Clinical Indication of Laparoscopic Surgery for Colorectal Cancer: The Optimal Extent of Lymph Node Dissection based on Depth of Colorectal Cancer and Technical Feasibility of Laparoscopic Colorectal Surgery.

Recently, laparoscopic colorectal surgery has been considered to be appropriate for colorectal cancer, and the feasibility of many laparoscopic techniques has been established; however, the indication for curative colorec-tal cancers is controversial. In this study, before laparoscopic procedure was performed on patients with colorectal cancers, 641 patients who had under-gone open laparotomy for colorectal cancer during the past 16 years were ev-aluated for the distribution of metastatic lymph nodes classified by depth of invasion. The results obtained were as follows: The rate of all lymph node metastasis of patients with pTis was 0%. The rate of intermediate lymph node (n2) metastasis of patients with pT1 and pT2 tumor was low (3.4% and 4.1% respectively) , however, in patients with pT3 and pT4 tumors, this rate was much higher (15.9% and 15.8% respectively) . Therefore, with re-gard to lymph nodes dissection for colorectal cancer it might be concluded that the intermediate lymph nodes metastases in patients with pT1 and pT2 tumors (less than 5%) were negligible. However, in patients with pT3 and pT4 tumors, for the purpose of performing a complete harvest of intermedi-ate lymph nodes, D3-dissection (including principal lymph node dissection) is required. it is questionable whether or not performance of the laparoscopic procedure for cancer achieves the same extent of lymph node dissection as compared with open laparotomy. Dissection was restricted to intermediate grade lymph node including the paracolic lymph nodes (D2) . Accordingly, patients with pT3 and pT4 tumor should be excluded from indication for laparoscopic procedure. Between October 1997 and November 1998, laparoscopic colorectal resec-actions were performed on a limited number of the above mentioned patients with Tis, Ti and T2 tumor. The grade of lymph node dissection was deter-mined by the results of a preoperative assessment of the depth of cancer in-vasion. With the exception of one patient, whose preoperative assessment for depth of cancer invasion was a limitation at the muscularis propria, but whose histological outcome had been pT3 tumor, all the other patients were able to undergo laparoscopic colorectal resection. The final histological results were as follows: 3 patients with pTis tumor, 6 pTl tumor, and 3 pT2 tumor. One of the pT3 patients alone was converted from a laparoscopic pro-cedure to open laparotomy because of the intraoperative proof of intermediate lymph node metastases, and subsequently this patient underwent principal lymph node dissection (D3-dissection) . With regard to the histological metas-tasis of harvested lymph nodes, no patients was found to have regional lymph node metastasis except for one patient only who had a pT3 tumor. Thus the histological findings were similar to those for conventional open laparotomy. In this study, it was concluded that by laparoscopic procedure a safe and complete dissection of intermediate lymph nodes including the paracolic lymph nodes (nl and n2) could be achieved. On the other hand, the true incidence of port site recurrence, and also its mechanism remain unknown to date. However, it is considered that the incidence of port site recurrence in patients with serosal invasion (T4 tumor) is higher than in those without (i.e., patients with pTis, pTl, pT2 and pT3 tumor) . We are also convinced that a number of patients with pTis, pTl and pT2 undergoing laparoscopic procedure were able to gain curative colorectal resection in terms of port site non-recurrence, and strongly believe that the application of laparoscopic col-orectal surgery for cancer might be acceptable

Gastric T-cell lymphoma associated with hemophagocytic syndrome

BACKGROUND: Lymphoma-associated hemophagocytic syndrome (LAHS) occurs in mostly extra nodal non-Hodgkin's lymphoma. LAHS arising from gastrointestinal lymphoma has never been reported. Here we report a case of gastric T-cell lymphoma-associated hemophagocytic syndrome. CASE PRESENTATION: A 51-year-old woman presented with pain, redness of breasts, fever and hematemesis. Hematological examination revealed anemia. Gastroscopy revealed small bleeding ulcers in the stomach and the computed tomography scan showed liver tumor. She underwent total gastrectomy for gastrointestinal bleeding and the histopathology revealed gastric T-cell lymphoma. She continued to bleed from the anastomosis and died on the 8th postoperative day. Autopsy revealed it to be a LAHS. CONCLUSIONS: If Hemophagocytic syndrome (HPS) occurs in lymphoma of the gastrointestinal tract, bleeding from the primary lesion might be uncontrollable. Early diagnosis and appropriate treatment are needed for long-term survival

Phase I clinical study of anti-apoptosis protein, survivin-derived peptide vaccine therapy for patients with advanced or recurrent colorectal cancer

