Rectal Cancer Cases Research Articles

Neoadjuvant radiotherapy for rectal cancer management.

Thirty per cent of all colorectal tumours develop in the rectum. The location of the rectum within the bony pelvis and its proximity to vital structures presents significant therapeutic challenges when considering neoadjuvant options and surgical interventions. Most patients with early rectal cancer can be adequately managed by surgery alone. However, a significant proportion of patients with rectal cancer present with locally advanced disease and will potentially benefit from down staging prior to surgery. Neoadjuvant therapy involves a variety of options including radiotherapy, chemotherapy used alone or in combination. Neoadjuvant radiotherapy in rectal cancer has been shown to be effective in reducing tumour burden in advance of curative surgery. The gold standard surgical rectal cancer management aims to achieve surgical removal of the tumour and all draining lymph nodes, within an intact mesorectal package, in order to minimise local recurrence. It is critically important that all rectal cancer cases are discussed at a multidisciplinary meeting represented by all relevant specialties. Pre-operative staging including CT thorax, abdomen, pelvis to assess for distal disease and magnetic resonance imaging to assess local involvement is essential. Staging radiology and MDT discussion are integral in identifying patients who require neoadjuvant radiotherapy. While Neoadjuvant radiotherapy is potentially beneficial it may also result in morbidity and thus should be reserved for those patients who are at a high risk of local failure, which includes patients with nodal involvement, extramural venous invasion and threatened circumferential margin. The aim of this review is to discuss the role of neoadjuvant radiotherapy in the management of rectal cancer.

Transanal lateral lymph node dissection surgery for 5 cases of mid-low rectal cancer

Objective: To evaluate the feasibility and safety of transanal lateral lymph node dissection for mid-low rectal cancer. Methods: A descriptive case series research method was used. Clinical and pathological data of 5 mid-low rectal cancer patients who underwent transanal lateral lymph node dissection at Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University from November 2018 to May 2019 were retrospectively collected and analyzed. Of 5 cases, 4 were male and 1 was female with mean age of (43.2±13.2) years and mean body mass index of (21.2±2.6) kg/m(2); the mean diameter of tumor was (3.2±2.4) cm; the mean distance between tumor and anus was (6.3±2.5) cm; 3 received preoperative neoadjuvant chemotherapy. In preoperative TNM staging, 2 cases were T3N1M0, 1 was T3cN2aM0, 1 was T3cN2bM0, and 1 was T2N1M0. All the patients had no intestinal obstruction before operation. Surgical methods: (1) total mesorectal excision: using general transanal and transabdominal methods to mobilize and resect total mesorectum, and dissect No.252, No.253 lymph nodes; (2) transanal lateral lymph node dissection: dissect the adipose lymphoid tissue on the surface of the iliococcygeal muscle, the coccygeal muscle, and the obturator muscle (the No.283 lymph nodes) upward, and dissect No.263d and No.263p lymph nodes with fat tissue sequentially till the bifurcation of the internal and external iliac artery; (3) take out the specimen from anus, and make anastomosis between proximal colon and anal canal. Intraoperative and postoperative variables was observed. Results: All the 5 patients completed surgery successfully, and no patient needed to convert to open approach. The mean operative time was (295.6±97.7) minutes, and the median intraoperative blood loss was 70 (50-500) ml. The mean length of specimen was (12.9±3.0) cm, and the mean number of harvested lymph node was 30.4±9.9. The positive lateral lymph nodes were founder in 4 patients. The median distance between tumor and distal resection margin was 1.5 (1.2-8.0) cm. The resection margin in all the patients was negative. The mean time to postoperative flatus was (4.2±1.6) days, the mean postoperative spontaneous urination was (3.0±1.9) days, time to drainage tube removal was (5.6±1.9) days, and the mean postoperative hospital stay was (9.4±2.1) days. The postoperative TNM staging by pathology was 1 case with T1N0M0, 1 with T2N1M0, 1 with T3N2bM0, and 2 with T3N2M0. Five patients were moderately differentiated adenocarcinoma. Only 1 patient developed postoperative abdominal bleeding, who was healed after conservative treatment. The other 4 patients did not develop any perioperative complications, such as incision infection, presacral abscess, pelvic abscess, anastomotic leakage, or anastomotic stricture. Four patients underwent postoperative chemotherapy. All the patients were followed up for 2 to 28 weeks after surgery and they all felt well. The patients with stoma had fluent bowel. Conclusions: Transanal lateral lymph node dissection is feasible and safe in the treatment of mid-low rectal cancer, which can achieve the purpose of extended radical resection of mid-low movement rectal cancer. Moreover, this procedure is a new method to treat rectal cancer patients with lateral lymph node metastasis.

