Hideyuki Ike

Male sexual function after autonomic nerve-preserving operation for rectal cancer

PURPOSE: Sexual dysfunction after surgery of the rectum is a serious complication to male patients. Autonomic nerve-preserving operation for rectal cancer has been performed within the recent ten years to maintain urinary and male sexual functions without spoiling of therapeutic radicality. To clarify male sexual function as the degree of autonomic nerve-preserving operation, the function was outlined through clinical interview. METHOD: In a series of 134 male patients who were undergoing autonomic nerve-preserving operation for rectal cancer, a detailed history of postoperative sexual function was obtained by interviews. RESULTS: In 87.7 and 66.9 percent of patients, erectile and ejaculatory potencies were maintained, respectively, which were higher rates than those after extended and conventional pelvic dissections. According to the preserving extent of autonomic nerve, patients undergoing complete preserving operations showed higher rates of maintained erectile (92.9 percent) and ejaculatory functions (82.5 percent), sexual intercourse (89.9 percent), and orgasm (93.9 percent) compared with those undergoing hemilateral autonomic nerve-preserving (82.3, 47.1, 52.9, 64.7 percent) or partial pelvic plexus-preserving operation (61.1, 0, 26.3, 22.2 percent). CONCLUSION: Pelvic plexus preservation is necessary to maintain erectile potency, and both hypogastric nerve and pelvic plexus preservation are necessary to maintain ejaculate function and orgasm. To maintain satisfactory sexual function, complete autonomic nerve-preserving operation is suitable.

Results of aggressive resection of lung metastases from colorectal carcinoma detected by intensive follow-up.

AbstractPURPOSE: Although outcome of resection for colorectal carcinoma has improved, about 30 percent of patients develop metastatic lesions. Small pulmonary metastases 1 cm or less in diameter now can be detected by diagnostic tests including chest radiography and computed tomography. We evaluated results of our strategy for intensive follow-up after resection of colorectal cancer and aggressive resection of lung metastases disclosed by these periodic examinations. METHODS: Our follow-up program for lung metastasis includes a serum carcinoembryonic antigen assay every two months and chest radiography every six months. Surgical resection of lung metastases was performed if the primary and any nonpulmonary metastases had been controlled, lung metastases numbered four or fewer, and pulmonary functional reserve was adequate. Standard operation for lung metastasis was lobectomy, and lymph node dissection was added in cases of tumor size over 3 cm. Forty-two patients underwent 50 lung resections for metastatic colorectal cancer between 1992 and 1999. Long-term survival was assessed in terms of clinical variables. RESULTS: Overall five-year survival rate after resection of lung metastases from colorectal cancer was 63.7 percent. Variables significantly affecting postthoracotomy survival were primary tumor histology, number of nodules, and disease-free interval up to appearance of the lung metastases, and primary tumor histology was an independent prognostic factor. CONCLUSION: Intensive follow-up for lung metastases after resection of colorectal cancer and aggressive resection improved postoperative survival rate. Patients with well-differentiated adenocarcinoma of primary tumor, a solitary metastatic nodule, and disease-free interval of at least two years after initial surgery are likely to be long-term survivors.

Activities of Daily Living and Quality of Life of Elderly Patients After Elective Surgery for Gastric and Colorectal Cancers

Objective:To establish reliable standards for surgical application to elderly patients 75 years old or older with gastric or colorectal cancer with special reference to the postoperative recovery of activities of daily living (ADL) and quality of life (QOL). Summary Background Data:ADL and QOL are important outcomes of surgery for the elderly. However, there has been only limited evidence on the natural course of recovery of functional independence. Methods:Two hundred twenty-three patients 75 years old or older with gastric or colorectal cancer were prospectively examined. Physical conditions, ADL, and QOL were evaluated preoperatively and at the first, third, and sixth postoperative month. Results:The mortality and morbidity rates were 0.4% and 28%, respectively. Twenty-four percent of patients showed a decrease in ADL at 1 month postoperatively, but most patients recovered from this transient reduction, with only 3% showing a decline at the sixth postoperative month (6POM). ADL of these patients was likely to decrease after discharge from the hospital. QOL of the patients showed a recovery to an extent equal to or better than their average preoperative scores. Conclusions:Of the patients 75 years old or older who underwent elective surgery for gastric or colorectal cancer, only a few showed a protracted decline in ADL and most exhibited better QOL after surgery. This indicates that surgical treatment should be considered, whenever needed, for elderly patients 75 years old or older with gastric or colorectal cancer. Estimation of Physical Ability and Surgical Stress is useful for predicting postoperative declines in ADL and protracted disability; this could aid in establishing a directed rehabilitation program for preventing protracted disability in elderly patients.

