Anorectal Cancer in Crohn's Disease Has a Poor Prognosis Due to its Advanced Stage and Aggressive Histological Features: a Systematic Literature Review of Japanese Patients

BACKGROUND

Patients with Crohn's disease (CD) are generally known to be at an increased risk of cancer. The anorectal area is the most frequent cancer site in Japanese CD patients. However, the risks are not well defined. The aim of this study was to clarify the clinicopathological characteristics of Japanese CD-associated anorectal carcinoma patients and to explore screening methods for the detection of cancer at earlier stages.

METHODS

A systematic review of case series and reports of Japanese CD-associated anorectal cancer patients published between 1983 and 2016 was conducted.

RESULT

There were 144 cases of cancer arising from anorectal lesions of CD. The median duration from the onset of CD to the cancer diagnosis was approximately 17 (0-39) years. The most prevalent histological type of cancer was mucinous carcinoma (49.3%), and 82.1% of patients were over T3 invasion. There were only 15.6% cases with early stage disease. A total of 82% patients had enhanced symptoms, whereas 56.3% of the early cancer cases had no symptomatic changes. Approximately 90% of cases were diagnosed preoperatively, and almost all early cancer patients were diagnosed with colonoscopy. The 5-year overall survival rate was 35.8%.

CONCLUSION

CD-associated anorectal carcinoma had a poor prognosis due to the advanced stage of the cases and aggressive histological features. As earlier-stage cancer is associated with a better prognosis than advanced stage disease, and it is also typically diagnosed by colonoscopy, surveillance colonoscopy may therefore help to improve the prognosis in cases without any symptomatic changes.

[A Resected Case of Cecal Cancer with Simultaneous Liver, Spleen, and Ovarian Metastasis and Peritoneal Dissemination]

We herein report the case of a patient with a cecal cancer with simultaneous liver, spleen, and ovarian metastases as well as peritoneal dissemination who achieved a long-term survival. The patient was a 67-year-old female. Ileocecal resection with partial hepatectomy, splenectomy, simple total hysterectomy, bilateral salpingo-oophorectomy, and resection of the peritoneal dissemination were performed. The final diagnosis was Stage IV (T4a, N1, M1b[H1, P3, OTH]). Adjuvant chemotherapy was administered, but abdominal computed tomography(CT)revealed a metachronous liver metastasis 41 months later. We performed partial hepatectomy, and the patient continued adjuvant chemotherapy. The patient is currently alive and disease-free 30 months after the last operation, 72 months after the initial surgery.

[Long-Term Survival of a Patient with Sigmoid Colon Cancer with Multiple Visceral Metastases]

A 66-year-old woman underwent total pelvic exenteration for a pelvic tumor. The pathological diagnosis was sigmoid colon cancer T4b(in the small intestine, uterus, and vagina), N0, M0, Stage II . The patient was treated with XELOX for 6 months as adjuvant chemotherapy and was then treated with IRIS for another 6 months. Brain metastasis developed in the left occipital lobe after 12 months, and she underwent craniotomy and enucleation of the tumor. Liver metastasis and peritoneal dissemination metastasis developed 16 months after her initial diagnosis. The patient underwent re-craniotomy and radiotherapy for recurrence of the brain metastasis 18 months after diagnosis and started taking TAS-102 3 months later. She began treatment with CPT-11 plus panitumumab 24 months after diagnosis, and the dose was increased 9 months later(ie, 35 months after the initial diagnosis). The patient remains alive 42 months after surgery.

Erythropoietin attenuates intestinal inflammation and promotes tissue regeneration

BACKGROUND

The prevalence of inflammatory bowel disease (IBD) is increasing. Since patients usually need long-term treatment and suffer from reduced quality of life, there is a need to develop new therapeutic strategy. The aim of this study was to investigate the therapeutic potential of erythropoietin (EPO) for the treatment of IBD.

METHODS

Murine colitis was induced by 3.0% Dextran Sulfate Sodium (DSS). Recombinant human EPO (rhEPO) was given to evaluate the anti-inflammatory and regenerative effects on intestinal inflammation. The effect of rhEPO on human colon epithelial cells was also evaluated. Immunohistochemical analysis of EPO receptor was performed in human IBD tissues.

