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Background This retrospective study aimed to demonstrate surgical operative approach of total pelvic exenteration combined with sacral resection with rectal cancer and elucidate the relationships between the level of sacral resection and short-term outcomes. Methods Twenty cases were selected. Data regarding sex, age, body mass index, neoadjuvant therapy, location of sacral resection (“Upper” or “Lower” relative to the level between the 3rd and 4th sacral segment), operative time, bleeding, and curability (R0/R1) were collected and compared to determine their association with complications exhibiting a Clavien-Dindo grade III. Results The complication rate was significantly higher for recurrent cancers (n = 10, 76.9%) than for primary cancers (n = 1, 14.3%) ( P = .007), and for “Upper” resection (n = 8, 72.7%) than for “Lower” resection (n = 3, 33.3%) ( P = .078). Significant differences were observed when complication rates for “Lower” and primary cancer resection (n = 3, .0%) were compared between “Upper” and recurrent cancers (n = 8, 100.0%) ( P = .007). Conclusion In patients with recurrent rectal cancer, “Upper” sacral resection during total pelvic exenteration is associated with a high complication rate, highlighting the need for careful monitoring.

The epithelial-to-mesenchymal transition (EMT) is an initial, critical step in hepatocellular carcinoma (HCC) tumor invasion and metastasis. Frizzled 2 (Fzd2) expression might drive EMT through the non-canonical Wnt pathway, one of the various EMT signaling pathways. The expression of epithelial (E-cadherin) and mesenchymal (vimentin) markers, as well as that of Wnt5b, Stat3, IL-6, Jak2 and Fzd2, were measured in 15 HCC cell lines. The EMT status (vimentin to E-cadherin mRNA expression ratio), Fzd2 mRNA expression, and pSTAT3 protein expression were assessed by immunostaining in 100 HCC patients, and correlations of their expression with clinicopathological factors and prognosis were analyzed. Cell proliferation, migration, and invasiveness were assessed after Fzd2 knockdown. Fzd2 expression was significantly correlated with a mesenchymal phenotype in the HCC cell lines. Treatment of the cell lines with Fzd2 siRNA resulted in significantly reduced migration and invasiveness but did not affect proliferation. A significant correlation was detected between the EMT status and Fzd2 expression in the HCC patients. Multivariate analysis revealed that Fzd2 expression was an independent predictor of recurrence (P=0.034). Patients with high Fzd2 expression had significantly poorer recurrence‑free survival than those with low expression (P=0.03). Finally, pSTAT3 expression was significantly correlated with the EMT and Fzd2 status (P=0.0028, and P=0.0066, respectively). Fzd2 expression induced EMT and enhanced cell migration and invasiveness, and it might be a novel predictor of HCC recurrence. Furthermore, Stat3 might be controlled by both the Wnt5/Fzd2 and IL-6/Jak2 signaling pathways and play an important role in EMT.

The Charlson age comorbidity index (CACI) is a useful measure of comorbidity to standardize the evaluation of surgical patients and has been reported to predict postoperative mortality in various cancers.A total of 379 patients who underwent R0/R1 resection for pancreatic cancer between 2003 and 2014 were enrolled in this study. According to the CACI, the age-adjusted comorbidity index was calculated by weighting individual comorbidities; CACI4 was considered the low-CACI group, whereas CACI≥4 was considered the high-CACI group. The correlations between the CACI and clinicopathologic features and survival outcomes were statistically analyzed.The patients with a high CACI were more likely to be old and had higher CA19-9 levels and lower incidences of portal vein resection and blood transfusion. The rate of patients who received chemotherapy was significantly higher in the low-CACI group than in the high-CACI group (87% vs. 69%, P 0.0001). The overall survival (OS) rate was significantly higher in the low-CACI group than in the high-CACI group (P = 0.047). Multivariable analysis showed that a high CACI was a predictor of poor survival (P = 0.024). In the high-CACI group, patients with high relative dose intensity (RDI) for postoperative adjuvant chemotherapy had significantly better relapse-free survival (RFS) and OS than those with low RDI (both P 0.0001).The CACI was a significant independent predictor of prognosis and compliance for postoperative adjuvant chemotherapy in the resected pancreatic cancer.

