A new spray-type adhesion barrier (AdSpray) improves condition for surgical treatment in the reversal of Hartmann procedure: A case report

RATIONALE

Hartmann procedure (HP) often causes severe postoperative adhesions in the pelvic space; therefore, the reversal of Hartmann procedure (RHP) is a challenging surgery. A new spray-type antiadhesion agent, AdSpray, has been reported to be useful in three-dimensional fields such as the liver. However, there are no reports of its use in HP. We present a case of a male patient with rectal cancer who underwent laparoscopic HP with AdSpray to prevent postoperative adhesions.

PATIENT CONCERNS

A 52-year-old man presented with melena and constipation.

DIAGNOSIS

Colonoscopy revealed an almost obstructive type II tumor at the rectosigmoid colon, and histopathological examination revealed moderately differentiated adenocarcinoma. Enhanced abdominal computed tomography revealed slightly enlarged regional lymph nodes but no ascites around the tumor, and there was no metastasis to the liver or lungs. Therefore, we diagnosed clinical stage T4aN1bM0 rectosigmoid colon cancer. Intraoperatively, a metastatic tumor of the liver surface and a high degree of valve retention in the oral colon were identified.

INTERVENTIONS

After performing laparoscopic HP with AdSpray, we scheduled a laparoscopic RHP with staged hepatic surgery for synchronous liver metastasis from colorectal cancer 1 month later.

OUTCOMES

No postoperative inflammatory adhesions were observed in the pelvis or around the rectal stump, allowing us to perform RHP by a single-incision laparoscopic surgery from the stoma site without any problem. The operation time for RHP was 80 minutes; the patient was in good general condition after the operation, and he was discharged on postoperative day 7.

LESSONS

In laparoscopic HP, Adspray was easy to use for three-dimensional fields such as the pelvis and effectively prevented postoperative inflammatory adhesions. Thus, RHP may become less risky and be performed more as a minimally invasive surgery.

[A Case of Double Colorectal Cancer Diagnosed by Preoperative CT Colonography]

A 66‒year‒old man was admitted to our hospital because of anemia and a positive fecal occult blood test in the medical examination. Colonoscopy revealed a type 2 advanced sigmoid colon cancer with circular stenosis. Computed tomography (CT)colonography was performed to examine the oral colon. The apple core signs were found both in the sigmoid and transverse colon. We diagnosed a double colon cancer and performed a laparoscopic left hemicolectomy and sigmoidectomy. The tumor was histopathologically diagnosed as a multiple cancer including a transverse and a sigmoid colon cancer. Although evaluations of the intestine for colon cancer with stenosis are performed by enema examination or endoscopic examination after colon stent placement, both examinations are invasive. CT colonography is considered to be a minimally invasive and an effective preoperative examination for colorectal cancer with stenosis.

Local recurrence in sigmoid cancer is a hidden problem, could CT prognostic factors be of value in their prevention? A multi-centre study of 414 patients

INTRODUCTION

The incidence and patterns of local recurrence of colon cancer are not well reported. The aim of this study was to investigate the contemporary rates and patterns of local recurrence after sigmoid cancer resection, comparing pre and post-operative biomarkers in predicting local disease recurrence.

MATERIALS AND METHODS

A multi-centre, retrospective analysis of 414 patients undergoing resectional surgery for sigmoid colon cancer was conducted. Multivariable Cox Proportional Hazard models were created to identify variables associated with local disease recurrence. Patterns of recurrence and prognostic significance of pre and post-operative variables were identified.

RESULTS

In 414 patients, the local recurrence rate was 12.6%. The R1/R2 rate was 2.4%. Local recurrence occurred most commonly within the peri-anastomotic region (50%), followed by the peritoneum (33%). On multivariate analysis, local recurrence was predicted by pathological T stage (HR 1.15) and R1 resection (HR 2.95), but also computerised tomography (CT) identified tumour deposits (HR 2.40) and local peritoneal infiltration (2.70).

CONCLUSIONS

Contemporary local recurrence rates for sigmoid cancer are high at 12.6%. Outcomes may be improved if local recurrence is reduced at the most common sites such as the peri-anastomotic area or peritoneum. Extra-nodal CT-imaging biomarkers of local peritoneal infiltration and tumour deposits were prognostically significant on multivariate analysis in addition to pathology staging variables.

Assessment of a Staging System for Sigmoid Colon Cancer Based on Tumor Deposits and Extramural Venous Invasion on Computed Tomography

IMPORTANCE

Preoperative TNM stratification of colon cancer on computed tomography (CT) does not identify patients who are at high risk of recurrence that could be selected for preoperative treatment.

OBJECTIVE

To evaluate the utility of CT findings for prognosis of sigmoid colon cancer.

DESIGN, SETTING, AND PARTICIPANTS

This prognostic study used retrospective data from patients who underwent bowel resection for sigmoid colon cancer between January 1, 2006, and January 1, 2015, at a tertiary care center receiving international and national referrals for colorectal cancer. Statistical analysis was performed in April 2019.

MAIN OUTCOMES AND MEASURES

Cox proportional hazards regression analysis was performed to investigate CT findings associated with disease recurrence. Kaplan-Meier survival plots were calculated for disease-free survival using CT staging systems.