RESULTS

While about 62% of control mice with severe colitis induced by 5-day DSS died, 85% of mice treated with rhEPO survived. Histological analysis confirmed that EPO treatment reduced the colonic inflammation. Furthermore, EPO treatment significantly downregulated the local expressions of IFN-γ, TNF-α and E-selectin in the colon, suggesting that the effect was associated with inhibiting local immune activation. In a 4-day DSS-induced colitis model, rhEPO significantly improved the recovery of body weight loss compared to controls. Furthermore, proliferating cell nuclear antigen expression was significantly upregulated in the colon tissue from mice treated with rhEPO compared to controls. In addition, rhEPO increased the growth of cultured human colon epithelial cells in a dose-dependent manner. Furthermore, EPO-receptor expression was confirmed in human IBD colon tissues.

CONCLUSION

Three major functions of EPO, hematopoiesis, anti-inflammation and regeneration, may produce significant effects on intestinal inflammation, therefore suggesting that rhEPO might be useful for IBD.

von Willebrand Factor-Rich Platelet Thrombi in the Liver Cause Sinusoidal Obstruction Syndrome following Oxaliplatin-Based Chemotherapy

Oxaliplatin-based chemotherapy is widely used to treat advanced colorectal cancer (CRC). Sinusoidal obstruction syndrome (SOS) due to oxaliplatin is a serious type of chemotherapy-associated liver injury (CALI) in CRC patients. SOS is thought to be caused by the sinusoidal endothelial cell damage, which results in the release of unusually-large von Willebrand factor multimers (UL-VWFMs) from endothelial cells. To investigate the pathophysiology of CALI after oxaliplatin-based chemotherapy, we analyzed plasma concentration of von Willebrand factor (VWF) and the distribution of VWFMs in CRC patients. Twenty-three patients with advanced CRC who received oxaliplatin-based chemotherapy with (n = 6) and without (n = 17) bevacizumab were analyzed. CALI (n = 6) and splenomegaly (n = 9) were found only in patients who did not treated with bevacizumab. Plasma VWF antigen (VWF:Ag) and serum aspartate aminotransferase (AST) levels increased after chemotherapy only in patients without bevacizumab. VWFM analysis in patients who did not receive bevacizumab showed the presence of UL-VWFMs and absence of high molecular weight VWFMs during chemotherapy, especially in those with CALI. In addition, plasma VWF:Ag and AST levels increased after chemotherapy in patients with splenomegaly (n = 9), but not in patients without splenomegaly (n = 14). Histological findings in the liver tissue of patients who did not receive bevacizumab included sinusoidal dilatation and microthrombi in the sinusoids. Many microthrombi were positive for both anti-IIb/IIIa and anti-VWF antibodies. Plasma UL-VWFM levels might be increased by damage to endothelial cells as a result of oxaliplatin-based chemotherapy. Bevacizumab could prevent CALI and splenomegaly through inhibition of VWF-rich platelet thrombus formation.

[A case of idiopathic portal vein obstruction identified by severe bleeding after a routine hemorrhoid operation]

We report our experiences of a case of repeated bleeding after hemorrhoid ligation. A 53-year-old man underwent hemorrhoid ligation for internal hemorrhoids at another hospital. Postoperatively, he developed severe and repeated bleeding. Scanning revealed extrahepatic portal venous obstruction. The severe bleeding persisted after transfer to our institution, where we re-sutured the ligature and performed superior rectal artery embolism, leading to arrest of bleeding. The rectal varix arose due to portal hypertension, which resulted in the diagnosis of idiopathic extrahepatic portal vein obstruction.

Visualization of Lymph/Blood Flow in Laparoscopic Colorectal Cancer Surgery by ICG Fluorescence Imaging (Lap-IGFI)

PURPOSE

In laparoscopic colorectal cancer (Lap-CRC) surgery, determination of a suitable mesentery division line and the appropriate degree of lymphadenectomy by tracing the blood supply is critical. We performed visualization of the lymph and blood flow by laparoscopic indocyanine green (ICG) fluorescence imaging (Lap-IGFI).

