Time-varying living arrangements and suicide death in the general population sample: 14-year causal survival analysis via pooled logistic regression

AIMS

While past research suggested that living arrangements are associated with suicide death, no study has examined the impact of sustained living arrangements and the change in living arrangements. Also, previous survival analysis studies only reported a single hazard ratio (HR), whereas the actual HR may change over time. We aimed to address these limitations using causal inference approaches.

METHODS

Multi-point data from a general Japanese population sample were used. Participants reported their living arrangements twice within a 5-year time interval. After that, suicide death, non-suicide death and all-cause mortality were evaluated over 14 years. We used inverse probability weighted pooled logistic regression and cumulative incidence curve, evaluating the association of time-varying living arrangements with suicide death. We also studied non-suicide death and all-cause mortality to contextualize the association. Missing data for covariates were handled using random forest imputation.

RESULTS

A total of 86,749 participants were analysed, with a mean age (standard deviation) of 51.7 (7.90) at baseline. Of these, 306 died by suicide during the 14-year follow-up. Persistently living alone was associated with an increased risk of suicide death (risk difference [RD]: 1.1%, 95% confidence interval [CI]: 0.3-2.5%; risk ratio [RR]: 4.00, 95% CI: 1.83-7.41), non-suicide death (RD: 7.8%, 95% CI: 5.2-10.5%; RR: 1.56, 95% CI: 1.38-1.74) and all-cause mortality (RD: 8.7%, 95% CI: 6.2-11.3%; RR: 1.60, 95% CI: 1.42-1.79) at the end of the follow-up. The cumulative incidence curve showed that these associations were consistent throughout the follow-up. Across all types of mortality, the increased risk was smaller for those who started to live with someone and those who transitioned to living alone. The results remained robust in sensitivity analyses.

CONCLUSIONS

Individuals who persistently live alone have an increased risk of suicide death as well as non-suicide death and all-cause mortality, whereas this impact is weaker for those who change their living arrangements.

Evaluation of the advantage of surgeons certified by the endoscopic surgical skill qualification system participating in laparoscopic low anterior rectal resection

Background

A technical qualification system was developed in 2004 by the Japan Society for Endoscopic Surgery. An analysis of the EnSSURE study on 3188 stage II-III rectal cancer patients, which was performed by including the participation of qualified surgeons as assistants and advisers without restricting their participation as operators, revealed that the participation of technically qualified surgeons in surgery improved the technical and oncological safety of laparoscopic rectal resection.

Aim

This secondary retrospective analysis of the EnSSURE study examined the advantage of qualified surgeons participating in laparoscopic low anterior resection (LAR).

Methods

The outcomes of low anterior resection were compared between groups with and without the participation of surgeons qualified by the Endoscopic Surgical Skill Qualification System (Q and non-Q groups, respectively). We used propensity score matching to generate paired cohorts at a one-to-one ratio. The postoperative complication rate, short-term results (hemorrhage volume, operative time, number of dissected lymph nodes, open conversion rate, intraoperative complication rate, and R0 resection rate), and long-term results (disease-free survival rate, local recurrence rate, and overall survival rate) were evaluated.

Results

The frequencies of postoperative complications, anastomotic bleeding, and intraperitoneal abscess were significantly lower, the operative time was significantly shorter, the postoperative hospital stay was significantly shorter, and the number of dissected lymph nodes was higher in the Q group. No significant differences were observed in disease-free survival, local recurrence, or overall survival rate rates between the groups.

Conclusion

The participation of qualified surgeons in LAR is technically advantageous.

Differentiation grade as a risk factor for lymph node metastasis in T1 colorectal cancer

Objectives

Japanese guidelines include high-grade (poorly differentiated) tumors as a risk factor for lymph node metastasis (LNM) in T1 colorectal cancer (CRC). However, whether the grading is based on the least or most predominant component when the lesion consists of two or more levels of differentiation varies among institutions. This study aimed to investigate which method is optimal for assessing the risk of LNM in T1 CRC.

Methods

We retrospectively evaluated 971 consecutive patients with T1 CRC who underwent initial or additional surgical resection from 2001 to 2021 at our institution. Tumor grading was divided into low-grade (well- to moderately differentiated) and high-grade based on the least or predominant differentiation analyses. We investigated the correlations between LNM and these two grading analyses.

Results

LNM was present in 9.8% of patients. High-grade tumors, as determined by least differentiation analysis, accounted for 17.0%, compared to 0.8% identified by predominant differentiation analysis. A significant association with LNM was noted for the least differentiation method (p < 0.05), while no such association was found for predominant differentiation (p = 0.18). In multivariate logistic regression, grading based on least differentiation was an independent predictor of LNM (p = 0.04, odds ratio 1.68, 95% confidence interval 1.00-2.83). Sensitivity and specificity for detecting LNM were 27.4% and 84.1% for least differentiation, and 2.1% and 99.3% for predominant differentiation, respectively.

Conclusions

Tumor grading via least differentiation analysis proved to be a more reliable measure for assessing LNM risk in T1 CRC compared to grading by predominant differentiation.

The "Watch and Wait" Method After Chemoradiotherapy for Rectal Cancer Requiring Abdominoperineal Resection

The present study examined the therapeutic effects of preoperative neoadjuvant chemoradiation therapy (NACRT) and predictive factors for complete clinical remission, compared the prognosis and costs of abdominoperineal resection (APR) and the "watch and wait" method (WW), and evaluated the usefulness of WW. In our department, patients with stage II-III lower rectal cancer requiring APR receive NACRT. NACRT was performed as a preoperative treatment (52 Gy + S-1: 80-120 mg/day × 25 days). Eight weeks after the completion of NACRT, rectal examination, endoscopic, computed tomography, and magnetic resonance imaging findings were evaluated to assess its therapeutic effects. APR was indicated for patients in whom endoscopic findings suggested a residual tumor in which a deep ulcer or marginal swelling remained or lymph node metastasis. However, WW was selected for patients who refused APR after informed consent was obtained. In the APR and WW groups, 5- and 20-year treatment costs after CRT were calculated using the Medical Fee Points of Japan in 2020. No significant differences were observed in 3-year disease-free survival rates for either parameter between the two groups. Regarding expenses, treatment costs were lower in the WW group than in the APR group. Organ preservation using active surveillance with CRT for rectal cancer requiring APR is feasible with the achievement of endoluminal complete remission.

Whole slide image-based prediction of lymph node metastasis in T1 colorectal cancer using unsupervised artificial intelligence

OBJECTIVES

Lymph node metastasis (LNM) prediction for T1 colorectal cancer (CRC) is critical for determining the need for surgery after endoscopic resection because LNM occurs in 10%. We aimed to develop a novel artificial intelligence (AI) system using whole slide images (WSIs) to predict LNM.

METHODS

We conducted a retrospective single center study. To train and test the AI model, we included LNM status-confirmed T1 and T2 CRC between April 2001 and October 2021. These lesions were divided into two cohorts: training (T1 and T2) and testing (T1). WSIs were cropped into small patches and clustered by unsupervised K-means. The percentage of patches belonging to each cluster was calculated from each WSI. Each cluster's percentage, sex, and tumor location were extracted and learned using the random forest algorithm. We calculated the areas under the receiver operating characteristic curves (AUCs) to identify the LNM and the rate of over-surgery of the AI model and the guidelines.

RESULTS

The training cohort contained 217 T1 and 268 T2 CRCs, while 100 T1 cases (LNM-positivity 15%) were the test cohort. The AUC of the AI system for the test cohort was 0.74 (95% confidence interval [CI] 0.58-0.86), and 0.52 (95% CI 0.50-0.55) using the guidelines criteria (P = 0.0028). This AI model could reduce the 21% of over-surgery compared to the guidelines.

CONCLUSION

We developed a pathologist-independent predictive model for LNM in T1 CRC using WSI for determination of the need for surgery after endoscopic resection.

TRIAL REGISTRATION

UMIN Clinical Trials Registry (UMIN000046992, https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000053590).

Optimal Timing of Laparoscopic Cholecystectomy After Conservative Therapy for Acute Cholecystitis

Background/Aim

According to the Tokyo Guidelines 2018, the operation for acute cholecystitis is recommended to be performed as early as possible. However, there are cases in which early surgeries cannot be performed due to complications of patients or facility conditions, resulting in elective surgery. Hence, we retrospectively analyzed elective surgery cases in this study.

Patients and Methods

There were 345 patients who were underwent laparoscopic cholecystectomy (LC) at our hospital from January 2019 to December 2020 in this retrospective study. A total of 83 patients underwent LC more than 3 days after conservative treatment. The elective LC patients were divided into the Early group (4-90 days after onset, n=36) and the Delayed group [91 days or more (13 weeks or more) after onset, n=31], excluding 16 patients who underwent percutaneous transhepatic gallbladder drainage.

Results

As for operative time, there was a significant difference between the Delayed and Early groups (91.2 vs. 117 minutes, p=0.0108). And also, there was a significant difference in the postoperative hospital stay, which was significantly shorter in the Delayed group than in the Early group (3.4 vs. 5.9 days, p=0.0436). Although there were no significant differences in either conversion rates or complication rates, both of these were decreasing in the Delayed group. In particular, there were no complications in the Delayed group.

Conclusion

When the conservative treatment for acute cholecystitis precedes and precludes urgent/early LC within 3 days, delaying LC for at least 91 days (13 weeks or more) after onset could reduce operative time and postoperative hospital stay. Moreover, there would be no complications after LC, and the rates of conversion during LC may be kept low.

Bowel movement frequency, stool consistency, and risk of disabling dementia: a population-based cohort study in Japan

OBJECTIVES

This population-based study aimed to evaluate the association between bowel habits from midlife and dementia.

STUDY DESIGN

This was a cohort study using certification records for national long-term care insurance in Japan.

