Mitsuyoshi Ota

Effects of a Diverting Stoma on Symptomatic Anastomotic Leakage after Low Anterior Resection for Rectal Cancer: A Propensity Score Matching Analysis of 1,014 Consecutive Patients

BACKGROUNDnRoutine creation of a diverting stoma (DS) in every patient who undergoes low anterior resection (LAR) remains controversial. We aimed to investigate the effect of DS on symptomatic anastomotic leakage (AL) after LAR.nnnSTUDY DESIGNnPatients with rectal cancer within 10 cm from the anal verge were eligible for this prospective, multicenter, cohort study (UMIN-CTR, number 000004017). Propensity score matching (PSM) was used to compare groups of patients with and without DS.nnnRESULTSnOne thousand fourteen consecutive patients were registered, of whom 936 patients who underwent LAR were analyzed. Before PSM, the overall rate of symptomatic AL was 13.2% (52 of 394) in patients with DS vs. 12.7% (69 of 542) in cases without DS (p = 0.84). Symptomatic AL requiring re-laparotomy occurred in 4.7% (44 of 936) of all patients, occurring in 1.0% (4 of 394) of patients with DS vs. 7.4% (40 of 542) of patients without DS (p < 0.001). After PSM, the 2 groups were nearly balanced, and the incidence rates of symptomatic AL in patients with and without DS were 10.9% and 15.8% (p = 0.26). The incidences of AL requiring re-laparotomy in patients with and without DS were 0.6% and 9.1% (p < 0.001). Multivariate analysis identified male sex (p < 0.001; odds ratio [OR] 3.2; 95% confidence interval [CI] 1.8 to 5.7) and tumor size (p < 0.001; OR 1.2; 95% CI 1.1 to 1.4) as independent risk factors of symptomatic AL.nnnCONCLUSIONSnDiverting stoma did not have a significant relationship with symptomatic AL before and after PSM. However, DS does seem to mitigate the consequences of leakage, reducing the need for urgent abdominal reoperation.

Male sexual dysfunction after rectal cancer surgery: Results of a randomized trial comparing mesorectal excision with and without lateral lymph node dissection for patients with lower rectal cancer: Japan Clinical Oncology Group Study JCOG0212

BACKGROUNDnWe conducted a randomized controlled trial (JCOG0212) to determine whether the outcome of mesorectal excision (ME) alone for rectal cancer is not inferior to that of ME with lateral lymph node dissection (LLND). The present study focused on male sexual dysfunction after surgery.nnnMETHODOLOGYnEligibility criteria included clinical stage II/III rectal cancer, the lower margin of the lesion below the peritoneal reflection, the absence of lateral pelvic lymph node enlargement, and no preoperative radiotherapy. After confirmation of R0 resection by ME, patients were intraoperatively randomized. Questionnaires using the International Index of Erectile Function (IIEF-5) about the sexual function of men were collected before and 1 year after surgery. Sexual dysfunction incidence was defined as the ratio of patients showing sexual dysfunction after surgery relative to the number who had no erectile dysfunction before surgery.nnnRESULTSnAmong 701 patients enrolled between June 2003 and August 2010, 472 males were included. Among them, 343 (73%) completed preoperative and postoperative questionnaires. According to the study protocol, the incidences of sexual dysfunction in patients who underwent ME alone and ME with LLND were 68% (17/25; 95%CI, 47-85%) and 79% (23/29; 95%CI, 60-92%), respectively (pxa0=xa00.37). Incidences of sexual dysfunction in patients with no or only mild erectile dysfunction before surgery who underwent ME alone and ME with LLND were 59% (48/81) and 71% (67/95), respectively (pxa0=xa00.15). Multivariate analysis identified age as the only risk factor for sexual dysfunction after surgery (pxa0=xa00.02).nnnCONCLUSIONSnLLND may not increase sexual dysfunction incidence after rectal cancer surgery. This incidence is associated with increased age. This trial is registered with ClinicalTrials.gov, number NCT00190541 and University Hospital Medical Information Network Clinical Trials Registry, number C000000034.

