A case of effective neoadjuvant chemoradiotherapy with capecitabine for locally advanced sigmoid colon cancer

A 60-year-old man was hospitalized for urodynia. Clinical examinations demonstrated a locally advanced sigmoid colon cancer with direct extension to the bladder, rectum, and pelvic wall. We considered that curative resection was not possible and performed temporary colostomy for fecal diversion. After colostomy, he was treated with neoadjuvant chemoradiotherapy(NACRT)for down staging. The radiation therapy was delivered with 45 Gy(1. 8 Gy/fraction; 5 days/week×5 weeks), and the concurrent chemotherapy was performed with capecitabine(825mg/m2 twice daily on radiotherapy days). CT scan confirmed a dramatic response with downstaging of the tumor following NA-CRT(clinical response, PR in the RECIST criteria). Invasion of the tumor to pelvic wall disappeared on CT scan, and[18F]fluorodeoxyglucose positron emission tomography( FDG-PET)failed to demonstrate any distant metastasis. We considered that the tumor was hence resectable and performed total pelvic exenteration(TPE)1 month after NACRT. A pathological examination of surgical specimens confirmed a R0 resection. The patient made an unremarkable postoperative recovery. He went on to receive adjuvant capecitabine chemotherapy, completing four cycles. He remains well and disease-free 10 months following surgery. NACRT with capecitabine appears effective even for unresectable locally advanced sigmoid colon cancer.     

膀胱体积变化对宫颈癌近距离放疗的影响

目的:分析膀胱体积变化对宫颈癌近距离治疗中肿瘤和正常组织受量的影响。方法:2015年1月至2017年12月于本院首诊的66例拟行根治性放疗的宫颈癌患者,治疗方案采用外照射放疗同期化疗加近距离治疗。均采用同期顺铂40 mg/m2每周方案化疗,外照射均采用常规分割外照射放疗,1.8~2 Gy/次,1次/天,5次/周,盆腔预防放疗剂量45 Gy/25次,阳性区域转移淋巴结处方剂量55~57.5 Gy/25次。后装采用三维自适应近距离放疗,A点剂量6 Gy每次,共4次,采用宫腔管和双侧阴道穹窿管或环形施源器,在定位CT图像上勾画高危临床靶区（high risk clinical tumor volume,HRCTV）、膀胱、直肠、乙状结肠,制定后装治疗计划后行近距离放疗。结果:后装近距离治疗期间,随着膀胱体积增大,膀胱D1cc、D2cc接受的放疗剂量逐渐升高,有显著统计学差异（P<0.001）,其中小于49.25 ml膀胱体积组膀胱受辐射量最小。而膀胱体积的变化不影响直肠D1cc和D2cc、乙状结肠D1cc和D2cc、HRCTV D90和HRCTV D95。随着后装次数的增加,膀胱体积有逐渐增加的趋势,虽然第一次后装时膀胱体积与第二、三次后装时膀胱体积无统计学差异,但是第一次后装时膀胱体积与第四次后装时膀胱体积有统计学差异(P=0.02)。结论:近距离治疗过程中控制膀胱体积可以减少膀胱受照射剂量,近距离治疗期间控制膀胱体积小于49.25 ml可能是一个更好地选择。     

A case of lung metastasis from colon cancer controlled effectively by the stereotactic radiotherapy

A 73-year-old man underwent a sigmoid colon resection and an insertion of a hepatic arterial infusion catheter for multiple liver metastases from sigmoid colon cancer. After the hepatectomy, the patient was detected a lung metastasis and was scheduled to undergo mFOLFOX6 chemotherapy. The tumor lesion was reduced once in size, but it has grown again after the chemotherapy. So, we underwent a stereotactic radiotherapy (60 Gy/10 Fr). The tumor lesion became a scar and the patient was doing well without any recurrence at 21 months after undergoing stereotactic radiotherapy. Lung resection has a better result than other treatments for a lung metastasis caused from colon cancer, but there are some cases with no indication of the operation due to a complication. Stereotactic radiotherapy can be an effective treatment for lung metastasis from colon cancer with no indication of the operation.     