RESULTS

Of the 414 patients who had sigmoid colon cancer (248 [60.0%] men; mean [SD] age, 66.1 [12.7] years), with median follow-up of 61 months (interquartile range, 40-87 months), 122 patients (29.5%) developed disease recurrence. On multivariate analysis, nodal disease was not associated with disease recurrence; only tumor deposits (hazard ratio [HR], 1.90; 95% CI, 1.21-2.98; P = .006) and extramural venous invasion (HR, 1.97; 95% CI, 1.26-3.06; P = .003) on CT were associated with disease recurrence. Significant differences in disease-free survival were found using CT-T3 substage classification (HR, 1.88; 95% CI, 1.32-2.68) but not CT-TNM (HR, 1.55; 95% CI, 0.94-2.55). The presence of tumor deposits or extramural venous invasion on CT (HR, 2.45; 95% CI, 1.68-3.56) had the strongest association with poor outcome.

CONCLUSIONS AND RELEVANCE

In this study, T3 substaging and detection of tumor deposits or extramural venous invasion on preoperative CT scans of sigmoid colon cancer were prognostic factors for disease-free survival, whereas TNM and nodal staging on CT had no prognostic value. T3 substaging and detection of tumor deposits or extramural venous invasion of sigmoid colon cancer was superior to TNM on CT and could be used to preoperatively identify patients at high risk of recurrence.

Breast metastasis from colorectal cancer treated by multimodal therapy: Case report and literature review

INTRODUCTION

Breast metastases from primary colorectal carcinoma are extremely rare, with only 45 cases being reported previously. Since the most common malignancy in the breast and axilla is primary breast cancer regardless of cancer history, non-hematologic metastases may be misdiagnosed initially. Nevertheless, differentiating breast metastases from primary breast cancer is crucial because of their differences in prognosis and management.

PATIENT CONCERNS

We present a case of a 44-year-old Asian woman who noticed a new right breast lump after undergoing surgery and chemotherapy for her primary sigmoid colon cancer.

DIAGNOSIS

Image and immunohistochemistry findings were consistent with breast metastasis from primary colorectal adenocarcinoma.

INTERVENTIONS

The patient underwent breast tumor excision and reinitiated chemotherapy.

OUTCOMES

The patient's disease progressed despite the interventions. She passed away 7 months after the detection of breast metastasis.

CONCLUSION

When a new breast lesion is detected in patients with colorectal cancer history, the physician should consider the possibility of breast metastasis due to the poor prognosis. If a biopsy is necessary, cancer history should be provided to the clinicians to prevent incorrect pathological interpretation. In establishing the diagnosis, certain immunohistochemical markers have been shown to be sensitive and specific in previously reported cases. The combination of tumor excision and chemotherapy was the most common strategy in managing this condition with inconsistent clinical outcomes.

Coexistence of colon adenocarcinoma, diffuse large B-cell lymphoma, and myelodysplastic syndrome: A case report

RATIONALE

Cases of coexistence of 2 cancers, such as colorectal cancer and diffuse large B-cell lymphoma (DLBCL), colorectal cancer and myelodysplastic syndrome (MDS), and DLBCL with MDS, have been reported, whereas the coexistence of 3 different cancers in a patient is extremely rare. Here we report a case of co-occurrence of colon adenocarcinoma, DLBCL, and MDS in a 78-year-old Chinese man.

PATIENT CONCERNS

He presented to our hospital with palpable lumps in the abdomen without any of the following symptoms including abdominal pain, fever, contact pain, tenesmus, changes in bowel habits and shape, nausea, and vomiting.

DIAGNOSES

The patient was first diagnosed with sigmoid colon adenocarcinoma and DLBCL in the right ascending colon using enhanced computed tomography, colonoscopy, and immunohistochemistry. After resection of the sigmoid adenocarcinoma and DLBCL, MDS was diagnosed according to the results of routine blood tests, bone marrow aspiration smear, and flow cytometry.

INTERVENTIONS

Overall, the patient was treated with surgical resection of the sigmoid adenocarcinoma and DLBCL of the colon, combined with 4 cycles of chemotherapies targeting MDS.

OUTCOMES

Blood test results and follow-up indicated that the treatment regimen showed promising outcomes.

LESSONS

In conclusion, a case of synchronous existence of colon cancer, DLBCL, and MDS is reported, which suggests that careful attention should be paid clinically to checking the state of bone marrow for elderly cancer patients. Efforts are also needed to establish an effective system for distinguishing the origin of multi-existent cancers and to develop effective therapeutic regimens for multi-existent cancers with fewer side effects.

Natural History of Pancreatic Ductal Adenocarcinoma Diagnosed During Observation of Other Organ Cancers

BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is a rapidly progressive malignancy that exhibits an extremely poor prognosis, with most cases diagnosed at an advanced stage. To date, few reports have explored the natural history of PDAC, and the period leading up to the detection of PDAC as a tumor with contrast-enhanced computed tomography (CECT) remains unclear. Here, we report 3 PDAC cases diagnosed incidentally by repeating imaging examinations during observation of other organ cancers. CASE REPORT Two patients were undergoing postoperative follow-up for colorectal cancer; owing to the elevation of serum CA19-9 or dilatation of the main pancreatic duct, both cases were finally diagnosed with PDAC. Another patient was administered neoadjuvant chemotherapy for a gastrointestinal stromal tumor; the fluorodeoxyglucose uptake in the pancreas with fluorodeoxyglucose positron emission tomography for the treatment assessment led to the diagnosis of PDAC. All patients underwent frequent CECT for assessment of other diseases, and PDAC became visible with CECT within 3-4 months of the appearance of indirect findings of PDAC. CONCLUSIONS The period leading up to the detection of PDAC as a tumor with CECT was approximately 3-4 months. These cases suggest that additional imaging examinations should be performed when the indirect findings of PDAC are noted. This report adds value to the literature by elucidating the natural course of PDAC.

