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A granular cell tumor (GCT) is an uncommon mesenchymal lesion that rarely occurs in the colon and the rectum. We describe the case of 51-year-old man with a 2-cm-sized rectal GCT 10 cm above the anal verge that was incidentally detected after a screening colonoscopy. Preoperative radiologic studies demonstrated a suspicious submucosal rectal mass with mesorectal fat infiltration, but without circumferential resection margin threatening, extramural vessel invasion, and regional lymph-node enlargement. The tumor was resected by using a transanal endoscopic operation (TEO) without immediate postoperative complications. The final pathology revealed that the tumor consisted of a GCT that had invaded the subserosa with clear margins. It had no other risk factors for malignancy according to Fanburg-Smith criteria. We systematically reviewed the English literature by using PubMed and Google Scholar. This report may be the first documented case in the literature to describe a TEO for a GCT that had invaded the subserosa in the rectum.
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Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been proposed for controlling peritoneal seeding metastasis in some kinds of cancers, including those of colorectal origin, but their safety and oncological benefits are subjects of debate. We present our early experience with those procedures.
Data were retrospectively collected from all patients with peritoneal carcinomatosis (PC) and pseudomyxoma peritonei (PMP) treated using CRS and HIPEC at Yonsei Cancer Center between July 2014 and July 2015. Short-term outcomes and risk factors for postoperative complications were analyzed.
Twenty-three patients with PC (n = 18) and PMP (n = 5) underwent CRS and HIPEC. Median follow-up and age were 2 months and 54 years, respectively. The median peritoneal carcinomatosis index score was 15, and CC0-1 was achieved in 78.3% of all patients. The median operation time and bleeding loss were 590 minutes and 570 mL, respectively. Grade-IIIa/grade-IIIb complications occurred in 4.3% (n = 1)/26.1% (n = 6) of the patients within 30 days postoperatively, and no 30-day mortalities were reported. Factors related to postoperative complications with CRS and HIPEC were number of organ resection (P = 0.013), longer operation time (P < 0.001), and amount of blood loss (P = 0.003). All patients treated with cetuximab for recurred colorectal cancer had grade-III postoperative complication.
Our initial experience with CRS and HIPEC presented about 30% grade-III postoperative complications. Therefore, expert surgeons need to perform those procedures with great caution in selected patients who might benefit from it.
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Previous studies have demonstrated the prognostic impact of the prognostic nutritional index (PNI), a proposed indicator of immunonutritional statuses of surgical patients, on patients with various gastrointestinal cancers. Although the prognostic impact of the PNI on patients with colorectal cancer has been well established, its value has not been studied in patients treated with preoperative chemoradiation (pCRT). This study aimed to evaluate the prognostic impact of PNI on patients receiving pCRT for locally advanced rectal cancer (LARC).
Patients with LARC who underwent curative pCRT followed by surgical resection were enrolled. The PNI was measured in all patients before and after pCRT, and the difference in values was calculated as the PNI difference (dPNI). Patients were classified according to dPNI (<5, 5–10, and >10). Clinicopathologic parameters and long-term oncologic outcomes were assessed according to dPNI classification.
No significant intergroup differences were observed in clinicopathologic parameters such as age, histologic grade, tumor location, tumor-node-metastasis stage, and postoperative complications. Approximately 53% of the patients had a mild dPNI (<5); only 15% had a high dPNI (>10). Univariate and multivariate analyses identified the dPNI as an independent prognostic factor for disease-free status (P < 0.01; hazard ratio [HR], 2.792; 95% confidence interval [CI], 1.577–4.942) and for cancer-specific survival (P = 0.012; HR, 2.469; 95%CI, 1.225–4.978).
The dPNI is predictive of long-term outcomes in pCRT-treated patients with LARC. Further prospective studies should investigate whether immune-nutritional status correction during pCRT would improve oncologic outcomes.
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Low Prognostic Nutritional Index Predicts Poor Clinical Outcomes in Patients with Stage IIIB Non-small-cell Lung Carcinoma Undergoing Chemoradiotherapy
Preoperative Fibrinogen-Albumin Ratio Index (FARI) is a Reliable Prognosis and Chemoradiotherapy Sensitivity Predictor in Locally Advanced Rectal Cancer Patients Undergoing Radical Surgery Following Neoadjuvant Chemoradiotherapy
A rectal carcinoma, including primary an adenosquamous and a squamous cell carcinoma (SCC), is a very rare disease, accounting for 0.025% to 0.20% of all large-bowel malignant tumors. Because SCCs have a higher mortality than adenosquamous carcinomas, determining whether the primary rectal cancer exhibits an adenomatous component or a squamous component is important. While differentiating between these 2 components, especially in poorly differentiated rectal cancer, is difficult, specific immunohistochemical stains enable accurate diagnoses. Here, we report the use of immunohistochemical stains to distinguish between the adenomatous and the squamous components in 2 patients with low rectal cancer, a 58-year-old man and a 73-year-old woman, who were initially diagnosed using the histopathologic results for a poorly differentiated carcinoma. These data suggest that using these immunohistochemical stains will help to accurately diagnose the type of rectal cancer, especially for poorly differentiated carcinomas, and will provide important information to determine the proper treatment for the patient.
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This study compared the perioperative and pathologic outcomes between an extralevator abdominoperineal resection (APR) in the prone position and a conventional APR.
Between September 2011 and March 2014, an extralevator APR in the prone position was performed on 13 patients with rectal cancer and a conventional APR on 26 such patients. Patients' demographics and perioperative and pathologic outcomes were obtained from the colorectal cancer database and electronic medical charts.
