Pre-operative chemoradiotherapy (CRT) is a preferable treatment option for patients with locally advanced rectal cancer. However, few data are available regarding pre-operative CRT for locally advanced colon cancer. Here, we describe two cases of successful treatment with pre-operative CRT and establish evidence supporting this treatment option in patients with locally advanced colon cancer. In the first case, a 65-year-old woman was diagnosed with ascending colon cancer with duodenal invasion. In the second case, a 63-year-old man was diagnosed with a colonic-duodenal fistula due to transverse colon cancer invasion. These case reports will help to establish a treatment consensus for pre-operative CRT in patients with locally advanced colon cancer.
Aged ; Chemoradiotherapy ; Colon ; Colon, Ascending ; Colon, Transverse ; Colonic Neoplasms ; Consensus ; Female ; Fistula ; Humans ; Middle Aged ; Rectal Neoplasms

BACKGROUND/AIMS: Early diagnosis of peritoneal metastases in patients with colorectal cancer (CRC) can influence patient prognosis. The aim of this study was to identify the clinical significance of carcinoembryonic antigen (CEA) in peritoneal fluid detected during operation in stage I–III CRC patients. METHODS: Between April 2009 and April 2015, we reviewed medical records from a total of 60 stage I–III CRC patients who had peritoneal fluid collected during operation. Patients who had positive cytology in the assessment of peritoneal fluid were excluded. We evaluated the values of CEA in peritoneal fluid (pCEA) to predict the long-term outcomes of these patients using Kaplan-Meier curves and Cox regression models. RESULTS: The median follow-up duration was 37 months (interquartile range, 21–50 months). On receiver operating characteristic analysis, pCEA had the largest area under the curve (0.793; 95% confidence interval, 0.635–0.950; P=0.001) with an optimal cutoff value of 26.84 (sensitivity, 80.0%; specificity, 76.6%) for predicting recurrence. The recurrence rate was 8.1% in patients with low pCEA ( < 26.84 ng/mL, n=37), and 52.2% in patients with high pCEA (≥26.84 ng/mL, n=23). In multivariate Cox regression analysis, high pCEA (≥26.84 ng/mL) was a risk factor for poor cancer-free survival (CFS) in stage I–III patients. CONCLUSIONS: In this study, we determined that high pCEA (≥26.84 ng/mL) detected during operation was helpful for the prediction of poor CFS in patients with stage I–III CRC.
Ascitic Fluid* ; Carcinoembryonic Antigen* ; Colorectal Neoplasms* ; Early Diagnosis ; Follow-Up Studies ; Humans ; Medical Records ; Neoplasm Metastasis ; Prognosis ; Recurrence ; Risk Factors ; ROC Curve ; Sensitivity and Specificity

BACKGROUND/AIMS: Laparoscopic surgery has been proven to be an effective alternative to open surgery in patients with colon cancer. However, data on laparoscopic surgery in patients with rectal cancer are insufficient. The aim of this study was to compare the long-term outcomes of laparoscopic and open surgery in patients with rectal cancer. METHODS: A total of 307 patients with rectal cancer who were treated by open and laparoscopic curative resection at Kosin University Gospel Hospital (Busan, Korea) between January 2002 and December 2011 were reviewed retrospectively. RESULTS: Regarding treatment, 176 patients underwent an open procedure and 131 patients underwent a laparoscopic procedure. The local recurrence rate after laparoscopic resection was 2.3%, compared with 5.7% after open resection (p=0.088). Distant metastases occurred in 6.9% of the laparoscopic surgery group, compared with 24.4% in the open surgery group (p<0.001). In univariate analysis, age (> or =75 years vs. < or =60 years), preoperative staging, surgical approach (open vs. laparoscopic), elevated initial CEA level, elevated follow-up CEA level, number of positive lymph nodes, and postoperative chemotherapy affected overall survival and disease free survival. However, in multivariate analysis, the surgical approach apparently did not affect long-term oncologic outcome. CONCLUSIONS: In this study, long-term outcomes after laparoscopic surgery for rectal cancer were not inferior to those after open surgery. Therefore, laparoscopic surgery would be an alternative operative tool to open resection for rectal cancer, although further investigation is needed.
Adult ; Aged ; Aged, 80 and over ; Antineoplastic Agents/therapeutic use ; Combined Modality Therapy ; Disease-Free Survival ; Female ; Follow-Up Studies ; Humans ; *Laparoscopy ; Male ; Middle Aged ; Neoplasm Recurrence, Local ; Neoplasm Staging ; Positron-Emission Tomography ; Rectal Neoplasms/mortality/*surgery/therapy ; Retrospective Studies ; Survival Rate ; Tomography, X-Ray Computed ; Treatment Outcome