Selection of Lymph Node–Positive Cases Based on Perirectal and Lateral Pelvic Lymph Nodes Using Magnetic Resonance Imaging: Study of the Japanese Society for Cancer of the Colon and Rectum

PurposeTo investigate the optimum cutoff for lymph node size to identify cases positive for perirectal lymph node (PRLN) and lateral lymph node (LPLN) metastasis of lower rectal cancer on magnetic resonance imaging (MRI).MethodsThe subjects were 449 patients who underwent preoperative MRI. Mesorectal excision was performed in all patients (combined with lateral pelvic lymph node [LN] dissection in 324) between 2004 and 2013 at 6 institutes. Cases were classified as cN positive and cN negative on the basis of the short axis of the largest LN being greater than or equal to a cutoff or less than a cutoff, respectively. PRLN and LPLN diagnoses using 5 and 10xa0mm cutoffs were compared with histologic diagnoses. Of the 449 patients, 55 received preoperative chemoradiotherapy. MRI was only performed after this therapy in all of these patients.ResultsFor PRLNs, 5 and 10xa0mm cutoffs gave area under the curve (AUC) values of 0.6364 and 0.5794, respectively. The 5xa0mm cutoff gave a significantly higher AUC value (Pxa0=xa00.0152), with an accuracy of 63.7xa0%, sensitivity of 72.6xa0%, and specificity of 54.7xa0%. For right LPLNs, the respective AUC values were 0.7418 and 0.6326 (Pxa0=xa00.0034), and the variables (5xa0mm cutoff) were 77.6, 68.6, and 79.7xa0%. For left LPLNs, AUC values were 0.7593 and 0.6559, respectively (Pxa0=xa00.0057), and the variables (5xa0mm cutoff) were 79.3, 70.8, and 81.0xa0%.ConclusionsIdentification of LN-positive cases on the basis of PRLN and LPLN sizes was superior at a short-axis 5xa0mm cutoff. Size-based diagnosis of LN metastasis is simple and useful, but further investigation is needed to clarify whether it is superior to diagnosis based on morphology, such as shape, border, and signal intensity.To investigate the optimum cutoff for lymph node size to identify cases positive for perirectal lymph node (PRLN) and lateral lymph node (LPLN) metastasis of lower rectal cancer on magnetic resonance imaging (MRI). The subjects were 449 patients who underwent preoperative MRI. Mesorectal excision was performed in all patients (combined with lateral pelvic lymph node [LN] dissection in 324) between 2004 and 2013 at 6 institutes. Cases were classified as cN positive and cN negative on the basis of the short axis of the largest LN being greater than or equal to a cutoff or less than a cutoff, respectively. PRLN and LPLN diagnoses using 5 and 10xa0mm cutoffs were compared with histologic diagnoses. Of the 449 patients, 55 received preoperative chemoradiotherapy. MRI was only performed after this therapy in all of these patients. For PRLNs, 5 and 10xa0mm cutoffs gave area under the curve (AUC) values of 0.6364 and 0.5794, respectively. The 5xa0mm cutoff gave a significantly higher AUC value (Pxa0=xa00.0152), with an accuracy of 63.7xa0%, sensitivity of 72.6xa0%, and specificity of 54.7xa0%. For right LPLNs, the respective AUC values were 0.7418 and 0.6326 (Pxa0=xa00.0034), and the variables (5xa0mm cutoff) were 77.6, 68.6, and 79.7xa0%. For left LPLNs, AUC values were 0.7593 and 0.6559, respectively (Pxa0=xa00.0057), and the variables (5xa0mm cutoff) were 79.3, 70.8, and 81.0xa0%. Identification of LN-positive cases on the basis of PRLN and LPLN sizes was superior at a short-axis 5xa0mm cutoff. Size-based diagnosis of LN metastasis is simple and useful, but further investigation is needed to clarify whether it is superior to diagnosis based on morphology, such as shape, border, and signal intensity.

