Purpose Since the introduction of robotic surgery, robots for colorectal cancer have replaced laparoscopic surgery, and a single-port robot (SPR) platform has been launched and is being used to treat patients. We analyzed the learning curve and initial complications of using an SPR platform in colorectal cancer surgery.
Methods We reviewed 39 patients who underwent SPR colectomy from April to October 2019. All surgeries were performed by the same surgeon using an SPR device. A learning curve was generated using the cumulative sum methodology to assess changes in total operation time, docking time, and surgeon console time. We grouped the patients into 3 groups according to the time period: the first 11 were phase 1, the next 11 were phase 2, and the last 17 were phase 3.
Results The mean age of the patients was 61.28±13.03 years, and they had a mean body mass index of 23.79±2.86 kg/m2. Among the patients, 23 (59.0%) were male, and 16 (41.0%) were female. The average operation time was 186.59±51.30 minutes, the average surgeon console time was 95.49±35.33 minutes, and the average docking time (time from skin incision to robot docking) was 14.87±10.38 minutes. The surgeon console time differed significantly among the different phases (P<0.001). Complications occurred in 8 patients: 2 ileus, 2 postoperation hemoglobin changes, 3 urinary retentions, and 1 complicated fluid collection.
Conclusion In our experience, the learning curve for SPR colectomy was achieved after the 18th case.
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Purpose Identification of type I protein arginine methyltransferase (PRMT) substrates and their functional significance during tumorigenesis is becoming more important. The present study aimed to identify target substrates for type I PRMT using 2-dimensional (2D) gel electrophoresis (GE) and 2D Western blotting (WB).
Methods Using immunoblot analysis, we compared the expression of type I PRMTs and endogenous levels of arginine methylation between the primary colorectal cancer (CRC) and adjacent noncancerous tissues paired from the same patient. To identify arginine-methylated proteins in HCT116 cells, we carried out 2D-GE and 2D-WB with a type I PRMT product-specific antibody (anti-dimethyl-arginine antibody, asymmetric [ASYM24]). Arginine-methylated protein spots were identified by mass spectrometry, and messenger RNA (mRNA) levels corresponding to the identified proteins were analyzed using National Center for Biotechnology Information (NCBI) microarray datasets between the primary CRC and noncancerous tissues.
Results Type I PRMTs and methylarginine-containing proteins were highly maintained in CRC tissues compared to noncancerous tissues. We matched 142 spots using spot analysis software between a Coomassie blue (CBB)-stained 2D gel and 2D-WB, and we successfully identified 7 proteins that reacted with the ASYM24 antibody: CACYBP, GLOD4, MAPRE1, CCT7, TKT, CK8, and HSPA8. Among these proteins, the levels of 4 mRNAs including MAPRE1, CCT7, TKT, and HSPA8 in CRC tissues showed a statistically significant increase compared to noncancerous tissues from patients using the NCBI microarray datasets.
Conclusion Our results indicate that the method shown here is useful in identifying arginine-methylated proteins, and significance of arginine modification in the proteins identified here should be further identified during CRC development.
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Technical Note
Malignant disease, Rectal cancer,Minimally invasive surgery
Recently, abdominoperineal resection (APR) using a robot has been demonstrated in other studies. However, there has been no report on APR for rectal cancer using the single-port robot (SPR) platform. In response to this research gap, we described the clinical experience of APR using a SPR. From April 2019 to March 2020, APR using a SPR platform was performed in a total of 4 patients. Three patients had a transumbilical approach, and 1 patient had a transstoma site approach. The average operation time was 307 minutes, and the patient docking time to the SPR platform was 133.5 minutes. There were no complications during the operation, and no laparoscopy or open conversion. No reoperation occurred within 30 days. Mild postoperative complications occurred in 2 patients. We found that APR has safety and feasibility in surgery using an SPR platform. There was no intraoperative event and severe postoperative complications.
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Original Articles
Special issue, Malignant disease, Rectal cancer,Colorectal cancer,Epidemiology & etiology
Purpose Coronavirus disease 2019 (COVID-19) has affected many parts of daily life and healthcare, including cancer screening and diagnosis. The purpose of this study was to determine whether there was an upshift in the colorectal cancer stage at diagnosis due to delays related to the COVID-19 outbreak.