A rare case of rectal cancer with perianal metastasis: a case report

BackgroundCancer metastasis from colon cancer to an anal fistula is very rare. We herein reported a rare case in which local excision was performed for metastatic anal fistula cancer originating from rectal cancer.Case presentationA 68-year-old man was referred to our institution with a diagnosis of rectal cancer. He had complained of anal fistula for 5 years. Based on a recent history of cerebral infarction, Hartmann’s operation was performed to treat the rectal cancer after the administration of preoperative chemotherapy for 3 months. However, 1 month after Hartmann’s operation, the anal fistula was found to have worsened. Pelvic magnetic resonance imaging (MRI) revealed tumor formation at the perianal lesion. Metastatic anal fistula cancer originating from the rectal cancer was diagnosed based on the examination of the biopsied tissue. We selected local excision because the anal tumor had not invaded the surrounding tissue. There has been no recurrence in the 31 months after the curative operation.ConclusionMetastatic cancer should be ruled out when treating left-sided colon cancer with anal fistula. Local excision is one possible treatment for metastatic anal fistula cancer.

Distribution of Neuroendocrine Marker-Positive Cells in Colorectal Cancer Tissue and Normal Mucosal Tissue: Consideration of Histogenesis of Neuroendocrine Cancer

Background: Colorectal neuroendocrine carcinoma (NEC) is a rare disease, and mixed cases with colorectal adenocarcinoma also exist. The histogenesis of this disease remains unclear. We studied the numbers of neuroendocrine marker-positive cells in adenocarcinoma tissue and in normal ­mucosal tissue to investigate the relation between adenocarcinoma and NEC and to discuss the histogenesis of NEC. Methods: We studied a total of 354 curatively resected cases of stage II or III colon cancer and 36 cases of rectal cancer treated at the Tokai University Hospital between 2007 and 2012. Adenocarcinoma tissue and normal mucosal tissue were immunohistochemically stained with chromogranin A, synaptophysin, and CD56. Cases in which neuroendocrine marker-positive cells were found in cancer tissue were defined as positive. In normal mucosa, the numbers of positive cells per 15 high-power fields (HPF) were counted. Results: Among the 390 cases, 181 cases had right sided colon cancer, 173 cases had left sided colon cancer, and 36 cases had rectal cancer. The rates of positive staining for chromogranin A, synaptophysin, and CD56 were significantly higher in the right sided colon than in the left sided colon, consistent with the preferred sites of NEC as reported previously. Cells positive for chromogranin A and synaptophysin in normal mucosa were significantly more common in the rectum and the left sided colon than in the right sided colon. No site-specific differences were found for CD56. Conclusions: Neuroendocrine marker-positive cells in colorectal cancer tissue are more common in the right sided colon, whereas neuroendocrine marker-positive cells in normal mucosa are more common in the rectum. These results suggest that NEC may arise from preceding adenocarcinomas.

Fertility preservation strategies for rectal cancer in reproductive-age women.

Despite rectal cancer being unusual before 40, fertility preservation (FP) remains a major concern for these reproductive-age women. Treatment usually involves pelvic radiotherapy, neoadjuvant chemotherapy, and surgery of rectum and mesorectum resection, at high risk of impairing fertility in women with risks of premature ovarian failure and radio-induced uterus damage. To date, there is no consensus on FP strategy for rectal cancer. We shared experiences between oncofertility experts from a French research network Groupe de Recherche et d'Etude en Cryoconservation Ovarienne et Testiculaire about a case of rectal cancer in a young woman. Indications, advantages and disadvantages of different FP strategies were discussed: ovarian transposition, cryopreservation of ovarian cortex and oocyte vitrification. This case was the starting point that led to the development of a French multidisciplinary e-meeting for sharing experiences and for suggesting the best strategy when faced with a complex oncofertility case.

DNA repair and cancer in colon and rectum: Novel players in genetic susceptibility.