High infiltration of mast cells positive to tryptase predicts worse outcome following resection of colorectal liver metastases

BackgroundAccumulation of tumor-infiltrating mast cells (MCs) predicts poor survival in several cancers after resection. However, its effect on the prognosis of patients with colorectal liver metastases (CRLM) is not known.MethodsOur retrospective study included 135 patients who underwent potentially curative resection for CRLM between 2001 and 2010. Expression of tryptase, MAC387, CD83, and CD31, which are markers for MCs, macrophages, mature dendritic cells, and vascular endothelial cells, respectively, was determined via immunohistochemistry of resected tumor specimens. The relationship between immune cell infiltration and long-term outcome was investigated.ResultsThe median follow-up time was 48.4xa0months for all patients and 57.5xa0months for survivors. Overall survival (OS) rates at 1, 3, and 5xa0years were 91.0, 62.4, and 37.4xa0%, respectively. Five-year disease-free survival (DFS) and OS rates were 21.6 and 38.1xa0%, respectively, in patients with high MC infiltration, and 42.6 and 55.6xa0%, respectively, in patients with low MC infiltration (pu2009<u20090.01 for both DFS and OS). Infiltration of other types of immune cells did not correlate with survival. Multivariate analyses indicated that hypoalbuminemia and high peritumoral MC infiltration were significant predictors of unfavorable OS.ConclusionHigh peritumoral MC infiltration predicts poor prognosis in patients who underwent hepatectomy for CRLM. The number of MCs in metastatic lesions is important for predicting the prognosis of CRLM patients and as an indication of therapy.

The important risk factor for lateral pelvic lymph node metastasis of lower rectal cancer is node-positive status on magnetic resonance imaging: study of the Lymph Node Committee of Japanese Society for Cancer of the Colon and Rectum

PurposeThis study seeks to evaluate lateral pelvic lymph node (LPLN) and perirectal lymph node (PRLN) status on magnetic resonance imaging (MRI) as potential risk factors for lymph node metastasis.MethodsThe subjects were 394 patients with lower rectal cancer who underwent MRI prior to mesorectal excision (combined with lateral pelvic lymph node dissection in 272 patients) at 6 institutes. No patients received neoadjuvant therapy. Cases were classified as cN(+) and cN(−) based on the short axis of the largest lymph node ≥5 and <5xa0mm, respectively. LPLN and PRLN status and other clinicopathologic factors were analyzed by multivariate logistic regression. The importance of identified risk factors for lymph node metastasis was examined using the area under the curve (AUC).ResultsIndependent risk factors for right LPLN metastasis included histopathological grade (G3xa0+xa0G4), pPRLN(+), M1, cLPLN(+) [odds ratio (OR) 10.73, 95xa0% confidence interval (CI) 4.59–27.1], and those for left LPLN metastasis were age (<64), histopathological grade (G3xa0+xa0G4), pPRLN(+), and cLPLN(+) (OR 24.53, 95xa0% CI 9.16–77.7). ORs for cLPLN(+) were highest. The AUCs for right and left cLPLN status of 0.7484 (95xa0% CI 0.6672–0.8153) and 0.7904 (95xa0% CI 0.7088–0.8538), respectively, were significantly higher than those for other risk factors. In contrast, the ORs for cPRLN(+) and cPRLN status of 2.46 (95xa0% CI 1.47–4.18) and 0.6396 (95xa0% CI 0.5917–0.6848) were not much higher than for other factors.ConclusionsAn LPLN-positive status with a short axis ≥5xa0mm on MRI is an important predictor of LPLN metastasis, but PRLN status is not a strong predictor of PRLN metastasis.

Perivascular epithelioid cell tumor of the rectum: report of a case and review of the literature

We report a case of perivascular epithelioid cell tumor arising in the rectum of a 55-year-old woman. The tumor was treated by transanal endoscopic microsurgery. After 1 year follow-up, the patient is alive with no radiologic or endoscopic evidence of recurrence. Perivascular epithelioid cell tumor is a rare mesenchymal tumor characterized by co-expression of melanocytic and smooth muscle markers. This rare tumor can arise in various organs, including the falciform ligament, uterus, uterine cervix, liver, kidney, lung, breast, cardiac septum, pancreas, prostate, thigh, and gastrointestinal tract. Perivascular epithelioid cell tumor of the gastrointestinal tract is very rare, with only 23 previously reported cases. We review the literature on perivascular epithelioid cell tumors arising in the gastrointestinal tract.