METHODS

Participants aged 50 to 79 years who reported bowel habits from eight districts within the Japan Public Health Center-based Prospective Study (JPHC Study) were followed from 2006 to 2016 for incident dementia. Hazard ratio (HR) and 95% confidence interval (CI) were estimated for men and women separately using Cox proportional hazards models accounting for various lifestyle factors and medical histories.

RESULTS

Among 19,396 men and 22,859 women, 1889 men and 2685 women were diagnosed with dementia. In men, the multivariable-adjusted HRs compared with bowel movement frequency (BMF) of once/day were 1.00 (95% CI: 0.87-1.14) for twice/day or more, 1.38 (1.16-1.65) for 5-6 times/week, 1.46 (1.18-1.80) for 3-4 times/week, and 1.79 (1.34-2.39) for <3 times/week (P for trend <0.001). In women, the corresponding HRs were 1.14 (0.998-1.31), 1.03 (0.91-1.17), 1.16 (1.01-1.33), and 1.29 (1.08-1.55) (P for trend = 0.043). Harder stool was associated with higher risk (P for trend: 0.0030 for men and 0.024 for women), with adjusted HRs compared to normal stool of 1.30 (1.08-1.57) for hard stool and 2.18 (1.23-3.85) for very hard stool in men, and 1.15 (1.002-1.32) and 1.84 (1.29-2.63) in women.

CONCLUSIONS

Lower BMF and harder stool were each associated with higher risk of dementia.

Novel "resect and analysis" approach for T2 colorectal cancer with use of artificial intelligence

BACKGROUND AND AIMS

Because of a lack of reliable preoperative prediction of lymph node involvement in early-stage T2 colorectal cancer (CRC), surgical resection is the current standard treatment. This leads to overtreatment because only 25% of T2 CRC patients turn out to have lymph node metastasis (LNM). We assessed a novel artificial intelligence (AI) system to predict LNM in T2 CRC to ascertain patients who can be safely treated with less-invasive endoscopic resection such as endoscopic full-thickness resection and do not need surgery.

METHODS

We included 511 consecutive patients who had surgical resection with T2 CRC from 2001 to 2016; 411 patients (2001-2014) were used as a training set for the random forest-based AI prediction tool, and 100 patients (2014-2016) were used to validate the AI tool performance. The AI algorithm included 8 clinicopathologic variables (patient age and sex, tumor size and location, lymphatic invasion, vascular invasion, histologic differentiation, and serum carcinoembryonic antigen level) and predicted the likelihood of LNM by receiver-operating characteristics using area under the curve (AUC) estimates.

RESULTS

Rates of LNM in the training and validation datasets were 26% (106/411) and 28% (28/100), respectively. The AUC of the AI algorithm for the validation cohort was .93. With 96% sensitivity (95% confidence interval, 90%-99%), specificity was 88% (95% confidence interval, 80%-94%). In this case, 64% of patients could avoid surgery, whereas 1.6% of patients with LNM would lose a chance to receive surgery.

CONCLUSIONS

Our proposed AI prediction model has a potential to reduce unnecessary surgery for patients with T2 CRC with very little risk. (Clinical trial registration number: UMIN 000038257.).

AB0158 PREDICT OF PROGNOSIS AT ONE YEAR AFTER THE ADMINISTRATION WITH b/tsDMARD FOR PATIENT WITH DIFFICULT-TO-TREAT RHEUMATOID ARTHRITIS

Background

Patients with difficult-to-treat rheumatoid arthritis (D2T RA) are the most serious problem in recent systemic RA treatment protocols [1].

Objectives

Prognosis after biologic or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) is beneficial when predicted in patients with D2T RA. Predictors of post b/tsDMARDs in D2T RA patients were investigated using retrospective cohort data.

Methods

RA patients more than 1 year after the start of newly administered b/tsDMARDs were recruited. The patients were divided into two groups according to the EULAR definition of D2T RA [2]. Patients who met the criteria were classified into the D2T RA group and others into the non-D2T RA group. The incidence of the clinical features described in the criteria of D2T RA and the rheumatoid disease comorbidity index (RDCI) [3] were compared between the two groups at the time of drug initiation (baseline). The primary endpoint was “Success or Failure” 1 year after baseline. Success was defined as b/tsDMARD persisted in remission as the 28 joint disease activity score with erythrocyte sedimentation rate (DAS28) ≤ 2.6, or as b/tsDMARD was discontinued upon achieving clinical remission. The Failure was defined as other decisions such as discontinuation due to failure, adverse events, or characteristic patient problems. In the discontinued cases, the monitoring value at the last observation was carried forward to 1 year.

Cox regression analysis was used to assess each variant as a potential risk factor for Failure. Receiver operating characteristic analysis (ROC) was tested on variants with significantly higher risk ratios, and Kaplan-Meier survival analysis was also tested for cut-off indices.

Results

71 cases of the D2T RA and 259 cases of the non-D2T RA group were analyzed. As shown in Table 1, the clinical characteristics of the D2T RA group were significantly worse than those of the non-D2T RA group.

Higher DAS28 had a significantly higher risk ratio for the Failure from month 3 in the D2T RA group, whereas from baseline in the non-D2T RA group (Figure 1-A). Other factors in the D2T RA group at and after baseline listed in the Table 1 had no significant risk ratios. PS-VAS and EQ5D score had significant higher risk ratios in the non-D2T RA group using univariate models, however, only DAS28 had significant higher risk ratio using multivariate model. The cut-off index (COI) and the area under the curve (AUC) using ROC for each observational period in the two groups were shown in Figure 1-B. Results of Kaplan-Meier survival analyses were shown in Figure 1-C. Hazard ratios of DAS28 > COI exceeded 2.5 even from months 3 with high sensitivity (p < 0.001) in the D2T RA group.

Conclusion

These results indicated that higher DAS 28 suggested a failure prognosis at 12 months after initiation in D2T RA and non-D2T RA patients. Even in patients with D2T RA, strict disease activity control is most important for prognostic management, with 1-year prognosis predictable in the first 3 months. However, this study is a short-term prognostic predictor, and accumulation of short-term predictions is a long-term predictor.

References

[1]Roodenrijs NMT, et al. Rheumatology (Oxford) 2021;60:3778-3788. doi:10.1093/rheumatology/keaa860

[2]Nagy G, et al. Ann Rheum Dis 2021;80:31-35.

[3]England BR, et al. Arthritis Care Res 2015;67:865-872. doi: 10.1002/acr22456.

Disclosure of Interests

None declared

AB1007 CLINICAL SIGNIFICANCE OF SERUM CREATININE-TO-CYSTATIN C RATIO AS A SURROGATE MARKER FOR INCIDENT OSTEOPOROTIC FRACTURE

Background

In a previous article, we introduced a novel index of osteoporosis that represented as T-score ≤ -2.5, which constituted the combined criteria of age, serum creatinine-to-cystatin C ratio (Cr/CysC), and tartrate-resistant acid phosphatase-5b.

Objectives

We hypothesized that serum cystine C to creatine ratio (CysC/Cr), that is the reciprocal of Cr/CysC, might function as a predictive marker of incident osteoporotic fractures in elderly population and tested this hypothesis in a retrospective cohort study.

Methods

Subjects were 50 years of age or older who had their lumbar spine and femoral neck bone mineral density (BMD) measured by dual-energy X-ray absorptiometry, and simultaneously had their CysC/Cr measured. The dates of BMD and CysC/Cr measurements were set as baseline. The primary outcomes were incidental major osteoporotic fractures (MOF), including vertebral fractures, proximal femur fractures, proximal humerus fractures, and distal radius fractures. Follow-up was continued until the first fracture occurred, was terminated at death, was lost to follow-up, or was completed. In these patients, the relationship between baseline developmental MOF and variants was investigated using Cox regression analysis. The variants were candidate risk factors for MOF for positivity and negativity. After identifying risk factors using univariate models, multivariate model was undergone in order to relative higher risk in the factors. Receivers operating characteristic analyses (ROC) were conducted in order to determine cut-off index (COI) of these factors. Kaplan-Meier survival analysis was tested in order to determine hazard ratio for presenting these risk factors.

Results

A total of 175 patients, 38 men and 137 women, were included in the dataset. The mean age at baseline was 70.2 years, ranged from 50 to 98 years, and the mean follow-up was 30.4 months. Mean BMD at baseline was 0.734 and 0.659 g/cm2 (T-score: -2.21 and -2.04) in lumbar spine and femoral neck, respectively, and mean CysC/Cr at baseline was 1.49. fall-ability, LSD, and pr-MOF, were present in, 59, 113, and 77, respectively. Administration of OPD, vitamin-D, GCS, and polypharmacy were present in 92, 170, 12, and 47, respectively (Table 1).

Table 1.

Results of receiver operation characteristics and Kaplan-Meier survival analysis for each factor

Factorcut-off indexarea under the curvep-valueHazard ratio (95%CI)p-valueCysC/Cr> 1.3450.614< 0.016.32 (2.87 – 13.92)< 0.01LSDpresent0.626< 0.013.60 (1.67 – 7.73)< 0.05Fall-abilitypresent0.703< 0.0014.83 (2.16 – 10.21)< 0.001CKDpresent0.612< 0.052.56 (1.06 – 6.20)< 0.05pr-MOFpresent0.685< 0.0014.81 (2.08 – 9.39)< 0.001

In Cox regression analysis, the presence of prevalent MOF (pr-MOF), fall-ability, lifestyle-related diseases (LSD), chronic kidney diseases (CKD) ≥ Grade3a, and higher CysC/Cr had significant higher risk ratios with univariate models. In these, the presence of LSD and fall-ability had significant higher risk ratios with multivariate model. All the binary factors had COI as the presence of each event such with 0.626, 0.703, 0.612, and 0.685 of area under the curve for LSD, Fall-ability, CKD, and pr-MOF, respectively. CysC/Cr also had COI (1.345) with 0.614 of the area under the curve.