Interindividual differences in DNA repair systems may play a role in modulating the individual risk of developing colorectal cancer. To better ascertain the role of DNA repair gene polymorphisms on colon and rectal cancer risk individually, we evaluated 15,419 single nucleotide polymorphisms (SNPs) within 185 DNA repair genes using GWAS data from the Colon Cancer Family Registry (CCFR) and the Genetics and Epidemiology of Colorectal Cancer Consortium (GECCO), which included 8,178 colon cancer, 2,936 rectum cancer cases and 14,659 controls. Rs1800734 (in MLH1 gene) was associated with colon cancer risk (p-value = 3.5 × 10-6 ) and rs2189517 (in RAD51B) with rectal cancer risk (p-value = 5.7 × 10-6 ). The results had statistical significance close to the Bonferroni corrected p-value of 5.8 × 10-6 . Ninety-four SNPs were significantly associated with colorectal cancer risk after Binomial Sequential Goodness of Fit (BSGoF) procedure and confirmed the relevance of DNA mismatch repair (MMR) and homologous recombination pathways for colon and rectum cancer, respectively. Defects in MMR genes are known to be crucial for familial form of colorectal cancer but our findings suggest that specific genetic variations in MLH1 are important also in the individual predisposition to sporadic colon cancer. Other SNPs associated with the risk of colon cancer (e.g., rs16906252 in MGMT) were found to affect mRNA expression levels in colon transverse and therefore working as possible cis-eQTL suggesting possible mechanisms of carcinogenesis.

Synchronous primary carcinomas of the prostate, thyroid and rectum: case report and review of the literature

We report a case of rectal cancer with an initial symptom of rectal bleeding. The clinical, morphological, immunohistochemical, and imaging findings supported a diagnosis of synchronous primary carcinoma of the prostate, rectal adenocarcinoma, and papillary thyroid tumor. The patient, whose poor cardiac function contraindicated surgery, underwent long-course chemoradiotherapy and hormonal therapy. The patient is currently asymptomatic, with stable disease and an improved quality of life. To our knowledge, synchronous primary carcinomas of the prostate, thyroid, and rectum are extremely rare in the literature. There are few published reports addressing parallel treatment and outcomes when such a synchronous diagnosis is made; we share here our experience in formulating a treatment plan.

Simultaneous robotic surgery with low anterior resection and prostatectomy/hysterectomy.

Cooperation with multiple departments is essential for the treatment of patients with rectal cancer and other pelvic cancers. In our department, we experienced two cases of rectal cancer that underwent robotic low anterior resection (LAR) and simultaneous resection of other pelvic organs (case 1 with prostatectomy and case 2 with hysterectomy) using the da Vinci Xi system. Here, we show the precise procedures of these two robotic surgeries. Under general anesthesia and lithotomy position, five da Vinci ports were symmetrically placed along the umbilical horizontal line with a 7cm interval, and a 5mm AirSeal Access Port was added in the right or left upper quadrant. Patients were placed with 22-degree Trendelenburg and 8-degree tilt to the right. The operators used the center port on the umbilicus as a camera port and chose the docking arms with either two-left-one-right or one-left-two-right setting depending on their preference. This port setting was quite useful for the operators from multiple departments to change the docking arms, even if their preference may be different. Moreover, assistants could use the remaining two ports to provide a well-expanded and safer surgical field. "With a familiar view" and "with a wide view" are our two concepts to safely perform extended pelvic surgeries. We have employed this symmetrical horizontal port site position as a general setting for usual rectal surgeries.

The importance of loco-regional control in metastatic rectal cancer

The number of new cases of rectal cancer (RC) estimated per year is across 704,000 worldwide. Approximately 310,000 death cases are reported per year among RC patients, globally (1). Roughly 20% of patients with RC present with metastatic disease and their prognosis depends on the extent of tumor burden (2).

Application of the cuff rectum drainage tube in total mesorectal excision for low rectal cancer: A retrospective case-controlled study.