Outcome of Total Pelvic Exenteration for Primary Rectal Cancer

AbstractPURPOSE: This retrospective study identifies the clinicopathologic factors (age, gender, size of tumor, location, tumor stage, lymph node metastasis, histologic differentiation, and adjuvant therapies) that are useful in predicting long-term survival in patients undergoing total pelvic exenteration for advanced primary rectal cancer. METHODS: We reviewed the medical records of 71 patients with stage T3 or T4 primary rectal cancer who underwent a curative total pelvic exenteration. The effects of various clinical variables on long-term survival were analyzed. RESULTS: The postoperative mortality, hospital death, and morbidity rates were 1.4, 4.2, and 66.2 percent, respectively. The overall five-year survival rate after total pelvic exenteration was 54.1 percent. The five-year survival rate was 65.7 percent for patients with T3 lesions and 39 percent for patients with T4 lesions. A univariate analysis showed that postoperative survival was affected by age, tumor stage, and lymph node metastasis, while a multivariate analysis showed that age and lymph node metastasis were independent prognostic factors. CONCLUSION: Total pelvic exenteration may enable long-term survival in younger patients with stage T3 or T4 primary rectal cancer and little or no lymph node metastasis.

Micrometastatic colorectal cancer lesions in the liver

A surgical resection of metastatic liver lesions from colorectal cancer contributes to an improved prognosis. However, the postoperative recurrence rate remains high, particularly in the residual liver. This is probably the result of the failure to detect small lesions. In the present study, we histologically examined the presence of intrahepatic micrometastases, which are considered to be related to recurrence in the residual liver. Intrahepatic micrometastases were histologically examined in 31 resected specimens of 25 patients undergoing a hepatic resection because of metastasis to the liver from colorectal cancer. Micrometastases were found in 14 of 25 cases (56.0%). They were located in the portal veins, central veins, sinusoid, and bile ducts. The longest distance from the main metastasis was 38.2 (mean 7.5±8.0) mm. The size of the macrometastases became larger, and the frequency of micrometastases and the distance of micrometastases from macrometastases had a tendency to increase. Continuous invasion of the macrometastases into the micrometastases through the vasculature or bile duct was also observed. These results suggested that some micrometastases observed in the metastatic liver from colorectal cancer were thus seeded from the primary lesions, while other micrometastases originated from the macrometastatic lesions as satellite lesions.

Metastatic Tumor Doubling Time: Most Important Prehepatectomy Predictor of Survival and Nonrecurrence of Hepatic Colorectal Cancer Metastasis

We determined the relative value of the metastatic colorectal cancer doubling time as a predictor of recurrence and survival after hepatectomy in comparison with other established predictors. Consecutive patients who underwent hepatic resection (n = 144) for colorectal cancer liver metastases were studied retrospectively to identify factors that influence overall survival and recurrence in the remnant liver. Overall 5-year survival and nonrecurrence rates were 49.8% and 50.8%, respectively. By multivariate analysis, large liver tumors (p = 0.038), p53 expression by the liver tumor (p = 0.011), and a short liver metastasis doubling time (≤ 45 days, p = 0.013) negatively affected survival; doubling times > 45 days (adjusted relative risk 0.06; p < 0.001) positively influenced disease-free survival. In patients with remnant liver recurrence, a short doubling time was associated with short disease-free intervals (7.3 ± 6.2 months), multiple metastases (63.6%), and fewer attempts at repeat hepatectomy (22.7%). The doubling time determines tumor size and reflects the patient’s immune and nutritional status. A short doubling time is the most reliable risk factor for multiple metastases, early recurrence, and poor prognosis. Further studies with a larger number of patients are needed to confirm this conclusion.

Results of surgical treatment for multiple (≥5 nodules) bi-lobar hepatic metastases from colorectal cancer

BackgroundThe surgery for the treatment of multiple (≥5) bi-lobar hepatic metastases from colorectal cancer is controversial. This retrospective study presents our experience in an attempt to develop reasonable treatment guidelines.MethodOne hundred sixty-one consecutive patients who underwent liver resection with curative intent were classified into three groups: H1 (unilateral), H2 (bilateral, ≤4 nodules), or H3 (bilateral, ≥5 nodules).ResultsThe overall cumulative 5-year survival rate was 46.7%. Survival was similar among patients with H1, H2, and H3 disease. Thirty-two patients with H3 disease underwent hepatectomy: straightforward hepatectomy in 12, portal vein embolization (PVE) prior to hepatectomy in eight, two-stage hepatectomy in two, and two-stage hepatectomy combined with PVE in ten. Two-stage hepatectomy with or without PVE was the standard approach in patients with synchronous liver metastases. The operating mortality in hepatectomy for H3 disease was 0%, and the morbidity was 15.2%. The overall response rate to neoadjuvant chemotherapy (NAC) was 41.7% (5/12). Patients who responded to NAC (n=5) had a better prognosis than non-responders (n=7) (P<0.05).ConclusionsExtended hepatectomy, including preoperative PVE and multi-step hepatectomy, combined with NAC, may result in a favourable prognosis, especially in patients who respond to NAC, but further studies with more patients are needed to confirm this.