Studies on the results of operations for carcinoma of the sigmoid colon

Of 734 patients with colorectal cancer operated on during the past 21 years, 142 had carcinoma of the sigmoid colon. Curative resections were performed in 103 patients and non-curative resections in 22, the resection rate being 88.0%. Among 103 patients with curative resection, resection of the sigmoid colon was performed in 79, and their 5-year survival rate was 84.6%. Eight patients died within 5 years due to recurrence. Many of them had the constricting type macroscopically and Dukes C with positive lymph node metastasis. Therefore, in such cases, resection of the sigmoid colon with extended lymph node dissection or left hemicolectomy should be performed.     

Esophageal cancer with colonic metastasis successfully treated by chemoradiotherapy followed by chemotherapy with S-1 and cisplatin

A 51-year-old man was hospitalized for evaluation of dysphagia and bloody stool. Gastrointestinal endoscopy showed esophageal cancer invading the gastric fundus. A metastatic lesion was demonstrated in the sigmoid colon. The patient agreed to have concurrent chemoradiotherapy for the primary lesion, followed by additional chemotherapy. The first course included 30Gy of radiotherapy given over 3 weeks, together with daily oral administration of S-1 (80mg/m² per day) for 2 weeks, and a 24-h infusion of cisplatin (70mg/m²) on day 8. After a second course of chemoradiotherapy, four additional courses of chemotherapy with S-1 and cisplatin were administered, at 4-week intervals. After the additional chemotherapy, gastroscopy and colonoscopy showed disappearance of both the primary and the metastatic lesions. One year after his initial hospitalization, no recurrence of either the primary or the metastatic tumor lesions is evident.     

A case of esophageal cancer successfully treated by chemoradiotherapy after resection for multiple liver metastasis of sigmoid colon cancer

The patient was a 56-year-old man. Colonoscopic findings showed a cancerous lesion of the sigmoid colon and we performed curative sigmoidectomy. Four months after the operation, abdominal CT scan revealed multiple metastatic lesions in the liver. We performed lateral segmentectomy and partial resection of the S4, S6, S8 segments and cannulation for hepatic arterial infusion chemotherapy. Continuous hepatic arterial infusion chemotherapy with 5-FU (1,000 mg/body/day) was performed for two weeks as a postoperative adjuvant chemotherapy. Immediately after the therapy, endoscopic examination for upper digestive tract showed a 0-lpl type cancer lesion in the middle of the thoracic esophagus. Concurrent chemoradiotherapy with low-dose FP was efficacious and a complete response was obtained. The patient has survived for nine months after the operation without any sign of recurrence. It is suggested that concurrent chemoradiotherapy an effective treatment for esophageal cancer.     

A case of stage IV gastric cancer treated sequentially for over two years by TS-1, paclitaxel, and CPT-11

We report a patient with advanced stage IV gastric cancer treated by chemotherapy for over two years. The patient was a 69-year-old man with paraaortic lymph node metastasis of gastric cancer. He underwent a distal gastrectomy in non-curative resection. After surgery, chemotherapy with TS-1 (100 mg/body/day) was performed. At 7 months after surgery, progression of lymph node metastasis in porta hepatis was recognized, and paclitaxel was administered at a weekly dose of 80 mg/m(2) for 3 weeks followed by one week rest. He remained stable for 12 months under paclitaxel treatment. At 26 months after surgery, progression of lymph node metastasis in porta hepatis was recognized again, and CPT-11 was administered at a bi-weekly dose of 80 mg/m(2). Although the patient died two years seven months after surgery, the chemotherapy with sequential administration of TS-1, paclitaxel and CPT-11 was thought to be effective for advanced gastric cancer.     

A case of mediastinal lymph node metastasis from rectal cancer successfully treated by carbon ion radiotherapy

We report a case of mediastinal lymph node metastasis from rectal cancer successfully treated by carbon ion radiotherapy. A 65-year-old woman underwent sigmoid colostomy against unresectable rectal cancer. After chemoradiotherapy, primary rectal cancer became resectable and low anterior resection was performed. Curative local resection was done and chemoradiotherapeutic effect was grade 2. Chemotherapy after the operation wasn't effective enough and the size of the mediastinal lymph node increased. So she underwent carbon ion radiotherapy (52.8 Gy) which markedly decreased the lymph node size (-48%). Multi-modality therapy, such as radiation, chemotherapy, operation and carbon ion radiotherapy was applied. Successfully, locally advanced rectal cancer was resected and distant lymph node metastasis was controllable.     