Methods From January to June of each year from 2017 to 2020, a total of 3,229 patients who were first diagnosed with colorectal cancer were retrospectively reviewed. Those enrolled from 2017 to 2019 were classified as the ‘pre-COVID’ group, and those enrolled in 2020 were classified as the ‘COVID’ group. The primary outcome was the rate of stage IV disease at the time of diagnosis.
Results There was no statistically significant difference in the proportion of stage IV patients between the pre-COVID and COVID groups (P=0.19). The median preoperative carcinoembryonic antigen level in the COVID group was higher than in the pre-COVID group in all stages (all P<0.05). In stage I, II patients who underwent radical surgery, the lymphatic invasion was more presented in COVID patients (P=0.009).
Conclusion We did not find significant stage upshifting in colorectal cancer during the COVID-19 outbreak. However, there were more initially unresectable stage IV colorectal cancer patients with a low conversion rate to resectable status, and more patients had factors related to poor prognosis. These results may become more apparent over time, so it is vital not to neglect cancer screening to not delay the diagnosis during the COVID-19 epidemic.
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Sung Hae Park, Jung Kyong Shin, Woo Yong Lee, Seong Hyeon Yun, Yong Beom Cho, Jung Wook Huh, Yoon Ah Park, Jin Seok Heo, Gyu Seong Choi, Seung Tae Kim, Young Suk Park, Hee Cheol Kim
Ann Coloproctol. 2021;37(4):244-252. Published online June 29, 2021
Purpose The survival benefit of neoadjuvant chemotherapy (NAC) prior to surgical resection in colorectal cancer with liver metastases (CRCLM) patients remains controversial. The aim of this study was to compare overall outcome of CRCLM patients who underwent NAC followed by surgical resection versus surgical treatment first.
Methods We retrospectively analyzed 429 patients with stage IV colorectal cancer with synchronous liver metastases who underwent simultaneous liver resection between January 2008 and December 2016. Using propensity score matching, overall outcome between 60 patients who underwent NAC before surgical treatment and 60 patients who underwent surgical treatment first was compared.
Results Before propensity score matching, metastatic cancer tended to involve a larger number of liver segments and the primary tumor size was bigger in the NAC group than in the primary resection group, so that a larger percentage of patients in the NAC group underwent major hepatectomy (P<0.001). After propensity score matching, demographic features and pathologic outcomes showed no significant differences between the 2 groups. In addition, there was no significant difference in short-term recovery outcomes such as postoperative morbidity (P=0.603) and oncologic outcome, including 3-year overall survival rate (P=0.285) and disease-free survival rate (P=0.730), between the 2 groups.
Conclusion NAC prior to surgical treatment in CRCLM is considered a safe treatment that does not increase postoperative morbidity, and its impact on oncologic outcome was not inferior.
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Purpose The impact of postoperative complications on long-term oncologic outcome after radical colorectal cancer surgery is controversial. The aim of this study was to examine the risk factors and oncologic outcomes of surgery-related postoperative complication groups.
Methods From January 2010 to December 2010, 310 patients experienced surgery-related postoperative complications after radical colorectal cancer surgery. These stage I–III patients were classified into 2 subgroups, minor (grades I, II) and major (grades III, IV) complication groups, according to extended Clavien-Dindo classification system criteria. Clinicopathologic differences between the 2 groups were analyzed to identify risk factors for major complications. The diseasefree survival rates of surgery-related postoperative complication groups were also compared.
Results Minor and major complication groups were stratified with 194 patients (62.6%) and 116 patients (37.4%), respectively. The risk factors influencing the major complication group were pathologic N category and operative method. The prognostic factors associated with disease-free survival were preoperative perforation, perineural invasion, tumor budding, and receiving neoadjuvant therapy. With a median follow-up period of 72.2 months, the 5-year disease-free survival rates were 84.4% in the minor group and 78.5% in the major group, but there was no statistical significance between the minor and major groups (P = 0.392).
Conclusion Advanced cancer and open surgery were identified as risk factors for increased surgery-related major complications after radical colorectal cancer surgery. However, severity of postoperative complications did not affect disease-free survival from colorectal cancer.
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This study aimed to compare short-term postoperative and oncologic outcomes of a transanal endoscopic total mesorectal excision (TME) to those of a transabdominal robotic TME.