In the Kaplan-Meier survival analysis, CysC/Cr > COI, Fall-ability, pr-MOF, LSD, CKD ≥ Grade 3 b was significantly higher in descending order of Hazard ratio (6.32, 4.83, 4.81, 3.60, 2.56, respectively) (Table 1).

Conclusion

These results suggest that CysC/Cr may be a predictor of MOF or a risk factor if it exceeds the COI. This value is the reciprocal of Cr/CysC, and if Cr/CysC reflects muscle mass, CysC/Cr is assumed to reflect low relative muscle mass. It is supposed that this is also affected by sex difference and age. There seems to be a correlation between MOF and CysC/Cr. Early measurement of CysC/Cr facilitates screening for fractures. As a result, it may be easier to implement fracture prevention programs such as drug interventions such as OPD and exercise habit guidance.

Disclosure of Interests

None declared

POS0554 CLINICAL CHARACTERISTICS OF PATIENTS WITH RHEUMATOID ARTHRITIS IN PRE-DIFFICULT-TO-TREAT STATUS

Background

Patients with rheumatoid arthritis (RA) who have a difficult-to-treat condition (D2T RA) are often a burden to both patients and rheumatologists.

Objectives

The aim of this study was to determine the risk factors for failure to treat in patients with refractory conditions and to find them relevant to prevention.

Methods

Patients with RA who were treated under treat-to-target (T2T) strategy more than one year were picked up. Their background characteristics such as sex, age, disease duration, anti-citrullinated polypeptide antibodies titer (ACPA), and disease duration, were collected, and their simplified disease activity index (SDAI) score, Health Assessment Questionnaire Disability Index (HAQ) score, pain score measured with visual analog scale (PS), EuroQol 5th-dimensions score (EQ5D) were monitored every three months. Sharp/van der Heijde score (SHS) was calculated annually.

Difficult-to-treat status was determined in according to the EULAR definition of D2T RA [1], and pre-D2T RA status was determined as follows: (Category-1) a failure history of one kind of action in biologic or targeted synthetic disease modifying anti-rheumatic drug (b/tsDMARD) and switched to another b/tsDMARD with other action mechanism or (Category-2) one or more of following status; mean SDAI score in recent three months exceeded 11 (MDA), three consecutive administration of glucocorticoid steroid no less than 7.5mg in prednisolone equivalent (GCS), rapid radiographic progression with 5 or more in SHS than last time (RRP), or decrease of EQ5D score less than -0.2 in recent 6 months (dEQ5D). Patients were recruited when Category-1 or -2 was matched in treating, and their results were determined in the last observation for each category. When second d/tsDMARD was failed until last observation in patient matched Category-1, the patient was judged as “failure”, and the other patient was judged as “success”. When Category-2 continued until last observation, the patient was judged as “failure”, and escaped from the category, the patient was judged as “success”. Risk factors for failure in background characteristics and monitored items in treating were evaluated for each category using binary logistic regression analysis.

Results

A total of 47 in Category-1 and 491 patients in Category-2 were recruited.

In Category-1 matched patients, female were 83.0% and mean age was 71.3. Mean SDAI score, HAQ score, PS, EQ5D score, and SHS at failure of b/tsDMARD (baseline) were 15.5, 0.457, 40.1, 0.811, and 72.9, respectively. Numbers of the first b/tsDMARD were 32 TNF inhibitors, 8 IL-6 inhibitors, 6 abatacepts, and 1 JAK inhibitor. Numbers of the second after the first were 13 IL-6 inhibitors and 19 JAK inhibitors after THF inhibitor, whereas 3 TNF inhibitors, 2 abatacepts, and 3 JAK inhibitors after IL-6 inhibitor failure, 1 TNF inhibitor, 1 IL-6 inhibitor, and 4 JAK inhibitors after abatacept failure, and 1 TNF inhibitor after 1 JAK inhibitor failure. In these, success counted 18 and failure counted 29. Significant risk factors for Category-1 failure were higher ACPA, higher SDAI score, higher HAQ score, and higher SHS at baseline (p<0.05). There was no significant difference between drugs.

In Category-2 matched patients, numbers of each status at first (baseline) were 455 MDAs, 20 GCSs, 17 RRPs, and 9 dEQ5Ds. Numbers in success and failure for each status at baseline were 315 and 140 for MDA, 16 and 4 for GCS, 9 and 0 for RRP, and 7 and 2 for dEQ5D, respectively. Significant risk factors for each failure status were higher mean SDAI score after baseline for MDA, higher HAQ score at baseline for GCS, and higher mean PS after baseline for dEQ5D (p<0.01).

Conclusion

Clinical background factors besides disease activity such as ACPA, HAQ score, and SHS at baseline were important for preventing fall-in D2T_RA. However, most weighted factor was disease activity control after falling in MDA status. Tight disease activity control is the overriding factor.

References

[1]Nagy G, et al. Ann Rheum Dis 2021;80:31-5.

Disclosure of Interests

None declared.

AB0383 COMPARISON OF EFFICACY AND SAFETY IN JAK INHIBITOR DUE TO A DIFFERENCE OF SELECTIVITY – TOFACITINIB vs. BARICITINIB –

Background

Each Janus Kinase Inhibitor (JAK-i) has different selectivity of JAKs, such as JAK1, JAK2, JAK3, and TIK2. However, little has been known regarding mode of action due to the selectivity difference in clinical practice for treating rheumatoid arthritis (RA).

Objectives

The aim of this study is to compare difference of efficacy and safety in two JAK-i; between tofacitinib (TOF) and baricitinib (BAR) in clinical practice using one-center retrospective cohort.

Methods

Within the case which administered TOF or BAR to the RA patient who the effect was insufficient in the existing treatment and the disease activity was over the middle disease activity using simplified disease activity index (SDAI). At the start of administration (baseline), 5 mg tablets of TOF were taken twice a day or 4 mg tablets of BAR were taken one a day. Patients were divided by drug and included their sex, age at onset, anti-cyclic citrullinated polypeptide antibodies (ACPA) titer, length of RA history at onset, Sharp/van der Heijde score (SHS) at onset, Naïve/Not Naive for biologic DMARDs or JAK-i, 28-joints disease activity score (DAS28), SDAI, Health Assessment Questionnaire Disability Index (HAQ-DI), and pain score with visual analog scale (PS-VAS). It was classified into large joint and small joint, and the point was independently scored by swelling and pressure pain by size and position in each joint. Total score of the involved joints for each part; upper-extremities, lower extremities, big joints, and small joints (UES/LES/BJS/SJS), rheumatoid factor (RF) titer, serum matrix metalloprotease-3 (MMP-3) level, serum creatinine (Cr) level, and estimated glomerular filtration rate (eGFR) of each part were measured. The mean values of each group were obtained at baseline, 1, 2, 3, 6, 9, and 12 months, and the two groups were statistically compared using the Mann-Whitney U-test. As a sub-analysis, each drug group was divided into bio or JAK-i naive, age ≥ 70 years, disease duration ≥ 10 years, SHS ≥ 100. The change of DAS28 under each 2 divided condition was compared using Mann-Whitney U-test. Similar comparison was carried out with RA patient who administered golimumab (GOL) as a control group. The significance level was less than 5%.

Continuation rate (the withdrawal after the remission introduction is put in the continuation) in 12 months after baseline was also compared.

Results

A total of 82 patients were picked up, in whom 22 TOF group, 31 BAR group, and 29 GOL group included. Both DAS28 and SDAI were consistently lower in the BAR than in the other 2 groups from 1 month after baseline. SDAI in the BAR was significantly lower than in the GOL at 3 months after the baseline. The HAQ-DI score at 6 months after baseline was significantly lower in the BAR than in the GOL. PS-VAS in the GOL was significantly higher than the other two groups at 2, 3 and 6 months after baseline. In the joint point, BJS in the BAR was significantly lower than that in the GOL at 2, 3, and 6 month after baseline. SJS in the GOL was significantly lower than that in the TOF at 6 and 12 months after baseline. There was no significant difference in MMP -3, RF, Cr and eGFR between the 3 groups in any observation month, but Cr increased after the start in the BAR group and eGFR tended to decrease.

In the sub-analysis, the decrease of DAS28 at 1 year after baseline with a history of ≥ 10 years was significantly greater than in those with a history of < 10 years in the TOF, as well as DAS28 at 1 year in those with SHS ≥ 100 decreased significantly more than that in those < 100. These phenomena was not observed in the BAR group.

The continuation rate at 12 months after the start of administration was 86.4% in the TOF, 89.3% in the BAR and 69.0% in the GOL.

Conclusion

Even JAK-i characteristics in action differs for each drug. It is needed to choose appropriate drug based on these drug characteristics.

Disclosure of Interests

None declared

AB0236 PRESENCE OF ANTI-CITRULLINATED POLYPEPTIDE ANTIBODIES DECREASES BONE MINERAL DENSITY IN BODY OF PATIENT WITH RHEUMATOID ARTHRITIS: A RETROSPECTIVE COHORT STUDY

Background

Presence of anti-citrullinated polypeptide antibodies (ACPA) is one risk factor of bone erosion of the joint in patients with rheumatoid arthritis (RA). However, bone absorption in the whole body is still not clarified in a longitudinal study.

Objectives

The aim of this study is to clarify effects of ACPA on bone mineral density (BMD) decrease using dual-energy X-ray absorptiometry (DXA) in patient with RA using retrospective longitudinal cohort study.

