Survival After Curative Resection for Mucinous Adenocarcinoma of the Colorectum

PURPOSE: Previous reports have suggested that mucinous colorectal adenocarcinomas are more advanced at diagnosis and have a poorer prognosis than nonmucinous colorectal adenocarcinomas. The purpose of this study was to clarify whether the mucin-producing histologic type of carcinoma is associated with a worse prognosis than nonmucinous, differentiated colorectal adenocarcinoma for patients who undergo curative surgery. METHODS: Using a database of 2,678 surgical patients with colorectal cancers operated on at Aichi Cancer Center between 1965 and 1994, we investigated 97 cases of mucinous adenocarcinoma and 2,197 cases of nonmucinous adenocarcinoma. We also evaluated the outcomes of patients who underwent surgery with curative intent. To determine whether the mucinous adenocarcinoma itself was an independent prognostic factor in the curative resected patients, a multivariate analysis was performed. RESULTS: The mucinous adenocarcinoma patients were found to be younger (P = 0.0003), have more lymph node involvement (48.5 vs. 40.3 percent; P = 0.0564), more peritoneal dissemination (19.6 vs. 5.6 percent; P < 0.0001), greater frequency of advanced stage disease (P = 0.0006), a lower rate of curative resection (76.3 vs. 84.4 percent; P = 0.0450), and lower overall 5-year survival rates (41 vs. 62.4 percent; P = 0.0002) than nonmucinous adenocarcinoma patients. In the subjects who underwent curative resection, the 5-year survival rate for those with mucinous adenocarcinoma was significantly worse than for those with nonmucinous adenocarcinoma (54 vs. 73.3 percent; P = 0.0020). Multivariate analysis using the Cox proportional hazards model showed that the clinically significant predictive factors were stage at diagnosis, mucinous histology, tumor location, gender and age. The mucinous histologic type itself was an independent factor for poor prognosis for patients who underwent curative surgery. CONCLUSIONS: In patients with colorectal carcinomas who underwent surgery with curative intent and who had colorectal carcinomas of the mucinous histologic type, there was significant correlation with prognosis as measured by overall survival rate after adjustment had been made for major confounders.     

Coronary artery bypass grafting following in-stent restenosis of drug-eluting stents deployed in the left main coronary artery.

Two cases of drug-eluting stent restenosis after percutaneous coronary intervention in the left main coronary artery and its bifurcation are presented. An off-pump coronary artery bypass grafting following in-stent restenosis was performed. Drug-eluting stents have shown a reduced frequency of in-stent restenosis and a good safety profile compared with bare metal stents. However, intervention with drug-eluting stents for left main coronary artery disease should be undertaken with care. It is also important to note that preoperative anti-platelet drug administration can increase the risk of major bleeding during and after emergent surgery.     

Analysis of immunological characteristics of newly isolated strains of Rickettsia tsutsugamushi using monoclonal antibodies

Since 1975, there has been an increase in the number of patients with tsutsugamushi disease in Japan, and marked antigenic heterogeneity has been found among newly isolated strains of Rickettsia tsutsugamushi. For antigenic analysis of these strains, we produced monoclonal antibodies against the Irie strain isolated in 1971, and the Hirano and Shimokoshi strains isolated in 1980. In all, 34 monoclonal antibodies were produced and their reactivities were determined by the immunofluorescent antibody test. The serological reactivity of the antibodies against these three strains and classic representative strains (Gilliam, Karp and Kato) showed varied reactive characteristics, i.e., serotype-specific, species-specific and intermediate reactivities. It was revealed that these strains are antigenically different from the classic ones. Moreover, by using the serotype-specific monoclonal antibodies, nine strains newly isolated in Miyazaki Prefecture were classified into the Irie and the Hirano types. The antigenicity of the Shimokoshi strain differed from those of the other strains used in this study. From these results, the strains of R. tsutsugamushi used in this study fell into six serotypes including the classic strains. SDS-PAGE and immunoblotting were performed to determine the molecular sizes of the antigenic polypeptides. The results revealed that the serotype-specific antigens belong to the 60-kDa class whereas the species-specific antigens belong to the 61-kDa, 60-kDa or 44-kDa class.     

The HEARTSTRING proximal seal system is a possible source of atheroembolism.