METHODS

ICG is injected into the submucosa near the tumor via colonoscopy, and the lymph flow is observed. Intestinal blood flow is evaluated by administering ICG intravenously.

RESULTS

For lymph flow, visualization of the main lymph node basin helped to determine the surgical division line for cases in which the blood flow was not completely visualized. Lap-IGFI changed the surgical plan of the lymphadenectomy in 23.5 %. In our experience, the metastatic rate of ICG-positive nodes was 10.0 %, and the metastatic rate of ICG-negative nodes was 5.3 %. Furthermore, there were no metastatic nodes that were ICG negative more than 5 cm from the tumor. For blood flow, the blood flow distribution of the intestinal wall from the last branch of the vasa recta of the anastomotic site was clearly visualized and proved useful in choosing the extent of intestinal resection. Lap-IGFI changed the surgical plan of the extensive intestinal resection in 16.7 %.

CONCLUSIONS

Lap-IGFI can noninvasively provide detailed lymph and blood flow information and is a useful device to aid in the accurate identification of individual patients' lymph drainage. This helps dictate adequate lymphadenectomy and the extent of intestinal resection in Lap-CRC surgery.

HVEM expression contributes to tumor progression and prognosis in human colorectal cancer

BACKGROUND

Herpesvirus entry mediator (HVEM) has been recently suggested to play certain roles in cancer biology. We examined HVEM expression in human colorectal cancer (CRC) to reveal its clinical importance.

MATERIALS AND METHODS

Immunohistochemical staining was carried-out in normal epithelium, benign and malignant lesions.

RESULTS

While intense HVEM expression was not observed in normal epithelium and hyperplastic polyps, 24% of adenoma and more than half of CRCs had high HVEM expression. In 234 CRCs, HVEM expression was significantly associated with tumor status and pathological stage. Patients with high HVEM expression had a significantly poorer prognosis than those with low expression. Importantly, HVEM status had an independent prognostic value in CRC. Furthermore, HVEM status was inversely corrected with the presence of tumor-infiltrating T-cells.

CONCLUSION

HVEM may play a critical role in tumor progression and immune evasion, and may also be a novel prognostic marker and potential therapeutic target in human CRC.

Mucinous adenocarcinoma associated with a chronic perianal fistula - a review of cases from a single institution

PURPOSE

The purpose of this study was to evaluate the clinicopathological features of mucinous adenocarcinoma associated with perianal fistulas (MAF), to assess the importance of preoperative MRI analysis, and to determine the optimal surgery.

METHODS

We performed a retrospective analysis of the data from seven patients with MAF treated at our hospital between 2000 and 2013, and herein discuss the importance of preoperative magnetic resonance imaging (MRI) and of radical surgery.

RESULTS

The male to female ratio was 5:2, and the mean age of the patients was 63 years old (28-70). The median duration of chronic fistulation was 16 years (5-40). The tumor extension was classified as II+III+IV in five patients and as II+III in 2 patients according to the Sumikoshi classification, as determned by pelvic MRI. The performed surgeries were 3 abdominoperineal resections with sacral resection and 4 pelvic exenterations with sacral resection. Two local recurrences developed in patients with R1 resection, and 1 distant metastasis occurred in 1 patient with R0 resection.

CONCLUSION

For patients with MAF, a curative surgical resection is the only definitive treatment that can be expected to provide a good prognosis. The application of the Sumikoshi classification using MRI may provide a precise assessment of the extension of MAF, which can allow the appropriate surgery to be selected for the patients with MAF.

[Four resections of metachronous liver metastases and lateral lymph node metastases of a rectal carcinoid tumor - a case report]

The authors present a case of rectal carcinoid tumor with lateral lymph node metastases and liver metastases that was successfully treated by 4 resections. A 70-year-old man was diagnosed with a rectal carcinoid tumor (20 mm in diameter) with submucosal (SM) invasion. Radical resection was performed at 25 months, 38 months, and 57 months, when abdominal computed tomography (CT) revealed metachronous liver metastases of the rectal carcinoid tumor. At 50 months, metachronous lateral lymph node metastases were also revealed. Three hepatectomies and a laparoscopic lateral lymph node dissection were performed. The patient is currently free of disease at 25 months after the last intervention.