Survivin is a member of the inhibitor of apoptosis protein (IAP) family containing a single baculovirus IAP repeat domain. It is expressed during fetal development but becomes undetectable in terminally differentiated normal adult tissues. We previously reported that survivin and its splicing variant survivin-2B was expressed abundantly in various types of tumor tissues as well as tumor cell lines and was suitable as a target antigen for active-specific anti-cancer immunization. Subsequently, we identified an HLA-A24-restricted antigenic peptide, survivin-2B80-88 (AYACNTSTL) recognized by CD8+ cytotoxic T lymphocytes (CTLs). We, therefore, started a phase I clinical study assessing the efficacy of survivin-2B peptide vaccination in patients with advanced or recurrent colorectal cancer expressing survivin. Vaccinations with survivin-2B peptide were given subcutaneously six times at 14-day intervals. Of 15 patients who finished receiving the vaccination schedule, three suffered slight toxicities, including anemia (grade 2), general malaise (grade 1), and fever (grade 1). No severe adverse events were observed in any patient. In 6 patients, tumor marker levels (CEA and CA19-9) decreased transiently during the period of vaccination. Slight reduction of the tumor volume was observed in one patient, which was considered a minor responder. No changes were noted in three patients while the remaining eleven patients experienced tumor progression. Analysis of peripheral blood lymphocytes of one patient using HLA-A24/peptide tetramers revealed an increase in peptide-specific CTL frequency from 0.09% to 0.35% of CD8+ T cells after 4 vaccinations. This phase I clinical study indicates that survivin-2B peptide-based vaccination is safe and should be further considered for potential immune and clinical efficacy in HLA-A24-expression patients with colorectal cancer

Clinical and immunological evaluation of anti-apoptosis protein, survivin-derived peptide vaccine in phase I clinical study for patients with advanced or recurrent breast cancer

<p>Abstract</p> <p>Background</p> <p>We previously reported that survivin-2B, a splicing variant of survivin, was expressed in various types of tumors and that survivin-2B peptide might serve as a potent immunogenic cancer vaccine. The objective of this study was to examine the toxicity of and to <b>c</b>linically and immunologically evaluate survivin-2B peptide in a phase I clinical study for patients with advanced or recurrent breast cancer.</p> <p>Methods</p> <p>We set up two protocols. In the first protocol, 10 patients were vaccinated with escalating doses (0.1–1.0 mg) of survivin-2B peptide alone 4 times every 2 weeks. In the second protocol, 4 patients were vaccinated with the peptide at a dose of 1.0 mg mixed with IFA 4 times every 2 weeks.</p> <p>Results</p> <p>In the first protocol, no adverse events were observed during or after vaccination. In the second protocol, two patients had induration at the injection site. One patient had general malaise (grade 1), and another had general malaise (grade 1) and fever (grade 1). Peptide vaccination was well tolerated in all patients. In the first protocol, tumor marker levels increased in 8 patients, slightly decreased in 1 patient and were within the normal range during this clinical trial in 1 patient. With regard to tumor size, two patients were considered to have stable disease (SD). Immunologically, in 3 of the 10 patients (30%), an increase of the peptide-specific CTL frequency was detected. In the second protocol, an increase of the peptide-specific CTL frequency was detected in all 4 patients (100%), although there were no significant beneficial clinical responses. ELISPOT assay showed peptide-specific IFN-γ responses in 2 patients in whom the peptide-specific CTL frequency in tetramer staining also was increased in both protocols.</p> <p>Conclusion</p> <p>This phase I clinical study revealed that survivin-2B peptide vaccination was well tolerated. The vaccination with survivin-2B peptide mixed with IFA increased the frequency of peptide-specific CTL more effectively than vaccination with the peptide alone, although neither vaccination could induce efficient clinical responses. Considering the above, the addition of another effectual adjuvant such as a cytokine, heat shock protein, etc. to the vaccination with survivin-2B peptide mixed with IFA might induce improved immunological and clinical responses.</p

A Simple and Safe Procedure to Repair Rectal Prolapse Perineally Using Stapling Devices

Rectal prolapses are not life-threatening, however the bleeding and fecal incontinence associated with them significantly erode quality of life and can cause concern among patients' caregivers in nursing homes. Many procedures have been reported that repair rectal prolapses, and the procedure used depends on the severity of the prolapse; however, the treatments are yet to be established. Here we report a simple and safe procedure to repair rectal prolapse perineally using stapling devices. We performed this procedure on 5 patients within a short time. All patients were followed up for over 24 months and none had any recurrences of their rectal prolapses. No complications occurred during the operations and postoperative periods. Most patients who have prolapses are elderly and fragile, so the treatment must be easy, safe, and rapid. While rectal prolapse is not life-threatening, the goal of treatment is to alleviate its symptoms. The procedure we describe is consistent with this concept. We suggest that this procedure, which uses surgical stapling devices, might be a better option for the treatment of complete rectal prolapse. We will continue to surgically correct complete rectal prolapses and investigate the long-term outcomes of the procedure

Is adjuvant chemotherapy by continuous infusion 5-fluorouracil plus daily low dose cisplatin useful in advanced (stageIV) pancreatic cancer ?

Thirty-five patients were analyzed in this study to elucidate the usefulness of adjuvant chemotherapy by continuous infusion of 5-fluorouracil plus daily low-dose cisplatin after resection in advanced (stage IV) pancreatic cancer. The patients were divided into 3 groups : 8 patients were treated with the above therapy (group A), 16 patients with conventional chemotherapy (group B), and 11 patients received no chemotherapy whatsoever (group C). Mean survival time was longer in group A than in group B and C. These results were remarkable given that the patients had been diagnosed as stage IVb and curability C. Al-though the occurrence of adverse effects was higher in group A, none of them were severe. We conclude in this retrospective study that continuous infusion of 5-fluorouracil plus daily low-dose cisplatin is effective adjuvant chemotherapy in the treatment of advanced cancer of the pancreas. Therefore, the prospective trial will be necessary in near future