Methods

Patient with RA who were measured BMD in lumbar spine (LS) and total hip (TH) using dual-energy X-ray absorptiometry (DXA) at first consultation (baseline) and were treated for more than five years, were recruited. Follow-up started at BMD measurement and continued until the development of the first fracture or censoring at death, loss to follow-up or end of the study. Every patients have been followed up with monitoring of SDAI and Health Assessment Questionnaire Disability Index (HAQ) at every another to three months. Sharp/van der Heijde Score (SHS) was measured at baseline and every another year thereafter. BMD were measured every six months. Relationship between BMD and candidate risk factors including ACPA positivity and serum titer level, and other variants for BMD loss were evaluated statistically using linear regression analysis. Evaluations were performed for the absolute value of BMD and Z-score at baseline, mean value of these during follow-up, and change from baseline. Change of Z-score during follow-up was also compared between groups what classified according to ACPA positivity (ACPA positive/negative group).

Results

A total of 222 patients were recruited including 17 male (7.7%) and 205 female (92.3%). The mean age of the patients was 69.2 years old. Mean disease duration at baseline and follow-up length after baseline were 6.4 and 63.3 months, respectively. Mean SDAI score, HAQ score and SHS at baseline were 22.2, 0.516, and 6.6, respectively. The mean ACPA level and positive rate were 202.1 and 77.5%, respectively.

Higher ACPA titer level correlated significantly low BMD and Z-score in TH (p<0.05), whereas ACPA positivity significantly correlated with low Z-score in LS and TH during follow-up using univariate models (p<0.05). The ACPA positivity also correlated with decrease of Z-score in both LS and TH using univariate models (p<0.05), whereas no significant correlation demonstrated using multivariate model.

Change of Z-score in the ACPA positive group was significantly lower than in the ACPA negative group despite no significant difference of disease activity between the two groups demonstrated (p<0.05) (Table 1).

Table 1.

Comparison of the two groups

parametersACPA-positive (n=172)ACPA-negative (n=50)p-valuefemale (%)91.396.50.10at baselineage (year-old)65.471.3<0.001disease duration (months)7.74.6<0.001RF (IU/L)138.3 (197.1)21.5 (49.3)<0.001SDAI26.3 (24.0)21.0 (17.8)<0.05HAQ0.496 (0.618)0.553 (0.639)0.48SHS8.4 (8.2)3.5 (5.0)<0.001BMD in LS (g/cm2)0.825 (0.167)0.849 (0.156)0.23BMD in H (g/cm2)0.700 (0.140)0.710 (0.132)0.75Z-score in LS-0.246 (1.300)0.123 (1.392)<0.05Z-score in TH-0.062 (1.034)0.261 (1.020)<0.05at follow-upfollow-up length (months)64.865.40.65SDAI4.5 (3.1)5.1 (4.4)0.22HAQ0.495 (0.616)0.516 (0.544)0.32SHS8.1 (8.2)3.4 (4.8)<0.001BMD in LS (g/cm2)0.839 (0.171)0.870 (0.165)0.16BMD in TH (g/cm2)0.710 (0.118)0.713 (0.115)0.99Z-score in LS-0.008 (1.361)0.368 (1.426)<0.05Z-score in TH0.129 (0.902)0.396 (0.891)0.11anti-osteoporotic drug administered, ever (%)73.469.80.72GCS administered, ever (%)35.832.90.68

The values are presented as mean (SD) unless indicated otherwise.

Statistically significant within 0.05 are shown as bold styles.

Conclusion

Presence of ACPA potentially have an independent risk of BMD decrease. Its action affects regardless gender and age.

Disclosure of Interests

None declared

AB0243 ASSOCIATIONS BETWEEN JOINT DEFORMITY, DISEASE DURATION, DISEASE ACTIVITY, ACTIVITIES OF DAILY LIVING, QUALITY OF LIFE, PAIN, AND FATIGUE IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Patient with rheumatoid arthritis (RA) have disease-related problems such as joint deformity, disease duration, disease activity, activities in daily life (ADL), quality of life, pain, and fatigue. All these problems correlate interactively.

Objectives

Aim of this study is to clarify association among these problems statistically using retrospective cohort data.

Methods

Patients with RA who were followed up more than three years were recruited. Their EuroQol-5th dimension (EQ5D) as an indicator of quality of life (QOL), simplified disease activity index (SDAI) as an indicator of disease activity, Health Assessment Questionnaire Disability Index (HAQ) as an indicator of ADL, pain score using visual analog scale (PS-VAS), and fatigue score using visual analog scale (FS-VAS), were monitored every three months. Sharp/van der Heijde score (SHS) as an indicator of joint deformity was calculated annually. Association among average values of these factors and patient’s sex, age, disease duration (DD), and anti-citrullinated polypeptide antibodies (ACPA) titer were evaluated using multivariate linear regression analysis. Statistical significance was set within 5%.

Results

A total of 447 patients, in whom 120 male and 327 female included, were analyzed. Mean age, disease duration, EQ5D score, SDAI score, HAQ score, SHS, PS-VAS, and FS-VAS during follow-up were 71.6-year-old, 12.9 years, 0.831, 4.26, 0.413, 46.9, 22.5, and 23.2, respectively.

EQ5D score correlated significantly with age, HAQ score, SDAI score, SHS, PS-VAS, FS-VAS, and DD using univariate models. In these, age, HAQ score, and FS-VAS correlated significantly using multivariate model (correlation coefficients (CC): 0.927). HAQ score correlated significantly with age, EQ5D score, SDAI score, SHS, PS-VAS, FS-VAS, and DD using univariate models. In these, EQ5D score, SHS, and FS-VAS correlated significantly using multivariate model (CC: 0.910). SDAI score correlated significantly with female gender, EQ5D score, HAQ score, SHS, PS-VAS, and FS-VAS using univariate models. In these, SHS and PS-VAS correlated significantly using multivariate model (CC: 0.620). SHS correlated significantly with age, female gender, EQ5D score, HAQ score, SDAI score, PS-VAS, and DD using univariate models. In these, HAQ score, SDAI score, and DD correlated significantly using multivariate model (CC: 0.685). PS-VAS correlated significantly with EQ5D, HAQ score, SDAI score, SHS, and FS-VAS using univariate models. In these, SDAI score and FS-VAS correlated significantly using multivariate model (CC: 0.732). FS-VAS correlated significantly with EQ5D score, HAQ score, SDAI score, and PS-VAS using univariate models. In these, EQ5D score, HAQ score, and PS-VAS correlated significantly using multivariate model (CC: 0.715). ACPA did not correlated with any factors significantly.

Conclusion

These results suggested that EQ5D score, namely QOL is influenced by various disease-related factors and aging, especially correlated with ADL and fatigue closely. The HAQ score, namely ADL level is influenced by fatigue level and joint deformity directly. The SDAI score, namely disease activity level correlated with pain level and joint deformity level, and correlates with the other factors indirectly. A schematic figure that represents relationships among factors were shown in Figure 1. These information would beneficial for conducting treatment protocol of RA.

Disclosure of Interests

None declared

A technique for constructing diverting loop ileostomy to prevent outlet obstruction after rectal resection and total colectomy: a retrospective single-center study

PURPOSE

Preventing outlet obstruction associated with a diverting stoma is important. Previously, we constructed a diverting loop ileostomy with the proximal limb of the small intestine on the caudal side, namely the oral inferior (OI) method. However, to address the issue of twisting and stenosis of the small intestine, we recently constructed a diverting loop ileostomy with the proximal limb on the cranial side, namely the oral superior (OS) method. We compared the incidence of outlet obstruction between the two methods.

METHODS

The subjects of this retrospective study were 133 patients who underwent colorectal resection or total colectomy, with D2 or more lymph node dissection and diverting loop ileostomy construction, between April, 2001 and December, 2018, at our hospital. The OI method was performed in 54 patients and the OS method was performed in 79 patients.

RESULTS

In the OS group, a history of laparotomy, neoadjuvant therapy, clinical stage III, and the use of anti-adhesion materials were more common, whereas blood loss and the incidence of outlet obstruction were significantly lower. Multivariate analysis identified only OS placement as a significant factor for reducing the incidence of outlet obstruction.

CONCLUSION

When constructing a diverting loop ileostomy, placing the proximal limb on the cranial side is important.

Clinicopathological features of small T1 colorectal cancers

BACKGROUND

Although small colorectal neoplasms (< 10 mm) are often easily resected endoscopically and are considered to have less malignant potential compared with large neoplasms (≥ 10 mm), some are invasive to the submucosa.

AIM

To clarify the clinicopathological features of small T1 colorectal cancers.

METHODS

Of 32025 colorectal lesions between April 2001 and March 2018, a total of 1152 T1 colorectal cancers resected endoscopically or surgically were included in this study and were divided into two groups by tumor size: a small group (< 10 mm) and a large group (≥ 10 mm). We compared clinicopathological factors including lymph node metastasis (LNM) between the two groups.

RESULTS

The incidence of small T1 cancers was 10.1% (116/1152). The percentage of initial endoscopic treatment in small group was significantly higher than in large group (< 10 mm 74.1% vs ≥ 10 mm 60.2%, P < 0.01). In the surgical resection cohort (n = 798), the rate of LNM did not significantly differ between the two groups (small 12.3% vs large 10.9%, P = 0.70). In addition, there were also no significant differences between the two groups in pathological factors such as histological grade, vascular invasion, or lymphatic invasion.

CONCLUSION

Because there was no significant difference in the rate of LNM between small and large T1 colorectal cancers, the requirement for additional surgical resection should be determined according to pathological findings, regardless of tumor size.

Impact of non-curative endoscopic submucosal dissection on short- and long-term outcome of subsequent laparoscopic gastrectomy for pT1 gastric cancer

BACKGROUND

The feasibility and oncological safety of non-curative endoscopic submucosal dissection (ESD) prior to additional gastrectomy for early gastric cancer (EGC) are still unclear. The aim of this study was to evaluate the impact of non-curative ESD on short- and long-term outcomes of subsequent laparoscopic gastrectomy (LG) for pathological T1 (pT1) EGC.