Prophylactic laparoscopic lateral pelvic lymph node dissection for lower rectal cancer: remarking on the vesicohypogastric fascia

OBJECTIVE

To introduce the prophylactic laparoscopic lateral pelvic lymph node dissection performing by remarking the vesicohypogastric fascia following total mesorectal excision for patients with advanced lower rectal cancer without radiological evidence of lymph node involvement.

SURGICAL METHOD

We set 5 ports for conventional laparoscopic rectal surgery. During the prophylactic laparoscopic lateral pelvic lymph node dissection, we retrieved the lymph nodes from the internal iliac area and obturator area. We recognized the pelvic nerve plexus, vesicohypogastric fascia (including internal iliac vessels), and parietal fascia (psoas muscle fascia, pubic bone and internal obturator muscle fascia) as the dissection borders from internal to external. Of note, the vesicohypogastric fascia can be recognized under magnified clear vision, and can be preserved by precise dissection, resulting in reduced hemorrhage from the internal iliac vessels and complications such as urinary dysfunction.

CONCLUSION

Prophylactic laparoscopic lateral pelvic lymph node dissection after remarking on the vesicohypogastric fascia may contribute to a less invasive surgery compared with conventional laparoscopic lateral pelvic lymph node dissection.

Exfoliated Tumor Cells in Intraluminal Lavage Samples after Colorectal Endoscopic Submucosal Dissection: A Pilot Study

Endoscopic submucosal dissection involves dissecting manipulation performed with tumors in an exposed condition for a long period of time. Thus, there is a risk for implantation of tumor cells. The objectives of this study were to examine exfoliated tumor cells after colorectal endoscopic submucosal dissection and to elucidate the effectiveness of intraluminal lavage to remove these cells. The subjects were 8 patients who had undergone colorectal endoscopic submucosal dissection at our hospital between September and December 2012. A retrospective study was conducted on the cytological findings of intraluminal lavage samples in these patients. Seven of the 8 patients (88%) had exfoliated tumor cells in the lavage samples at the beginning of lavage. Only 3 patients (3 8%) had exfoliated tumor cells after lavage with 300 ml of water. A large number of tumor cells were thought to have exfoliated into the intestinal lumen after endoscopic submucosal dissection. Sufficient intraluminal lavage after colorectal endoscopic submucosal dissection is necessary to remove exfoliated tumor cells.

Local recurrence after rectal endoscopic submucosal dissection: a case of tumor cell implantation

We report a case of local recurrence of cancer after rectal endoscopic submucosal dissection (ESD). A 52-year-old male underwent a curative resection with ESD for rectal intramucosal cancer. Seventy-four months after ESD, surveillance colonoscopy showed an elevated lesion on the ESD scar, suspicious of a recurrence. The patient subsequently underwent a low anterior resection (intersphincteric) with lymph node dissection. Pathology revealed a well-differentiated adenocarcinoma, similar to the ESD specimen. We suspected that the local recurrence was caused by implantation of tumor cells during the ESD, due to surgical manipulation performed with the tumor in an exposed setting for a long period of time.

Clinical outcomes of pelvic exenteration for locally advanced primary or recurrent non-colorectal pelvic malignancies

OBJECTIVE

The aim of this study was to evaluate the outcomes of patients who underwent extensive pelvic surgery for locally advanced primary or recurrent non-colorectal pelvic malignancies.

PATIENTS AND METHODS

We performed a retrospective review of the medical records of 19 patients with non-colorectal pelvic malignancies who underwent extensive surgery at our institution between January 2005 and May 2013. Overall survival and progression-free survival were estimated using the Kaplan-Meier method and compared using the logrank test.