Sigmoid Colon Metastasis from Sarcomatoid Renal Cell Carcinoma

The sarcomatoid histological type of renal cell carcinoma is a clinically aggressive variant of parenchymal tumor, typically resistant to systemic treatment. We report the case of a 65-year-old female patient who had undergone a left radical nephrectomy for a sarcomatoid renal cell carcinoma together with enucleation of a mass of the right kidney and a contralateral nodule diagnosed as clear cell carcinoma. One year later lung, adrenal and sigmoid colon metastases from sarcomatoid renal cell carcinoma were detected and the patient was started on systemic immunotherapy with interleukin-2 and interferon-α. Computed tomography showed marked disease progression and the patient died 3 weeks later. Sigmoid colon metastasis from a primary sarcomatoid renal cell carcinoma has never been described in the literature.

[Curative Resection for Unresectable Locally Advanced Colorectal Cancer Following Intensive Chemotherapy plus Molecular Targeted Agent - Report of Three Cases]

Intensive chemotherapy plus molecular targeted agent improve overall survival for patients with unresectable colorectal cancer.We performed laparoscopic surgery following intensive chemotherapy of mFOLFOX6 or FOLFIRI plus molecular targeted agent for 3 patients with unresectable locally advanced colorectal cancer with abscess formation.A 60-year-old man was diagnosed as having unresectable rectal cancer with abscess formation and underwent curative resection after partial response following chemotherapy.A 42-year-old woman was diagnosed as having unresectable sigmoid colon cancer with abscess formation and underwent curative resection after partial response following chemotherapy.A 56-year-old woman was diagnosed as having unresectable sigmoid colon cancer with abscess formation and underwent curative resection after partial response following chemotherapy.They are alive after surgery for 69, 74 and 72 months, respectively.Intensive chemotherapy plus molecular targeted agent for unresectalbe locally advanced colorectal cancer with abscess formation will be one of useful strategies for minimum invasive surgery and effective local control.

[COMPLETE RESECTION OF URACHAL CARCINOMA WITH SIGMOID COLON INVASION AFTER FOLFOX CHEMOTHERAPY: A CASE REPORT]

A 45-years-old man presented discharge of abscess from the umbilicus with lower abdominal pain. CT scan showed huge tumor from the bladder to the umbilical part with sigmoid colon invasion. He was diagnosed as urachal carcinoma, which was confirmed by pathological examination. We started FOLFOX chemotherapy according to advanced colon cancer. Approximately 80% of reduction was accomplished after 11 courses of FOLFOX. We performed radical cystectomy with sigmoid colon resection. Pathological examination revealed complete resection with negative surgical margin. No recurrence and metastasis were observed after 30 months of surgery. Urachal carcinoma is often advanced cancer when diagnosed. Effective chemotherapy is not established well. FOLFOX chemotherapy demonstrated the well antitumor effect in this case.

[A Case of Sigmoid Colon Cancer It Was Found from Penetration of Sigmoid Diverticulum]

A 52-year-old woman presented with sudden left lower abdominal pain, fever, and vomiting. As the symptom got improved immediately she went home then. She consulted our hospital with chief complaint of the left lower abdominal mass. Abdominal computed tomography revealed sigmoid colon cancer with abscess. She was diagnosed with sigmoid colon cancer via colonoscopy. Sigmoidectomy including partial resection of the abdominal wall was performed(D3 lymphadenectomy). Surgical specimen showed penetration of diverticulum on mucous membrane of the lesion which had been thought of a abdominal wall permeation and a tumor of I sp type at anal side. Pathological examination showed diverticulitis with penetration and the tumor was tubular adenocarcinoma(tub1, pT1bpN0, pStage I ). We had doubted penetration of sigmoid colon cancer most, but the cause of penetration turned out to be diverticulitis. We experienced a case in which we could performed surgery of sigmoid colon cancer and penetration of diverticulum at the same time.

Accuracy of ultrasound in prediction of rectosigmoid infiltration in epithelial ovarian cancer

OBJECTIVE

To examine prospectively the accuracy of ultrasound in predicting rectosigmoid tumor infiltration in patients with epithelial ovarian cancer.

METHODS

Patients referred for a suspicious pelvic mass between 2012 and 2014 were examined by ultrasound following the standard protocol for assessment of tumor infiltration. Of the 245 patients examined, 191 had proven ovarian cancer and underwent primary surgery and were included in the analysis. Patients with apparently benign or inoperable disease were excluded. Rectosigmoid infiltration was evaluated by histopathology or according to perioperative findings. Clinical, pathological and laboratory parameters were analyzed as factors potentially affecting the sensitivity and specificity of sonography.

