Kitarou Futami

A Clinicopathological Investigation of "Tumor Nodules" in Colorectal Cancer

PurposeTumor nodules (tn) have been histologically identified within the fatty tissue or the detached fatty tissue around dissected lymph nodes, or else picked up as lymph nodes from resected specimens with no lymph node components. The TNM classification of malignant tumors provides a description of how to deal with tn, but there has so far been no description within the Japanese classification of colorectal carcinoma. The aim of this study was to determine whether we should regard tn as metastatic lymph nodes from the viewpoint of prognosis.MethodsA total of 544 patients who underwent a resection of colorectal adenocarcinoma between 1985 and 1995 were reviewed.ResultsTumor nodules were found in 54 (17.6%) of 307 colon cancer patients, and in 41 (17.3%) of 237 rectal cancer patients. We classified the curability A patients into four groups for both colon and rectal cancer; positive lymph nodes with tn (Group A), negative lymph nodes with tn (Group B), positive lymph nodes without tn (Group C), and negative lymph nodes without tn (Group D). The prognosis was not significantly different between Groups A, B, and C, but it was significantly different between Group D and Groups A, B, and C (P < 0.01) in both the colon and the rectum.ConclusionFrom the viewpoint of prognosis, it thus appears justifiable to regard tn as lymph node metastasis.

Asymptomatic pulmonary cryptococcosis in a patient with Crohn's disease on infliximab: case report.

To the Editor: Tumor necrosis factor alpha (TNFa) inhibitor is widely used as an effective treatment for inflammatory bowel disease (IBD) worldwide. In Japan, infliximab (IFX) has been used for patients with moderate to severe active Crohn’s disease (CD) who show resistance to other treatments. In addition, since treatment with IFX was also provided to patients with moderate to severe ulcerative colitis (UC) from June 2010, it is considered that the frequency of IFX use will increase in the future. It is important to know the various adverse effects of this treatment in order to use it safely. Opportunistic infection is one of the severe adverse effects of IFX use. Physicians sometimes come into contact with patients suffering serious infection during IFX treatment. It has been reported that older age, high activity of the disease, and steroid use were risk factors of opportunistic infection. Interestingly, the spectrum of infectious disease associated with the use of a TNF-a inhibitor is similar to that in patients with AIDS. The increased occurrence of cryptococcal infections during TNF-a inhibitor treatment may be explained by the critical role of TNF-a in the development of a protective T-cell mediated immunity to Cryptococcus neoformans. To date, there are only three case reports of pulmonary cryptococcosis during IFX treatment (Table 1). Of these three cases, all had chronic rheumatoid arthritis. There are no case reports of pulmonary cryptococcosis in IBD patients during IFX treatment. In this report we present the first case with regard to this infectious complication in patients with CD receiving IFX treatment. The case was a 39-year-old Japanese man who was diagnosed with ileocolic-type CD in 1996. The patient had no pets; however, he lived in an area where there were many wild pigeons. In 2006 he was referred to our gastrointestinal department with subileus and severe anal fistula. He received total parenteral nutrition and ileal resection with subtotal colectomy, ileal stoma, and seton drainage was performed. Although surgery was performed, his severe anal fistula was not improved. Therefore, in May 2008, IFX treatment was commenced with standard induction therapy (5 mg/kg at weeks 0, 2, and 6). After that, maintenance therapy (5 mg/kg every 8 weeks) was continued. Screening by chest x-ray before IFX treatment revealed normal results. After five infusions of IFX, anal fistula was completely improved. The patient was admitted to our hospital in January 2009 in order to close the ileal stoma. Upon admission, he had no respiratory symptoms such as cough, sputum, or fever and physical examination was normal. Laboratory findings were notable for a peripheral white blood cell count of 6100 cells/lL, 15.6 g/dL

Time trend and risk factors for reoperation in Crohn's disease in Japan.

BACKGROUND/AIMS We aimed to evaluate time changes in reoperation rate after initial surgery in Crohns disease (CD) over the last five decades in Japan and to assess the risk factors for reoperation, given that a decrease in the reoperation rate for CD remains controversial. METHODOLOGY CD patients (n-476) who underwent initial intestinal surgery were examined. Case records were collected from 13 institutions and scrutinized retrospectively. The primary outcome measure was the reoperation rate needing intestinal surgery. To evaluate the time changes, we compared medical treatment and reoperation rate in patients from two different periods of time; before and after 2002 when infliximab became available in Japan (1963-2002 and 2003-2008 groups). Univariate and multivariate analyses were performed to examine the influence of independent variables on the cumulative reoperation rate. RESULTS A total of 201 patients underwent reoperation. Overall 5-year and 10-year cumulative reoperation rates were 31.4% and 61.2%, respectively. In multivariate analysis, an onset of the disease between 1963-2002 (p=0.0199) and postoperative administration of infliximab (p=0.0003) and immunosuppressants (p<0.0001) were significant risk factors for reoperation. The cumulative 5-year reoperation rate decreased significantly in the 2003-2008 group compared to the 1963-2002 group (6.3% vs. 32.9%, p<0.05). CONCLUSIONS The reoperation rate for CD has decreased significantly in recent years in Japan. However, to further confirm this time trend, we need to evaluate CD patients with a longer follow-up period.

Gastrectomy with limited surgery for elderly patients with gastric cancer

BACKGROUND/OBJECTIVE Elderly patients with gastric cancer can receive standard gastrectomy or gastrectomy with reduced nodal dissection, i.e., limited surgery, in order to prevent postoperative complications. This study evaluated the feasibility of gastrectomy with limited surgery for elderly patients with gastric cancer. METHODS A total of 267 elderly patients (≥70 years old) were divided into two groups according to the level of nodal dissection: patients who received nodal dissection according to guidelines were included in the standard surgery group (standard group), and those who received reduced nodal dissection were included in the limited surgery group (limited group). The surgical outcomes of the two groups were compared. RESULTS There were 170 patients in the standard group and 97 patients in the limited group. The limited group had significantly poorer nutrition status and a significantly higher proportion with comorbidities. Morbidity and mortality were similar in both groups. Multivariate analysis showed that the overall survival rates were significantly worse in patients with advanced age, male gender, low body mass index, low prognostic nutrition index, and higher tumor stage. The disease-specific survival rate was significantly lower in the limited group than in the standard group (p<0.001). CONCLUSION Gastrectomy according to the gastric treatment guidelines for elderly patients with gastric cancer is recommended. Elderly male patients with poor nutrition have poor prognosis; prognostic nutrition index <40. Limited surgery is a treatment option for such patients.