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Intestinal pneumatosis refers to the presence of gas in the gastrointestinal wall. It is often difficult to clinically differentiate this condition from gastrointestinal perforation, sometimes resulting in emergency surgery. Imaging studies are important to establish the differential diagnosis. However, there have been few studies showing the efficacy of computed tomography (CT) colonography in diagnosing pneumatosis. We report a case of intestinal pneumatosis in which CT colonography was of significant diagnostic value. A 43-year-old man was referred to our hospital for a detailed investigation of multiple submucosal tumor-like lesions associated with multiple pneumatosis from the cecum to the ascending colon. These lesions were revealed by colonoscopy performed in another hospital on May 21, 2008. Abdominal 3-dimensional CT showed multiple pneumatic lesions from the cecum to the ascending colon, and the patient was diagnosed as having intestinal pneumatosis. The patient is being followed conservatively because he is asymptomatic.

Background: We review the results of surgical radiofrequency ablation of both atria in patients of mitral valve disease approached by septal-superior exposure and discuss the availability of this approach. Methods: Eighteen patients with a mean age of 65 years were included in this study. Thirteen patients had mitral valve regurgitation predominantly and five had mitral valve stenosis. Eleven patients underwent mitral valve plasty and valve replacement was carried out in seven. All ablation lesions were created on both atria using radiofrequency energy delivered by a unipolar malleable radiofrequency ablation catheter with seven electrodes at a minimum temperature of 80–85°C for a period of 2 min. Results: At the time of discharge, 14 patients were showed normal sinus rhythm and one patient remained in AF. The other three patients were free from atrial fibrillation; however, they received dual-mode, dual-pacing, dual-sensing pacemaker implantation because of bradycardia during the early postoperative phase. At a mean time of 7 months after surgery, all patients were free from atrial fibrillation; 13 patients showed normal sinus rhythm and five patients received dual-mode, dual-pacing, dual-sensing pacemakers. Conclusion: Septal-superior exposure provides an excellent operative view both for mitral valve surgery and for radiofrequency ablation. However, this exposure has not been considered a first-line approach because of the high rate of pacemaker implantation.

Retrospective studies have shown that primary tumor resection improves the prognosis of patients with colorectal cancer with unresectable metastasis (mCRC). Prognostic significance of lymph node dissection (LND) in mCRC has not been examined previously. The aim of this study was to investigate the prognostic impact of primary tumor resection and LND in mCRC. A total of 1,982 patients with mCRC from January 1997 to December 2007 were retrospectively studied. The impact of primary tumor resection and LND on overall survival (OS) was analyzed using Cox proportional hazards model and propensity score analysis to mitigate the selection bias. Covariates in the models for propensity scores included treatment period, institution, age, sex, carcinoembryonic antigen, tumor location, histology, depth, lymph node metastasis, lymphovascular invasion, and number of metastatic organs. In a multivariate analysis, primary tumor resection and treatment in the latter period were associated with an improved OS, and age over 70 years, female sex, lymph node metastasis, and multiple organ metastasis were associated with a decreased OS. In the propensity-matched cohort, patients treated with primary tumor resection showed a significantly better OS than those without tumor resection (median OS 13.8 vs. 6.3 months; p = 0.0001). Furthermore, among patients treated with primary tumor resection, patients treated with D3 LND showed a significantly better OS than those with less extensive LND (median OS 17.2 vs. 13.7 months; p