Background There have been no reports showing the incidence of anastomotic stenosis of continuous hepaticojejunostomy (HJ) and identifying its risk factors for patients who underwent pancreaticoduodenectomy (PD). Method We retrospectively investigated 200 patients whose HJ was established by unified method, single layered continuous suture. HJ stenosis was diagnosed with endoscopic or radiologic examinations. Uni and multivariable unconditional logistic modeling were performed to explore the predictive factors and to estimate odds ratios (ORs) and their 95% confidence intervals (CIs). Results Sixteen patients (8.0%) were diagnosed as HJ stenosis. Multivariable analysis showed that body mass index (BMI) (OR: 1.24; 95% CI: 1.03–1.51), absence of preoperative biliary stenting (OR: 11.10; 95% CI: 1.22–101.12), operative time (OR: 1.74 per one hour increase; 95% CI: 1.01–2.98), age (OR: 1.58 per 10 years increase; 95% CI: 0.88–2.85), and absence of nodal metastasis (OR: 3.43; 95% CI: 0.90–13.12) correlated with HJ stenosis. Among these, BMI and preoperative biliary stenting were associated with stenosis with a lower P-value than the others (P = 0.026 and 0.033, respectively). Conclusions The incidence of HJ stenosis was 8.0%. Close attention would be needed especially for patients at high risk of HJ stenosis, such as high BMI or absence of preoperative biliary stenting.

This study aimed to assess the pathogenic causes, clinical conditions, surgical procedures, in-hospital mortality, and operative death associated with emergency operations at a high-volume cancer center. Although many reports have described the contents, operative procedures, and prognosis of elective surgeries in high-volume cancer centers, emergency operations have not been studied in sufficient detail. We retrospectively enrolled 28 consecutive patients who underwent emergency surgery. Cases involving operative complications were excluded. The following surgical procedures were performed during emergency operations: closure in 3 cases (10.7%), diversion in 22 cases (78.6%), ileus treatment in 2 cases (7.1%), and hemostasis in 1 case (3.6%). Closure alone was performed only once for peritonitis. Diversion was performed in 17 cases (77.3%) of peritonitis, 4 cases (18.2%) of stenosis of the gastrointestinal tract, and 1 case (4.5%) of bleeding. There was a significant overall difference (P = 0.001). The frequency of emergency operations was very low at a high-volume cancer center. However, the recent shift in treatment approaches toward nonoperative techniques may enhance the status of emergency surgical procedures. The results presented in this study will help prepare for emergency situations and resolve them as quickly and efficiently as possible.

There have been no reports showing the incidence of anastomotic stenosis of continuous hepaticojejunostomy (HJ) and identifying its risk factors for patients who underwent pancreaticoduodenectomy (PD).We retrospectively investigated 200 patients whose HJ was established by unified method, single layered continuous suture. HJ stenosis was diagnosed with endoscopic or radiologic examinations. Uni and multivariable unconditional logistic modeling were performed to explore the predictive factors and to estimate odds ratios (ORs) and their 95% confidence intervals (CIs).Sixteen patients (8.0%) were diagnosed as HJ stenosis. Multivariable analysis showed that body mass index (BMI) (OR: 1.24; 95% CI: 1.03-1.51), absence of preoperative biliary stenting (OR: 11.10; 95% CI: 1.22-101.12), operative time (OR: 1.74 per one hour increase; 95% CI: 1.01-2.98), age (OR: 1.58 per 10 years increase; 95% CI: 0.88-2.85), and absence of nodal metastasis (OR: 3.43; 95% CI: 0.90-13.12) correlated with HJ stenosis. Among these, BMI and preoperative biliary stenting were associated with stenosis with a lower P-value than the others (P = 0.026 and 0.033, respectively).The incidence of HJ stenosis was 8.0%. Close attention would be needed especially for patients at high risk of HJ stenosis, such as high BMI or absence of preoperative biliary stenting.

The occurrence of intra-abdominal sterile abscesses due to remnant clips after laparoscopic sigmoidectomy is rare. Here, we report one such case in a 74-year-old woman. Two years after laparoscopic sigmoidectomy, abdominal CT indicated an area of fluid accumulation approximately 5 cm in diameter and located in the middle of the abdominal cavity that contained a cluster of clips. Fine-needle aspiration of the fluid was performed through the wall of the sigmoid colon. The luminal fluid was found not to contain cancer cells on histological examination. After 1 year, abdominal surgery was performed. The abscess was located in the mesorectum at the anastomosis site; it was incised and a significant quantity of ivory-white viscous solution containing a cluster of clips was extracted. This case emphasizes the importance of reducing the number of clips used in laparoscopic surgery.