RESULTS

With regard to tumor histology, 6 patients (31.6%) had gynecological tumors, 8( 42.1%) had urological tumors, 2( 10.5%) had sarcomas, and 3( 15.8%) had other malignancies. Total pelvic exenteration was performed in 13 patients (68.4%), and other procedures were performed in 6 patients( 31.6%). For all patients, the median operation time and blood loss were 699 min and 2,930 mL, respectively. Complete tumor resection( R0) was achieved in 13 patients( 68.4%), and 16 patients had complications( 84.2%). The median overall survival was 18.5 months for patients who underwent R0 resection, compared with 7.3 months for those who underwent R1/R2 surgery (p=0.113), and the median progression-free survival was 7.3 months for cases of R0 resection, compared with 2.0 months for cases of R1/R2 surgery (p=0.035).

CONCLUSION

Our findings indicate that extensive pelvic surgery may be an optimal treatment for some patients with locally advanced primary or recurrent non-colorectal pelvic malignancies. Careful patient selection according to oncological, anatomical, and patient-related factors may improve the outcomes of patients undergoing this extensive, aggressive pelvic surgical procedure.

The "sliding door" technique for closure of abdominal wall defects after rectus abdominis musculocutaneous flap transposition

Radical surgery is often necessary in patients with local recurrence of rectal cancer or in those with carcinoma associated with an anal fistula. The surgery may include extended excision of the perineal area and can create a large dead space in the pelvis and a large skin defect, often necessitating reconstruction of the pelvic floor using rectus abdominis musculocutaneous (RAM) flap transposition. Wound dehiscence and incisional hernia are common complications of RAM flap transposition. We report herein our encounter with 3 patients in whom we used a "sliding door" technique for reconstruction of the abdominal wall after the creation of a RAM flap. One patient underwent abdominoperineal resection with sacrectomy and RAM flap transposition; he experienced a postoperative surgical site infection and wound dehiscence, which we urgently repaired by reconstructing the abdominal wall using the sliding door technique. Two other patients underwent posterior pelvic exenteration with sacrectomy and RAM flap transposition. These patients underwent simultaneous abdominal wall reconstruction using the sliding door technique. No patient experienced postoperative pelvic sepsis, wound dehiscence, or incisional hernia. The sliding door technique might be useful for preventing wound dehiscence and incisional hernia in patients undergoing RAM flap transposition.

Laparoscopic lateral pelvic lymph node dissection for lower rectal cancer: initial clinical experiences with prophylactic dissection

AIM

To evaluate the technical feasibility of laparoscopic lateral pelvic lymph node dissection (LPLD) following total mesorectal excision (TME) as prophylaxis for patients with advanced lower rectal cancer but no radiologic evidence of lymph node involvement.

PATIENTS AND METHODS

TME was performed on 30 patients with cT3N1-2M0 lower rectal cancer. LPLD was performed by laparoscopic surgery in 12 patients (LAP group),and open surgery in 18 patients (Open group). Statistical analysis was used to compare the number of harvested lymph nodes, operative time, operative blood loss, transfusion rate, and volume of transfusion between the groups.

RESULTS

No significant difference was observed in the number of harvested lymph nodes. Operative time was significantly longer in the LAP group; however, operative blood loss, transfusion rate, and volume of transfusion were significantly lower in the LAP group.

CONCLUSION

Laparoscopic LPLD, when performed by a well-trained laparoscopic team, is safe and feasible in some selected lower rectal cancer patients. This approach has the potential to achieve oncologic lymph node clearance equivalent to open surgical LPLD, and to overcome the cited disadvantages of LPLD, which include greater operative blood loss and urinary dysfunction.

[A case of multiple gastrointestinal stromal tumors of the small intestine associated with von Recklinghausen disease]

A 63-year-old woman was admitted to our hospital because of tarry stool several years previously. At the time, café-au-lait spots and dermal nodules were found on her entire body, and a diagnosis of von Recklinghausen disease was established. Small bowel endoscopy revealed a submucosal tumor in the jejunum. Laparotomy was therefore performed on the suspicion of intestinal GIST. Numerous extramural tumors with a diameter of 3-5mm were observed along the jejunum and ileum, in addition to the primary tumor. Partial resection of the jejunum, including the primary tumor and only one small nodule was performed to prevent short bowel syndrome. Immunopathological studies of the tumors were positive for KIT and CD34 and we diagnosed multiple intestinal GISTs. Imatinib mesylate was not administered, but no growth of the residual tumors have been recognized for 10 months after surgery.