Adenocarcinoma of sigmoid colon with metastasis to an ovarian mature teratoma: A case report

BACKGROUND Colorectal cancer ranks third in global cancer-related mortality,often due to metastases to liver and lungs.Ovarian metastases are less common,accounting for 3.6%to 7.4%of cases.In contrast,mature ovarian teratomas are frequently benign.Tumor-to-tumor metastasis is a rare phenomenon,with a limited number of documented cases.Three cases of mature ovarian teratomas metastasizing from different cancers have been reported.This report focuses on a case of tumor-totumor metastasis from sigmoid colon adenocarcinoma to a mature ovarian teratoma.CASE SUMMARY A 41-year-old Taiwan residents woman with no known systemic diseases presented with lower back pain,which led to imaging revealing malignant lesions in the spine,pelvis,liver,and multiple lung metastases.She was diagnosed with sigmoid colon adenocarcinoma with metastases to the liver,lung,bone,and a left ovarian teratoma.Treatment involved radiotherapy and chemotherapy,resulting in regression of the primary tumor and stable lung and liver lesions.Due to abdominal symptoms,she underwent exploratory surgery,unveiling a mature teratoma in the left ovary with signs of metastatic adenocarcinoma.CONCLUSION Consider resecting mature ovarian teratomas with concurrent colorectal adenocarcinoma to prevent tumor-to-tumor metastasis.

Validity,Reliability,and Measurement Invariance of the Thai Smartphone Application-Based Addiction Scale and Bergen Social Media Addiction Scale

Background:In recent years,there has been increased research interest in both smartphone addiction and social media addiction as well as the development of psychometric instruments to assess these constructs.However,there is a lack of psychometric evaluation for instruments assessing smartphone addiction and social media addiction in Thailand.The present study evaluated the psychometric properties and gender measurement invariance of the Thai version of the Smartphone Application-Based Addiction Scale(SABAS)and Bergen Social Media Addiction Scale(BSMAS).Method:A total of 801 Thai university students participated in an online survey from January 2022 to July 2022 which included demographic information,SABAS,BSMAS,and the Internet Gaming Disorder Scale-Short Form(IGDS9-SF).Results:Confirmatory Factor Analyses(CFAs)found that both the SABAS and BSMAS had a one-factor structure.Findings demonstrated adequate psychometric properties of both instruments and also supported measurement invariance across genders.Moreover,scores on the SABAS and BSMAS were correlated with scores on the IGDS9-SF.Conclusion:The results indicated that the SABAS and BSMAS are useful psychometric instruments for assessing the risk of smartphone addiction and social media addiction among Thai young adults.

Chemotherapy plus percutaneous radiofrequency ablation in patients with inoperable colorectal liver metastases

AIM:To access the efficacy of chemotherapy plus radiofrequency ablation(RFA)as one line of treatment in inoperable colorectal liver metastases.METHODS:Eligible patients were included in three PhaseⅡstudies.In the first study percutaneous RFA was used first followed by 6 cycles of 5-fluorouracil,leucovorin and irinotecan combination(FOLFIRI)(adjunctive chemotherapy trial).In the other two,chemotherapy(FOLFIRI or 5-fluorouracil,leucovorin and oxaliplatin combination)up to 12 cycles was used first with percutaneous RFA offered to responding patients (primary chemotherapy trials).RESULTS:Thirteen patients were included in the adjunctive chemotherapy trial and 17 in the other two.At inclusion they had 1-4 liver metastases(up to 6.5 cm in size).Two patients died during chemotherapy.All patients in the adjunctive chemotherapy trial and 44%in the primary chemotherapy studies had their metastases ablated.Median PFS and overall survival in the adjunctive study were 13 and 24 mo respectively while in the primary chemotherapy studies they were 10 and 21 mo respectively.Eighty one percent of the patients had tumour relapse in at least one previously ablated lesion.CONCLUSION:Chemotherapy plus RFA in patients with low volume inoperable colorectal liver metastases seems safe and relatively effective.The high local recurrence rate is of concern.