RESULTS

The sensitivity of ultrasound in detecting rectosigmoid infiltration in patients with ovarian cancer was 86.3%, with specificity of 95.8%, positive predictive value of 92.6%, negative predictive value of 91.9% and overall accuracy of 92.1%.

CONCLUSION

Ultrasound is a highly accurate method for detecting rectosigmoid tumor infiltration in ovarian cancer patients, and thus, can be used for planning adequate management, including patient consultation, surgical team planning, suitable operating time and postoperative care. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Interdigitating dendritic cell sarcoma presenting in the sigmoid colon mesentery: A case report and literature review

RATIONALE

Interdigitating dendritic cell sarcoma (IDCS) is an extremely rare disease. It commonly occurs in middle-aged males and mainly involves the lymph nodes. Pathological examination plays an important role in differentiating from other tumors, but far less published literature focuses on the imaging characteristics of IDCS.

PATIENT CONCERNS

Here, we reported a case of IDCS in a 52-year-old male involving the pelvis with medical imaging and pathologic findings.

DIAGNOSES

Preoperative unenhanced CT scan revealed a 6.0 × 6.3 × 8.0 cm mass with density equal to that of adjacent muscle, located in the pelvis. On contrast-enhanced CT images, the tumor presented apparent homogeneous enhancement. CT angiography showed that the tumor was supplied by the branches of inferior mesenteric artery. Pelvic magnetic resonance imaging manifested a lobulated solid mass with low signal on T1-weighted and intermediate to high signal on T2-weighted images. Simultaneously, significantly high signal intensity was exhibited on the diffusion-weighted images. This patient underwent operative resection of the tumor. The pathologic diagnosis was IDCS.

INTERVENTIONS

This patient underwent operative resection of the tumor. The resection margins were negative for the neoplastic proliferation and no distant metastases were found. The patient did not receive advanced radiotherapy or chemotherapy.

OUTCOMES

Three months after surgery, the follow-up CT scan did not reveal any recurrence or metastases.

LESSONS

This case adds to the experience with IDCS by summarizing its characteristics as well as reviewing the literature.

[A Case of Trousseau Syndrome Associated with Advanced Rectal Cancer]

We report a case of Trousseau syndrome associated with advanced rectalcancer. A 67-year-old man visited our hospital for right hemiparesis and gait disturbance. Head magnetic resonance imaging showed multiple cerebral infarctions. Abdominal computed tomography showed wallthickening of the rectum and colonoscopy showed type 2 circumferentialrectalcancer. Therefore, he was diagnosed with Trousseau syndrome. After anticoagulation therapy with heparin, an operation was performed. Thereafter, chemotherapy was continued and he has experienced no recurrence of cerebralinfarction.

A Case of Plasmablastic Lymphoma Achieving Complete Response and Durable Remission after Lenalidomide-Based Therapy

BACKGROUND

Plasmablastic lymphoma (PBL) is an uncommon variant of diffuse large B-cell lymphoma that is characterized by its plasmacytoid features, aggressive tendencies, and frequent association with human immunodeficiency virus (HIV) infection or other immunocompromised states. Multi-agent, intensive chemotherapy regimens are recommended as first-line treatment by the National Comprehensive Cancer Network. However, the toxicity of these regimens is high and prognosis remains poor.

CASE REPORT

We report a patient with HIV-negative PBL who achieved complete response and durable remission using a lenalidomide-based chemotherapy regimen as first-line therapy.

CONCLUSION

Cyclophosphamide, lenalidomide, dexamethasone (CRD) may provide an alternative initial therapeutic option for patients with PBL who cannot tolerate the intensive chemotherapy regimens currently recommended.

[Unresectable Stage IV Sigmoid Colon Cancer with Extended Resection for Primary Tumor - A Case Report]

A 65-year-old woman who was diagnosed with unresectable Stage IV sigmoid colon cancer underwent transverse colostomy with double orifices. Although KRAS gene mutation was observed, we could not administer bevacizumab because of the risk of bleeding from the primary tumor and peritumoral abscess. We started bi-weekly XELOX therapy but bloody bowel discharge continued. We planned extended resection of the primary tumor in order to control the bleeding and perforation. Sigmoidectomy, partial resection of the left ureter and small intestine, partial hysterectomy, bilateral salpingo-oophorectomy, and umbilical tumor resection were performed and the patient was discharged on the 10th day after surgery. After surgery, bloody bowel discharge disappeared and bevacizumab was administered in the 55th day. Extended resection for a primary tumor may contribute to bleeding control and broaden treatment options.

Magnified endoscopic observation of early colorectal cancer by linked color imaging with crystal violet staining (with video)

BACKGROUND AND AIMS

Many reports have shown the usefulness of magnification endoscopy with crystal violet (CV) staining for delineating the pit pattern in the diagnosis of colorectal carcinoma. However, the diagnostic accuracy of this method is not adequate for assessing the depth of invasion of early stage cancers. The novel technology of linked color imaging (LCI) combined with CV staining is expected to improve the accuracy of determining the depth of invasion.

METHODS

We studied 3 patients with early stage colorectal cancer who were referred to our hospital. After CV spraying, high-magnification endoscopy was conducted by using the LCI mode. Efficacy of this modality was evaluated by comparing the preoperative diagnostic endoscopic images with posttreatment histopathologic findings.

