Koki Sunouchi

Randomized, controlled trial of lateral node dissection vs. nerve-preserving resection in patients with rectal cancer after preoperative radiotherapy.

PURPOSE: The effectiveness of preoperative radiation therapy for advanced lower rectal carcinoma to preserve the function of pelvic organs and reduce local recurrences was examined in a prospective, randomized, controlled study. METHODS: Fifty-one patients with a diagnosis of localized and resectable adenocarcinoma of the lower rectum undergoing 50 Gy of preoperative radiotherapy were recruited into the trial between April 1993 and March 1995. The patients were randomly allocated to complete autonomic nerve-preserving surgery without lateral node dissection (D1), or surgery with dissection of the lateral lymph nodes including autonomic nerves (D2) followed by oral administration of carmofur for one year. RESULTS: No difference was observed in either survival or disease-free survival between D1 and D2 groups. There was no difference between the two groups in terms of recurrence rate. A significant difference was observed in urinary and sexual function (P= 0.02 and 0.02, respectively) one year after surgery between D1 and D2 groups. CONCLUSION: This study suggests that lateral node dissection is not necessary in terms of curability for patients with advanced carcinoma of the lower rectum who undergo preoperative radiotherapy.

Local immunity and metastasis of colorectal carcinoma.

The subsets of tumor-infiltrating lymphocytes (TIL) and prostaglandin (PG) E2were measured in the resected tissues of 32 colorectal cancers without metastasis and 14 with metastasis in order to investigate the local immunity in metastasis of colorectal carcinoma. Subsets of TIL (Leu 1, Leu 2a, Leu 3a, Leu 10, Leu 1 1b, IL-2 receptor) were detected by immunohistochemical staining of frozen tissues. The number of positive cells was counted and expressed as number positive per 250 × 250μm2.The numbers of T cells (Leu 1) and natural killer cells (Leu 11b) were larger in early cancers and decreased in parallel with the presence of metastasis (control [n=9]: 89±28, 6±4; early cancers [n=9]: 269±112*,76±56*;advanced cancers without metastasis [n=11]: 182±80*,56±59*;advanced cancers with metastasis [n=11]: 76±42*,26±21; values are mean ± SD;*P< 0.05, ANOVA). The level of PG E2from the draining vein (V) measured by radioimmunoassay was higher than that from the feeding artery (A) (119.1±14.3vs.15.4±1.9 pg/ml;P<0.001). The PG E2V/A ratio of cancers with metastasis was significantly higher than that of those without metastasis (132±2.4vs.5.6 ±0.8;P<0.001). TIL was decreased in parallel with the increase of PG E2V/A ratio. We conclude that TIL and PG E2may play an important role in metastasis of colorectal carcinoma and that PG E2has an adverse effect in suppressing local immunity and enhancing metastasis.

How should patients 80 years of age or older with colorectal carcinoma be treated

PURPOSE: The aim of this study was to determine how extensive resection affects operative morbidity, mortality, and long-term survival in elderly patients with colorectal cancer. METHODS: A total of 119 patients 80 years of age or older were given a diagnosis of colorectal carcinoma at our hospital between 1985 and 1997. Eleven patients who did not undergo surgery were excluded. The remaining 108 patients underwent laparotomy and were reviewed. Serum levels of interleukin-6 were measured perioperatively in 22 patients to assess the degree of operative stress. RESULTS: Potentially curative resection was performed in 64 (88.9 percent) of the 72 patients in the active performance status group and 13 (36.1 percent) of the 36 patients in the sedentary performance status group (P<0.001). The inhospital mortality rate was 8.3 percent in group the active performance status group and 38 percent in the sedentary performance status group (P=0.007). Patients in the sedentary performance status group and those who underwent emergency operations had higher levels of IL-6 than patients in the active performance status group or those who underwent elective operations. CONCLUSIONS: Preoperative performance status, operative curability, and tumor stage have a significant impact on outcome in patients with colorectal cancer who are 80 years of age or older. Knowledge of early postoperative response of IL-6 is useful in predicting postoperative mortality and morbidity in this subgroup of patients.

Limitations of endorectal ultrasonography

PURPOSE: The accuracy of diagnosis of metastatic lymph nodes for rectal carcinoma has not improved. A low echoic lesion more than 5 mm in size detected by endorectal ultrasonography is preoperatively assessed as a metastatic lymph node. What does a low echoic lesion more than 5 mm in size correspond to histologically? METHODS: Forty-seven patients with lower rectal carcinoma (Term I, 1986–1990) and 48 patients with lower rectal carcinoma (Term II, 1991–1995) undergoing endorectal ultrasonography were reviewed. Surgically resected rectal specimens from 40 patients with rectal carcinoma underwent ultrasonography. Low echoic lesions more than 5 mm in size were taken from resected specimens and were stained with hematoxylin, followed by histologic examination. RESULTS: The accuracy of diagnosis of metastatic lymph nodes of Term II was not higher than that of Term I. Twenty-five low echoic lesions were detected by ultrasonography using 40 resected specimens. Seventeen of these 25 lesions (68 percent) were histologically confirmed to be metastatic lymph nodes. One of 25 (4 percent) was found to be lymphadenitis with no metastasis. Among the 25 lesions, 5 (20 percent) were histologically confirmed to be tumor deposits, 2 (8 percent) fatty tissue, and 22 (88 percent) carcinoma. CONCLUSIONS: Low echoic lesions were histologically confirmed to be tumor deposits (20 percent) and metastatic lymph nodes (68 percent). Although these data show deficiencies and limitations of the accuracy of endorectal ultrasonography, they compare favorably with other series, and no other current technology can show similar accuracy.