Gene expression profile of peripheral blood in colorectal cancer

AIM:Optimal molecular markers for detecting colorectal cancer(CRC)in a blood-based assay were evaluated.METHODS:A matched(by variables of age and sex)case-control design(111 CRC and 227 non-cancer samples)was applied.Total RNAs isolated from the338 blood samples were reverse-transcribed,and the relative transcript levels of candidate genes were analyzed.The training set was made of 162 random samples of the total 338 samples.A logistic regression analysis was performed,and odds ratios for each gene were determined between CRC and non-cancer.The samples(n=176)in the testing set were used to validate the logistic model,and an inferred performance(generality)was verified.By pooling 12 public microarray datasets(GSE 4107,4183,8671,9348,10961,13067,13294,13471,14333,15960,17538,and 18105),which included 519 cases of adenocarcinoma and 88 controls of normal mucosa,we were able to verify the selected genes from logistic models and estimate their external generality.RESULTS:The logistic regression analysis resulted in the selection of five significant genes(P<0.05;MDM2,DUSP6,CPEB4,MMD,and EIF2S3),with odds ratios of 2.978,6.029,3.776,0.538 and 0.138,respectively.The five-gene model performed stably for the discrimination of CRC cases from controls in the training set,with accuracies ranging from 73.9%to 87.0%,a sensitivity of 95%and a specificity of 95%.In addition,a good performance in the test set was obtained using the discrimination model,providing 83.5%ac-curacy,66.0%sensitivity,92.0%specificity,a positive predictive value of 89.2%and a negative predictive value of 73.0%.Multivariate logistic regressions analyzed 12 pooled public microarray data sets as an external validation.Models that provided similar expected and observed event rates in subgroups were termed well calibrated.A model in which MDM2,DUSP6,CPEB4,MMD,and EIF2S3 were selected showed the result in logistic regression analysis(H-L P=0.460,R2=0.853,AUC=0.978,accuracy=0.949,specificity=0.818 and sensitivity=0.971).CONCLUSION:A novel gene expression profile was associated with CRC and can potentially be applied to blood-based detection assays.

How robotics is changing and will change the field of colorectal surgery

During the last decade there has been a significant upward trend in colon and rectal minimally invasive surgery which can be attributed largely to the acceptance of robotic surgery platforms such as the da Vinci?robotic system.The fourth generation da Vinci?system,introduced in 2014,includes integrated table motion,intelligent laser targeted docking and more sophisticated instrumentation and imaging.These developments have enabled more surgeons to efficiently and safely perform multi-quadrant operations.Firefly?technology allows assessment of colon perfusion and identification of ureters,and has shown potential in detecting occult recurrence or metastasis using molecular-labelled tumor markers.Wristed instrumentation has increased the technical ease of intracorporeal anastomosis(ICA)for many surgeons,leading to more common use of ICA during right colectomy.Advanced imaging has shown potential to decrease the incidence of presacral nerve injury and improve urogenital outcomes after pelvic surgery,as has been the case in robotic urologic procedures.Finally,the robotic platform lends itself to surgical simulation for surgical trainees,as a pre-operative tool for mock operations and as an ongoing assessment tool for established colorectal surgeons.Given these advantages,surgeons should anticipate continued and increased utilization of this beneficial technology.

Outcomes of neoadjuvant chemoradiotherapy followed by radical resection for T4 colorectal cancer