Successfully treated case of hypopharyngeal and cervical esophageal squamous cell carcinoma with laryngeal preservation

The patient suffering from getting something lodged was admitted to our hospital in October 2008. He was diagnosed as hypopharyngeal cancer (cT2N1M0, cStage III) and cervical esophageal cancer (cT2N1M0, cStage III). Firstly he was administered 5-FU, DXR and CDDP as induction chemotherapy. The response evaluation was PR according to RECIST criteria. After the induction chemotherapy, he was treated with chemoradiotherapy (64.8 Gy/54 fr, concurrent with weekly DOC 10 mg/m2). Since cervical lymph node metastases were still remaining with complete response of the primary sites, we performed a neck lymph node dissection as salvage surgery in July 2009. There has been no evidence of recurrence after the salvage surgery.     

A case of long-term survival after curative resection of advanced rectal cancer treated by pre-operative chemoradiotherapy

We report a long-term survival case of rectal cancer that was initially thought unresectable treated with chemoradiotherapy (CRT). The patient was a 50s female with advanced rectal cancer and liver metastasis. The primary tumor was expanded locally and made abscess around the rectum. We evaluated the primary lesion as unresectable, and we performed CRT after colostomy. After radiation therapy (total 60 Gy) and chemotherapy with S-1 (3 courses), the primary tumor was remarkably reduced. The liver metastasis showed a progressive growth in size but not in number. She underwent complete resection of rectal tumor and partial resection of metastatic liver tumor. Postoperative course was uneventful, and she is alive without a recurrence for 5 years after the surgery.     

Successful management of the recurrent esophageal cancer following esophagectomy at a different time with combined local treatment of chemoradiotherapy and hepatic arterial infusion chemotherapy

A 63-year-old man who underwent radical resection for esophageal cancer (cStage III)was diagnosed with metastasis of the paraaortic lymph node 5 months after the surgery. He was treated with concomitant chemoradiotherapy (CRT)with low-dose FP(5-FU, CDDP)and 60 Gy of irradiation. The effect of CRT was a complete response. Seven months later, there was a metastasis to the liver(S4). He received systemic chemotherapy(5-FU, ADR, CDDP: FAP), but it was not effective, so hepatic arterial infusion chemotherapy(FAP)was performed. Hepatic artery infusion therapy( 5-FU 1,000 mg/3.5 h x ADR 10 mg/1 h x CDDP 10 mg/1 h)was given for 1 day at an interval of 2 weeks for 18 months. Since ADR reached the maximum dose, hepatic artery infusion of 5-FU(1,000 mg/3.5 h)and CDDP(10 mg/ 1 h)was continued for 14 months at an interval of 4 weeks. The recurrent lesion disappeared completely 9 months after beginning hepatic artery infusion therapy. The patient is alive 69 months after surgery without any evidence of recurrence. Most cases with recurrent esophageal cancer have multiple metastases, and the treatment is mainly systemic therapy. However, in a patient with recurrent tumors at different times, it is possible to achieve a complete response and long-time survival by local treatment with fewer side effects as in this case. Combined local treatments could be the second treatment option after failed systemic chemotherapy for recurrent tumors in patients with esophageal cancer. Further investigations are necessary.     