To investigate therapeutic effect of cuff rectum drainage tube (CDT) in preventing the postoperative complications of total mesorectal excision (TME) and promoting the recovery of the patients.The clinical data of 84 cases of low rectal cancer performed TME from June 2015 to June 2017 in the First Affiliated Hospital of Xiamen University were analyzed retrospectively. All the cases were performed anus-retained operation without preventive colostomy. Patients were divided into 2 groups according to the material of the anorectal drainage tube placed in the colonic cavity. Group I (CDT group) was transanal cuff rectal drainage tube placement (Patent No. ZL 201320384337.8) (n = 48), and group II (conventional group) was transanal clinical conventional drainage tube placement (n = 36). Anastomotic fistula incidence, the time of anal exsufflation, postoperative first ambulation time, intestinal function recovery time, the incidence of interrelated complications of drainage tube and postoperative hospital stay between 2 groups were analyzed retrospectively.Both postoperative first ambulation and anal exhaust time in CDT group were shorter than those in the conventional group ([2.3 ± 0.4] d vs [3.0 ± 0.2] d, P < .05; [3.3 ± 0.3] d vs [3.9 ± 0.5] d, P < .05). Meanwhile, the postoperative hospital stay of CDT group was significantly decreased than that in the conventional group ([10.3 ± 1.6] d vs [11.8 ± 1.1] d, P < .05). Significant different occurrence of complications existed in anastomotic fistula (2.1% [1/48] vs 16.7% [6/36], P < .05), frequent defecation (8.3% [4/48] vs 27.8% [10/36], P < .05), defecating unfinished feeling (12.5% [6/48] vs 30.6% [11/36], P < .05), drainage tube complication (4.2% [2/48] vs 22.2% [8/36], P < .05).The cuff rectum drainage tube may reduce incidence of anastomotic fistula after TME, shorten postoperative first ambulation and anal exsufflation time, enable faster recovery with good toleration and decrease postoperative hospital stay.

Loss of PTPN4 activates STAT3 to promote the tumor growth in rectal cancer.

Colorectal cancer (CRC) is one of the most common types of malignant tumor. Many genetic factors have been proved to show high association with the occurrence and development of CRC and many mutations are detected in CRC. PTPN4/PTP‐MEG1 is a widely expressed non–receptor protein tyrosine phosphatase. Over the past three decades, PTPN4 has been demonstrated in the literature to participate in many biological processes. In this study, we identified a nonsense mutation of PTPN4 with a mutation ratio of 90.90% from 1 case of rectal cancer, leading to loss of function in PTPN4 gene. Several somatic mutations occurred in 5/137 rectal cancer samples from The Cancer Genome Atlas Rectum Adenocarcinoma (TCGA READ) database. Interestingly, we found that PTPN4 negative cytoplasm staining was more prone to lymphatic metastasis (N = 50, P = 0.0153) and low expression of PTPN4 in rectal cancer was highly associated with poor prognosis. Overexpression of PTPN4 suppressed the cell growth, and moreover, the loss of PTPN4 accelerated cell growth and boosted clonogenicity of CRC cells. Furthermore, we revealed that the deletion of PTPN4 promoted the tumor formation of NCM460 cells in vivo. In terms of the molecular mechanism, we demonstrated that PTPN4 dephosphorylates pSTAT3 at the Tyr705 residue with a direct interaction and suppresses the transcriptional activity of STAT3. In summary, our study revealed a novel mechanism that the tumorigenesis of colorectal cancer might be caused by the loss of PTPN4 through activating STAT3, which will broaden the therapy strategy for anti–rectal cancer in the future.

Increased Levels of Genomic Instability and Mutations in Homologous Recombination Genes in Locally Advanced Rectal Carcinomas.

