Michio Itabashi

Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2010 for the treatment of colorectal cancer

Colorectal cancer is a major cause of death in Japan, where it accounts for the largest number of deaths from malignant neoplasms among women and the third largest number among men. Many new methods of treatment have been developed during recent decades. The Japanese Society for Cancer of the Colon and Rectum Guidelines 2014 for treatment of colorectal cancer (JSCCR Guidelines 2014) have been prepared as standard treatment strategies for colorectal cancer, to eliminate treatment disparities among institutions, to eliminate unnecessary treatment and insufficient treatment, and to deepen mutual understanding among health-care professionals and patients by making these guidelines available to the general public. These guidelines have been prepared as a result of consensuses reached by the JSCCR Guideline Committee on the basis of careful review of evidence retrieved by literature searches and taking into consideration the medical health insurance system and actual clinical practice in Japan. They can, therefore, be used as a guide for treating colorectal cancer in clinical practice. More specifically, they can be used as a guide to obtaining informed consent from patients and choosing the method of treatment for each patient. As a result of the discussions of the Guideline Committee, controversial issues were selected as clinical questions, and recommendations were made. Each recommendation is accompanied by a classification of the evidence and a classification of recommendation categories, on the basis of consensus reached by Guideline Committee members. Here we present the English version of the JSCCR Guidelines 2014.

Value of PET/CT imaging for diagnosing pulmonary metastasis of colorectal cancer.

BACKGROUND/AIMS Several types of cancer can be clinically diagnosed by PET/CT, which can also perform whole-body imaging based on 18F-fluorodeoxyglucose (FDG) uptake. The present study assesses the value of PET/CT for diagnosing of pulmonary metastasis of colorectal cancer. METHODOLOGY We staged or restaged 256 patients with colorectal cancer by PET/CT. Actual and suspected pulmonary metastases were detected in 37 (male, n=23; female, n=14) patients with primary or recurrent colorectal cancer. Among them, 35 (21 males, 14 females) patients had extant homochronous (n=7) and metachronous (n=28) pulmonary metastasis. RESULTS The sensitivity and specificity of FDG-PET/CT for pulmonary metastasis were 57.1% and 99.1%, respectively, and the positive and negative predictive values were 90.1% and 93.6%, respectively. The uptake of FDG was affected by the size of the metastatic nodules; uptake was positive and negative in pulmonary metastases with an average size of 14.9mm and 5.75mm, respectively. The limit of positive FDG uptake was reached in pulmonary metastases of about 9mm. CONCLUSIONS Pulmonary metastasis of colorectal cancer can be accurately and conveniently diagnosed by PET/CT, especially when nodules are >9mm.

Clinical use of PET/CT in peritoneal carcinomatosis from colorectal cancer.

BACKGROUND/AIMS Peritoneal carcinomatosis (PC) from colorectal cancer has been associated with poor survival but new approaches and postoperative chemotherapy have improved survival. The purpose of this study was to evaluate the clinical utility of imaging in cases of PC from colorectal cancer. METHODOLOGY This is a retrospective single-institution study which examined 23 patients with colorectal cancer who underwent positron emission tomography (PET), computed tomography (CT) and received a final diagnosis PC in our institute between 2005 and 2010. RESULTS PET/CT detected PC in 19 of 23 cases (82.6%), whereas CT detected PC in 6 of 20 cases (30%). Four cases of PC were FDG-negative, all with maximal size <10mm, representing smaller tumors. FDG-negative PC was diffuse in 3 cases and nodular in 1. The distributed spotty uptake of FDG-negative PC was harder to detect. Diagnostic detection of PC was only achieved in 3 of 23 cases (13%). In the remaining cases, clinical diagnosis was metastasis to lymph nodes, recurrence, or normal FDG uptake by intestine. CONCLUSIONS PET/CT offers efficient detection of PC and has the potential to improve clinical diagnosis when coupled with an understanding of the pathways of flow for ascitic fluid and peritoneal seeding.

