Masato Ono

Curative Surgery for Local Pelvic Recurrence of Rectal Cancer

Background/Aims: Local pelvic recurrence of rectal cancer after radical resection has been associated with morbidity and cancer-related death. This study retrospectively evaluated outcome following curative resection for rectal cancer recurring after surgery on the basis of prognosis, type of procedure and perioperative morbidity. Methods: A total of 85 consecutive patients with local pelvic recurrence of rectal cancer were evaluated. Of these, 43 underwent microscopic curative surgery for local recurrence. Among the 43 patients, 23 underwent surgery alone and 17 received preoperative radiotherapy (40 Gy) (XRT group) in addition to the surgery. Of the 43 patients, 26 were asymptomatic. Results: Curative resection was higher in the recurrences that were associated with implantation, incomplete surgical margin clearance, and intrapelvic lymph node metastasis than in other types of recurrence. With regard to surgical procedure, abdominoperineal resection (APR), with or without sacral resection, was standard following previous sphincter-preserving surgery, while total pelvic exenteration (TPE), with or without sacral resection, was common following previous APR. Local excision was not considered appropriate surgery. There was a high incidence of perioperative morbidity (64%) in patients receiving TPE. Re-recurrence was observed in 18 patients (50%) after curative surgery. After a follow-up of 2 years or more, the local re-recurrence rate was 28%. The overall 5-year survival rate for patients receiving curative resection was 39%, for patients in the XRT group, 51%, and for patients in the surgery-alone group, 24% (p = 0.07). The survival rate in 26 asymptomatic patients was higher than in 17 patients with symptoms, with 5-year survival rates of 62 and 23% (p < 0.05), respectively. The cumulative local control in the preoperative radiotherapy plus en bloc surgery group (XRT group) was significantly better than in the surgery-alone group (p < 0.01), and survival in the XRT group tended to be better than in surgery alone. Conclusions: These results suggest that careful patient selection according to the pattern of recurrence, area of invasion and presence of symptoms is important for successful curative surgery. Aggressive surgery with adjuvant therapy may lead to an improved salvage rate.

The fibrotic focus in advanced colorectal carcinoma: a hitherto unrecognized histological predictor for liver metastasis

Abstract A fibrotic focus (FF) is a clearly defined area consisting of fibroblasts and/or collagen fibres arranged in irregular or storiform patterns within tumours. We looked to see whether FF in advanced colorectal carcinoma was associated with distant organ metastasis especially to the liver. The correlation between FF and the presence of synchronous or total (synchronous and/or metachronous) liver metastasis and tumour recurrence was assessed in 77 patients with Dukes B and C advanced colorectal carcinoma treated by resection. The median follow-up period was 21 months. In multivariate analysis, FF significantly increased the relative risk (RR) of synchronous liver metastasis (RR=4.9, P<0.05) and total liver metastasis (RR=4.6, P<0.05). FF also increased the RR of tumour recurrence (RR=2.4), but the increase was not statistically significant. FF is a newly recognized histological indicator of liver metastasis in advanced colorectal carcinoma.

Long-Term Survival in Advanced Small Cell Carcinoma of the Colorectum: Report of a Case

Abstract A 47-year-old man was referred to our institution with bloody diarrhea. An endoscopic examination showed a 6-cm tumor with central ulceration in the upper rectum. A high anterior resection of the rectum with lymphadenectomy was performed with the diagnosis of colorectal cancer. An intraoperative cytological examination found many free cancer cells in the peritoneal lavage fluid. Histologically, the tumor had invaded deeply and exposed the serosa, and was diagnosed as a small cell carcinoma of the colorectum with marginal lymph node metastasis. The patient is alive without any evidence of recurrence approximately 37 months after surgery despite the aggressive clinical behavior and a high mortality rate associated with this tumor. This case of an advanced small cell carcinoma of the colorectum showed a good outcome even though the cytology of the peritoneal lavage was positive.

Phase II study of sequential high-dose methotrexate and fluorouracil combined with doxorubicin as a neoadjuvant chemotherapy for scirrhous gastric cancer.

Background. The prognosis of scirrhous gastric cancer remains poor when it is treated with surgical resection alone or chemotherapy alone. A phase II study of sequential high-dose methotrexate and fluorouracil, combined with doxorubicin, as a neoadjuvant chemotherapy was conducted in an attempt to evaluate the efficacy of this regimen in improving the survival of patients with scirrhous gastric cancer. Methods. Patients were eligible if they had potentially resectable scirrhous gastric cancer with adequate organ functions and no prior treatment. The treatment schedule consisted of methotrexate (1 g/m2, day 1) fluorouracil (1.5 g/m2, day 1), leucovorin (15 mg/m2, days 2–4), and doxorubicin (30 mg/m2, day 15), repeated at a 28-day interval, and followed by radical surgery. Results. A total of 20 eligible patients were registered. Objective responses in the neoadjuvant chemotherapy segment were observed in 3 of the 20 (15%) patients. No complete remission was observed. The neoadjuvant chemotherapy was associated with grade 3 or 4 neutropenia in 14 of the 20 (70%) patients. The median time from the initial therapy to the operative day was 82 days. Thirteen of the 20 (65%) patients underwent curative resection. No treatment-related deaths occurred. However, the 2-year survival rate in this treatment program (25%) did not show any superiority over that in historical controls. Conclusions. Sequential high-dose methotrexate and fluorouracil, combined, with doxorubicin, as a neoadjuvant chemotherapy for scirrhous gastric cancer did not improve the survival rate in spite of improving the curative resection rate.