With advancement of minimal invasive surgery, a simultaneous laparoscopy-assisted resection for colorectal cancer and metastasis has become feasible. Hence, we report three cases of simultaneous laparoscopic surgery for colorectal cancer with liver or lung metastasis. In the first case, laparoscopic right hemicolectomy and left lateral segmentectomy of liver was performed for ascending colon cancer and liver metastasis. In the second case, laparoscopic right hemicolectomy and wedge resection of right lower lung was performed for cecal cancer and lung metastasis. In the third case, laparoscopic right hemicolectomy and wedge resection of left lower lung was performed for ascending colon cancer and lung metastasis. In the first two cases, patients quickly returned to normal activity. In the third case, postoperative bleeding was observed, but spontaneously stopped. There was no postoperative mortality. Simultaneous laparoscopic surgery represents a feasible option for colorectal cancer with metastases on the other organs.
Cecal Neoplasms ; Colon, Ascending ; Colorectal Neoplasms* ; Hemorrhage ; Humans ; Laparoscopy ; Liver ; Lung ; Mastectomy, Segmental ; Mortality ; Neoplasm Metastasis*

OBJECTIVE: Free hand insertion of an external ventricular drain (EVD) is one of the most common emergency neurosurgical procedures, usually performed on critically ill patients. Complications such as infection and hemorrhage that accompany the placement of an EVD have been studied thoroughly, but few reports have focused on the accuracy of EVD positioning. As a result, the authors of this paper retrospectively studied the accuracy of tip positioning in the placement of an EVD. METHODS: One hundred and thirteen emergency EVDs were performed through Kocher's point during the past 3 years. All patients underwent the following procedures: at least one routine post-EVD computed tomographic (CT) scan that was retrospectively reviewed for accuracy of the EVD tip position, calculation of the Evan's index, and measurement of the intracranial length of the EVD. We divided the EVD tip position into 6 groups as follows:1) ipsilateral frontal horn of the lateral ventricle, 2) contralateral frontal horn of the lateral ventricle, 3) third ventricle, 4) body of the ipsilateral or contralateral lateral ventricle, 5) basal cisterns, or 6) brain parenchyma. Among the 6 groups, only the ipsilateral frontal horn group was considered to be the correct position for the EVD tip. RESULTS: The mean age of the patients was 55.6+/-15.3 years (age range, 12~90 years), and the most common indication for the EVD was supratentorial intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) (57.5%). Forty-five out of a total of 113 EVDs were placed by inexperienced neurosurgical trainees, and the remaining 68 were placed by experienced practitioners. Among 113 post-EVD CT scans, 48 EVD tips (42.5%) were in the ipsilateral frontal horn of the lateral ventricle (considered to be the correct position); 22 (19.5%) were in the third ventricle, 16 (14.1%) in the body of the ipsilateral or contralateral lateral ventricle, 14 (12.4%) in the contralateral frontal horn of the lateral ventricle, 11 (9.7%) within the brain parenchyma and 2 (1.8%) in the basal cistern. The mean estimated EVD length was 57+/-8.4mm. The mean length of EVDs that were positioned in the ipsilateral frontal horn was 55+/-4.3 mm, whereas the mean lengths of EVDs in the parenchyma and basal cistern were 64+/-14mm and 72+/-3.5mm, respectively. In addition, there was no statistically significant relationship between the surgeon's experience and the accuracy of the position of the EVD tip (p > 0.05). CONCLUSION: Emergency free hand placement of an EVD might be an inaccurate procedure. Further multi-institutional prospective studies are required to assess the accuracy and complications of free hand insertion of EVDs in an emergency setting. Studies are also needed on the feasibility of routine use of intra-operative neuro-navigation of other guidance tools, such as ultrasonography.
Animals ; Brain ; Cerebral Hemorrhage ; Critical Illness ; Emergencies ; Hand ; Hemorrhage ; Horns ; Humans ; Lateral Ventricles ; Neurosurgical Procedures ; Retrospective Studies ; Third Ventricle