Management of local recurrence of colorectal cancer: the role of PET/CT

AimThe aim was to examine the clinical applicability of positron-emission tomography/computed tomography (PET/CT) for diagnosing local recurrence of colorectal cancer.MethodsFrom August 2003 to August 2008, 256 patients with colorectal cancer underwent PET/CT scanning for staging or restaging. Local recurrence was detected in 22 patients (18 men, 4 women) postsurgically.ResultsOf the 22 patients, 21 (95.5%) underwent positive 2-[fluorine-18]-fluoro-2-deoxy-d-glucose uptake and were diagnosed with local recurrence by PET/CT; the results were negative in one case (4.5%). The sensitivity, specificity, positive predictive value, and negative predictive value for local recurrence were 95.5%, 100%, 100%, and 99.6%, respectively. CT/MRI scans yielded the following results: positive, 10 cases (45.5%); suspected positive, 11 cases (50.0%); negative, 1 case (4.5%). In the suspected positive cases, not only imaging but also colonoscopy and tumor markers among other techniques were used for definitive diagnosis.ConclusionPET/CT has high sensitivity and specificity for diagnosing local recurrence of colorectal cancer and would be useful especially in the case of locally recurrent colorectal cancer suspected to be positive by CT/MRI.

Significance of FDG-PET in Identification of Diseases of the Appendix – Based on Experience of Two Cases Falsely Positive for FDG Accumulation

A discussion of the significance of F-fluorodeoxyglucose positron emission tomography (FDG-PET) in the identification of diseases of the appendix is presented based on two cases falsely positive for FDG accumulation. Both cases were palpable for a tumor in the lower right abdominal region and a prominently enlarged appendix was depicted by CT. Although the patients underwent ileocecal resection based on a strong suspicion of appendiceal cancer rather than appendicitis since abnormal accumulation exhibiting maximum standard uptake values (SUVs) of 7.27 and 17.11, respectively, was observed at the same site in FDG-PET examination and since there no malignant findings observed histologically, the patients were diagnosed with appendicitis. Although FDG specifically accumulates not only in malignant tumors, but also in diseases such as acute or chronic inflammation, abscesses and lymphadenitis, and identification based on SUVs has been reported to be used as a method of identification, the two cases reported here were both false-positive cases exhibiting high maximum SUVs. At the present time, although the significance of FDG-PET in the identification of diseases of the appendix is somewhat low and there are limitations on its application, various research is currently being conducted with the aim of improving diagnostic accuracy, and it is hoped that additional studies will be conducted in the future.

Effectiveness of leukocytapheresis in suppressing the occurrence of surgical site infections following surgery for ulcerative colitis.

PurposeSurgical site infections (SSIs) occur more frequently in surgery for patients with ulcerative colitis than in regular colon surgery. We report here on a joint study that was prospectively conducted by six facilities to verify that performing leukocytapheresis (LCAP) therapy immediately following surgery regulates neutrophil activity and acts to suppress the occurrence of SSIs.MethodsLCAP was performed using Cellsorba EX with nafamostat mesilate as an anticoagulant; therapy was begun within 2 h postoperatively. Subjects were 143 patients undergoing surgery in cases of ulcerative colitis (LCAP group, 40 patients; control group, 103 patients).Results1) With regard to the SSI incidence rate, SSIs occurred in 4 of 37 patients (10.8%) in the LCAP group overall, whereas they occurred in 29 of 103 patients (28.2%) in the control group overall; in the LCAP group, the occurrence of SSIs tended to be suppressed (P = 0.069). With 2-stage surgery in particular, SSIs occurred in the LCAP group in 1 of 28 patients (3.6%) and in the control group in 21 of 86 patients (24.4%); in the LCAP group, the occurrence of SSIs was significantly lower (P = 0.013). The length of postoperative hospitalization was 24.9 ± 11.1 days for the 36 patients in the LCAP group and 31.2 ± 14.6 days for the 103 patients in the control group; the length was significantly reduced in the LCAP group (P = 0.018). 2) From pre-surgery to day 1 of hospitalization, the granulocyte elastase level rose both in patients who experienced SSIs and in patients who did not experience them. It remained high in patients who experienced SSIs in comparison with patients who did not experience SSIs and was significantly higher prior to LCAP in particular. 3) While LCAP was being performed, there were adverse events in 5 of 40 patients (12.5%), but these were all transient; it was determined that LCAP presented no problems in terms of safety.ConclusionLCAP therapy was effective in suppressing the occurrence of SSIs following 2-stage surgery for ulcerative colitis and also reduced the length of postoperative hospitalization.