METHODS

We retrospectively investigated 422 patients who underwent LG for pT1 EGC between January 2007 and December 2017 at our center. Eighty-five of these patients underwent ESD with curative intent before surgery. Using propensity-score matching for sex, age, body mass index, American society of anesthesiologists score, history of previous abdominal surgery, tumor location, mucosal/submucosal infiltration, histology, lymph node metastasis, extent of lymph node dissection, operative method, lymphatic invasion, and venous invasion, the clinicopathologic and survival data of these patients were compared.

RESULTS

The median follow-up period was 60 (range 2-168) months. Using propensity-score matching from a total of 422 patients, 75 patients were selected in the Non-ESD and the ESD cohorts each. There were no significant differences in terms of characteristics and clinicopathological findings between the two groups. Furthermore, there were no significant differences in postoperative morbidity (13.3% vs. 17.3%; P = 0.497) and mortality (1.3% vs. 0%; P = 0.316). Both the 5-year overall survival ratio (88.8% vs. 86.9%; P = 0.757) and 5-year disease-specific survival ratio (97.1% vs. 98.4%; P = 0.333) were similar in the two groups.

CONCLUSION

Short- and long-term outcomes of LG in patients with pT1 EGC are not related to preoperative ESD history. Even for non-curative resections, ESD prior to surgery is feasible in terms of oncological and surgical outcomes in pT1 EGC.

Visceral fat accumulation and left atrial phasic function in the general population

Background

Obesity carries independent risk for incident atrial fibrillation (AF), although the impact of abdominal fat distribution on LA morphological and functional remodeling is not fully elucidated. Speckle-tracking echocardiography is a novel and sensitive tool that allows quantification and detection of subtle alterations in left atrial (LA) phasic function.

Purpose

This study aimed to investigate whether increased visceral adiposity is independently associated with impaired LA phasic function in a community-based cohort.

Methods

We included 527 participants without overt cardiac disease who underwent laboratory testing, abdominal computed tomographic examination and speckle-tracking echocardiography. Abdominal adiposity was quantitatively assessed as visceral fat area (VFA) and subcutaneous fat area (SFA) at the level of the umbilicus. Speckle-tracking echocardiography was performed to assess LA phasic function including reservoir, conduit and pump strain as well as left ventricular global longitudinal strain (LVGLS).

Results

Mean age was 57±10 years and 362 of the participants (69%) were men. LA reservoir and conduit strain were decreased according to the VFA quartiles (both p&lt;0.05), whereas there was no significant difference in LA volume index and LA pump strain. When stratified by SFA, there was no significant differences in LA volume index and all LA phasic strain across the quartiles. In multivariable analysis, VFA as continuous variable was significantly associated with LA conduit strain, independent of traditional cardiovascular risk factors, pertinent laboratory parameters and LV morphology and function including LVGLS (standardized b=−0.146, p=0.011). Representative cases are shown in the Figure.

Conclusion

In a sample of the general population, VFA accumulation was independently associated with worse LA conduit strain, which may be involved in the pathophysiological mechanism of obesity-related AF.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Yamauchi Susumu Scholarship for Cardiovascular Research

Carotid intima-media thickness and subclinical left heart dysfunction in the general population

Background

Although carotid intima-media thickness (IMT) is an established marker of atherosclerosis and carries independent risk for cardiovascular disease, its possible association with subclinical cardiac dysfunction has not been extensively evaluated. Left ventricular global longitudinal strain (LVGLS) and peak left atrial longitudinal systolic strain (PALS) can detect subclinical left heart dysfunction.

Purpose

This study aimed to investigate the association between carotid IMT and subclinical left heart dysfunction in a large sample of the general population without overt cardiac disease.

Methods

We examined 1,161 participants who underwent extensive cardiovascular examination. Ultrasonography of common carotid artery was performed for the measurement of maximal carotid IMT. LVGLS and PALS were assessed by 2-dimensional speckle-tracking echocardiography.

Results

Mean age was 62±12 years, and 56% were male. The prevalence of abnormal LVGLS (&gt;−18.6%) and PALS (&lt;31.4%) was greatest in the upper quartile of carotid IMT (both p&lt;0.001; Figure). In multivariable analyses, carotid IMT was associated with abnormal LVGLS (adjusted odds ratio = 1.33 per 1SD increase of IMT, p=0.003) as well as PALS (adjusted odds ratio = 1.33 per 1SD increase of IMT, p=0.005) independent of traditional cardiovascular risk factors, echocardiographic parameters including LV ejection fraction, LV mass index and diastolic dysfunction, and pertinent laboratory parameters. The independent association between carotid IMT and PALS persisted even after adjustment for LVGLS. When carotid IMT was examined as a categorical variable, the upper quartile of carotid IMT carried a significant risk of abnormal LVGLS and PALS in a fully-adjusted model including echocardiographic and laboratory parameters (adjusted odds ratio 2.27 and 3.03 vs. lower quartile, both p&lt;0.01).

Conclusion

Participants with increased IMT had significantly impaired LV and LA function in an unselected community-based cohort. This association may be involved in the higher incidence of cardiovascular disease in individuals with increased carotid IMT.

Funding Acknowledgement

Type of funding source: None

Treatment policy for colonic laterally spreading tumors based on each clinicopathologic feature of 4 subtypes: actual status of pseudo-depressed type

BACKGROUND AND AIMS

Laterally spreading tumors (LSTs) are originally classified into 4 subtypes. Pseudo-depressed nongranular types (LSTs-NG-PD) are gaining attention because of their high malignancy potential. Previous studies discussed the classification of nongranular (LST-NG) and granular types (LST-G); however, the actual condition or indication for endoscopic treatment of LSTs-NG-PD remains unclear. We aimed to compare the submucosal invasion pattern of LSTs-NG-PD with the other 3 subtypes.

METHODS

A total of 22,987 colonic neoplasms including 2822 LSTs were resected endoscopically or surgically at Showa University Northern Yokohama Hospital. In these LSTs, 322 (11.4%) were submucosal invasive carcinomas. We retrospectively evaluated the clinicopathologic features of LSTs divided into 4 subtypes. In 267 LSTs resected en bloc, their submucosal invasion site was further evaluated.

RESULTS

The frequency of LSTs in all colonic neoplasms was significantly higher in women (14.9%) than in men (11.0%). Rates of submucosal invasive carcinoma were .8% in the granular homogenous type (LSTs-G-H), 15.2% in the granular nodular mixed type (LSTs-G-M), 8.0% in the nongranular flat elevated type (LSTs-NG-F), and 42.5% in LSTs-NG-PD. Tumor size was associated with submucosal invasion rate in LSTs-NG-F and LSTs-NG-PD (P < .001). The multifocal invasion rate of LSTs-NG-PD (46.9%) was significantly higher than that of LSTs-G-M (7.9%) or LSTs-NG-F (11.8%). In LSTs-NG-PD, the invasion was significantly deeper (≥1000 μm) if observed in 1 site.

CONCLUSIONS

For LSTs-G-M and LSTs-NG-F that may have invaded the submucosa, en bloc resection could be considered. Considering that LSTs-NG-PD had a higher submucosal invasion rate, more multifocal invasive nature, and deeper invasion tendency, regardless if invasion was only observed in 1 site, than LSTs-NG-F, we should endoscopically distinguish LSTs-NG-PD from LSTs-NG-F and strictly adopt en bloc resection by endoscopic submucosal dissection or surgery for LSTs-NG-PD. (Clinical trial registration number: UMIN 000020261.).

Sex-specific difference in the association between arterial stiffness and subclinical left ventricular dysfunction

Background

Increased arterial stiffness has been proposed as one of the key mechanisms of incident heart failure with preserved ejection fraction (HFpEF). However, the possible association between arterial stiffness and subclinical left ventricular (LV) dysfunction and possible sex-specific differences remain unclarified. LV strain is emerging as a highly sensitive tool to unmask early LV abnormalities.

Purpose

We investigated whether increased arterial stiffness is independently associated with subclinical LV dysfunction in a large community-based cohort without overt cardiovascular disease.

Methods

We examined 1,155 participants who underwent extensive cardiovascular examination. Speckle-tracking echocardiography was employed to assess LV global longitudinal strain (LVGLS) and circumferential strain (GCS), and arterial stiffness was assessed by cardio-ankle vascular index (CAVI).

Results

Mean age was 62±12 years, and 56% were male. CAVI as continuous variable was associated with abnormal LVGLS (&gt;−18.6%), independent of cardiovascular risk factors and pertinent laboratory and echocardiographic parameters (adjusted odds ratio [OR] 1.23, p=0.034), whereas there was no relationship with LVGCS. In sex-stratified analysis, more pronounced association between quartiles of CAVI and abnormal LVGLS was observed in women than in men (unadjusted OR = 6.43 in women and 2.46 in men for upper quartile vs. lower quartile, both p&lt;0.01; Figure). Multivariable analyses demonstrated that CAVI was significantly associated with abnormal LVGLS independent of cardiovascular risk factors in both sexes. However, after further adjustment for LV mass index and diastolic parameters, the independent association persisted in women (adjusted OR 1.49, p=0.041), but not in men (adjusted OR 1.15, p=0.209).

Conclusion

Increased arterial stiffness was independently associated with decreased LVGLS even in the absence of overt cardiovascular disease; a sex-specific pattern exists in the alteration of vascular-ventricular coupling, which might partially explain the greater susceptibility to HFpEF in women.