Two cases of colon cancer after resection of recurrence at peritoneal dissemination were for long-term survival with adjuvant chemotherapy

Generally the peritoneal dissemination of digestive cancer was difficult to control. The symptom of dissemination will decrease quality of life (QOL) for these patients. The diagnosis for the range of dissemination was difficult. Therefore, the decision of the treatment was wavered between an operation and chemotherapy. The effect of chemotherapy was controversial so the cure was inconsistent. We experienced with two recurrent colon cancer patients who underwent resection of peritoneal dissemination and adjuvant chemotherapy. Case 1 was a 62-year-old man. He was operated for left colectomy against descending colon cancer with perforation. After two years, the recurrence of peritoneal dissemination and short bowel obstruction appeared. He was performed short bowel resection and FOLFIRI chemotherapy after surgery. Case 2 was a 72-year-old woman. She was operated on sigmidectomy against sigmoid colon cancer. After three years, the recurrence of peritoneal dissemination at the anastomotic lesion appeared. She was performed low anterior resection (LAR) and S-1 chemotherapy after surgery. But after 3.5 years, the peritoneal dissemination at the anastomotic lesion appeared once more. We decided to have LAR operation and FOLFOX 4 chemotherapy. Both cases maintained a good QOL for a long time. The operation against peritoneal dissemination was one of the good treatments if the range of peritoneal dissemination was clearly restricted.     

A case of colon cancer with long-term survival treated by resection of recurrence on the rectum and chemotherapy for lung metastasis

A 69-year-old male was operated on sigmoidectomy for sigmoid colon cancer (SS, N2, H0, P0, M0, stage IIIb) 7 years ago. Two years later, he was diagnosed for rectal cancer and bilateral lung metastases by TBLB. We performed Mile's operation, and the rectal focus was pathologically diagnosed with a recurrence of sigmoid colon cancer. After surgery, chemotherapy with FOLFOX was started for bilateral lung metastases, resulting in CR during the 22 months. But bilateral lung metastases were exacerbated, and then we administered several other chemotherapies. Five years have passed since chemotherapy started, although the focuses tended to progress. Right now, he has been a chemotherapy outpatient for last 5 years.     

局部晚期宫颈癌CT图像引导下192Ir三维腔内后装治疗剂量体积参数与疗效关系

目的 观察CT图像引导下192Ir三维腔内后装治疗的肿瘤靶区及危及器官受照射体积剂量参数与肿瘤局部控制率及晚期副反应之间关系.方法 10例局部晚期宫颈癌患者在完成盆腔外照射40 Gy及同期化疗后开始每周1次的CT图像引导下192Ir三维腔内后装治疗,每次治疗前进行CT扫描定位,勾画肿瘤靶区(GTV、CTV)和危及器官,利用PLATO治疗计划系统进行逆向治疗计划设计及优化,CTV单次处方剂量为6 Gy,治疗5～7次.结果 1年盆腔控制率为90%,1～2级放射性肠炎发生率为50%,无≥3级副反应.90%CTV等效生物剂量(BED)和相当于2 Gy分次的等效剂量(EQD2)分别为(95.50±7.81)Gy和(79.73±6.57)Gy(α/β=10).90%GTV的BED和EQD2分别为(101.86±7.27)Gy和(84.95±6.1)Gy(α/β=10).90%处方剂量对GTV、CTV的覆盖率分别为92%±4%、87%±7%.直肠、乙状结肠2 cm3体积受到的最小照射剂量分别为(74.97±1.64)、(67.93±4.30)Gy(EQD2,α/β=3).与二维治疗计划相比,三维治疗计划在没有改变A点剂量、直肠参考点剂量情况下提高了GTV、CTV的90%体积受照射剂量及90%处方剂量对GTV、CTV的覆盖率.结论 CT图像引导下192Ir三维腔内后装治疗提高了处方剂量对肿瘤靶区的覆盖率,1年盆腔控制率为90%且无严重副反应,远期疗效观察中.