Methods
A total of 62 patients with rectal cancer underwent transanal (n = 26) or robotic (n = 36) TME between June 2013 and December 2014. After case-matching by tumor location and TNM stage, 45 patients were included for analysis. The median follow-up period was 21.3 months. Operative, histopathologic and postoperative outcomes and recurrences were analyzed.
Results
Patients younger than 60 years of age were more frequently observed in the robotic TME group (75.0% vs. 47.6%, P = 0.059), but tumor location, cT and cN category, and preoperative chemoradiotherapy were not different between the 2 groups. Estimated blood loss was greater in the transanal group (283 mL vs. 155 mL, P = 0.061); however, the operation time and the rate of a diverting ileostomy and subsequent ileostomy repair were not different between the groups. The proximal resection margin was longer in the transanal TME group (20.8 cm ± 16.0 cm, P = 0.030), but the distal resection margins, involvements of the circumferential resection margin, TME quality, numbers of retrieved lymph nodes, postoperative complications, including anastomotic leak and voiding difficulty, and recurrence rates for the 2 groups were not statistically different.
Conclusion
Transanal endoscopic and transabdominal robotic TME showed similar histopathologic and postoperative outcomes with the exception of the estimated blood loss and the proximal resection margin for a select group of patients.
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The aim of this study is to evaluate the prognosis for patients with a signet-ring-cell carcinoma (SRCC) who undergo curative surgery by comparing them to patients with an adenocarcinoma (ADC), excluding a mucinous ADC.
Methods
Between September 1994 and December 2013, 14,110 patients with colorectal cancer underwent surgery and among them, 12,631 patients were enrolled in this study. 71 patients with a SRCC and 12,570 patients with a ADC were identified. We analyzed the disease-free survival and the overall survival rates before and after a 1:2 propensity score matching and evaluated those rates after stage stratification.
Results
The median follow-up durations were 48.5 months for the SRC group and 48.6 months for the ADC group. The disease-free survival rates and the overall survival rates were significantly lower in the SRC group before and after propensity score matching (P < 0.001). After stratification by stage, no differences were observed between the SRC and the ADC groups for the disease-free survival (DFS) and the overall survival (OS) rates for patients with cancer in its early stages (P = 0.913 and P = 0.380 for the DFS and the OS, respectively, in stages 0 and I, and P = 0.223 and P = 0.991 for the DFS and the OS, respectively, in stage II), but those rates were significantly lower in the SRC group for cancer in its later stages (P < 0.001, respectively in stages III and IV).
Conclusion
For cancer in advanced stages, patients with a resectable colorectal SRCC had a poorer prognosis after propensity score matching than those with an ADC did. Therefore, more intensive surveillance and closer observation should be offered to such patients.
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Adjuvant chemotherapy is currently recommended for Stage IIIA colon cancers. This study aimed to elucidate the oncologic outcomes of Stage IIIA colon cancer according to the chemotherapeutic regimen based on a retrospective review.
Methods
From 1995 to 2008, Stage IIIA colon cancer patients were identified from a prospectively maintained database at a single institution. Exclusion criteria were as follows: rectal cancer, another malignancy other than colon cancer, no adjuvant chemotherapy and unknown chemotherapeutic regimen. One hundred thirty-one patients were enrolled in the study, and the clinicopathologic and the oncologic characteristics were analyzed. The number of males was 72, and the number of females was 59; the mean age was 59.5 years (range, 25 to 76 years), and the median follow-up period was 33 months (range, 2 to 127 months).
Results
Of the 131 patients, fluorouracil/leucovorin (FL)/capecitabine chemotherapy was performed in 109 patients, and FOLFOX chemotherapy was performed in 22 patients. When the patients who received FL/capecitabine chemotherapy and the patients who received FOLFOX chemotherapy were compared, there was no significant difference in the clinicopathologic factors between the two groups. The 5-year overall survival and the 5-year disease-free survival were 97.2% and 94.5% in the FL/capecitabine patient group and 95.5% and 90.9% in the FOLFOX patient group, respectively, and no statistically significant differences were noted between the two groups.
Conclusion
Stage IIIA colon cancer showed good oncologic outcomes, and the chemotherapeutic regimen did not seem to affect the oncologic outcome.