PURPOSE: The purpose of this study is to evaluate the usefulness of positron emission tomography (PET)-computed tomography (CT) for preoperative tumor staging in cases of colorectal cancer. METHODS: Between July 2006 and September 2007, seventy-six patients with a diagnosis of colorectal cancer (43 males and 33 females; mean age: 60.4+/-10.13 years; range: 34~82 years) selected prospectively were studied for staging by using Chest X-ray, abdominal CT and PET-CT. RESULTS: The sensitivities and the specificities for N-staging were 76.9% and 35.1% for CT, 61.8% and 66.7% for PET-CT, and both procedures showed a relatively low diagnostic accuracy (CT 57.9%, PET-CT 61.8%). In the PET-CT alone, six distant metastatic lesions and four multiple primary malignancies were found. The locations of the distant metastases were the liver, the axillary node, the common iliac node, the subclavicular node, the peritoneum, and the lung. The locations of the multiple primary maligancies in extracolonic sites were 3 in the thyroid and 1 in the nasopharynx. CONCLUSIONS: For N-staging, preoperative PET-CT is no more useful than CT, but PET-CT is required before surgery to find lesions that cannot be found with conventional studies.
Colorectal Neoplasms ; Electrons ; Humans ; Liver ; Lung ; Male ; Nasopharynx ; Neoplasm Metastasis ; Neoplasm Staging ; Peritoneum ; Positron-Emission Tomography ; Prospective Studies ; Thorax ; Thyroid Gland

Herniation of the small bowel through a drain site is a rare complication of surgery. We report here on a case of strangulated small bowel hernia through the site of a drain placed in the right lower quadrant of the abdomen after abdominal surgery. A 70 year-old male underwent aneurysmoplasty for an abdominal aortic aneurysm through a midline abdominal incision. A silicone drain (a sump drain) with an external diameter of 15 mm was inserted through an 18 mm stab incision in the right lower quadrant of the abdomen. The drain was removed after 5 days. Two hours later, a 25 cm segment of small bowel herniated through the drain site and became strangulated. Segmental resection of the strangulated small bowel was performed through extended incision of the drain site wound. The patient recovered and he was discharged 17 days later without further complications.
Abdomen ; Aged ; Aortic Aneurysm, Abdominal ; Hernia* ; Humans ; Male ; Silicones ; Wounds and Injuries