Abstract：

Objective To investigate the correlation between dose volume histogram(DVH)of tumor targets and organs at risk(OAR)at CT-image based 192Ir brachytherapy and effects and complications for patients with locally advanced cervical cancer. Methods Ten patients with FIGO stage ⅢB cervical cancer received CT image-based 192Ir intracavitary brachytherapy after 54 Gy of three-dimentional four-field pelvic external beam radiotherapy and concurrent weekly cisplatin chemotherapy. Before each brachytherapy,CT images were acquired with applicators in place. Gross tumor volume(GTV), clinical target volume (CTV)and OAR were contoured and inverse treatment planning was designed and optimized by using PLATO treatment planning system. Conventional two-dimensional plans were also designed for comparison.The total intracavitary brachytherapy dose was 30 -42 Gy in 5 -7 fractions. The patients were followed, and the local control and complications were analyzed. The biologically equivalent dose(BED)and biologically equivalent dose in 2 Gy fractions(BED2)for GTV, CTV and OAR were calculated. The minimum dose in the most irradiated tissue volume 2 cm3(D2 cm3)adjacent to the applicator of the sigmoid colon, rectum,bladder and small bowel was determined from the DVH. Results The 1-year local pelvic control rate was 90% and grade 1-2 late complication of sigmoid colon and rectum was 50%. No grade 3 or more complications developed. On CT-image based planning, the BED and BED2 to 90% of the CTV(D90)were 95.50 Gy ± 7. 81 Gy and 79. 73 Gy ± 6. 57 Gy. The BED and BED2 to 90% of the GTV(D90)were 101.86 Gy ± 7.27 Gy and 84. 95 Gy ± 6. 1 Gy. The volume enclosed by 90% of prescribed dose(V90)for GTV and CTV were 92% ±4% and 87% ±7% respectively. The D2cm3 for rectum and sigmoid colon were 74. 97 Gy ±1.64 Gy and 67. 93 Gy ± 4. 30 Gy(EQD2, α/β = 3). Comparing with 2D brachytherapy plans , CT - image based planning has improved D90 and V90 for GTV and CTV with similar dose at point A and rectum reference point. Conclusions Computer tomography-image based 192Ir brachytherapy has resulted in the better dose distribution to the tumor targets with excellent tumor control and acceptable toxicity.     

Repeated resections for originally unresectable liver metastasis from colorectal cancer after multiagent chemotherapy

We describe the case of a 74-year-old man with liver resection for originally unresectable liver metastasis from colorectal cancer after multiagent chemotherapy. Eleven bilobar liver metastases appeared four months after curative resection for double cancer of sigmoid colon and upper rectum. After 6 courses of multiagent chemotherapy (mFOLFOX 6 with bevacizumab), the number of liver metastasis decreased from 11 to 5. The patient underwent curative resection for liver metastasis. A new lesion of 7 mm in the segment 6 appeared 8 months after an initial liver resection. After 3 months' observation, two more liver metastases appeared. All liver metastases were resected. Solitary lung metastasis appeared 10 months after the second liver resection. The lung metastasis was also resected. The patient was alive with no evidence of disease in 33 months after the initial liver resection. We experienced the case with repeated liver resections after multiagent chemotherapy for originally unresectable bilobar liver metastasis. The therapeutic strategy which combines surgical resection with cytotoxic chemotherapy will be important more than ever.     

Estimated Dose to the Rectum and Colon in Prostate Cancer Patients Treated with Exclusive Radiation Therapy Presenting a Secondary Colorectal Malignancy

AimsTo estimate the dose to colorectal structures after external beam radiation therapy (EBRT) delivered to prostate cancer patients who developed secondary colorectal cancers (sCRC).Materials and methodsUsing data from a population-based cancer registry of 1134 prostate cancer patients, 11/264 (4.2%) patients treated with EBRT presented a sCRC. To evaluate the dose delivered to the colon and rectum, each individual index patient was matched with a study case and, using the index case treatment characteristics, dose calculations were carried out on the latter.ResultsThe median maximum, mean and minimum doses delivered to the colon or rectum affected by the sCRC were 39.3 (range 0.2–66.0), 5.4 (range 0.2–41.3) and 0.6 (range 0.2–7.8) Gy, respectively. All but three sCRCs occurred outside the treatment fields. The estimated rectal doses after prostate radiation therapy were substantially higher than those delivered to non-rectal colic structures (mean dose 47.2 ± 16.6 vs 9.4 ± 6.4Gy), but only one (9%) patient presented a rectal cancer. The differential mean doses given to the rectosigmoid junction and sigmoid colon, with or without sCRC, were not different.ConclusionsThese data suggest that the administered dose after EBRT for prostate cancer to the colon, excluding the rectum, may be below the Gy unit in sCRC patients.     