Age and preoperative carcinoembryonic antigen (CEA) level were significantly different between the conventional and the extralevator APR in the prone position (median age, 65 years vs. 55 years [P = 0.001]; median preoperative CEA level, 4.94 ng/mL vs. 1.81 ng/mL [P = 0.011]). For perioperative outcomes, 1 (3.8%) intraoperative bowel perforation occurred in the conventional APR group and 2 (15.3%) in the extralevator APR group. In the conventional and extralevator APR groups, 12 (46.2%) and 6 patients (46.2%) had postoperative complications, and 8 (66.7%) and 2 patients (33.4%) had major complications (Clavien-Dindo III/IV), respectively. The circumferential resection margin involvement rate was higher in the extralevator APR group compared with the conventional APR group (3 of 13 [23.1%] vs. 3 of 26 [11.5%]).
The extralevator APR in the prone position for patients with advanced low rectal cancer has no advantages in perioperative and pathologic outcomes over a conventional APR for such patients. However, through early experience with a new surgical technique, we identified various reasons for the lack of favorable outcomes and expect sufficient experience to produce better peri- or postoperative outcomes.
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Four consecutive cases of a colonic stricture following a da Vinci robot-assisted ultra-low anterior resection (LAR) with coloanal anastomosis and diverting ileostomy for the treatment of rectal cancer are reported. The colonic strictures developed after early proximal colonic ischemia without anastomotic site leakage or disruption. All patients were treated with preoperative chemoradiation therapy. During the postoperative recovery period, patients developed colonic ischemia, presenting with a high, spiking fever, but without any symptoms of peritonitis. Patients were treated with conservative management (antibiotic therapy) and discharged after two weeks when in good condition. Several months after discharge, all four patients developed a long-segment colonic stricture from the anastomosis site to the distal colon. Management of the colon strictures, including the anastomotic site, involved colonic dilation with a Hegar dilator in an outpatient clinic for several months. The ileostomies in three patients could not be closed.
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Single-port plus one-port, reduced-port laparoscopic surgery (RPLS) may decrease collisions between laparoscopic instruments and the camera in a narrow, bony, pelvic cavity while maintaining the cosmetic advantages of single-incision laparoscopic surgery. The aim of this study is to describe our initial experience with and to assess the feasibility and safety of RPLS for tumor-specific mesorectal excisions (TSMEs) in patients with colorectal cancer.
Between May 2010 and August 2012, RPLS for TSME was performed in 20 patients with colorectal cancer. A single port with four channels through an umbilical incision and an additional port in the right lower quadrant were used for RPLS.
The median operation time was 231 minutes (range, 160-347 minutes), and the estimated blood loss was 100 mL (range, 50-500 mL). We transected the rectum with one laparoscopic stapler in 17 cases (85%). The median time to soft diet was 4 days (range, 3-6 days), and the length of hospital stay was 7 days (range, 5-45 days). The median total number of lymph nodes harvested was 16 (range, 7-36), and circumferential resection margin involvement was found in 1 case (5%). Seven patients (35%) developed postoperative complications, and no mortalities occurred within 30 days. During the median follow-up period of 20 months (range, 12-40 months), liver metastasis occurred in 1 patient 10 months after surgery, and local recurrence was nonexistent.
RPLS for TSME in patients with colorectal cancer is technically feasible and safe without compromising oncologic safety. However, further studies comparing RPLS with a conventional, laparoscopic low-anterior resection are needed to prove the advantages of the RPLS procedure.
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The incidence of extramammary Paget's disease (EMPD) is very low. An 84-year-old Korean man was treated with topical and oral medications at a local dermatologic clinic for a year, but the symptoms did not improve. He visited Severance Hospital and underwent a perianal skin biopsy and was finally diagnosed with EMPD. The authors performed a wide local excision according to a 1-cm margin around the lesion. For the skin and the soft tissue defects, bilateral inferior gluteal artery perforator flap transpositions were performed. The size of the lesion was 14 cm2 × 9 cm2, and the lateral and the basal margins were all disease free.
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The aim of this study is to assess the effects of age on the short-term outcomes of a laparoscopic resection of colorectal cancer in elderly (≥75 years old), as compared with younger (<75 years old), patients.
A retrospective analysis of patients who underwent laparoscopic surgery for colorectal cancer between January 2007 and December 2009 was performed. There were two groups: age <75 years old (group A) and age ≥75 years old (group B). The perioperative outcomes between group A and group B were compared.
The study included 824 patients in group A and 92 patients in group B. The body mass index (BMI) and the American Society of Anesthesiologists (ASA) score were significantly different between group B and group A (BMI: 22.5 vs. 23.5, P = 0.002; ASA score: 1.88 vs. 1.48, P = 0.001). Mean operating times were similar between the groups (325.4 minutes vs. 351.6 minutes, P = 0.07). We observed a higher overall complication rate in group B than in group A (12.0% vs. 6.2%, P = 0.047), but the number of severe complications of Accordion Severity Classification ≥3 (those that required an invasive procedure) was not significantly different between the two groups (6.5% vs. 3.4%, P = 0.142). There was no significant difference in the length of hospital stay (13.0 days vs. 12.0 days, P = 0.053).
Although the elderly patients had a significantly higher overall postoperative complication rate, no significant difference was seen in either the number of severe complications of Accordion Severity Classification ≥3 or in the length of hospital stay. A laparoscopic colorectal cancer resection in elderly patients, especially those aged 75 years or older, is safe and feasible.
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