Proliferative activities of tumor stromal cells play important roles in tumor thickness and progression of T3 ulcerative-type colorectal cancer

The central depressed area thickness (tumor thickness) of colorectal cancers is an important prognostic parameter for colorectal cancer patients. We examined whether the proliferative activities of tumor and stromal components play important roles in the increase of tumor thickness and the progression of colorectal cancers. Colorectal cancers were classified into thin and thick groups according to tumor thickness. The proliferative activities of fibroblasts and endothelial cells were immunohistochemically evaluated in 157 T3 ulcerative-type colorectal cancers by CD31/MIB-1 (anti-Ki-67 antigen) double staining. The MIB-1 labeling index was estimated as the percentage of fibroblasts with positive nuclei. The CD31-positive microvessels lined by MIB-1-positive endothelial cells were assessed. The proliferative microvessel index was defined as the percentage of proliferative microvessels relative to all microvessels. The fibroblast MIB-1 labeling index was the only parameter significantly associated with tumor thickness (P=0.049). High fibroblast MIB-1 labeling indices showed significant correlation with tumor recurrence in the thin group (P=0.020). High proliferative microvessel index was a significant parameter of tumor recurrence in the thick group (P=0.003) in multivariate analyses. This study strongly suggests that proliferative activities of stromal components are useful parameters of tumor biology and of prognosis for T3 ulcerative-type colorectal cancer patients.

Efficacy of surgery after successful chemotherapy for advanced gastric cancer

BackgroundWe evaluated the efficacy of surgical resection after successful chemotherapies in patients with advanced gastric cancer.MethodsEighteen surgical patients who had had successful chemotherapies were selected after a review of 218 case records.ResultsThe 18 patients were grouped by their pretreatment status: 8 patients with distant lymph node metastases (N4 group), 7 with a small amount of ascites (P group), and 3 with both factors (N4+P group). Good responses were achieved in all of the 11 patients with node metastases, including 4 patients with a complete response. Ascites in 7 of 10 patients disappeared. Two of 18 patients (11%) achieved curability A resections, while 8 patients (44%) achieved curability B and 8 (44%) achieved curability C resections. Pathologic complete responses were documented in 2 patients of the N4 group. The median survival time of the 18 patients was 14 months, with a 1-year survival rate of 61%. Six patients have survived more than 2 years, and 3 more than 5 years to date. The 8 N4-group patients who had surgery showed significantly better survival than 19 similar patients who had distant metastases and responded to chemotherapy but did not have surgery. A similar comparison of the P-group patients found no significant difference in survival associated with surgery.ConclusionsSurgery after chemotherapy might be beneficial for patients with distant lymph node metastases, but not effective for those with peritoneal dissemination.

Colonic perforation after endoscopic biopsy of a submucosal tumor: successful conservative treatment

Colonoscopy is a powerful diagnostic and therapeutic procedure with a recognized risk of complications ranging from perforation to hemorrhage and septicemia. Perhaps the most dangerous complication associated with this procedure is bowel perforation. Although some colonic perforations can be treated medically, prompt surgery is generally preferred to minimize morbidity and mortality. We present a case of colonic perforation resulting from bite biopsy followed by mucosal resection of a submucosal tumor. Perforation occurred in a delayed manner despite prophylactic closure of the mucosal defect by the replacement of endoclips. The patient recovered spontaneously after antibiotic treatment and reduction of oral intake. We carried out successful conservative medical treatment of a minor iatrogenically induced bowel perforation without operation.

Correlation Between the Depth of Invasion and Hardness of Resected Gastric Carcinoma Specimens Using a New Ultrasound Tactile Sensor

Abstract: We assessed the objective measurement of gastric wall hardness in gastric cancer specimens with a new tactile sensor. The basic principle of measuring hardness and/or softness of living tissue is based on changes in the frequency of the tactile sensor. The change in resonance frequency, Δf=fx‐fo, is the difference between the frequency of the sensor in contact with the specimen, fx, and the non‐contact frequency, fo. The change in resonance frequency increases as tissue hardness decreases. We measured hardness at 5 points in 13 fresh specimens obtained by gastrectomy and analyzed the histopathological features corresponding to each point. We found that the more deeply the tumor had invaded, the harder the cancerous areas tended to be as compared to normal areas. However, the hardness of gastric cancer areas was influenced not only by the depth of invasion, but also by tumor size, the presence of associated fibrosis within the lesion, and the tumor stroma quantity. Gastric wall hardness correlated with the depth invasion of lesions less than 40 mm in size, the absence of tumor fibrosis, and medullary type tumor extension.