Funding Acknowledgement

Type of funding source: None

Reinvestigation of the virulence of Rhodococcus equi isolates from patients with and without AIDS

Rhodococcus equi emerged as a zoonotic pathogen of human immunodeficiency virus-infected patients over the last three decades. Two virulence plasmid types of R. equi, pVAPA and pVAPB associated with equine and porcine isolates, have been recognized, and more recently, pVAPN, a novel host-associated virulence plasmid in R. equi, was found in bovine and caprine isolates. We reinvestigated 39 previously reported isolates of R. equi from patients with and without acquired immunodeficiency syndrome (AIDS) by detecting vapA, vapB and vapN using PCR and plasmid profiling. After excluding one isolate that could not be cultured from frozen storage, eight isolates carried a virulence plasmid encoding vapA (pVAPA), 10 carried a virulence plasmid encoding vapB (pVAPB), seven carried a virulence plasmid encoding vapN (pVAPN) and 13 were negative for those genes. Of the 29 isolates from patients with AIDS, 7, 10 and 5 harboured pVAPA, pVAPB and pVAPN respectively. Among nine isolates from patients without AIDS, one and two harboured pVAPA and pVAPN respectively. This study demonstrated that pVAPN-positive R. equi existed in human isolates before 1994 and reaffirmed that equine-associated pVAPA-positive, porcine-associated pVAPB-positive and bovine- or caprine-associated pVAPN-positive R. equi are widely spread globally. Because domestic animals might be major sources of human infection, further research is needed to reveal the prevalence of pVAPN-positive R. equi infection in cattle and goats.

[Complete Response of Liver Metastases from a HER2-Positive Gastric Cancer Treated with Combined S-1/Trastuzumab Chemotherapy]

A 74-year-old man with upper abdominal pain and anorexia was referred to our hospital in December 2013. Based on computed tomography(CT)and gastroendoscopy findings, the patient was diagnosed as having advanced gastric cancer with multiple liver metastases(S3, S5, and S6 lesions). Because of high pyloric stenosis, distal gastrectomy Roux-en-Y reconstruction was performed in mid-December 2013. Histopathological findings of the patient were L, Ant-Gre, 35×60 mm, type 2, pT4a(SE), tub2>tub1, int, INF b, ly2, v1(VB), pPM0(95mm), pDM0(15mm), pN0(0/2), HER2(IHC 3+). Postop- eratively, the patient received combined S-1/trastuzumab chemotherapy toward the end of January 2014. The clinical response was PR after 2 courses and clinical CR(cCR)after 4 courses. Because hand-foot syndrome caused by S-1 was prolonged, the dosage was completed in 11 courses. He remains alive 4.5 years after surgery without recurrence. Although ToGA examination showed that trastuzumab was effective for HER 2-positive unresectable gastric cancer, few reported cases showed progression to cCR after the treatment followed by a regimen of trastuzumab without CDDP, and they had good prognosis. Furthermore, in this case, the liver metastases showed complete response without CDDP. Thus, trastuzumab might be a chemotherapy option for patients who have difficulty using platinum analogs, including the elderly patients.

Measures of body fatness and height in early and mid-to-late adulthood and prostate cancer: risk and mortality in The Pooling Project of Prospective Studies of Diet and Cancer

BACKGROUND

Advanced prostate cancer etiology is poorly understood. Few studies have examined associations of anthropometric factors (e.g. early adulthood obesity) with advanced prostate cancer risk.

PATIENTS AND METHODS

We carried out pooled analyses to examine associations between body fatness, height, and prostate cancer risk. Among 830 772 men, 51 734 incident prostate cancer cases were identified, including 4762 advanced (T4/N1/M1 or prostate cancer deaths) cases, 2915 advanced restricted (same as advanced, but excluding localized cancers that resulted in death) cases, 9489 high-grade cases, and 3027 prostate cancer deaths. Cox proportional hazards models were used to calculate study-specific hazard ratios (HR) and 95% confidence intervals (CI); results were pooled using random effects models.

RESULTS

No statistically significant associations were observed for body mass index (BMI) in early adulthood for advanced, advanced restricted, and high-grade prostate cancer, and prostate cancer mortality. Positive associations were shown for BMI at baseline with advanced prostate cancer (HR = 1.30, 95% CI = 0.95-1.78) and prostate cancer mortality (HR = 1.52, 95% CI = 1.12-2.07) comparing BMI ≥35.0 kg/m2 with 21-22.9 kg/m2. When considering early adulthood and baseline BMI together, a 27% higher prostate cancer mortality risk (95% CI = 9% to 49%) was observed for men with BMI <25.0 kg/m2 in early adulthood and BMI ≥30.0 kg/m2 at baseline compared with BMI <25.0 kg/m2 in early adulthood and BMI <30.0 kg/m2 at baseline. Baseline waist circumference, comparing ≥110 cm with <90 cm, and waist-to-hip ratio, comparing ≥1.00 with <0.90, were associated with significant 14%-16% increases in high-grade prostate cancer risk and suggestive or significant 20%-39% increases in prostate cancer mortality risk. Height was associated with suggestive or significant 33%-56% risks of advanced or advanced restricted prostate cancer and prostate cancer mortality, comparing ≥1.90 m with <1.65 m.

CONCLUSION

Our findings suggest that height and total and central adiposity in mid-to-later adulthood, but not early adulthood adiposity, are associated with risk of advanced forms of prostate cancer. Thus, maintenance of healthy weight may help prevent advanced prostate cancer.

2140Association of arterial stiffness with left atrial structure and phasic function: a community-based cohort study

Background

Increased arterial stiffness is recognized as an independent risk factor for atrial fibrillation, although the pathophysiological mechanisms remain unclear. Cardio-ankle vascular index (CAVI) is emerging as an important tool to assess arterial stiffness noninvasively which is derived from the concept of stiffness β index and is less dependent on blood pressure at the time of measurement than pulse wave velocity.

Purpose

This study aimed to investigate the association of arterial stiffness with left atrial (LA) volume and phasic function in a community-based cohort.

Methods

We included 1,156 participants without overt cardiovascular disease who underwent extensive cardiovascular examination. Arterial stiffness was evaluated by CAVI. Speckle-tracking echocardiography was employed to evaluate LA phasic function including reservoir, conduit and pump strain as well as left ventricular global longitudinal strain (LVGLS).

Results

CAVI was negatively correlated with reservoir and conduit strain (r=−0.37 and −0.45, both p<0.001; Figure), whereas weakly, but positively correlated with LA volume index and pump strain (r=0.12 and 0.09, both p<0.01). In multivariable analysis, CAVI was significantly associated with reservoir and conduit strain independent of traditional cardiovascular risk factors, pertinent laboratory parameters and LV morphology and function including LVGLS (standardized β=−0.22 and −0.26, respectively, both p<0.001), whereas there was no independent association with LA volume index and pump strain. In the categorical analysis, the abnormal CAVI (≥9.0) carried the significant risk of impaired reservoir (<31.4%) and conduit (<12.4%) strain (adjusted odds ratio = 2.63 and 3.71 vs. normal CAVI, both p<0.01) in a fully-adjusted model including laboratory and echocardiographic parameters.

Figure 1

Conclusion

Arterial stiffness was independently associated with LA reservoir and conduit function, even in the absence of overt cardiovascular disease. This association may explain the higher incidence of atrial fibrillation in individuals with increased arterial stiffness.

Cigarette smoking and cervical cancer risk: an evaluation based on a systematic review and meta-analysis among Japanese women

Background

There is a body of evidence to suggest that cigarette smoking increases the risk of cervical cancer in women, but no study has examined the magnitude of the association in Japanese women. Here, we evaluated the association between cigarette smoking and the risk of cervical cancer in Japanese women based on a systematic review of epidemiological evidence.

Methods

Original data were obtained from a MEDLINE search using PubMed or from a search of the 'Ichushi' database, as well as by a manual search. Evaluation of associations was based on the strength of evidence and the magnitude of association, together with biological plausibility as evaluated previously by the International Agency for Research on Cancer. Meta-analysis of associations was also conducted to obtain a summarized overview of the data.

Results

We identified two cohort studies and three case-control studies. All five studies had indicated strong positive associations between cigarette smoking and the risk of cervical cancer. Our summary estimate indicated that the relative risk (RR) for individuals who had ever-smoked relative to never-smokers was 2.03 (95% confidence interval: 1.49-2.57). Four studies had also demonstrated dose-response relationships between cigarette smoking and the risk of cervical cancer.

Conclusion

We conclude that there is convincing evidence that cigarette smoking increases the risk of cervical cancer among Japanese women.

High Serum CA19-9 Concentration Predicts Poor Prognosis in Elderly Patients with Stage IV Colorectal Cancer

BACKGROUND/AIM

The optimal treatment strategy for elderly patients with stage IV colorectal cancer (CRC) remains controversial due to limited research data. The purpose of this study was to evaluate treatment results and to clarify the prognostic factors, especially poor prognosis factors, in elderly patients with stage IV CRC.

METHODS

We retrospectively reviewed the data of 82 elderly patients (aged ≥75 years) with stage IV CRC who underwent surgical treatment at our hospital between April 2001 and March 2017. Factors that affected prognosis and the ability to undergo treatment were analyzed via multivariate analysis.

RESULTS

The median overall survival (OS) in the patients with high pretreatment serum carbohydrate antigen 19-9 (CA19-9) concentration (> 370 U/mL) was significantly worse than in those with lower serum CA19-9 concentration (0-370 U/mL) (8.5 vs. 19.2 months, p = 0.0059). In univariate analysis, age (≥80 years) (p = 0.014), performance status of 1-3 (p = 0.028), and high pretreatment serum CA19-9 concentration (p = 0.014) were significant prognostic factors for poor OS. By contrast, resection of the primary tumor (p = 0.024), chemotherapy (p < 0.0001), and resection of distant metastasis (p = 0.0005) were significant prognostic factors for favorable OS. Multivariate analysis showed that a high pretreatment serum CA19-9 concentration was an independent prognostic factor for poor OS (p = 0.01). Meanwhile, resection of the primary tumor (p = 0.033), chemotherapy (p < 0.0001), and resection of distant metastasis (p = 0.0008) were prognostic factors for favorable OS.