Pre-operative 5-fluoracil-based chemoradiotherapy (nCRT) is the standard treatment for patients with locally advanced rectal cancer (LARC). Patients with pathological complete response (pCR–0% of tumor cells in the surgical specimen after nCRT) have better overall survival and lower risk of recurrence in comparison with incomplete responders (pIR). Predictive biomarkers to be used for new therapeutic strategies and capable of stratifying patients to avoid overtreatment are needed. We evaluated the genomic profiles of 33 pre-treatment LARC biopsies using SNP array and targeted-next generation sequencing (tNGS). Based on the large number of identified genomic alterations, we calculated the genomic instability index (GII) and three homologous recombination deficiency (HRD) scores, which have been reported as impaired DNA repair markers. We observed high GII in our LARC cases, which was confirmed in 165 rectal cancer cases from TCGA. Patients with pCR presented higher GII compared with pIR. Moreover, a negative correlation between GII and the fraction of tumor cells remaining after surgery was observed (ρ = –0.382, P = 0.02). High HRD scores were detected in 61% of LARC, of which 70% were incomplete responders. Using tNGS (105 cancer-related genes, 13 involved in HR and 5 in mismatch repair pathways), we identified 23% of cases with mutations in HR genes, mostly in pIR cases (86% of mutated cases). In agreement, the analysis of the TCGA dataset (N = 145) revealed 21% of tumors with mutations in HR genes. The HRD scores were shown to be predictive of better response to PARP-inhibitors and platinum-based chemotherapy in breast and ovarian cancer. Our results suggest that the same strategy could be applied in a set of LARC patients with HRD. In conclusion, we identified high genomic instability in LARC, which was related to alterations in the HR pathway, especially in pIR. These findings suggest that patients with impaired HRD would clinically benefit from PARP-inhibitors and platinum-based therapy.

Childhood Body Mass Index Is Associated with Risk of Adult Colon Cancer in Men: An Association Modulated by Pubertal Change in Body Mass Index.

The relative contribution of childhood and pubertal body mass index (BMI) for the risk of adult colorectal cancer is not known. The aim of this study was to evaluate the independent associations for childhood BMI and pubertal BMI change with risk of colorectal cancer in men. We included 37,663 men born in 1946 to 1961 who had weight and height measured at 8 (childhood) and 20 (young adult age) years of age available from the BMI Epidemiology Study. Information on colorectal cancer was retrieved from the Swedish National Patient Register (257 cases of colon cancer and 159 cases of rectal cancer). Childhood BMI at 8 years of age [HR, 1.19 per SD increase; 95% confidence interval (CI), 1.06-1.33], but not pubertal BMI change (HR, 1.02; 95% CI, 0.90-1.15), was associated with increased risk of colon cancer. Due to a significant interaction between childhood BMI and pubertal BMI change (P < 0.001), we stratified the analyses according to the median of pubertal BMI change. Childhood BMI was associated with risk of colon cancer in individuals with a pubertal BMI change above, but not below, the median (above: HR = 1.48, 95% CI, 1.26-1.74; below: HR = 0.95, 95% CI, 0.80-1.12). Neither childhood BMI nor pubertal BMI change was associated with rectal cancer. High childhood BMI was associated with increased risk of colon cancer only if it was followed by a pubertal BMI increase above the median. Further studies should evaluate prepubertal childhood BMI in relation to pubertal BMI change and BMI in middle age for the risk of colon cancer.

EFFECT OF NATIONAL PROGRAMS IN ONCOLOGY ON SURVIVAL OF PATIENTS WITH RECTAL CANCER: A POPULATION-BASED ANALYSIS

Objective. Assessment of the impact of National Program «Health» on a rectal cancer (RC) tumor-specific survival in the Arkhangelsk region (AR), Russia over the period 2000–2017 by the data of Arkhangelsk Regional Cancer Registry (ARCR)Materials and methods. Anonymized data on all cases of RC (C19.0–C21.0) in the AR in 2000–2017 were extracted from the database of the ARCR. Over the study period, 4173 cases of the RC were selected. To assess the impact of the National Health Project in 2006 and All-national Dispensarization in 2013, the three time periods were chosen — 2000–2006, 2007–2012 and 2013–2017. Cancer-specific survival (CSS) was calculated. Separate influence of baseline factors on differences in CSS between periods was performed using Cox regression with consecutive input.Results. One- and five year CSS were 62,6% (95% confidence interval (CI) 60,03–65,05%%) and 27,8% (95% CI 25,4–30,2%) in 2000–2006, 65,1% (95% CI 62,5–67,5%) and 32% (95% CI 29,5–34,5%) in 2007–2012, 67,7% (95% CI 65,2–70,1%) and 37,4% (95% CI 33,7–41,1%) in 2013–2017, respectively.In univariate analysis the risk of death in the latest time periods was significantly lower: HR 0.86 (95% CI 0.79–0.95), p &lt; 0.05 and 0.74 (95% CI 0.67–0.82), p&lt;0.0001 for 2007–2012 and 2013–2017, respectively, comparing to 2000–2006. In a multivariate model only correction for treatment type has led to change of the coefficients between time periods: HR 0.94 (95% CI 0.86–1.03) and 0.84 (95% CI 0.75–0.93) for 2007–2012 and 2013–2017, respectively. The CSS was also in­dependently influenced by stage, age at diagnosis, place of residence and type of treatment.Conclusion. Population-based five-year CSS of patients with RC increased by 8% during the analyzed period. Better CSS in the latest time period is associated rather with improvement of treatment than earlier detection of RC.