RESULTS

In 2 cases of rectal cancer, although conventional endoscopic examination could not exclude the possibility of submucosal cancer, use of the LCI mode with CV staining confirmed mucosal cancer. Eventually, EMR was conducted and achieved curative resection. In 1 case of sigmoid colon cancer, both conventional and CV magnification endoscopy suggested submucosal cancer. However, mucosal cancer was diagnosed by the novel method, and EMR achieved curative resection.

CONCLUSIONS

LCI high-magnification endoscopy combined with CV staining provides images close to histopathologic findings and is expected to improve the accuracy of endoscopic diagnosis of the depth of invasion for early stage colorectal cancer.

What Can We Find Behind a Parietal Abscess? Case Report

We report a rare case of a 71-year-old female who presented to the First Clinic of Surgery from “Sf. Spiridon” Hospital Iasi, Romania with a mass in the left iliac fossa that started to discharge a feculent secretion five days prior to presentation. The patient had a history of constipation, several episodes of hematochezia associated with significant weight loss over the past 6 months. Following evaluation, a diagnosis of enter cutaneous fistula secondary to a locally advanced sigmoid cancer was made. The patient underwent semi-elective resection of the sigmoid tumor (measuring 20 cm) with 10 cm safe margins, and of the involved lymph nodes and abdominal wall. A termino-terminal colo-rectal anastomosis was performed. The patient was discharged the 10th postoperative day after an uneventful evolution for oncological evaluation. The authors presented this case in order to illustrate the challenges associated with diagnostic and therapeutic management of advanced colorectal cancer that has been discovered through a parietal abscess.

[The usefulness of intraoperative Doppler echo and laparoscopic echo in laparoscopic colectomy]

Laparoscopic surgery has been increasingly performed in colon cancer patients; it has also been adapted for cases of advanced colorectal cancer. While performing an operation for rectosigmoid colon cancer, preservation of the left colic artery and prompt and accurate detection of the branch of the left colic artery from the inferior mesenteric artery is important. Detecting the left colon arterial bifurcation takes time, especially because of the presence of mesenteric fat, which is observed in many cases. In addition, in cases in which preoperative enhanced computed tomography (CT) cannot be performed, the surgery is sometimes performed without knowing the traveling vessel. As palpation is impossible, it is impossible to tactile running of the arteries as laparotomy in laparoscopic surgery. With endoscopic echo or Doppler echo, real-time identification of the blood vessels during surgery is possible without being invasive. It would be in laparoscopic surgery impossible palpation, and the combined use of intraoperative echo in ensuring the safety to be useful.

Sigmoidal polyp with adenocarcinoma discovered by transvaginal three-dimensional ultrasonographic virtual colonoscopy

Adenocarcinoma of the colon represents the third most frequent cause of death from cancer, being surpassed only by lung and stomach cancer. Early screening and diagnosis of polyps are important for a good prognosis. Based on a clinical case, a novel approach is presented for screening of sigmoidal polyps and neoplasia using transvaginal 2D, 3D mode in women. This novel and simple technique can be used to visualize the sigmoid diverticula during routine gynecological examination via 3D transvaginal ultrasound probe.

Primary extragastrointestinal stromal tumor of the sigmoid mesocolon with metastatic spread to greater omentum: case report

A 71-year-old female complained of abdominal pain, weight loss and abdominal distension. Gynecologic examination revealed a hardly movable, palpable mass in the lower abdomen, reaching the umbilicus. An abdominal ultrasound and computed tomography (CT) scan suggested a large abdominal mass with the possible origin in the left ovary and without significant lymph node enlargements. The patient subsequently underwent complete evacuation of tumor tissue, omentectomy and total abdominal hysterectomy and bilateral salpingo-ovariectomy. Immunohistochemical examination revealed strongly positive staining of tumor cells for CD117. The final pathologic diagnosis was a primary extragastrointestinal stromal tumor (EGIST) of the sigmoid mesocolon with omental metastasis. The differential diagnosis of the tumor presented in the lower abdomen should consider the EGIST as well.

[Lipoma as the cause of intussusception of the rectum in a 46-year-old woman]

We present a case with a 46-year-old woman who had experienced six days of abdominal pain and some days of anal bleeding. She had no prior medical history. At the clinical examination it was found that she had a soft abdomen, but there was tenderness in the lower part. A computed tomography showed an intussusception of the sigmoideum into the rectum. An oncological resection was performed, since it could not at the time of the operation be determined if it was a malignant proces. The histology showed a benign submucosal lipoma.

Contrast-enhanced sonographic appearance of malignant fibrous histiocytoma in the sigmoid colon: a case report

Malignant fibrous histiocytoma (MFH) of the sigmoid colon is extremely rare and imaging characteristics of MFH during contrast-enhanced sonography have not been described yet. Here we report the case of a 55-year-old man suffering from MFH in the sigmoid colon, with an emphasis on contrast-enhanced sonography findings.