Regression of adenomas in Gardner's syndrome induced by systemic chemotherapy

A 31-year-old male was admitted to our hospital with Gardner's syndrome and sigmoid colon cancer. Palliative resection (sigmoid colectomy) was performed due to hepatic and lymph node metastasis. Systemic chemotherapy with MMC, 5-FU and PSK was started postoperatively. Barium enema study on the 23rd successive post-operative day and fiberscopic study on the 134th post-operative day showed regression of the size and number of the polyps in the remaining colon and rectum. We suggest that the administration of anticancer drugs may be useful in the treatment of familial polyposis or Gardner's syndrome which have been treated with only surgical therapy.     

A case whose lung metastasis was detected and resected eleven years after resection of primary colon cancer

In July 1999, a 79-year-old man underwent sigmoidectomy and D3 lymphadectomy for sigmoid colon cancer (ss, n(-), stage II, cur A). In September 2000, hepatectomy of right lobe and cholecystectomy were performed for his liver metastasis. Every three to six months follow-up had been kept since adjuvant chemotherapy (200 mg/day of 5-FU per os for two years) completed. Eleven years and two months after sigmoidectomy (in September 2010), a chest X-ray examination detected a small nodule in upper area of his right lung, which was diagnosed as either primary lung cancer or metastatic lung tumor followed by chest CT scan and PET-CT examination. In November 2010, laparoscopy-assisted partial resection of his right lung was performed. Histochemical examination of the resected lung tumor resulted cytokeratin 7(-), cytokeratin 20(+) and TTF-1(-), confirming its final diagnosis as lung metastasis from sigmoid colon cancer. He has been alive for six months without any recurrence since resection of his lung metastasis. It was a very rare case to have more than ten-year interval between colon cancer resection and detection of its lung metastasis. However, when we diagnosed the patient with lung tumor, who had undergone a colorectal resection, we should consider if he had a lung metastasis from colorectal cancer.     

A case of low anterior resection combined with resection of the prostate seminal vesicle urethra for douglas' pouch metastasis of the colon cancer

A-71-year-old man with sigmoid colon cancer underwent sigmoidectomy in 2004. Ascites cytology was positive. He had a postoperative chemotherapy, but cancer recurred on the Douglas' pouch in the first year after the surgery. After chemoradiation, he underwent a low anterior resection with combined resection of the prostate seminal vesicle urethra in 2005. Four years after the recurrence, metastasis of the right lung S9 occurred, and he underwent right lower lobectomy. One year later, metastasis of the left lung S6 occurred, he underwent a partial resection of S6. Later a local recurrence has not been observed. Among the colon cancer recurrence, we think the surgery was effective for local recurrence disease with adequate observation.     

A case report--TS-1/CDDP combined chemotherapy found effective for metastatic recurrence after operation for colon cancer

A 68-year-old male with a history of gastric resection for gastric cancer underwent resection of the sigmoid colon for a sigmoid colon cancer in February, 2000. The cancer was classified as stage III b. After operation, l-LV + 5-FU therapy was administered, but metastases to the abdominal wall, right inguinal lymph node and spleen developed in succession, and resection was repeated. In October 2001, 1 year and 8 months after sigmoidectomy, however, multiple metastasis to the intraperitoneal lymph node had developed. As surgery was not indicated, TS-1/CDDP combined chemotherapy was started. TS-1 80 mg/day was administered for 4 weeks, the drug was withdrawn for 2 weeks and CDDP 80 mg was injected by intravenous drip at the 8th day of TS-1 administration, which was used as one course. From the second course after inception of the administration, CA19-9 decreased, and after the third course the upper intraperitoneal metastatic lesion disappeared on CT. CR has been continued for 4 months up to the present. Our results suggest a possibility that this therapy is effective not only for gastric cancer but also for colon cancer. This therapy can be administered at home. It is considered to be a useful therapy from the viewpoint of QOL as well. The high DPD activity of the tumor may have been one reason this treatment was effective. This case also seems significant from the viewpoint of attaining individualization of the drug selection in chemotherapy.