Long distance to hospital is not a risk factor for non-reversal of a defunctioning stoma

PurposeTo see if road distance to hospital influences stoma reversal rate, time from index operation to stoma reversal, and occurrence of permanent stoma.MethodsData from all diagnosed cases of rectal cancer from three counties in northern Sweden were extracted from the Swedish Rectal Cancer Registry. The three counties are sparsely populated, with a population density roughly one fifth the average density in Sweden. Distances to nearest, operating, and largest hospital were obtained using Google Maps™. Matched data on socioeconomic variables were retrieved from Statistics Sweden.ResultsIn univariate logistic regression analysis, patients living closer to the operating hospital had a higher likelihood of non-reversal than those living farther away (OR 0.3; 95% CI 0.12–0.76). However, no difference was seen in the multivariate analysis. Of the 717 cases included, 54% received a permanent stoma and 38% a defunctioning stoma at index surgery. The reversal rate of a defunctioning stoma was 83%. At follow-up, 61% still had a stoma, 89% of these were permanent, and 11% non-reversed defunctioning stomas. Median time to stoma reversal was 287 days (82–1557 days). Of all 227 stoma reversals, 77% were done more than 6 months after index surgery.ConclusionsLonger distance to hospital is not a risk factor for non-reversal of a defunctioning stoma. Only 23% had their defunctioning stoma reversed within 6 months after index surgery. Future studies aiming to determine reversal rate need to extend their follow-up time in order to receive accurate results.

Outcomes of younger patients diagnosed with locally advanced rectal cancer.

500 Background: The incidence of rectal cancer is higher in the older population. In developed nations there has been a rise in incidence in young onset rectal cancer (yRC). We evaluated and compared the presentation and survival outcomes of treatments for locally advanced rectal cancer in yRC patients to that of older patients. Methods: All cases of rectal cancers referred to a large tertiary referral cancer centre in Western Sydney between 2009-2016 were examined. Patient demographics, presenting symptoms, treatment, clinico-pathological characteristics, progression free survival (PFS) and overall survival (OS) were obtained. Under 50 years old was used as the cut-off age for defining yRC. Results: One hundred sixty-two patients were identified, 33 in the yRC and 129 in the older patient group. The median age at diagnosis was 62 (24 – 92). Median follow-up was 40 months. There was no difference in presenting symptoms between the two groups, with per rectal bleeding being the most common symptom at presentation. 17.5% of yRC presented with stage IV disease, compared with 22.1% of older patients. yRC were more likely to complete neoadjuvant therapy (97% vs 81%; P=0.02). yRC were more likely to proceed to surgery (91% vs 72%, P=0.02). There were no significant differences in surgical outcomes, including complications and postoperative TNM staging. yRC were more likely to have microsatellite high tumours (18% vs 4%; P=0.01). No statistical differences were seen in survival outcomes (PFS 57.1 vs 62.9 months, P=0.26; OS 85.1 Vs 92.8 months, P=0.57) between older and yRC patients. Eight progressions (eight deaths) were observed in the yRC group and 40 progressions (36 deaths) were observed in the older patient group. Conclusions: 20% of rectal cancers were considered yRC. These patients were more likely to complete neoadjuvant therapy and proceed to surgery. In this cohort, median PFS and OS were longer compared to the older patient group, although this was not statistically significant. yRC were more likely to have MMR deficiency. Patients under 50 years with alarm symptoms including per rectal bleeding require vigilance in investigations to allow for earlier detection and appropriate management of rectal cancer.

Pelvic Exenteration with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS + HIPEC) for Rectal Cancer-Case Series with Review of Literature.