[A case of sigmoid colon cancer with peritoneal dissemination responding to third-line therapy employing bevacizumab combination therapy after failure of FOLFOX and FOLFIRI]

A58 -year-old man with sigmoid colon cancer with peritoneal dissemination was treated with bevacizumab (BV) plus mFOLFOX6 therapy as third-line chemotherapy after treatment failures with FOLFOX4 and FOLFIRI regimen. BV combination therapy resulted in a decrease in ascites and disappearance of the primary lesion. His ECOG performance status (PS) recovered from level 3 to level 1, and BV combination therapy improved his quality of life. This case suggested that BV in combination with chemotherapy could be a promising systemic chemotherapy for patients with colorectal cancer with peritoneal dissemination, and this regimen may be useful for patients progressing after receiving FOLFOX, FOLFIRI regimen.

Sigmoidorectal intussusception in adults: a case report

A 75-year-old women was admitted to our hospital due to anal bleeding from 5 days. At clinical examination abdomen was soft but tenderness in the lower quadrants, where a soft, mobile, round mass measuring 10 cm in diameter was palpable. CT scan demonstrated the presence of sigmoido-rectal intussusception. The patient underwent emergency anterior resection of rectum with stapled termino-terminal colo-rectal anastomosis. Postoperative course was uneventful and the patient was discharged 7 days after the operation. Histopathological examination demonstrated a tubular adenoma with low grade dysplasia, 1,2 cm in diameter, located in the distal sigmoid colon. Intussusception is a rather common pediatric condition that rarely presents in adults. Adults intussusception represents 5% of all cases of intussusception. In children it is usually primary and benign, and pneumatic or hydrostatic reduction of the intussusception is sufficient to treat the condition in 80% of patients. In contrast a demonstrable etiology is found in 70% to 90% of cases in adults, and approximately 40%-50% of them are caused by malignant neoplasms. Surgical intervention is necessary in all cases of intussusception in adults. Due to the low incidence and the rare consideration given to this condition among adults the preoperative diagnosis can be difficult, especially in emergency cases. Abdominal CT provides the most accurate diagnostic rate for intestinal intussusception.

[A case of upper urinary tract metastases from sigmoid colon cancer]

We report a case of colorectal cancer with metastasis to the upper urinary tract. A 56-year-old man had left flank pain. Ultrasonography and computed tomographic (CT) examination demonstrated left hydronephroureter and a soft-tissue structure within the left ureter. Urinary cytology of the left ureter showed class IIIb. We diagnosed him with ureteral cancer and performed left nephroureterectomy. Microscopic examination demonstrated adenocarcinoma located in ureteral and pelvic wall, especially in blood vessels, with intact mucosa and similar to adenocarcinoma of colon cancer. Therefore metastatic upper urinary tract tumor was suspected. Barium enema and positron emission tomography-CT demonstrated sigmoid colon cancer. Biopsy specimen of colon cancer demonstrated adenocarcinoma, which was consistent with the ureteral tumor. Finally we diagnosed him with metastatic upper urinary tract tumor of sigmoid colon cancer.

[Abstract: case report of isolated metastasis to the spleen in a patient operated due to cancer of the sigmoid colon]

Isolated metastatic tumor of the spleen is rare and usually encompass the presence of neoplasmatic dissemination. The most frequent location of metastasis is right lobe of the liver, however solitaire secondary tumor to distant organ such as brain, lung, bone marrow or other might be discovered. This report refers to the 15th case of isolated intrasplenic metastasis from colon and rectal cancer. Splenectomy is a method of choice therefore may be justified in presence of isolated metastatic disease, because of low complication rate, providing potential long-term survival.

[A case of multiple liver metastases of sigmoid colon cancer responding well to UFT+Leucovorin therapy]

The subject was a 75-year-old female. For the treatment of multiple liver metastases from sigmoid colon cancer, the administration of UFT(300 mg/day)and oral Leucovorin(75 mg/day)was initiated after a resection of the sigmoid colon. A decrease in the liver metastases was observed in a CT scan 4 months after the start of this administration, and the disappearance of the metastatic focus in the liver was confirmed at 10 months thereafter. The administration of UFT and oral Leucovorin was continued for 2 months. Thereafter, at 12 months after the start of this administration, was continued with only the administration of UFT(300 mg/day)for 1 year. Now, 26 months have passed since the liver metastases disappeared and no recurrence has been found, even within the abdominal cavity. The condition of the patient has been excellent. The subject of this study was an elderly person, but an excellent QOL was secured without any adverse events, and the chemotherapy regimen could be maintained for 2 years. These findings suggest that UFT and oral Leucovorin can be expected to have an excellent therapeutic effect as an oral chemotherapeutic agent.

[A case of sigmoid colon cancer with metastases of para-aortic lymph nodes treated with curative resection after irinotecan plus 5-fluorouracil and l-leucovorin combination chemotherapy]

A 54-year-old woman visited our hospital with a chief complaint of lower abdominal pain and melena. The patient was diagnosed with sigmoid colon cancer using colonoscopy. Abdominal CT revealed metastases to para-aortic lymph node, so our diagnosis was unresectable sigmoid colon cancer. She underwent a transverse colostomy to avoid stenosis. Two weeks after surgery, she underwent a 1-week chemotherapy regimen (CPT-11 80 mg/m(2)/week+5-FU 2,000 mg/m(2)/week+l-LV 250 mg/m(2)/week) modified AIO regimen combined irinotecan for 3 weeks, followed by a 1-week rest interval as one course. Throughout the period of treatment, there was no adverse event, and this regimen has been maintained for 5 courses. After 5 courses of chemotherapy, primary tumor and metastases to para-aortic lymph nodes were remarkably reduced on colonoscopy and abdominal CT. So, she could undergo curative resection. Pathological efficacy was Grade 3, a complete response. This combination therapy may well be useful for advanced colon cancer patients.