CONCLUSIONS

A high pretreatment serum CA19-9 concentration (> 370 U/mL) was a reliable predictive factor for poor prognosis, and aggressive treatments should be performed carefully in these patients. Moreover, various treatments, including surgery and chemotherapy, might improve OS in elderly patients with stage IV CRC.

Menstrual and reproductive factors and risk of vertebral fractures in Japanese women: the Japan Public Health Center-based prospective (JPHC) study

This large-scale population-based cohort study in Japan was conducted to clarify the effects of menstrual and reproductive factors on the risk of later-life vertebral fractures in women. Significant associations were seen for later menarche, irregular menstruation, and shorter reproductive years, corresponding to the effect of reproductive hormonal disturbance on bone metabolism.

INTRODUCTION

This study investigated the association between menstrual and reproductive factors and the risk of later-life vertebral fractures in women.

METHODS

Participants were 43,652 women aged 40-69 years who were followed in the 10-year survey of the Japan Public Health Center-based prospective (JPHC) study. Menstrual/reproductive factors were as follows: age at menarche and menopause, menstrual regularity and cycle length, natural or surgical menopause, years since menopause, reproductive years, parity, age at first birth, number of births, breastfeeding, and female hormone use. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by logistic regression analysis with adjustment for well-known fracture risk factors and menstrual/reproductive factors.

RESULTS

During the 10-year period, 250 women reported first onset of vertebral fractures. Menarche at ≥16 years [OR (95% CI) = 2.08 (1.24-3.48)] compared to ≤ 13 years and irregular menstruation [1.42 (1.01-2.00)] compared to regular menstruation showed significantly higher adjusted ORs. Longer reproductive years had significant inverse association [0.96 (0.92-0.99)] in menopausal women. Women with both menarche ≥ 15 years and irregular menstruation had higher adjusted ORs (95% CI) [2.37 (1.51-3.73) in all women, 2.25 (1.35-3.76) in menopausal women] compared to women without these, and both factors had significant interaction, particularly in menopausal women (additive p = 0.025, multiplicative p = 0.0499).

CONCLUSIONS

Menstrual and reproductive factors, corresponding to the effect of reproductive hormonal disturbance on bone metabolism, might affect the risk of later-life vertebral fractures.

Evidence-based cancer prevention recommendations for Japanese

A comprehensive evidence-based cancer prevention recommendation for Japanese was developed. We evaluated the magnitude of the associations of lifestyle factors and infection with cancer through a systematic review of the literature, meta-analysis of published data, and pooled analysis of cohort studies in Japan. Then, we judged the strength of evidence based on the consistency of the associations between exposure and cancer and biological plausibility. Important factors were extracted and summarized as an evidence-based, current cancer prevention recommendation: 'Cancer Prevention Recommendation for Japanese'. The recommendation addresses six important domains related to exposure and cancer, including smoking, alcohol drinking, diet, physical activity, body weight and infection. The next step should focus on the development of effective behavior modification programs and their implementation and dissemination.

Predictive performance of a genetic risk score using 11 susceptibility alleles for the incidence of Type 2 diabetes in a general Japanese population: a nested case-control study

AIMS

To assess the predictive ability of a genetic risk score for the incidence of Type 2 diabetes in a general Japanese population.

METHODS

This prospective case-control study, nested within a Japan Public Health Centre-based prospective study, included 466 participants with incident Type 2 diabetes over a 5-year period (cases) and 1361 control participants, as well as 1463 participants with existing diabetes and 1463 control participants. Eleven susceptibility single nucleotide polymorphisms, identified through genome-wide association studies and replicated in Japanese populations, were analysed.

RESULTS

Most single nucleotide polymorphism loci showed directionally consistent associations with diabetes. From the combined samples, one single nucleotide polymorphism (rs2206734 at CDKAL1) reached a genome-wide significance level (odds ratio 1.28, 95% CI 1.18-1.40; P = 1.8 × 10^-8 ). Three single nucleotide polymorphisms (rs2206734 in CDKAL1, rs2383208 in CDKN2A/B, and rs2237892 in KCNQ1) were nominally significantly associated with incident diabetes. Compared with the lowest quintile of the total number of risk alleles, the highest quintile had a higher odds of incident diabetes (odds ratio 2.34, 95% CI 1.59-3.46) after adjusting for conventional risk factors such as age, sex and BMI. The addition to the conventional risk factor-based model of a genetic risk score using the 11 single nucleotide polymorphisms significantly improved predictive performance; the c-statistic increased by 0.021, net reclassification improved by 6.2%, and integrated discrimination improved by 0.003.

CONCLUSIONS

Our prospective findings suggest that the addition of a genetic risk score may provide modest but significant incremental predictive performance beyond that of the conventional risk factor-based model without biochemical markers.

High serum total cholesterol is associated with suicide mortality in Japanese women

OBJECTIVE

To investigate the association between serum total cholesterol (TC) and suicide using a large general population cohort with long follow-up times.

METHOD

Analyses included 16 341 men and 28 905 women aged 40-69 from the Japan Public Health Center-based Prospective Study followed from 1990 to 2012. TC levels were defined per clinical guidelines: low (<4.66 mmol/l [180 mg/dl]), normal (4.66-5.70 mmol/l [180-220 mg/dl]), and high (≥5.70 mmol/l [220 mg/dl]). Cox proportional hazards regression models were used to determine hazard ratios (HR) and confidence intervals (CI) for suicide according to TC level. Mean follow-up time was 19 years for men and 20 years for women.

RESULTS

There were 185 suicides (men: 107; women: 78) during follow-up. Compared to women with normal TC, women with high TC had a significantly increased risk of suicide (HR = 1.90, 95% CI, 1.13-3.19). Incremental increases (0.26 mmol/l [10 mg/dl]) of low-density lipoprotein (HR = 1.11, 95% CI, 1.02-1.21) and non-high-density lipoprotein cholesterol (HR = 1.09, 95% CI, 1.01-1.18) were also associated with increased risk of suicide in women. There was no association between TC levels, or lipid fractions, and suicide in men.

CONCLUSION

High TC levels may be associated with an increased risk of suicide in women.

Dietary intake of antioxidant vitamins and risk of stroke: the Japan Public Health Center-based Prospective Study

BACKGROUND/OBJECTIVES

Epidemiologic evidence on the relationship between antioxidant vitamin intake and stroke is limited. We aimed to investigate the association between dietary intake of antioxidant vitamins and the incidence of total stroke and ischemic stroke.

SUBJECTS/METHODS

The subjects were 82 044 Japanese men and women aged 45-74 years under the Japan Public Health Center-based Prospective Cohort Study. Between 1995 and 1997, dietary assessment was done using a food frequency questionnaire. During 983 857 person-years of follow-up until the end of 2009 we documented 3541 incident total strokes and 2138 ischemic strokes.

RESULTS

Dietary intakes of α-carotene, β-carotene, α-tocopherol and vitamin C were not inversely associated with the incidence of total stroke and ischemic stroke adjustment for cardiovascular risk factors and selected lifestyle variables. When stratified by current smoking status, the inverse association between dietary vitamin C intake and incidence of total stroke observed among non-smokers but not smokers, with respective multivariable hazard ratios for the highest versus lowest quintiles of vitamin C of 0.81 (95% confidence interval (CI), 0.68-0.96; P-trend=0.03) among non-smokers; and 1.03 (0.84-1.25; P-trend=0.55) among smokers. As for ischemic stroke, the corresponding multivariable hazard ratios were 0.76 (0.60-0.96; P-trend=0.02) among non-smokers; and 1.00 (0.78-1.28; P-trend=0.61) among smokers.

CONCLUSIONS

Dietary vitamin C intake was inversely associated with the incidence of total stroke and ischemic stroke among non-smokers.

Impact of obesity on short- and long-term outcomes of laparoscopy assisted distal gastrectomy for gastric cancer

BACKGROUND

Laparoscopy assisted distal gastrectomy (LADG) for gastric cancer has been rapidly adopted for the treatment of both early and advanced gastric cancers which need lymph node dissection, but remains difficult procedure, especially in patients with obesity. We evaluated the impact of obesity on short- and long-term outcomes of LADG for gastric cancer.

METHODS

We retrospectively investigated 243 patients who underwent LADG for gastric cancer between January 2007 and December 2014. The patients were classified based on their body mass index (BMI) into the Obese (BMI ≥ 25) and Non-Obese (BMI < 25) Groups. Patient characteristics, clinicopathologic and operative findings, and short- and long-term outcomes were investigated and compared between the groups.

RESULTS

The groups did not differ in age, sex, American Society of Anesthesiologists score, the presence of comorbidities, or pathologic stage. Operative time (265 ± 46.6 vs. 244 ± 55.6 min; P = 0.007) and estimated blood loss (113 ± 101.4 vs. 66.5 ± 95.2 ml; P = 0.007) were greater in the Obese Group. Fewer lymph nodes were retrieved in the Obese Group (38 ± 23.7 vs. 47.5 ± 24.3; P = 0.004). No differences were evident in postoperative complication rate (20% vs. 17%; P = 0.688) or the duration of postoperative hospital stay (9 ± 8.5 vs. 9 ± 5.1 days; P = 0.283) between the two groups. In the Obese Group, the 5-year overall survival rate was significantly lower than in the Non-Obese Group (67.6% vs. 90.3%; P = 0.036). Furthermore, 5-year disease-specific survival was significantly lower in the Obese Group than in the Non-Obese Group (72.7% vs. 94.9%; P = 0.015).

CONCLUSIONS

LADG in patients with obesity could be performed as safe as in patients without obesity, with comparable postoperative results. But obesity may be a poor prognostic factor in gastric cancer.