Incidence of synchronous peritoneal metastases (PM) in colorectal cancer is approximately 5%, with another 5% of the patients develop metachronous PM. Colorectal PM has been hypothesized to be a loco-regional disease rather than a systemic spread, and cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has been considered as a viable treatment option. Pelvic exenteration is an established treatment option for locally advanced rectal cancer, but it is associated with significant morbidity. However, there are no studies evaluating the role of such procedure probably because the majority consider it as an exclusion criterion. Here, we present our experience with three cases of locally advanced rectal cancer with PM, treated successfully with pelvic exenteration and CRS-HIPEC.

Development and innovation of international minimally invasive gastrointestinal surgery

Minimally invasive surgery has got a great development in the past 30 years. Currently, a series of new technique and novel technology have been introduced, which bring us a new prospect and also new challenges. In surgery methods, Adenocarcinoma of esophagogastric junction (AEG) is also a hot topic recently, especially the gastrointestinal tract reconstruction of AEG in total laparoscopic surgery. Transanal total mesorectal excision has several advantages in difficult cases of lower rectal cancer, but is still under debate for oncological safety. 3D laparoscopic surgery, glass-free 3D laparoscopic surgery, 4K laparoscopic surgery and laparoscopic indocyanine green fluorescence imaging are innovative technology in minimally invasive surgery at home and abroad. The fusion and hybrid of the new technique and novel technology might be the future of the minimally invasive surgery. Key words: Gastric neoplasms; Intestinal neoplasms; Gastrointestinal surgery; Minimally inva-sive; Laparoscopy

Workplace Diesel Exhausts and Gasoline Exposure and Risk of Colorectal Cancer in Four Nordic Countries.

BackgroundEvidence on associations between occupational diesel exhaust and gasoline exposure and colorectal cancer is limited. We aimed to assess the effect of workplace exposure to diesel exhaust and gasoline on the risk of colorectal cancer.MethodsThis case–control study included 181,709 colon cancer and 109,227 rectal cancer cases diagnosed between 1961 and 2005 in Finland, Iceland, Norway, and Sweden. Cases and controls were identified from the Nordic Occupational Cancer Study cohort and matched for country, birth year, and sex. Diesel exhaust and gasoline exposure values were assigned by country-specific job-exposure matrices. Odds ratios and 95% confidence intervals were calculated by using conditional logistic regression models. The results were adjusted for physical strain at work and occupational exposure to benzene, formaldehyde, ionizing radiation, chlorinated hydrocarbons, chromium, and wood dust.ResultsDiesel exhaust exposure was associated with a small increase in the risk of rectal cancer (odds ratio = 1.05, 95% confidence interval 1.02-1.08). Gasoline exposure was not associated with colorectal cancer risk.ConclusionThis study showed a small risk increase for rectal cancer after workplace diesel exhaust exposure. However, this finding could be due to chance, given the limitations of the study.

Genetic analysis of subsequent second primary malignant neoplasms in long-term pancreatic cancer survivors suggests new potential hereditary genetic alterations.

BackgroundThe principal aim of this report was to study second primary malignant neoplasms (SMNs) in long-term survivors of pancreatic ductal adenocarcinoma (PDAC) with regard to the germline genetic background.Patients and methodsA total of 118 PDAC patients after a curative-intent surgery who were treated between 2006 and 2011 were analyzed. Of the 22 patients surviving for >5 years, six went on to develop SMNs. A genetic analysis of 219 hereditary cancer-predisposition and candidate genes was performed by targeted next-generation sequencing in germline DNA from 20 of these patients.ResultsOf all the radically resected PDAC patients, six patients went on to subsequently develop SMNs, which accounted for 27% of the long-term survivors. The median time to diagnosis of SMNs, which included two cases of rectal cancer, and one case each of prostate cancer, malignant melanoma, breast cancer, and urinary bladder cancer, was 52.5 months. At the time of analysis, none of these patients had died as a result of PDAC progression. We identified four carriers of germline pathogenic mutations in 20 analyzed long-term survivors. One carrier of the CHEK2 mutation was found among four analyzed patients who developed SMNs. Of the remaining 16 long-term PDAC survivors, 3 patients (19%) carried germline mutation(s) in the MLH1+ ATM, CHEK2, and RAD51D gene, respectively.ConclusionThis retrospective analysis indicates that SMNs in PDAC survivors are an important clinical problem and may be more common than has been acknowledged to be the case. In patients with good performance status, surgical therapy should be considered, as the SMNs often have a favorable prognosis.