The safety of laparoscopic surgery for rectal cancer following chemoradiotherapy (CRT) has not been fully established. The aim of our retrospective study was to examine the outcomes and the factors contributing to the difficulty of laparoscopic surgery after CRT. Eighty-seven consecutive rectal cancer patients treated with CRT were analyzed. Clinicopathological factors were compared between laparoscopic surgery (n = 57) and open surgery (n = 30) groups, and factors that correlated with operation time and blood loss were analyzed in low anterior resection (LAR) cases in the laparoscopic surgery group (n = 46). There was less blood loss in the laparoscopic surgery group than in the open surgery group (191 vs. 1,043 ml, p = 0.0001), and the operation time in the two groups was similar (329 vs. 322 min, p = 0.8). The rate of conversion from laparoscopic surgery to open surgery was 1.8 %. There was no significant difference in the morbidity rate (laparoscopic surgery 22.8 % vs. open surgery 33.3 %, p = 0.3). All circumferential resection margins were clear. Three-year cumulative rates of local recurrence were as follows: laparoscopic surgery: 1.9 % vs. open surgery: 8.4 % (p = 0.4), and distant recurrence was 28.5 % in laparoscopic surgery vs. 22.7 % in open surgery (p = 0.8) and these rates were not significantly different. In laparoscopic LAR cases, a shorter distance of the tumor from the anal verge was associated with a longer operation time. A high computed tomography Hounsfield units value of the mesorectum (CTV) was associated with increased blood loss in the first 23 cases, but not in the other 23 cases. Laparoscopic surgery following CRT was safe and feasible. A shorter anal verge was associated with a longer operation time. Blood loss increased in cases with high CTV, but this can likely be mitigated by experience.

Purpose To examine whether chromosomal instability (CIN) phenotype, determined by the severity of CIN, can predict survival for stages II and III colorectal cancer (CRC). Patients and Methods We determined microsatellite instability (MSI) and loss of heterozygosity (LOH) status in 1,103 patients (training [n = 845] and validation [n = 258] sets with stages II and III CRC). The LOH ratio was defined as the frequency of LOH in chromosomes 2p, 5q, 17p, and 18q. According to the LOH ratio, non–MSI high tumors were classified as CIN high (LOH ratio ≥ 33%) or CIN low (LOH ratio < 33%). CIN-high tumors were subclassified as CIN high (mild type; LOH ratio < 75%) or CIN high (severe type; LOH ratio ≥ 75%). We used microarrays to identify a gene signature that could classify the CIN phenotype and evaluated its ability to predict prognosis. Results CIN high showed the worst survival (P < .001), whereas there was no significant difference between CIN low and MSI high. CIN high (severe type) showed poorer survival than CIN high (mild type; P < .001). Multivariate analysis revealed that CIN phenotype was an independent risk factor for disease-free and overall survival, respectively, in both the training (P < .001 and P = .0155) and validation sets (P < .001 and P = .0076). Microarray analysis also revealed that survival was significantly poorer in those with the CIN-high than in the CIN-low gene signature (P = .0203). In a validation of 290 independent CRCs (GSE14333), the CIN-high gene signature showed significantly poorer survival than the CIN-low signature (P = .0047). Conclusion The CIN phenotype is a predictive marker for survival and may be used to select high-risk patients with stages II and III CRC.

One rare complication of a ventriculoperitoneal (VP) shunt is perforation of the gastrointestinal tract by the catheter. We report a case in which the catheter severed spontaneously inside the peritoneal cavity, creating a communication between the intestinal tract and the peritoneal cavity. The patient was a 41-year-old man who presented with a VP shunt catheter protruding from the anus. Computed tomography showed that the VP shunt catheter, which had been put in place 25 years earlier, had severed spontaneously. The distal end had then perforated and entered the intestinal tract. The patient was hospitalized and emergency surgery was performed to repair the intestinal tract perforation caused by the end of the VP shunt catheter. Laparotomy revealed that the catheter had perforated the sigmoid colon. The VP shunt catheter was removed, and the perforation in the intestinal tract was closed by suturing. The patient was discharged on postoperative day 20.