Ultrasonographic diagnosis of adult intussusception caused by pedunculated colon carcinoma

Adult intussusception is clinically rare. We report a case with colon intussusception caused by a pedunculated polyp of the sigmoid colon in a 54-year-old male. Abdominal ultrasonographic screening for hematochezia showed intussusception in the sigmoid colon, demonstrating a multiple concentric ring sign and a mobile leading colon polyp. Histological examination of a biopsy specimen of the polyp revealed adenoma. This report suggests that ultrasound imaging is a modality of choice for differential diagnosis of intestinal intussusception with hematochezia in adults.

[A case of complete response in supraclavicular lymph node involvement from cancer of the sigmoid colon to FOLFOX4 therapy after laparoscopy-assisted colectomy]

We reported a case of sigmoid colon cancer with left supraclavicular lymph node involvement that completely responded to FOLFOX4 therapy following laparoscopy-assisted colectomy (LAC). A 69-year-old female presented with left supraclavicular tumor and was diagnosed as sigmoid colon cancer. Abnormally high CEA (128 ng/mL) and CA19-9 (59.3 U/mL) levels were detected in serum. She was operated palliatively by LAC, and FOLFOX4 therapy was initiated. The serum CEA and CA19-9 values regained their normal level after 5 and 4 courses of FOLFOX4, respectively. After 5 courses, metastatic nodes disappeared on her CT. After 12 courses no abnormal accumulations were detected on FDG-PET. Antitumor efficacy was judged as CR. Grade 1 neutropenia and grade 2 peripheral neuropathy were noted, but no other serious adverse reactions occurred during FOLFOX4 therapy. CR has been maintained at present. She has been treated with FOLFOX4 therapy without oxaliplatin to prevent neuropathy. Establishment of maintenance therapy following CR to FOLFOX4 is awaited.

[A case of sigmoid colon cancer with multiple liver metastases responding to S-1]

A 74-year-old woman was referred to our hospital with complaints of constipation and abdominal distention caused by a sigmoid colon tumor. After examination, she was diagnosed as sigmoid colon cancer with multiple liver metastases. To prevent bowel obstruction, a sigmoid colon resection was performed. On postoperative days 15, S-1 was started, and she was discharged on postoperative day 26. Each course consisted of daily oral administration S-1 for 4 weeks followed by 2 drug-free weeks. However, because of grade 2 anorexia in the 1st course, the treatment plan was changed to administration for 2 weeks and withdrawal for 1 week. After 7 courses of treatment, computed tomography revealed that the liver metastases were remarkably reduced. Although she experienced an adverse event involving a cutaneous symptom of grade 2, the treatment was continued under ambulatory management. After eight courses, elevation of tumor marker and metastasis at the right femur were found, and she died of the cancer 12 months after the operation. S-1 is expected to be an effective agent for the treatment of advanced colorectal cancer.

CT colonography to detect rectosigmoid involvement in patients with primary ovarian cancer

INTRODUCTION

We retrospectively evaluated the performance of preoperative computed tomographic (CT) colonography to detect tumor involvement of the rectosigmoid wall and predict the need for rectosigmoid resection in patients with primary ovarian cancer.

METHODS

Thirty-three patients with primary ovarian cancer who underwent preoperative CT colonographic examination were evaluated. The images of the examination were analyzed and compared with the subsequent surgical findings.

RESULTS

All abnormal findings (malignant infiltration of the rectosigmoid mucosa and extrinsic compression) revealed by conventional colonoscopy were correctly observed as extrinsic compression using CT colonography. The sensitivity, specificity, positive predictive value and negative predictive value of CT colonography for the prediction of rectosigmoid resection were 100%, 64.7%, 72.7%, and 100%, respectively. Though conventional colonoscopic examinations could not be completed in five patients because of the presence of extrinsic stenosis and occlusion at the sigmoid colon, CT colonography enabled the entire large bowel to be examined in these patients.

CONCLUSIONS

This preliminary study showed that the CT colonographic examination is feasible and safe. CT colonography seems to have several advantages over conventional colonoscopy for the detection of rectosigmoid involvement in patients with advanced ovarian cancer. For confirmation of the efficacy of CT colonography, further large prospective studies are needed.

Endoscopically removed giant submucosal lipoma

BACKGROUND

Although uncommon, giant submucosal colon lipomas merit attention as they are often presented with dramatic clinical features such as bleeding, acute bowel obstruction, perforation and sometimes may be mistaken for malignancy. There is a great debate in the literature as to how to treat them.

CASE REPORT

A patient, 67-year old, was admitted to the Clinic due to a constipation over the last several months, increasing abdominal pain mainly localized in the left lower quadrant accompanied by nausea, vomiting and abdominal distension. Physical examination was unremarkable and the results of the detailed laboratory tests and carcinoembryonic antigen remained within normal limits. Colonoscopy revealed a large 10 cm long, and 4 to 5 cm in diameter, mobile lesion in his sigmoid colon. Conventional endoscopic ultrasound revealed 5 cm hyperechoic lesion of the colonic wall. Twenty MHz mini-probe examination showed that lesion was limited to the submucosa. Since polyp appeared too large for a single transaction, it was removed piecemeal. Once the largest portion of the polyp has been resected, it was relatively easy to place the opened snare loop around portions of the residual polyp. Endoscopic resection was carried out safely without complications. Histological examination revealed the common typical histological features of lipoma elsewhere. The patient remained stable and eventually discharged home. Four weeks later he suffered no recurrent symptoms.