Fecal Volume after Laparoscopic Low Anterior Resection Predicts Anastomotic Leakage

BACKGROUND/AIM

Anastomotic leakage (AL) is a major complication after laparoscopic low anterior resection (Lap-LAR). Many surgeons encounter AL following severe postoperative diarrhea. However, little is known about the relationship between postoperative fecal volume and AL. This study determined whether postoperative fecal volume can predict AL.

METHODS

A retrospective assessment was performed with data from 176 patients with rectal cancers who underwent Lap-LAR between April 2011 and August 2015. A transanal tube was routinely placed in all cases. The fecal volume from the transanal tube was measured daily. The total fecal volume for 3 days after surgery was compared between the AL and non-AL groups.

RESULTS

AL occurred in 11 patients. There were 3 patients with a fecal volume ≥1,000 mL for 3 days after surgery. AL occurred in these 3 patients. In patients with a fecal volume <1,000 mL, the total fecal volume was significantly greater in the AL group than that in the non-AL group (p = 0.0003). The cut-off value of the total fecal volume in AL was 118 mL.

CONCLUSIONS

The volume of fecal discharge for 3 days after surgery is associated with the incidence of AL, and a fecal volume ≥118 mL may be a reliable predictor for AL.

Plasma 25-hydroxy vitamin D and subsequent prostate cancer risk in a nested Case-Control study in Japan: The JPHC study

BACKGROUND/OBJECTIVES

Although vitamin D has been experimentally reported to inhibit tumorigenesis, cell growth and prostate cancer invasion, epidemiologic data regarding prostate cancer risk are inconsistent, and some studies have suggested positive but nonsignificant associations. Further, the impact of vitamin D on prostate cancer between Western and Japanese populations may differ due to different plasma vitamin D levels.

SUBJECTS/METHODS

We performed a nested case-control study within the Japan Public Health Center-based Prospective (JPHC) Study in 14,203 men (40-69 years) who answered a self-administered questionnaire at baseline (1990-1994) and gave blood samples, and were followed until 2005. We identified 201 prostate cancers which are newly diagnosed during follow-up (mean 12.8 years). We selected two matched controls for each case from the cohort. We used a conditional logistic regression model to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for prostate cancer with respect to levels of 25-hydroxy vitamin D (25(OH)D) in plasma.

RESULTS

We did not observe statistically significant association between 25(OH)D level and total prostate cancer (multivariate OR=1.13 (95%CI=0.66-1.94, P_trend=0.94) for the highest versus lowest tertile) However, 25(OH) levels were slightly positively associated with advanced cancer. The results remained substantially unchanged after stratification by intake of fish or calcium intake.

CONCLUSIONS

25(OH)D level showed no association with overall prostate cancer among Japanese men in this large cohort.

Spontaneously ruptured hepatic cyst treated with laparoscopic deroofing and cystobiliary communication closure: A case report

The rupture of a nonparasitic hepatic cyst with biliary communication is rare. We report the case of a patient with a hepatic cyst with biliary communication that spontaneously ruptured and was successfully treated by laparoscopic deroofing and closure of the communication. A 61-year-old woman presented at our hospital with a chief complaint of right upper abdominal pain. Enhanced abdominal CT showed a collapsed hepatic cyst and fluid collection. Drip infusion CT cholangiography showed contrast medium pooling in the collapsed cyst. Therefore, hepatic cyst rupture with biliary communication was diagnosed, and laparoscopic deroofing and closure of the communication were performed. The postoperative course was uneventful, and the patient was discharged on postoperative day 6. In cases of hepatic cyst rupture, even in the presence of biliary communication, laparoscopic deroofing and closure of the communication should be recommended as the first-choice treatment.

Morphology as a risk factor for the malignant potential of T2 colorectal cancer

Currently, depressed type T1 colorectal cancer is often detected and its malignant potential is being revealed. However, few reports have focused on the morphology of T2 colorectal cancer types. The aim of the present retrospective study was to clarify the characteristics of colorectal T2 cancer types derived from depressed type T1 cancer. The present study included 195 patients with colorectal T2 cancer surgically resected at a referral hospital between April 2001 and April 2009. A total of 48 lesions (25%) with lymph node metastasis and 4 (2%) with distant metastasis were found. The lesions were classified by their form during endoscopy into four categories: Group A, depressed type (the periphery consists of normal mucosa); group B, laterally spreading type; group C, protruded type; group D, ulcerative type (the periphery consists of neoplastic mucosa). Tumor size, lymphatic and venous involvement, lymph node metastasis, and distant metastasis were compared between the four categories. The distribution of patients were as follows: Group A, 73 (37%), group B, 26 (13%), group C, 24 (12%) and group D, 72 (37%). The average tumor size for each category was 23, 51, 30 and 36 mm for groups A, B, C and D, respectively. The number of positive findings for lymphatic involvement, venous involvement, lymph node metastasis and distant metastasis for each category were: Group A, 50 (69%), 54 (74%), 19 (26%) and 1 (1%); group B, 14 (54%), 12 (46%), 8 (31%) and 0 (0%); group C, 14 (58%), 8 (33%), 6 (25%) and 0 (0%); group D 35 (49%), 41 (57%), 16 (22%) and 3 (4%). Group A demonstrated a significantly smaller tumor size (P<0.01), and higher rates of lymphatic and venous involvement (P=0.0333 and P=0.0019, respectively). No significant differences were observed between categories with regards to nodal and distant metastases. Of the T2 cancer types, ~40% were the depressed type. Compared with the other forms, depressed type lesions exhibited a smaller tumor size, and higher rates of lymphatic and venous involvement, which suggested these lesions were of a more malignant nature.

Donor Left-Sided Heptectomy by Use of the Real-Time Moving Windows Method With 8-Centimeter Transverse Skin Incision

BACKGROUND

In this study, we demonstrated our new device for open donor liver surgery with left-sided heptectomy by use of the real-time moving windows (RTMW) method with 8-cm transverse skin incision for living donors from the viewpoints of cosmetic, economic, and safety procedures.

METHODS

After the upper abdominal 8-cm transverse skin incision was made, the subcutaneous area was exfoliated and the reverse T-shaped-abdominal incision was made, as in open surgery. After that, the 2 Kent hooks for the upper region and the 2 surgical arms for the lower region were placed. The operative fields of hepatic vein, hepatic hilus, and common hepatic artery were explored, respectively, by use of the RTMW method with the use of the 4 surgical hooks. Hepatic parenchymal dissection was carried out with the use of CUSA and laparosonic coagulating shears. Manipulations of 3 hepatic vessels and the hepatic duct were done by the usual procedure of open surgery.

RESULTS

This operative procedure could be performed without laparoscopic techniques. The operative time was 7 hours, without blood transfusion. The operative course was uneventful, and the patient was discharged on postoperative day 11.

CONCLUSIONS

Our RTMW method for donor left-sided hepatectomy is considered to be a useful operative procedure from the viewpoints of donor safety, cosmetic advantage, and cost performance.

Tumor Diameter is an Easy and Useful Predictor of Recurrence in Stage II Colorectal Cancer

BACKGROUND/AIMS

Adjuvant chemotherapy for stage II colorectal cancer (CRC) can generally be administered to high-risk subgroups. To better identify these patients, we aimed at assessing factors that affect recurrence.

METHODS

In our hospital, 432 colon and 96 rectal stage II cancer patients who underwent surgical resection between 2001 and 2011 were divided into recurrence and non-recurrence groups. Age, sex, lymphatic vessel invasion, venous invasion, tumor diameter, tumor depth, histological type, preoperative carcinoembryonic antigen level, number of sampled nodes, adjuvant chemotherapy, morphology, surgical approach, anastomotic leakage, preoperative bowel obstruction, and preoperative perforation were retrospectively compared between the groups.

RESULTS

For colon cancer, multivariate analysis revealed a significant association between tumor diameter ≥40 mm and recurrence (p = 0.039). For rectal cancer, multivariate analysis revealed that tumor diameter ≥50 mm (p = 0.001) and ≤12 sampled nodes (p = 0.021) were associated with recurrence. Tumor diameter in rectal cancer was associated with worse disease-free survival (p = 0.026).

CONCLUSION

Tumor diameter is a significant predictor of recurrence in stage II CRC. This is an important finding because tumor diameter is easy to evaluate clinically and might help to identify candidates for adjuvant chemotherapy.

Transverse colon cancer occurring at a colostomy site 35 years after colostomy: a case report

Background

Carcinomas occurring at colostomy sites are rare, and most of these are metachronous colorectal cancers. The median time between colostomy and development of a carcinoma at a colostomy site is 22 years, which exceeds the length of the recommended follow-up period. We report a rare case of a carcinoma of the transverse colon occurring at a colostomy site in a patient without a history of colorectal cancer.

Case report

An 89-year-old woman presented with a tumor occurring at a colostomy site. Thirty-five years previously, she had undergone a transverse loop colostomy for an iatrogenic colon perforation that occurred during left ureteral lithotomy. Upon physical examination, the patient had a hard nodule measuring 3 cm at the colostomy site. A biopsy of the nodule suggested adenocarcinoma, and the preoperative diagnosis was transverse colon cancer. A laparotomy was performed via a peristomal incision with 5-mm skin margins, and the tumor was covered by a surgical glove to avoid any tumor seeding. The colon was separated from the tumor by 5-cm margins, and the specimen was removed en bloc. An end colostomy was constructed to a new site on the right side of the abdomen. The deficit in the abdominal wall was repaired, and the skin was closed via a purse-string suture. The final diagnosis of the stoma tumor was transverse colon cancer (T2, N0, M0, stage I). One year and five months after surgery, there was no evidence of recurrence.

Conclusions

The occurrence of carcinomas at colostomy sites in patients without a history of colorectal cancer is rare. It is important to train ostomates to monitor the stoma for possible tumor recurrence.