A 67-year-old man had rectal cancer with para-aortic lymph node metastasis. Prior to surgical resection, tegafur-uracil and leucovorin had been administered orally as chemotherapy, and radiotherapy (50.4 Gy) was applied for the rectum and para-aortic lymph nodes. Low anterior resection was then performed, followed by 45 cycles of chemotherapy in total. Enlargement of the left axillary lymph nodes was noted during treatment, but nodes shrank in response to treatment with bevacizumab + FOLFIRI (i.e., irinotecan + 5-fluorouracil/leucovorin). As of the time of writing, 36 months after diagnosis, no swelling of the para-aortic lymph nodes was evident and chemotherapy was being continued. This patient was alive after achieving response to neoadjuvant therapy comprising chemotherapy and irradiation of the para-aortic lymph nodes, along with postoperative chemotherapy. This therapeutic approach of preoperative chemotherapy plus irradiation of the primary lesion and para-aortic lymph nodes has potential as an effective treatment.

Skin metastases from visceral cancers are rare and the reported incidence from all visceral cancers is 1.4% to 10%. Skin metastases from colorectal cancers account for only 5% of metastatic skin cancers, among which scalp metastases are very rare. We describe a 53-year-old man with scalp metastasis derived from sigmoid colon cancer that was diagnosed and surgically resected in 2005. Metastatic lung tumors that developed thereafter were surgically resected and then chemotherapy was administered. However, metastatic brain tumors occurred in 2008, and these were treated by γ-knife radiosurgery. Around the same time, a raised lesion that appeared on the scalp was diagnosed as skin metastasis and treated with best supportive care. Thereafter, the brain metastases continued to spread, and the patient died in October 2008.

Cancers which arise in the proximal and distal colon are suggested to be different clinically, pathologically, and genetically. The aim of this study is to clarify whether clinical behavior of colonic poorly differentiated adenocarcinoma, mucinous adenocarcinoma, and signet-cell carcinoma (Por/Muc/Sig cancers), minor and aggressive subpopulation in colonic cancers, differs in accordance with the tumor location. A total of 3,175 patients with curatively resected colonic cancers were studied. Clinical and pathological features were compared between Por/Muc/Sig cancers and well or moderately differentiated adenocarcinomas (Wel/Mod cancers) and between proximal and distal cancers in each histologic type. Por/Muc/Sig cancers (n = 213) were more advanced in the TNM stage and showed worse disease-specific survival than Wel/Mod cancers (n = 2,692). In Por/Muc/Sig cancers, but not in Wel/Mod cancers, proximal cancers showed significantly better disease-specific survival than distal cancers (88.9% vs. 76.5%, p = 0.0234), and a multivariate analysis showed that proximal tumor location was an independent predictor of fair prognosis (hazard ratio (HR), 0.458; 95% confidence interval (CI), 0.218–0.961; p = 0.0390). In addition, female gender also was an independent predictor of fair prognosis in Por/Muc/Sig cancers (HR, 0.373; 95% CI, 0.151–0.922) and not in Wel/Mod cancers. Proximal Por/Muc/Sig cancers were suggested to be a distinct subpopulation with a favorable oncologic outcome. Tumor location and gender might be helpful in the risk stratification after curative surgery for Por/Muc/Sig cancers.

Concomitant chemotherapy increases the therapeutic effect of preoperative radiotherapy for rectal cancer. The aim was to investigate the clinical benefit of tegafur-uracil (UFT) and leucovorin (LV) in preoperative chemoradiotherapy for rectal cancer.Patients who had undergone curative resections of rectal cancers following preoperative radiotherapy (50-50.4Gy) with UFT and LV (CRT group: n=30) or radiotherapy without chemotherapy (RT group: n=33) were studied. Clinical outcomes were compared between both groups.Responders to preoperative therapy (66% pathological resolution of their cancer) comprised 56.7% and 36.4% of the CRT and RT groups, respectively. Complete response was observed in 10.0% and in 6.1% of the CRT and RT groups, respectively. Pathological lymph node metastasis was positive in 10.0% and in 39.4% of the CRT and RT groups, respectively (p=0.0001). Sphincter-preserving surgery was performed in more patients in the CRT group than in the RT group (63.3% vs. 36.4%, p=0.04). Anastomotic leakage or pelvic abscess was seen in 6.7% and 27.3% of the CRT and RT groups, respectively. Anal function, estimated by the frequency of defecation and the Wexner incontinence score, was equally fair in both groups.Administration of UFT and LV enhanced the pathological response to preoperative radiotherapy, especially that of lymph node metastasis, and increased the frequency of sphincter-preserving surgery without compromising postoperative course.