Background: Pancreatic cancer is one of the incurable cancers among solid malignancies. Basically, R0 tumor resection could be one of the critical factors for their prognosis. However, pathological diagnosis of surgical margins is sometimes unreliable due to tissue shrinkage and skipped lesion like tumor budding. We applied our ‘molecular surgical margin analysis' using tissue imprinting procedure to evaluate the precise surgical margin status of the surgical specimens after pancreatoduodenectomy. Methods: Quantitative methylation specific PCR (QMSP) assay for 3 representative tumor-specific methylation markers (CD1D, KCNK12, PAX5) were established and validated by paired normal and tumor tissues from pancreatic ductal carcinoma cases (n=48). Then, these markers were applied to prospectively collected peritoneal lavage samples (n=16), drainage fluid samples (n=18) and surgical margin imprinting samples (n=11). Results: QMSP values of tumor tissues were significantly higher than adjacent normal tissues and relatively high specificity to cancer cells in all three markers with optimal cut-off values (CD1D: P Conclusion: Very cancer-specific methylation detection assay was established. Although we still need to follow-up the cases for a year or more, invisible cancer cells in the fluid or on the surgical margin might have an association with tumor recurrence after the surgery. Citation Format: Masamichi Hayashi, Suguru Yamada, Hiroshi Tanabe, Yoshiyasu Kato, Katsuhito Tanaka, MItsuru Tashiro, Haruyoshi Tanaka, Tomonari Asano, Hideki Takami, Masaya Suenaga, Yukiko Niwa, Yasuhiro Kodera. Molecular surgical margin analysis of pancreatic cancers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3330.

症例は54歳の男性．黄疸・食思不振を主訴に入院となった．精査にて，十二指腸乳頭部小細胞癌と診断され，亜全胃温存膵頭十二指腸切除術・リンパ節郭清（D2）を施行した．術後51病日より，CBDCAおよびCPT-11の化学療法を全4コース施行した．その後上腸間膜動脈周囲のリンパ節再発を認め，CDDPおよびVP-16の化学療法と放射線療法を施行し，リンパ節の縮小を認めた．しかし，多発性骨転移を認め，術後247病日に多臓器不全にて死亡した．十二指腸乳頭部小細胞癌は本邦では自験例を含め35例が報告されているが，その予後は極めて不良で，手術に加えて化学療法や放射線療法などより有効な集学的治療法の開発が必要である．

495 Background: The Charlson age comorbidity index (CACI) is a useful measure of comorbidity to standardize the evaluation of surgical patients and has been reported to predict postoperative mortality in various cancers. Methods: A total of 379 patients who underwent R0/R1 resection for pancreatic cancer between 2003 and 2014 were enrolled in this study. According to the CACI, the age-adjusted comorbidity index was calculated by weighting individual comorbidities; CACI < 4 was considered the low-CACI group, whereas CACI ≥ 4 was considered the high-CACI group. The correlations between the CACI and clinicopathologic features and survival outcomes were statistically analyzed. Results: The patients with a high CACI were more likely to be old and had higher CA19-9 levels and lower incidences of portal vein resection and blood transfusion. The rate of patients who received chemotherapy was significantly higher in the low-CACI group than in the high-CACI group (87% vs. 69%, P< 0.0001). There was no difference in relapse-free survival (RFS) between the low- and high-CACI groups; however, the overall survival (OS) rate was significantly higher in the low-CACI group than in the high-CACI group ( P= 0.047). Multivariable analysis showed that a high CACI was a predictor of poor survival. In the high-CACI group, patients with high relative dose intensity (RDI) for postoperative adjuvant chemotherapy had significantly better RFS and OS than those with low RDI (both P< 0.0001). Conclusions: The CACI was a significant independent predictor of prognosis and compliance for postoperative adjuvant chemotherapy and could be clinically useful for decision-making in the treatment strategy for pancreatic cancer.