PURPOSE: Firstly, to analyze factors in terms of radiation treatment that might potentially cause subfrontal relapse in two patients who had been treated by craniospinal irradiation (CSI) for medulloblastoma. Secondly, to explore an effective salvage treatment for these relapses. MATERIALS AND METHODS: Two patients who had high-risk disease (T3bM1, T3bM3) were treated with combined chemoradiotherapy. CT-simulation based radiation-treatment planning (RTP) was performed. One patient who experienced relapse at 16 months after CSI was treated with salvage surgery followed by a 30.6 Gy IMRT (intensity modulated radiotherapy). The other patient whose tumor relapsed at 12 months after CSI was treated by surgery alone for the recurrence. To investigate factors that might potentially cause subfrontal relapse, we evaluated thoroughly the charts and treatment planning process including portal films, and tried to find out a method to give help for placing blocks appropriately between subfrotal-cribrifrom plate region and both eyes. To salvage subfrontal relapse in a patient, re-irradiation was planned after subtotal tumor removal. We have decided to treat this patient with IMRT because of the proximity of critical normal tissues and large burden of re-irradiation. With seven beam directions, the prescribed mean dose to PTV was 30.6 Gy (1.8 Gy fraction) and the doses to the optic nerves and eyes were limited to 25 Gy and 10 Gy, respectively. RESULTS: Review of radiotherapy portals clearly indicated that the subfrontal-cribriform plate region was excluded from the therapy beam by eye blocks in both cases, resulting in cold spot within the target volume. When the whole brain was rendered in 3-D after organ drawing in each slice, it was easier to judge appropriateness of the blocks in port film. IMRT planning showed excellent dose distributions (Mean doses to PTV, right and left optic nerves, right and left eyes: 31.1 Gy, 14.7 Gy, 13.9 Gy, 6.9 Gy, and 5.5 Gy, respectively. Maximum dose to PTV: 36 Gy). The patient who received IMRT is still alive with no evidence of recurrence and any neurologic complications for 1 year. CONCLUSION: To prevent recurrence of medulloblastoma in subfrontal-cribriform plate region, we need to pay close attention to the placement of eye blocks during the treatment. Once subfrontal recurrence has happened, IMRT may be a good choice for re-irradiation as a salvage treatment to maximize the differences of dose distributions between the normal tissues and target volume.
Brain ; Chemoradiotherapy ; Craniospinal Irradiation ; Humans ; Medulloblastoma* ; Optic Nerve ; Radiotherapy ; Recurrence*

Neutropenic enterocolitis is a serious complication of chemotherapy for malignancies such as acute leukemia or lymphoma. The acute inflammatory disease may involve the terminal ileum, cecum and ascending colon. Although conservative care is recommended as the primary treatment modality, surgical intervention is essential for intestinal perforations, abscesses, or bleeding. We experienced a case of neutropenic enterocolitis with a liver abscess in a young leukemia patient. A 13-year-old boy with acute myelogenous leukemia had completed two cycles of chemotherapy (Arabinoside 300 mg, Dactinomycin 40 mg, VP-16 150 mg, 6- mercaptopurin 60 mg, dexametasone 3 mg). Ten days after completing the second cycle he had abdominal pain, low abdominal tenderness and a high fever. The WBC count in the peripheral blood was 210 cell/mm3. A CT scan demonstrated wall thickening of the terminal ileum and ascending colon, as well as 5 cm, and 6 cm sized homogeneous low-density areas in both hepatic lobes. A presumptive diagnosis was neutropenic enterocolitis with a liver abscess. The patient was managed conservatively with fluid resuscitation, a bowel rest, and broad-spectrum antibiotics. Twenty-five days later his abdominal pain was abruptly aggravated. The CT scan and Chest X-ray demonstrated free air in the peritoneal cavity. An emergency laparotomy was performed under a diagnosis of peritonitis with an intestinal perforation. The laparotomy show that, there were perforations at the pylorus of the stomach, and full thickness necrosis at multiple segments of the small bowel. Primary closure of the stomach, a segmental resection and an end-to-end anastomosis of the small bowel, and ileostomy were performed. However, postoperative leakage developed at the stomach. The patient recovered with supportive management. The patient had a third chemotherapy series 3 months after surgery. Three days after completing the third cycle, the patient developed peritonitis. A pyloric re-perforation of the stomach was observed on the laparotomy. Postoperative leakage developed after the primary closure of the stomach. The patient died of sepsis 54 days later. Therefore, intensive monitoring and close collaboration between the hematologist and the surgeon is essential for patients with neutropenic enterocolitis. Postoperative complications are quite common and can be fatal in patients with neutropenic enterocolitis that develops after chemotherapy.
Abdominal Pain ; Abscess ; Adolescent ; Anti-Bacterial Agents ; Cecum ; Colon, Ascending ; Cooperative Behavior ; Dactinomycin ; Diagnosis ; Drug Therapy* ; Emergencies ; Enterocolitis, Neutropenic* ; Etoposide ; Fever ; Hemorrhage ; Humans ; Ileostomy ; Ileum ; Intestinal Perforation ; Laparotomy ; Leukemia* ; Leukemia, Myeloid, Acute ; Liver Abscess* ; Liver* ; Lymphoma ; Male ; Necrosis ; Peritoneal Cavity ; Peritonitis ; Postoperative Complications ; Pylorus ; Resuscitation ; Sepsis ; Stomach ; Thorax ; Tomography, X-Ray Computed