Micropapillary carcinoma (MC) has been recently recognized to be a rare but distinctive variant of adenocarcinoma. At present, only a limited number of colorectal MC cases have been reported. We present a case of MC of the ascending colon with distant metastasis. A 61-year-old female patient was hospitalized with a complaint of abdominal pain. A diagnostic work-up revealed cancer of the ascending colon with multiple lung metastases. The patient underwent a right hemicolectomy with lymph node dissection. A peritoneal nodule was observed in the abdominal cavity during surgery, and this nodule was also resected. The pathologic findings of the colon tumor revealed components of conventional tubular adenocarcinoma and micropapillary carcinoma. Lymph nodes and a peritoneal nodule revealed tubular adenocarcinoma. MC is a rare disease but has high malignant potential. In the present case the tumor was small in size, but the patient had a peritoneal and multiple lung metastases.

Distant small bowel metastases from head and neck squamous cell carcinomas are extremely rare, and tongue cancer metastasizing to the small bowel has not been previously reported. We describe a 40-year-old male patient who underwent subtotal gross laryngectomy for squamous cell carcinoma of the tongue in February 2007 and then presented in November 2008 with severe abdominal pain. Abdominal computed tomography (CT) and X-rays revealed free air, suggesting intestinal perforation. Emergency surgery revealed a 10-mm perforation at the ileum and a palpable hard tumor at the perforation site. The ileum was resected, and pathologic findings showed squamous cell carcinoma at the perforation site, which was consistent with metastasis from tongue cancer.

The response of rectal cancer to preoperative chemoradiotherapy (PRT) varies widely among patients, and predictors of the response remain to be elucidated. The purpose of this study is to investigate whether radiation-induced apoptosis (RIA) of peripheral blood lymphocytes (PBLs) reflects the underlying intrinsic radiosensitivity of rectal cancer. Forty-one patients with clinical T3-4, M0 low rectal cancers, treated with PRT and curative surgery, were retrospectively studied. PBLs were obtained from blood samples of the patients, irradiated at 0, 2, 8, and 16 Gy in vitro, and analyzed for RIA by flow cytometry using Annexin V (AV) and propidium iodide (PI). The correlation of the RIA of PBLs and histological regression of rectal cancer in response to PRT was examined. Both the proportions of AV+/PI− PBLs (early apoptosis) and AV+/PI + PBLs (late apoptosis) were significantly higher in patients with high histological regression than in those with low histological regression. Age, sex, tumor size, and clinical T and N stages did not affect the RIA of PBLs. This study showed that the RIA of PBLs is correlated with the histological regression of rectal cancer in response to PRT and suggested that the radiosensitivity of rectal cancer might be estimated by the RIA of PBLs.

A 74-year-old female had occasionally experienced right lower abdominal pain in the past. She underwent a barium enema examination during a medical checkup, which revealed a wall irregularity around the appendix, but the appendix itself was not visualized. The patient was referred to our hospital for possible appendiceal neoplasm. Colonoscopy revealed a tumor-like protrusion with marked redness at the entrance to the appendix. Pathologic analysis of biopsy specimens revealed only inflammatory cells. Differential diagnosis of appendiceal Crohn's disease or appendiceal neoplasm was made, and laparoscopic appendectomy was performed. Pathologic examination revealed inflammation in all layers of the appendiceal wall and noncaseating epithelioid cell granuloma, and a diagnosis of appendiceal Crohn's disease was made. The postoperative course was uneventful, and the patient was discharged from the hospital 3 days after surgery. No sign of recurrence has been observed up to now, 6 months after surgical treatment.