Overexpression of p53 protein and histologic grades of dysplasia in colorectal adenomas.

PURPOSE: To clarify the relation between tumor-suppressor gene p53 expression and histologic grades of dysplasia in colorectal adenomas, we performed immunohistochemical analysis in a series of 59 colorectal polyps and 40 advanced carcinomas. METHODS: Adenomatous polyps were stained by hematoxylin and eosin and classified into mild, moderate, and severe dysplasia (intramucosal carcinoma), according to the World Health Organizations classification. RESULTS: p53 was positive in 7.1 percent (2/28) of mild, 29.4 percent (5/17) of moderate, and 62.5 percent (5/8) of severe dysplasia. In submucosal and advanced carcinomas, positivity rates were 75 percent (3/4) and 47.5 percent (19/40), respectively. Different staining patterns were found, according to grades of dysplasia. In the adenomas with mild or moderate dysplasia, a few focal crypts showed localized p53-positive staining. Adenomas with severe dysplasia had two different staining types. One was a focal staining type as shown in mild or moderate dysplasia; the other was a diffuse staining type, in which glands with mild or moderate dysplasia, surrounding severe dysplasia area, were also stained. Submucosal and advanced carcinomas showed a strong positive staining in cancer cells only. CONCLUSIONS: Overexpression of p53 protein in adenomas with mild or moderate dysplasia and existence of two types of expression in adenomas with severe dysplasia were observed. These facts suggested the possible existence of different pathways in the adenoma to carcinoma progression.

Clinical impact of carcinoembryonic antigen messenger ribonucleic acid expression in tumor-draining vein blood on postoperative liver metastasis in patients with colorectal carcinoma: A prospective, cohort study

PURPOSE This study was designed to determine the clinical impact of carcinoembryonic antigen messenger ribonucleic acid expression in tumor-draining vein blood on postoperative liver metastasis in patients with colorectal carcinoma. METHODS The study comprised 37 patients with colorectal carcinoma who underwent laparotomy (Dukes A, 3; Dukes B, 16; Dukes C, 15; and Dukes D, 3). Blood samples were drawn from the tumor-draining vein and the tumor-feeding artery. Total ribonucleic acid was extracted from the blood and subjected to reverse transcriptase-polymerase chain reaction to detect carcinoembryonic antigen messenger ribonucleic acid. Tissue sections of tumor were stained with hematoxylin and eosin and were examined immunohistochemically. The duration of follow-up ranged from two years and three months to three years and six months. RESULTS Expression of amplified carcinoembryonic antigen messenger ribonucleic acid in tumor-draining vein blood was positive in 16 (43 percent) of the 37 patients, while that in the feeding artery blood was positive in 3 patients (8 percent). There was no relation between the protein level of carcinoembryonic antigen and positive expression of carcinoembryonic antigen messenger ribonucleic acid. Positive expression of carcinoembryonic antigen messenger ribonucleic acid was observed in two patients with histologic evidence of massive venous invasion and in all three patients with synchronous liver metastasis. Immunohistochemical studies revealed that all tumor specimens with stromal type (5/5) of carcinoembryonic antigen staining had positive expression of carcinoembryonic antigen messenger ribonucleic acid. Postoperative liver metastasis was detected in four patients, three of whom (75 percent) had positive expression of carcinoembryonic antigen messenger ribonucleic acid in tumor-draining vein blood. CONCLUSIONS Positive expression of carcinoembryonic antigen messenger ribonucleic acid in tumor-draining vein blood differed by the type of immunohistochemical staining with carcinoembryonic antigen. These data suggest that patients with positive expression of carcinoembryonic antigen messenger ribonucleic acid in tumor-draining vein blood may be at a high risk for postoperative liver metastasis.