Pre-hepatectomy prognostic staging to determine treatment strategy for colorectal cancer metastases to the liver

BackgroundAttempts at identifying prognostic factors after hepatectomy in patients with colorectal liver metastases have not achieved consensus. We investigated prognostic factors ascertainable before hepatectomy for colorectal metastasis.MethodClinicopathological data for 149 consecutive patients with colorectal cancer who underwent curative resection of primary lesions and metastatic liver disease at one institution were subjected to multivariate analysis concerning metastatic status and the primary lesion.ResultsPoorly differentiated adenocarcinoma or mucinous carcinoma as the primary tumor (Poor/muc; P=0.026), marked vascular invasion by the primary tumor (V; P=0.002), bi-lobar liver metastases (P=0.048), and short doubling time (DT) of the liver tumor (P=0.028) were characteristics assessable before hepatectomy that independently indicated poorer survival. A four-stage classification based on these factors was related to overall (P<0.01) and disease-free (P<0.01) survival rates. No pattern of recurrence site was evident in stage I (patients with no risk factor). Recurrence was usually extrahepatic in stage IV (patients with Poor/muc) but favored the remnant liver in stage II (patients with bi-lobar metastases or short DT) or III (patients with V; P=0.037). Stage III showed more multiple and early hepatic recurrences than stage II, and repeat hepatectomy was less frequent (P<0.05).ConclusionPre-hepatectomy prognostic staging should help to guide treatment of liver metastases.

Metastasis of rectal cancer to lymph nodes and tissues around the autonomic nerves spared for urinary and sexual function

PURPOSE: To clarify the indications for autonomic nerve-sparing operations for rectal cancer, the presence of lymph nodes and metastasis in the tissue around the autonomic nerve were examined in 28 rectal cancer patients. These were staged as pT2 in 8 patients, pT3 in 19 patients, and pT4 in 1 patient histopathologically. METHODS: The specimens of the autonomic nerve including the inferior mesenteric plexus, preaortic plexus, superior hypogastric plexus, hypogastric nerve, and pelvic plexus were removed with radical abdominopelvic lymphadenectomy after the autonomic nerve-sparing rectal cancer operation. RESULTS: In the tissue around the autonomic nerve, lymph nodes were 11.2±9.6 in number and 2.6±2.4 mm in size (mean ± standard deviation). The frequency of presence of lymph nodes was higher and the number of lymph nodes was larger in the inferior mesenteric plexus (70.4 percent; 3.6) and the preaortic plexus (66.7 percent; 2.1) than in the left and right pelvic plexuses (39.1 percent, 1; 36 percent, 1). Metastasis to the lymph nodes or lymphatic permeation in the tissue around the autonomic nerve were observed in four cases (14.3 percent) of lower rectal cancer, consisting of three with Stage III cancer (pT3, pN1-3, and M0) and one with Stage IV cancer (pT4, pN1, and pM1 (HEP)). CONCLUSION: Radical rectal excision that includes lymph nodes and adjacent tissue around the autonomic nerves may result in metastatic tumor removal that would otherwise be leftin situwith nerve-sparing techniques for advanced rectal cancer in Stage III.

Treatment strategies for hepatic metastasis from colorectal cancer

Hepatic micrometastases of the parenchyma adjacent to a macroscopic lesion were detected in 17 of 31 resected liver metastases. Fifty-nine micrometastatic lesions were detected in total; 26 lesions were situated in the portal vein (PV), 22 in the central vein (CV), 5 in the bile duct (BD), and 6 in the sinusoid (SS). A histological study confirmed the direct invasion of the macrometastatic cancer cells into the adjacent PV, CV, BD, and SS. According to the tumor doubling time, the mean diameter of the macrometastases in 19 remnant livers was calculated to have been 0.57±0.87 cm at the time of the primary resection. The calculated diameter of 3 of these 19 macrometastases was found to be less than 0.01 cm, the minimum implantable size, indicating that the cancer recurrence in these specimens may have developed from macroscopic metastatic lesions as a satellite, and not from the primary tumor. In 13 patients who received doses of 5250 mg or more of 5 fluorouracil (FU) via the hepatic artery, the cumulative disease-free rate 2 years postoperatively was 100%; this value was 47.6% in 11 patients who received less than 5250 mg of 5 FU via the hepatic artery, and 0% in 39 patients who received no chemotherapy (P<0.005). These results suggest that anatomical hepatic resection for satellite lesions, combined with prophylactic hepatic arterial chemotherapy for micrometastases, decreases the recurrence rate of hepatic metastases in the remnant liver.