A 63-year-old male patient suddenly suffered right lower abdominal pain. The patient had tenderness and rebound tenderness at the right lower abdomen. Marked small bowel dilatation and an intestinal obstruction were evident upon abdominal X-ray and abdominal computed tomography (CT) imaging. CT imaging also revealed a dilated small bowel cluster in a wrapped round shape in the right lower abdomen. The cecum and the ascending colon were displaced inward. Strangulation in the ileocecal region was suspected, and emergency surgery was performed. A part of the small bowel was incarcerated within the retrocecal recess, and the intestinal tract was strangulated in the hernia orifice, by which paracecal hernia was diagnosed. The strangulated intestinal tract was repositioned, and the orifice to the hernia was closed. Paracecal hernia is a rare disease; an internal hernia should always be considered in patients with ileus without a history of surgery.

The prediction of peritoneal recurrence in colorectal cancer patients is required for improvement of prognosis. In this study, we focused on establishing a novel rapid RNA direct amplification system with transcription-reverse transcription concerted reaction (TRC) to detect carcino-embryonic antigen (CEA) mRNA in peritoneal washings, and its usefulness as a prophylactic tool for peritoneal recurrence and survival in patients with colorectal cancer. Peritoneal washes were obtained from 161 patients with colorectal cancer during laparotomy. CEA mRNA and porphobilinogen deaminase (PBGD) mRNA levels of peritoneal washes were detected using the TRC method. Genetic detection in the CEA mRNA of peritoneal washes by TRC showed a significant correlation to the depth of invasion, lymphatic invasion, venous invasion, lymph node metastasis, peritoneal dissemination and stage. The overall survival and peritoneal recurrence-free survival rates of CEA mRNA-positive patients were significantly poorer than those of marker gene-negative patients. CEA mRNA levels in peritoneal washes were a significant independent prognostic factor for overall survival and peritoneal recurrence-free survival. In conclusion, our study demonstrated that the detection of CEA mRNA in peritoneal washings by TRC is a useful, rapid genetic diagnosis for the prediction of peritoneal recurrence and survival in patients with colorectal cancer.

There is no standardized consensus at each institution about a treatment for pulmonary metastases from colorectal cancer. A case of pulmonary radical resection can expect a good result. However, a result of a nonoperative case is extremely poor. A focal control until the time of operation to a metastatic lesion is very important. We want to have a safe and effective chemotherapy. We experienced a resectable case by CPT-11/5'-DFUR combination therapy.

Two episodes of hypotension caused by oral beraprost sodium administration following cardiac surgery are described. The first case was a 67-year-old female who underwent concomitant surgery for mitral valve replacement, tricuspid annuloplasty, and a radiofrequency maze procedure for atrial fibrillation. The second case was a 45-year-old female who underwent 4-vessel coronary artery bypass grafting associated with endarterectomy in the right coronary artery. Beraprost sodium was administered for the treatment of residual pulmonary hypertension in the first case, and was initiated as an antiplatelet agent following coronary endarterectomy in the second case. Hypotension occurred at approximately one hour after beraprost sodium administration in both cases. Careful observation to prevent this adverse effect is critical after the administration of beraprost sodium, especially in patients who have undergone cardiac surgery.

A 53-year-old man with Behcet's disease was admitted to our hospital for investigation of back and lower abdominal pain. Computed tomography (CT) showed a projecting saccular aneurysm below the right renal artery. We placed a stent-graft just below the right renal artery, successfully excluding the abdominal aortic aneurysm (AAA). His C-reactive protein level and white blood cell count remained elevated after stent-grafting. About 5 months later, he was readmitted with recurrent back and lower abdominal pain and CT showed progression of the AAA. Thus, we performed straight grafting using a woven Dacron graft just below the right renal artery. The patient had an uneventful postoperative course. We discuss the controversial issue of treating AAA in patients with Behcet's disease, focusing on the indications and timing of surgery.