It is necessary to use side clamps to construct proximal anastomoses in off-pump coronary artery bypass, and this can be related to neurologic complications. Recently a new device, the HEARTSTRING device, was developed. We present a 78-year-old man who underwent emergent bypass surgery using the HEARTSTRING device to avoid a side clamp. We found atherosclerotic debris from the punched hole and, unfortunately, a postoperative neurological complication resulted. We strongly suggest that it is most important that potential candidates for the HEARTSTRING device be carefully selected to reduce possible neurologic complications. We report that while this new device is useful, there is a potential pitfall in using it; that it is a possible source of atheroembolism.     

Implantation metastasis along the percutaneous transhepatic biliary drainage sinus tract

We describe herein the case of a 75-year-old man with metastatic tumor seeding at the percutaneous transhepatic biliary drainage tract that occurred following a pylorus-preserving pancreatoduodenectomy for carcinoma of the distal common bile duct. On postoperative day 30, the catheter was removed and ethanol was injected into the percutaneous transhepatic biliary drainage sinus tract to prevent cancer implantation. One year and 3 months after the initial operation, abdominal computed tomography showed dilation of the left lateral segmental bile ducts and a 2-cm mass. The location of this mass corresponded to the puncture point from the previously performed percutaneous transhepatic biliary drainage. Implantation of the bile duct carcinoma at the percutaneous transhepatic biliary drainage sinus tract was diagnosed, and the recurrent tumor was successfully resected by performing a left hepatic lobectomy. Currently, 1 year after the second operation, the patient is in good health without any signs of recurrence. This case report demonstrates the importance of resecting the percutaneous transhepatic biliary drainage sinus tract during the initial surgery. If left in place, careful follow-up and awareness of this mode of tumor recurrence may lead to a timely resection, with preservation of a good quality of life and long-term survival.     

The first case of tsutsugamushi disease in Ehime Prefecture

The first case of tsutsugamushi disease in Ehime Prefecture was experienced in December 1987 with successful isolation of the causative agent. The patient was taken ill twelve days after infection. Immunofluorescent antibody tests using the isolate, Yamazaki strain, and Gilliam, Karp, Kato, Irie and Shimokoshi strains as antigens revealed that the specific antibodies against these antigens appeared and increased in the blood of the patient during the course of the disease. And the antibody titers to the Yamazaki antigen were the highest of these antigens. Agglutinin for Proteus OXK did not appear in the blood of the patient. The immunofluorescent antibody test using type-specific monoclonal antibodies to Gilliam, Karp, Kato, Irie and Shimokoshi strains and these five strains and the Yamazaki strain as antigens revealed that the Yamazaki strain was identified as Karp type of Rickettsia tsutsugamushi.     

Coronary disease morphology and distribution determined by quantitative angiography and intravascular ultrasound--re-evaluation in a cooperative multicenter intravascular ultrasound study (COMIUS).

Although previous studies have demonstrated that even quantitative coronary angiography (QCA) can not provide accurate disease morphology, there has not been a systematic comparison of disease morphology determined by QCA and intravascular ultrasound (IVUS), particularly in Japanese patients. Therefore, the present study prospectively examined patients in a multicenter cooperative study. A total of 491 coronary sites from 562 patients (446 men, 116 women; mean age, 64+/-11 years) who underwent coronary interventions were enrolled. The target lesions (>50% diameter stenosis) were evaluated pre-operatively by both QCA and IVUS operating at 30-40 MHz and the percent area stenosis, eccentricity index (EI) and lesion length were determined. The minimal (min) and maximal (max) distances from the center of the stenotic lesion to the outline of the vessel wall were measured, and the EI was calculated by the formula: [(max - min)/max]. By QCA, lesion length was determined by measuring the distance between the proximal and distal shoulders of the lesion. When the lesions were observed by IVUS with a motorized pull-back system, the length was calculated by multiplying the time for observation of the disease and 0.5 or 1 mm/s. Although the severity of the stenosis determined by QCA (86+/-10%, mean +/- SD) did not differ from that by IVUS (83+/-13%), there was no correlation between them (r=0.32, y=0.25x+65) and the correlation did not improve when lesions with remodeling, enlargement (n=176) or shrinkage (n=79) were omitted from the calculation. The EIs by QCA and IVUS were 0.51+/-0.26 and 0.52+/-0.22, respectively (NS), and there was no correlation between them (r=0.30, y=0.36x+33). However, when the lesions with remodeling were excluded, the correlation greatly improved (r=0.80, y=0.84x+10.6, p<0.05). Lesion length determined by QCA (12.4+/-6.1 mm) was significantly shorter than that by IVUS (16.3+/-8.9 mm, p<0.01). These results demonstrate that coronary angiography significantly misinterprets disease morphology in terms of severity, eccentricity and length, in part because of vessel remodeling that can be accurately determined only by IVUS.