Neutropenic enterocolitis is a serious complication of chemotherapy for malignancies such as acute leukemia or lymphoma. The acute inflammatory disease may involve the terminal ileum, cecum and ascending colon. Although conservative care is recommended as the primary treatment modality, surgical intervention is essential for intestinal perforations, abscesses, or bleeding. We experienced a case of neutropenic enterocolitis with a liver abscess in a young leukemia patient. A 13-year-old boy with acute myelogenous leukemia had completed two cycles of chemotherapy (Arabinoside 300 mg, Dactinomycin 40 mg, VP-16 150 mg, 6- mercaptopurin 60 mg, dexametasone 3 mg). Ten days after completing the second cycle he had abdominal pain, low abdominal tenderness and a high fever. The WBC count in the peripheral blood was 210 cell/mm3. A CT scan demonstrated wall thickening of the terminal ileum and ascending colon, as well as 5 cm, and 6 cm sized homogeneous low-density areas in both hepatic lobes. A presumptive diagnosis was neutropenic enterocolitis with a liver abscess. The patient was managed conservatively with fluid resuscitation, a bowel rest, and broad-spectrum antibiotics. Twenty-five days later his abdominal pain was abruptly aggravated. The CT scan and Chest X-ray demonstrated free air in the peritoneal cavity. An emergency laparotomy was performed under a diagnosis of peritonitis with an intestinal perforation. The laparotomy show that, there were perforations at the pylorus of the stomach, and full thickness necrosis at multiple segments of the small bowel. Primary closure of the stomach, a segmental resection and an end-to-end anastomosis of the small bowel, and ileostomy were performed. However, postoperative leakage developed at the stomach. The patient recovered with supportive management. The patient had a third chemotherapy series 3 months after surgery. Three days after completing the third cycle, the patient developed peritonitis. A pyloric re-perforation of the stomach was observed on the laparotomy. Postoperative leakage developed after the primary closure of the stomach. The patient died of sepsis 54 days later. Therefore, intensive monitoring and close collaboration between the hematologist and the surgeon is essential for patients with neutropenic enterocolitis. Postoperative complications are quite common and can be fatal in patients with neutropenic enterocolitis that develops after chemotherapy.
Abdominal Pain ; Abscess ; Adolescent ; Anti-Bacterial Agents ; Cecum ; Colon, Ascending ; Cooperative Behavior ; Dactinomycin ; Diagnosis ; Drug Therapy* ; Emergencies ; Enterocolitis, Neutropenic* ; Etoposide ; Fever ; Hemorrhage ; Humans ; Ileostomy ; Ileum ; Intestinal Perforation ; Laparotomy ; Leukemia* ; Leukemia, Myeloid, Acute ; Liver Abscess* ; Liver* ; Lymphoma ; Male ; Necrosis ; Peritoneal Cavity ; Peritonitis ; Postoperative Complications ; Pylorus ; Resuscitation ; Sepsis ; Stomach ; Thorax ; Tomography, X-Ray Computed