Clinical Impact of Carcinoembryonic Antigen Messenger Ribonucleic Acid Expression in Tumor-Draining Vein Blood on Postoperative Liver Metastasis in Patients With Colorectal Carcinoma

AbstractPURPOSE: This study was designed to determine the clinical impact of carcinoembryonic antigen messenger ribonucleic acid expression in tumor-draining vein blood on postoperative liver metastasis in patients with colorectal carcinoma. METHODS: The study comprised 37 patients with colorectal carcinoma who underwent laparotomy (Dukes A, 3; Dukes B, 16; Dukes C, 15; and Dukes D, 3). Blood samples were drawn from the tumor-draining vein and the tumor-feeding artery. Total ribonucleic acid was extracted from the blood and subjected to reverse transcriptase-polymerase chain reaction to detect carcinoembryonic antigen messenger ribonucleic acid. Tissue sections of tumor were stained with hematoxylin and eosin and were examined immunohistochemically. The duration of follow-up ranged from two years and three months to three years and six months. RESULTS: Expression of amplified carcinoembryonic antigen messenger ribonucleic acid in tumor-draining vein blood was positive in 16 (43 percent) of the 37 patients, while that in the feeding artery blood was positive in 3 patients (8 percent). There was no relation between the protein level of carcinoembryonic antigen and positive expression of carcinoembryonic antigen messenger ribonucleic acid. Positive expression of carcinoembryonic antigen messenger ribonucleic acid was observed in two patients with histologic evidence of massive venous invasion and in all three patients with synchronous liver metastasis. Immunohistochemical studies revealed that all tumor specimens with stromal type (5/5) of carcinoembryonic antigen staining had positive expression of carcinoembryonic antigen messenger ribonucleic acid. Postoperative liver metastasis was detected in four patients, three of whom (75 percent) had positive expression of carcinoembryonic antigen messenger ribonucleic acid in tumor-draining vein blood. CONCLUSIONS: Positive expression of carcinoembryonic antigen messenger ribonucleic acid in tumor-draining vein blood differed by the type of immunohistochemical staining with carcinoembryonic antigen. These data suggest that patients with positive expression of carcinoembryonic antigen messenger ribonucleic acid in tumor-draining vein blood may be at a high risk for postoperative liver metastasis.

Small spot sign of rectal carcinoma by endorectal ultrasonography: Histologic relation and clinical impact on postoperative recurrence

PURPOSE: We observed small spots at the margin of rectal carcinomas on endorectal ultrasonography. Our aim was to study the relationship between ultrasonographic evidence of these spots and histologic characteristics of disease and postoperative recurrence. PATIENTS AND METHODS: The study group comprised 55 patients, 36 men and 19 women, with rectal carcinoma as confirmed by biopsy. The patients were followed up at three-month intervals for six months to three years and six months after the operation. Endorectal ultrasonography was performed in the usual manner. Surgically resected specimens were stained with hematoxylin and eosin and histologically examined. Vessel invasion was graded from 0 (not invasive) to 3 (most invasive). RESULTS: Among the 55 patients studied, 3 had Stage T2,N0,M0 rectal carcinomas and 35 had Stage T3,N0,M0 carcinomas, 5 (14.3 percent) of whom had echographic evidence of small spots. Thirteen patients had Stage T3,N1/2,M0 carcinomas, comprising 12 (92.3 percent) with small spots, and four patients had T3,N1/2,M1 carcinomas, all with small spots. Vessel invasion of Grade 2 or higher was observed around the carcinomas in 20 of 21 patients who had small spots. Ten of 13 patients with many spots at the margin of the carcinoma (a spot grade of ++) histologically had marked venous or lymphatic invasion (an invasion Grade 3). The presence of small spots was closely associated with massive venous or lymphatic invasion (a vessel invasion grade of 2 or more). Four patients had synchronous liver metastases, and small spots were found in all four. Distant metastases and local recurrence were found in 11 of 21 patients with small spots. We found no recurrence in any patient without small spots on endorectal ultrasonography. CONCLUSIONS: Small spots indicate the presence of massive venous or lymphatic invasion and a high risk of postoperative recurrence.

Paraplegia from spinal cord injury after thoracic epidural catheterization performed under general anesthesia

as halothane, isoflurane, and sevoflurane, without problems (6). Only one case of successful spinal anesthesia has been reported (7). Although proper positioning and prevention from trauma may be a problem during spinal anesthesia in patients with Huntington’s chorea, in appropriate surgical procedures spinal anesthesia may be effective, comfortable, and preferable to general anesthesia, yielding frequent success rates while preventing the possible disadvantages of general anesthesia.

The Role of Lateral Lymphnode Dissection in the Prevention of Recurrence for Rectal Cancer

In an attempt to clarify the role of lateral node dissection in preventing the local recurrence of rectal cancer, 203 patients undergoing surgery for advanced lower rectal cancer in our surgical department from 1963 to 1991 were studied retrospectively. The incidence of lateral lymphnode metastases was higher in patients with tumors invading beyond the subserosa and a higher recurrence rate was observed in patients with lymphnode metastasis diagnosed at or before operation. Lymphnode metastases were found in 18.2% of the patients undergoing lateral node dissection, and surgery was succeeded in 66.7% of these patients, although 50% of the cases had tumors invading beyond the subserosal layer. The recurrence rate was 33.3%. We concluded that the lateral node dissection plays an important role in preventing local recurrence of rectal cancer, and should be indicated for all patients with either lymphnode metastases or tumors invading beyond the subserosal layer.