reported case of penile metastasis from a cecal carcinoma. A 67-year-old Japanese man with clinical T3N1M0 cecal carcinoma underwent ileocecal resection. Histopathological examination of the resected specimen showed a well-differentiated adenocarcinoma of the cecum. The pathological stage was T3N1M0 stage IIIB (Dukes C). The patient remained well until 12 months after surgery, when he presented with increasing pain in the penis and inguinal region. Multiple palpable nodules were present on the dorsum of the penile shaft. The body of the penis was elastic hard , but there was no true priapism. Pathological examination of specimens obtained by excisional biopsy of the penile nodules and high inguinal orchiectomy showed a welldifferentiated adenocarcinoma compatible with metastasis from the cecal carcinoma. A computed tomography (CT) scan revealed no other distant metastases. Because pain was poorly controlled by nonsteroidal anti-inflammatory drugs and morphine, total penectomy and vesicostomy were carried out 15 months after ileocecal resection. Histopathological examination of the specimens showed multiple nodules in the corpus carvernosum penis, consisting of moderately to welldifferentiated adenocarcinoma compatible with metastases from the carcinoma of the cecum. Penectomy decreased pain and improved the patient’s quality of life. Two weeks after penectomy, a CT examination revealed multiple lung metastases, mediastinal lymph-node metastasis, and left adrenal metastasis. The patient received nine courses of combination chemotherapy with oxaliplatin, 5-fluorouracil, and levofolinate (FOLFOX4 regimen), followed by four courses of a combination of irinotecan, 5-fluorouracil, and levofolinate (FOLFIRI regimen). He survived for 26 months after the diagnosis of penile metastasis. Although the penis has an abundant blood supply, penile metastasis is extremely rare. Penile metastasis from cecal carcinoma was previously reported by Perez-Mesa et al. and Perdomo et al.; to our knowledge this is the third reported case in the English-language literature. The metastatic route to the penis from cecal carcinoma is unknown. If the primary lesion is an intrapelvic tumor, such as rectal cancer or prostate cancer, tumor cells may obstruct the intrapelvic venous plexus and the proximal portion of the lymph ducts, causing tumor cells to flow in a retrograde manner into the dorsal veins of the penis and the lymph ducts. Such flow can lead to retrograde venous or lymphatic transplantation. However, cecal carcinomas are anatomically less likely to cause retrograde metastasis or direct lymphatic spread. Histopathological examination in our own patient revealed no tumor emboli in blood or lymphatic vessels. The outcomes of patients with penile metastasis have been very poor (Table 1). All three patients had metastases to organs besides the penis. Since penile metastasis is only one sign of systemic disease, systemic chemotherapy is necessary to improve survival. Penectomy should be carried out only to improve patients’ quality of life, including pain control. This treatment option should be carefully explained to the patient before surgery.