A 75-yearold Japanese female was admitted with sudden onset of massive rectal bleeding. Colonoscopy was performed immediately, but no apparent cause of bleeding was detected (Fig. 1). Abdominal multi-detector row computed tomography (MDCT) revealed venodilation around the rectum, which was diagnosed as varicose veins (Fig. 2). Rectal varices are usually associated with portal hypertension caused by liver disorders such as liver cirrhosis. However, the patient had no apparent comorbidities, and her liver function was normal. The etiology of her rectal varices was unclear. She was successfully managed expectantly and discharged with no further episode of rectal bleeding. Rectal varices may cause massive rectal

Letter to Editor We read with interest the study by Kang and colleagues published in the recent issue of Medical Oncology [1]. They examined the usefulness of mcrosatellite instability (MSI) status as a predictive factor for stage II or III colorectal cancer (CRC) patients who received adjuvant doxifluridine therapy. MSI-H showed a favorable survival trend for overall survival and significant survival benefit for relapse-free survival. In a univariate analysis, the doxifluridine-treated patients with MSI-H showed improved relapse-free survival compared to those with low or stable MSI (MSI-L/S), however, in a multivariate analysis, MSI-H was not significantly associated with relapse-free survival. Therefore, they concluded that MSI-H patients with stage II or III CRC did not seem to benefit from doxifluridine adjuvant therapy. As the author stated, the predictive role of the MSI status remains unclear at the present time. We have previously demonstrated that adjuvant chemotherapy is effective for stage II and stage MSI CRC [2]. However, other studies show conflicting results [3]. Kang et al. showed results of patients who received doxifluridine adjuvant therapy and there have been very few studies that have addressed the effect of doxifluridine in MSI CRC in adjuvant setting. In this sense, Kang’s study presented an important result. However, to draw their conclusion there is a major issue that needs to be discussed. Kang et al. examined 564 stage II or III patients, however, more than half of the patients were stage II (290 patients). Although, effectiveness of adjuvant chemotherapy has been well established in stage III CRC, its role in stage II CRC is still unclear. Furthermore, in our previous study, we selected high-risk stage II patients, because these patients may be good candidates for adjuvant therapy. Also, it should be noted that in Kang’s study there were only 13 MSI stage III patients and 30 MSI stage II patients. These numbers seem too small in order to evaluate any effect of adjuvant therapy. In fact, overall survival curves and relapse-free survival curves in both all patients and patients who received adjuvant therapy all show better outcome in MSI patients than in MSI-L/S patients. To accurately evaluate the efficacy of doxifluridine adjuvant therapy, larger numbers of high-risk stage II and stage III patients are necessary. Until above issue is sufficiently addressed, we believe it is premature to conclude that MSI-H patients with stage II or III CRC did not benefit from doxifluridine adjuvant therapy.

However, in Ogino et al’s study,they showed no significant difference in 5-year colorectal cancer–specific survival or 5-year overall survival between patients with 18qLOH-positive tumors and 18q LOH-negative tumors. Furthermore,multivariate analysis did not show prognostic significance of 18qLOH.Fromtheseresultstheyconcludedthat18qLOHdidnotasso-ciate with patient survival in patients with non-microsatellite–highcolorectal cancer. However, we are concerned about the conclusionreached by the authors. There are two major issues that need tobediscussed.The most important issue is the small number of stage III andhigh-riskstageIIpatientsinOginoetal’s

To the Editors: We read with interest Malesci et al's article in the recent issue of Clinical Cancer Research ([1][1]). They showed that microsatellite instability (MSI) was a significant stage-dependent predictor of survival in patients with colorectal cancer. Malesci et al. introduced our previous