259 Background: In the past, various prognostic factors in pancreatic ductal carcinoma (PDAC) have been identified, and there found to be not only tumor-specific clinicopathological factors but also individual patient characteristics. In particular, weight loss, muscle wasting and cachexia are hallmarks of PDAC that may be associated with depletion of both skeletal muscle and adipose tissue. Most notably, sarcopenia is defined to be degenerative loss of skeletal muscle mass that is quantifiable using cross sectional imaging computed tomography (CT) by measurement of psoas area and the muscle’s density. Furthermore, visceral adipose tissue loss also has been reported to associate with a poor survival among patients with PDAC. Methods: A total of 265 patients who underwent curative surgery for PDAC were examined in this study. The total skeletal muscle and fat tissue areas were evaluated in a single image obtained at the third lumber vertebra during a preoperative computed tomography (CT) scan. The patients were assigned to either the sarcopenia or non-sarcopenia group based on their skeletal muscle index (SMI) and classified into high visceral fat area (H-VFA) or low VFA (L-VFA) groups. The association of clinicopathological features and prognosis with the body composition were statistically analyzed. Results: There were 170 patients (64.2%) with sarcopenia. The median survival time (MST) was 23.7 months for sarcopenia patients and 25.8 months for patients without sarcopenia. The MST was 24.4 months for H-VFA patients and 25.8 months for L-VFA patients. However, sarcopenia patients with BMI ≥ 22 exhibited significantly poorer survival than patients without sarcopenia (MST: 19.2 vs. 35.4 months, P = 0.025). There was a significant difference between patients with and without sarcopenia who did not receive chemotherapy (5-year survival rate: 0% vs. 68.3%, P = 0.003). The multivariate analysis revealed that tumor size, positive dissected peripancreatic tissue margin, and sarcopenia were independent prognostic factors. Conclusions: Sarcopenia is an independent prognostic factor in PDAC patients with a BMI ≥ 22. Therefore, evaluating skeletal muscle mass may be a simple and useful approach for predicting patient prognosis.

A 63-year-old woman with chief complaints of abdominal distention and vomiting was brought to our hospital in May, 2010. Her radiological examination revealed that she was suffering from perforative peritonitis. The patient underwent emergency open laparotomy. Perioperatively, we made a diagnosis of unresectable transverse colon cancer accompanied with tough peritoneal dissemination, and therefore performed intraperitoneal irrigation drainage, transverse loop colostomy and biopsy of omental dissemination. A pathological examination of omental dissemination demonstrated mucinous adenocarcinoma with the wild-type Kras gene, and the cytology of ascites was negative. FOLFOX4 combined with panitumumab therapy was initiated 1 month after the operation. Seventeen courses of this chemotherapy regimen were performed, although adverse events including grade 3 neutropenia and grade 2 skin symptoms were noted. Consequently, serum CEA levels decreased to 5. 5 ng/mL, although the size of the primary lesion of transverse colon cancer was unchanged on abdominal computed tomography(CT). Chemotherapy has been continued without marked side effects, although 1 year has passed since we started medical treatment for this difficult case. We found that a multidisciplinary approach with a focus on FOLFOX4 therapy combined with panitumumab is useful for patients with highly advanced mucinous adenocarcinoma of the colon that develops into peritoneal dissemination.

We compared stair-step artifacts and radiation dose between prospective electrocardiography (ECG)-gated coronary computed tomography angiography (prospective CCTA) and retrospective CCTA using 64-detector CT and determined the optimal padding time (PT) for prospective CCTA.We retrospectively evaluated 183 patients [mean heart rate (HR)65 beats/min, maximum HR instability5 beats/min] who had undergone CCTA. We scored stair-step artifacts from 1 (severe) to 5 (none) and evaluated the effective dose in 53 patients with retrospective CCTA and 130 with prospective CCTA (PT 200 ms, n = 32; PT 50 ms, n = 98).Mean artifact scores were 4.3 in both retrospective and prospective CCTAs. However, statistically more arteries scored3 (nonassessable) on prospective CCTA (P0.001). Mean scores for prospective CCTA with 200- and 50-ms PT were 4.1 and 4.3, respectively (no significant difference). The radiation dose of prospective CCTA was reduced by 59.1% to 80.7%.Prospective CCTA reduces the radiation dose and allows diagnostic imaging in most cases but shows more nonevaluable artifacts than retrospective CCTA. Use of 50-ms instead of 200-ms PT appears to maintain image quality in patients with a mean HR65 beats/min and HR instability of5 beats/min.

We report a rare case of primitive neuroectodermal tumor of the kidney. The diagnosis was confirmed by the immunohistochemical profile and fluorescence in situ hybridization in formalin-fixed, paraffin-embedded tissues. The patient received intensive chemoradiotherapy after radical surgery and remains alive without recurrence 1 year after initial presentation.