Impact of overexpression of Sushi repeat-containing protein X-linked 2 gene on outcomes of gastric cancer.

Sushi repeat‐containing protein X‐linked 2 (SRPX2) was first described as a downstream target gene for E2A‐HLA, which causes pro‐B acute leukemia. SRPX2 is considered to promote cellular migration and adhesion in cancers. Our objective was to evaluate the relative expression of the SRPX2 gene and to determine whether such expression correlates with outcomes in patients with gastric cancer.

Evaluation of the Glasgow Prognostic Score in patients receiving chemoradiotherapy for stage III and IV esophageal cancer

High Glasgow Prognostic scores (GPSs) have been associated with poor outcomes in various tumors, but the values of GPS and modified GPS (mGPS) in patients with advanced esophageal cancer receiving chemoradiotherapy (CRT) has not yet been reported. We have evaluated these with respect to predicting responsiveness to CRT and long-term survival. Between January 2002 and December 2011, tumor responses in 142 esophageal cancer patients (131 men and 11 women) with stage III (A, B and C) and IV receiving CRT were assessed. We assessed the value of the GPS as a predictor of a response to definitive CRT and also as a prognostic indicator in patients with esophageal cancer receiving CRT. We found that independent predictors of CRT responsiveness were Eastern Cooperative Oncology Group (ECOG) performance status, GPS and cTNM stage. Independent prognostic factors were ECOG performance status and GPS for progression-free survival and ECOG performance status, GPS and cTNM stage IV for disease-specific survival. GPS may be a novel predictor of CRT responsiveness and a prognostic indicator for progression-free and disease-specific survival in patients with advanced esophageal cancer. However, a multicenter study as same regime with large number of patients will be needed to confirm these outcomes.

Is Routine Prophylactic Cholecystectomy Necessary During Gastrectomy for Gastric Cancer? Reply

Background nPerforming routine prophylactic cholecystectomy during gastrectomy in gastric cancer patients has been controversial. The frequency of cholelithiasis, cholecystitis, and cholangitis after gastrectomy has not been reported for large patient populations, so we carried out this retrospective study to aid the assessment of the necessity for prophylactic cholecystectomy.

Urinary dysfunction after rectal cancer surgery: Results from a randomized trial comparing mesorectal excision with and without lateral lymph node dissection for clinical stage II or III lower rectal cancer (Japan Clinical Oncology Group Study, JCOG0212)

BACKGROUNDnPostoperative urinary dysfunction is a major complication of rectal cancer surgery. A randomized controlled trial (JCOG0212) concluded that the noninferiority of mesorectal excision alone to mesorectal excision with lateral lymph node dissection was not confirmed in terms of relapse-free survival.nnnMETHODSnEligibility criteria included histologically proven clinical stage II/III rectal cancer, a main lesion located in the rectum with the lower margin below the peritoneal reflection, and the absence of lateral lymph node enlargement. After confirming R0 resection by mesorectal excision, patients were randomized intraoperatively. The residual urine volume was measured three times. Urinary dysfunction was defined as ≥50xa0mL residual urine occurring at least once or no measurement of residual urinary volume. This trial was registered with the UMIN Clinical Trials Registry, number C000000034.nnnRESULTSnIn the mesorectal excision alone and the mesorectal excision with lateral lymph node dissection groups, the incidence of early urinary dysfunction were 58% and 59%, respectively. A tumor location in the lower rectum (vs. upper rectum) and a blood loss of ≥500xa0mL (vs. <500xa0mL) were associated with an increased risk of early urinary dysfunction. However, only blood loss was independently predictive of early urinary dysfunction (relative risk, 1.25 [95% CI: 1.10-1.55], pxa0=xa0.04).nnnCONCLUSIONSnMesorectal excision with lateral lymph node dissection is not associated with a significant increase in the incidence of urinary dysfunction. Urinary dysfunction is associated with tumor location and blood loss.