A case of locally extended rectal cancer responding to intra-arterial infusion therapy via the internal iliac artery

Chemotherapy with combined administration of 5-FU and l-Leucovorin has been reported to be effective for advanced rectal cancer. A 61-year-old woman with a huge, locally extended advanced rectal cancer was treated with intra-arterial infusion therapy via internal iliac artery. Catheters were inserted from the bilateral femoral arteries to the opposite internal iliac arteries and the bilateral upper and lower gluteal arteries and lateral sacral artery were embolized with a metallic coil. The port was positioned under the skin of her lower abdominal wall. The chemotherapy regimen was 5-FU (500 mg/body) and l-Leucovorin (250 mg/m2), administered over 5 hours once weekly to bilateral reservoirs through an infuser pump. After 5 sessions of the chemotherapy, the perineal pain decreased and the patient no longer needed morphine. Following 34 administrations (at 10 months) of this regimen, reductions of tumor size on pelvic CT and CEA level were confirmed. Side effects of the intra-arterial infusion chemotherapy were pygal dermatitis, leg desensitization, infection of circumferential reservoir and obstruction of the catheter due to flection were observed. Local intra-arterial infusion chemotherapy via the internal iliac artery appears to be effective for local advanced rectal cancer.     

“On Table” Positioning for Optimal Access for Cancer Excision in the Lower Rectum

Poor visualization and restricted access often make tumor lesions in the lower rectum difficult to excise, particularly in a narrow male pelvis. The aim of this study was therefore to study whether (and if so to what extent) different positions of the patient on the operating table might improve accessibility. Twenty consecutive patients (men and women) undergoing laparotomy with surgery of the lower rectum were studied. The geometric configuration of the pelvis was studied and compared on lateral radiographs obtained at the operating table in each of four positions. Compared with the conventional lithotomy position, the thighs-flat position caused significant extension movement of the lumbosacral joint. Augmentation of the lumbar lordosis widened the pelvic view and enabled a more vertical view of the lower rectum (27.5 degrees in lithotomy position, 13.0 degrees in the thighs-flat position). Insertion of a lumbar pad contributed further to the augmentation (7 degrees). When compared on radiographic studies, the thighs-flat position is preferable to the conventional lithotomy position in terms of facilitating low rectal surgery by improving both visibility and accessibility to the pelvic cavity.     

Partial nephrectomy for small localized renal cell carcinoma

We retrospectively reviewed the records of 54 patients with RCC who underwent partial nephrectomy for the primary lesion between 1992 and 2001. The indications for partial nephrectomy were elective in 43 and imperative in 11 patients. We selected 51 patients with clinical stage T1a who underwent open radical nephrectomy for localized RCC for comparison during the same period. We evaluated the peri- and postoperative complications, disease-free survival rates and changes of renal function in the partial nephrectomy (PN) group, compared to the radical nephrectomy (RN) group. There was no significant difference with regard to pathological findings and clinical outcomes between two groups, except for the amount of intraoperative bleeding. Three patients in the PN group developed postoperative complications, consisting of urine leakage in 2 patients and renal hypertension in 1 patient. The 5-year disease-free survival rates in the PN and RN groups were 90% and 97%, respectively. Local recurrence from the resected area of the renal parenchyma was not found in patients in the PN group. All patients in the PN group maintained satisfactory and stable renal function. In the RN group, renal function slowly deteriorated in 2 patients. Therefore, partial nephrectomy offers cancer control and an acceptable low mortality rate, comparable to those of radical nephrectomy.     

Analysis of clinical manifestations and endocrinological aspects of patients having PADAM-like symptoms

PURPOSE: To analyze clinical manifestations and endocrinological aspects of the patients who visited our hospital to be examined for partial androgen deficiency in the aging male (PADAM). MATERIALS AND METHODS: Two hundred forty-three patients were evaluated. History taking and questionnaires were employed for analysis of their symptoms. Serum total testosterone (T), free-T and other hormones were measured for evaluation of the androgen deficiency. RESULTS: The chief complains of the patients were categorized as psychological symptoms, somatovegatative symptoms, and sexual symptoms, accounting for 51%, 36%, and 13%, respectively. A depressed mood, hot flashes and sweating and erectile dysfunction were dominant in these symptom categories, respectively. The prevalence of the psychological symptoms and somatovegatative symptoms was relatively high in the 30-50-year-old and 60-70-year-old groups, respectively. The free-T, but not total-T, was significantly decreased with aging as measured by the RIA method. Twenty one percent of the patients showed a lower total-T level than the normal range (2.7-10.7 ng/ml). The percentage of those with a total-T level lower than 2.0 ng/dl, which is the criterion for T-replacement recommended by the American Association of Clinical Endocrinologists guidelines, was 9%. Eighty two percent and 30% of the patients had lower free-T levels than the normal range (15.2-43.5 pg/ml) and that of men in their twenties in the Canadian data (9.3-26.5 pg/ml). Depending on the criteria of androgen deficiency, not all patients had low total-T and free-T levels. CONCLUSION: Patients suspected of having PADAM present various clinical symptoms and endocrinological aspects.     

Recent interpretations of Denonvilliers' fascia and the lateral ligament of the rectum

The terms “Denonvilliers' fascia” and “lateral ligament of the rectum” will be very familiar to colorectal surgeons. However, how these structures are conceptualized remains controversial. Here, we review past and recent interpretations of these two terms. Denonvilliers' fascia is likely derived from the fusion of the two walls of an embryonic cul‐de‐sac to form a clear boundary between the neurovascular bundle and the mesorectum. When performing anterior dissection for mobilization of the rectum, it remains unclear whether the optimal dissection plane is in front of or behind Denonvilliers' fascia. Anatomical studies have shown that the lateral ligament may not be a clearly definable structure and that the middle rectal artery is not clinically significant. In the future, careful laparoscopic observations will give us a better understanding of these currently controversial anatomical features.     

Clinical efficacy of modified M-VAC chemotherapy for advanced urothelial carcinoma and influence of squamous cell carcinoma-associated antigen on efficacy of the chemotherapy

The efficacy of modified M-VAC chemotherapy was evaluated in twenty-two patients with advanced urothelial carcinoma (18 cases of transitional cell carcinoma, 3 of transitional cell associated with squamous cell carcinoma and 1 of squamous cell carcinoma). Among the 22 patients, 14 underwent two or more courses of modified M-VAC chemotherapy and had lesions suitable for the evaluation. Three of the 14 patients achieved complete response and 6 partial response, resulting in a 64.3% response rate. With regard to the direct effect according to the site of the lesion, the response rate was 75% for the urinary bladder, 100% for lung, 100% for subcutaneous tissues, and 75% for lymph nodes metastasis, whereas the chemotherapy was ineffective for metastasis in the bone and muscle. With this neoadjuvant chemotherapy the primary tumor of the urinary bladder was downstaged from T2 to T0 in one patient who showed complete response. In 4 of 5 patients achieving partial response, the primary tumors were downstaged from T2 to T1. Of 9 patients given this chemotherapy for metastatic lesions, 2 achieved complete response and are alive, whereas all 3 without response died of cancer within the 1 year following the chemotherapy. Since most of the cases associated with the squamous cells carcinoma component showed no response to the therapy, it seems that the level of serum squamous cell carcinoma-associated antigen may be helpful for predicting the efficacy of modified M-VAC chemotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)