CONCLUSION

Colonic lipomas can be endoscopically removed safely eliminating unnecessary surgery.

Synchronous Laparoscopic Resection of Colorectal and Renal/Adrenal Neoplasms

Synchronous laparoscopic resections of coexisting abdominal diseases are shown to be feasible without additional postoperative morbidity. We report our experience with synchronous laparoscopic resection of colorectal carcinoma and renal/adrenal neoplasms with an emphasis on surgical and oncologic outcomes. Five patients diagnosed to have synchronous colorectal carcinoma and renal/adrenal neoplasms (renal cell carcinoma in 2 patients, adrenal cortical adenoma in 2 patients, and adrenal metastasis in 1 patient) underwent synchronous laparoscopic resection. The median operative time was 420 minutes and the median operative blood loss was 1000 mL. Three patients developed minor complications, including wound infection in 2 patients and retention of urine in 1 patient. There was no operative mortality. The median duration of hospital stay was 11 days. At a median follow-up of 17.6 months, no patient developed recurrence of disease. Synchronous laparoscopic resection of colorectal and renal/adrenal neoplasms is technically feasible and safe.

Second cancers discovered by 18FDG PET/CT imaging for choroidal melanoma

BACKGROUND

Positron-emission tomography/computed tomography (PET/CT) is a unique imaging tool that aids in the detection of cancerous lesions. It is currently and widely used for cancer staging (both initial and follow-up). Here we report our findings of second primary cancers incidentally discovered during PET/CT staging of patients with choroidal melanomas.

METHODS

We performed a retrospective case review of 139 patients with uveal melanoma who were subsequently evaluated by whole-body [18-fluorine-labeled] 2-deoxy-2-fluoro-D-glucose ((18)FDG) PET/CT imaging. In this series, 93 were scanned before treatment and 46 during the course of their follow-up systemic examinations. Their mean follow-up was 50.9 months.

RESULTS

Six patients (4.3%) had second primary cancers revealed by PET/CT imaging. Three patients (50%) were synchronous (found at initial staging), and the remaining 3 patients (50%) were metachronous (found at follow-up staging). Second primary cancers were found in the lung, breast, uterus, colon, and thyroid.

CONCLUSIONS

Although whole-body PET/CT scans were ordered as part of the staging process of patients with diagnosed choroidal melanoma, both synchronous and metachronous second primary cancers were found. PET/CT has become an indispensable tool for staging, diagnosis, and treatment planning for choroidal melanoma. The possibility of detecting second primary cancers should also be considered valuable.

[Tumours of the large bowel and rectum: possibilities and limitations of sonographic evaluation]

PURPOSE

Sonographic detection rate of colorectal tumours in comparison with endoscopy.

MATERIALS AND METHODS

Within a period of 32 months all sonographically detected colorectal tumours were registered and the results compared with endoscopic findings within the same period. The patients had no peroral preparation for the sonographic examination which was always performed before coloscopy.

RESULTS

The study encloses 521 tumours in 417 patients. The tumours can be subdivided into 181 cancers, 122 polyps > or = 1 cm, 207 polyps < 1 cm and 11 other tumours. 62 % (112/181) of cancers could be detected by sonography, 30 % of stage pTis, pT1 or pT2, 82 % of stage pT3 or pT4. The detection rate was 20 % for polyps > or = 1 cm, but only 2 % for polyps < 1 cm. The majority of larger tumours not detected on sonography (15/18) was located in the rectum and lower sigmoid colon.

CONCLUSION

Colorectal cancers of stage T3 and T4 can be detected sonographically in a high percentage of cases. Sonography provides insufficient results in detecting polyps and small cancers, and even larger tumours may be missed especially in the lower sigmoid colon and rectum.

Routine preoperative abdominal computed tomography in colon cancer: a utility study

BACKGROUND

There is no proven utility for preoperative scanning of intraperitoneal colonic cancer with computed tomography (CT). A prospective study was conducted where CT was preoperatively incorporated into the management algorithm to ascertain its role in patient treatment.

METHODS

Thoraco-abdominal CT was performed in both the elective and emergency settings in an unselected group of 73 patients referred to a coloproctology unit established over the last 30 months at the Queen Elizabeth Hospital, Barbados. CT and operative findings were compared to determine the influence that the preoperative CT had on surgical decision making.

RESULTS

Unexpected additional pathology was found in 6.8% of patients. Sensitivity for the detection of visceral metastatic disease was 84.6%. Preoperative CT was deemed to be of clinical value in 24.7% of cases and to definitively alter surgical management in 13.7% of patients. These alterations in management included several types of multivisceral resections, the need for ureteric stenting or reimplantation, the utilization of stomas alone and the avoidance of resection in known metastatic disease.

CONCLUSIONS

Preoperative CT of intraperitoneal colonic cancer adds important technical information to the conduct of the surgery and alters therapy in a selected patient group.