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Distinctive oncological features of stage IIIA colorectal cancer: Analysis of prognostic factors for selective adjuvant chemotherapy Soo Yeun Park, Gyu‐Seog Choi, Jun Seok Park, Hye Jin Kim, Yoshiharu Sakai, Suguru Hasegawa, Toshiaki Watanabe, Seon Hahn Kim Journal of Surgical Oncology.2015; 111(7): 882. CrossRef
Recently, an increase in well-differentiated rectal neuroendocrine tumors (WRNETs) has been noted. We aimed to evaluate transanal endoscopic microsurgery (TEM) for the treatment of WRNETs.
Methods
Between December 1995 and August 2009, 109 patients with WRNETs underwent TEM. TEM was performed for patients with tumors sizes of up to 20 mm and without a lymphadenopathy. These patients had been referred from other clinics after having been diagnosed with WRNETs by using a colonoscopic biopsy; they had undergone a failed endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) and exhibited an involved resection margin and remaining tumor after ESD or EMR, regardless of the distance from the anal verge. This study included 38 patients that had more than three years of follow-up.
Results
The mean age of the patients was 51.3 ± 11.9 years, the mean tumor size was 8.0 ± 3.9 mm, and no morbidity occurred. Thirty-five patients were asymptomatic. TEM was performed after a colonoscopic resection in 13 cases because of a positive resection margin, a residual tumor or a non-lifting lesion. Complete resections were performed in 37 patients; one patient with a positive margin was considered surgically complete. In one patient, liver metastasis and a recurrent mesorectal node occurred after five and 10 years, respectively.
Conclusion
TEM might provide an accessible and effective treatment either as an initial or as an adjunct after a colonoscopic resection for a WRNET.
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An anorectal melanoma (AM) is a very rare tumor. However, sufficient data supporting effective surgical options for the disease do not exist. This retrospective review aimed to analyze treatment outcomes for an AM.
Methods
From June 1999 to December 2008, we retrospectively reviewed a prospectively collected consecutive series of 19 patients who had undergone a surgical resection for an AM at a single institute. Surgical method and clinicopathological factors were analyzed.
Results
The median age was 61.4 years (range, 46 to79 years). Main symptoms were an anal mass, hematochezia, perianal pain, tenesmus, fecal incontinence, and bowel habit change. The average duration of symptoms before diagnosis was 7.8 months (range, 1 to 36 months). S-100 and HMB-45 were positive in all patients, even in non-melanin pigmentation. There were 12 abdominoperineal resections (APRs) and 7 wide local excisions (WEs). The APR showed longer overall survival when compared with the WE (64.1 months vs. 10.9 months, P < 0.001). No patients who underwent a WE survived more than 13 months.
Conclusion
A high index of suspicion is necessary to establish the diagnosis for an AM in patients with anal symptoms, and S-100 and HMB-45 can be useful markers for an AM. Even with the small number of cases and the short follow-up, our data suggest that an APR for an AM may provide longer survival than a WE.
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Oral capecitabine has been used as adjuvant therapy for colorectal cancer patients since the 1990s. Patient-initiated cessation or reduced use of capecitabine occurs widely for various reasons, yet the consequences of these actions are unclear. The present study sought to clarify treatment outcomes in such patients.
Methods
The study included 173 patients who had been diagnosed with stage II or III colon cancer according to the pathologic report after radical surgery at Samsung Medical Center from May 2005 to June 2007 and who had received capecitabine as adjuvant therapy. The patients were divided into groups according to whether the dose was reduced (I, dose maintenance; II, dose reduction) or stopped (A, cycle completion; B, cycle cessation). Recurrence and disease-free survival rates between the two groups each were analyzed.
Results
Of the 173 patients, 128 (74.6%) experienced complications, most frequently hand-foot syndrome (n = 114). Reduction (n = 35) or cessation (n = 18) of medication was most commonly due to complications. Concerning reduced dosage, both groups displayed no statistically significant differences in recurrence rate and 3-year disease-free survival rate. Concerning discontinued medication use, the cycle completion group showed an improved recurrence rate (P = 0.048) and 3-year disease-free survival rate (P = 0.028).
Conclusion
The results demonstrate that maintaining compliance with capecitabine as an adjuvant treatment for colon cancer to preventing complications positively affects patient prognosis.
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