Lateral pelvic lymph node dissection can be omitted in lower rectal cancer in which the longest lateral pelvic and perirectal lymph node is less than 5 mm on MRI.

The goal of the study was to examine the use of magnetic resonance imaging (MRI) for identification of patients with lower rectal cancer who may benefit from lateral pelvic lymph node dissection (LPLD).

Proposal of a new prognostic staging system for pulmonary metastases from colorectal cancer

PurposeThe aim of this retrospective study was to establish a new prognostic staging system for pulmonary metastases from colorectal carcinoma (CRC).MethodsThe baseline characteristics and outcomes on 352 CRC patients who underwent complete pulmonary resection were collected from 19 institutions by the Japanese Society for Cancer of the Colon and Rectum (JSCCR) Study Group (group A). The clinical and pathological factors were entered into a multivariate analysis to identify independent variables that were helpful for accurately predicting the long-term prognosis after pulmonary resection. Using the selected variables in group A, we developed a new prognostic staging system (PSS). The new PSS was examined in a validation study in a series of 841 patients from 110 institutions of the JSCCR by the 78th society of the JSCCR (group B).ResultsWe evaluated four variables selected in the multivariate analysis: the number of pulmonary metastases, the distribution, the disease-free interval and the lymph node metastases of primary cancer in group A. Using these four variables, we developed a new PSS. This PSS was found to significantly predict the prognosis in group B.ConclusionsOur new PSS was useful for the selection of patients suitable for pulmonary resection.

A Logistic Model Including Risk Factors for Lymph Node Metastasis Can Improve the Accuracy of Magnetic Resonance Imaging Diagnosis of Rectal Cancer

BACKGROUND To evaluate use of magnetic resonance imaging (MRI) and a logistic model including risk factors for lymph node metastasis for improved diagnosis. MATERIALS AND METHODS The subjects were 176 patients with rectal cancer who underwent preoperative MRI. The longest lymph node diameter was measured and a cut-off value for positive lymph node metastasis was established based on a receiver operating characteristic (ROC) curve. A logistic model was constructed based on MRI findings and risk factors for lymph node metastasis extracted from logistic-regression analysis. The diagnostic capabilities of MRI alone and those of the logistic model were compared using the area under the curve (AUC) of the ROC curve. RESULTS The cut-off value was a diameter of 5.47 mm. Diagnosis using MRI had an accuracy of 65.9%, sensitivity 73.5%, specificity 61.3%, positive predictive value (PPV) 62.9%, and negative predictive value (NPV) 72.2% [AUC: 0.6739 (95%CI: 0.6016-0.7388)]. Age (<59) (p=0.0163), pT (T3+T4) (p=0.0001), and BMI (<23.5) (p=0.0003) were extracted as independent risk factors for lymph node metastasis. Diagnosis using MRI with the logistic model had an accuracy of 75.0%, sensitivity 72.3%, specificity 77.4%, PPV 74.1%, and NPV 75.8% [AUC: 0.7853 (95%CI: 0.7098-0.8454)], showing a significantly improved diagnostic capacity using the logistic model (p=0.0002). CONCLUSIONS A logistic model including risk factors for lymph node metastasis can improve the accuracy of MRI diagnosis of rectal cancer.

Comprehensive data of 3,820 patients newly diagnosed with colorectal liver metastasis between 2005 and 2007: report of a nationwide survey in Japan

To collect big data for further research to improve treatment outcomes in patients with colorectal liver metastasis (CRLM), the Joint Committee for Nationwide Survey on CRLM was established by the Japanese Society for Cancer of the Colon and Rectum and the Japanese Society of Hepato‐Biliary‐Pancreatic Surgery. The joint committee initiated data collection since 2014. The data of 4,237 patients newly diagnosed with CRLM between 2005 and 2007 were registered from 134 departments of 127 institutions (64%) among 209 departments (from 201 institutions) that agreed to participate in this study. Finally, 3,820 patients were enrolled in this report after a quality management process by the joint committee. We report the comprehensive data obtained from 3,820 patients, clinicopathological findings, treatment strategies, prognoses, and implementation status of chemotherapy. The joint committee is prospectively collecting data of patients newly diagnosed with CRLM after 2013 and will provide these raw data, including data of patients diagnosed between 2005 and 2007, to researchers who will conduct meaningful studies that meet the aim of the joint committee.