BACKGROUND Patients with clinical T4 colorectal cancer(CRC)have a poor prognosis because of compromised surgical margins.Neoadjuvant therapy may be effective in downstaging tumors,thereby rendering possible radical resection with clear margins.AIM To evaluate tumor downsizing and resection with clear margins in T4 CRC patients undergoing neoadjuvant concurrent chemoradiotherapy followed by surgery.METHODS This study retrospectively included 86 eligible patients with clinical T4 CRC who underwent neoadjuvant concurrent chemoradiotherapy followed by radical resection.Neoadjuvant therapy consisted of radiation therapy at a dose of 45-50.4 Gy and chemotherapy agents,either FOLFOX or capecitabine.A circumferential resection margin(CRM)of<1 mm was considered to be a positive margin.We defined pathological complete response(p CR)as the absence of any malignant cells in a specimen,including the primary tumor and lymph nodes.A multivariate logistic regression model was used to identify independent predictive factors for p CR.RESULTS For 86 patients who underwent neoadjuvant chemoradiotherapy and surgery,the rate of p CR was 14%,and the R0 resection rate was 91.9%.Of the 61 patients with rectal cancer,7(11.5%)achieved p CR and 5(8.2%)had positive CRMs.Of the 25 patients with colon cancer,5(20%)achieved p CR and 2(8%)had positive CRMs.We observed that the FOLFOX regimen was an independent predictor of p CR(P=0.046).After a median follow-up of 47 mo,the estimated 5-year overall survival(OS)and disease-free survival(DFS)rates were 70.8%and 61.4%,respectively.Multivariate analysis revealed that a tumor with a negative resection margin was associated with improved DFS(P=0.014)and OS(P=0.001).Patients who achieved p CR exhibited longer DFS(P=0.042)and OS(P=0.003)than those who did not.CONCLUSION Neoadjuvant concurrent chemoradiotherapy engenders favorable p CR and R0 resection rates among patients with T4 CRC.The R0 resection rate and p CR are independent prognostic factors for patients with T4 CRC.

Incidence trends and predictors for cost and average lengths of stay in colorectal cancer surgery

AIM:To evaluate the changing trends and outcomes of colorectal cancer(CRC)surgery performed at a large single institution in Taiwan.METHODS:This study retrospectively analyzed 778patients who received colorectal cancer surgery at E-Da Hospital in Taiwan from 2004 to 2009.These patients were from health examination,inpatient or emergency settings.The following attributes were analyzed in patients who had undergone CRC surgical procedures:gender,age,source,surgical type,tumor number,tumor size,number of lymph node metastasis,pathologic differentiation,chemotherapy,distant metastases,tumor site,tumor stage,average hospitalization cost and average lengths of stay(ALOS).The odds ratio and95%confidence intervals were calculated to assess the relative rate of change.Regression models were employed to predict average hospitalization cost and ALOS.RESULTS:The study sample included 458(58.87%)males and 320(41.13%)females with a mean age of64.53 years(standard deviation,12.33 years;range,28-86 years).The principal patient source came from inpatient and emergency room(96.02%).The principal tumor sites were noted at the sigmoid colon(35.73%)and rectum(30.46%).Most patients exhibited a tumor stage of 2(37.28%)or 3(34.19%).The number of new CRC surgeries performed per 100000 persons was12.21 in 2004 and gradually increased to 17.89 in 2009,representing a change of 46.52%.During the same period,the average hospitalization cost and ALOS decreased from$5303 to$4062 and from 19.7 to 14.4 d,respectively.The following factors were associated with considerably decreased hospital resource utilization:age,source,surgical type,tumor size,tumor site,and tumor stage.CONCLUSION:These results can be generalized to patient populations elsewhere in Taiwan and to other countries with similar patient profiles.

MTNR1B polymorphisms with CDKN2A and MGMT methylation status are associated with poor prognosis of colorectal cancer in Taiwan

BACKGROUND Identifying novel colorectal cancer(CRC)prognostic biomarkers is crucial to helping clinicians make appropriate therapy decisions.Melatonin plays a major role in managing the circadian rhythm and exerts oncostatic effects on different kinds of tumours.AIM To explore the relationship between MTNR1B single-nucleotide polymorphism(SNPs)combined with gene hypermethylation and CRC prognosis.METHODS A total of 94 CRC tumour tissues were investigated.Genotyping for the four MTNR1B SNPs(rs1387153,rs2166706,rs10830963,and rs1447352)was performed using multiplex polymerase chain reaction.The relationships between the MTNR1B SNPs and CRC 5-year overall survival(OS)was assessed by calculating hazard ratios with 95%CIs.RESULTS All SNPs(rs1387153,rs2166706,rs10830963,and rs1447352)were correlated with decreased 5-year OS.In stratified analysis,rs1387153,rs10830963,and rs1447352 risk genotype combined with CDKN2A and MGMT methylation status were associated with 5-year OS.A strong cumulative effect of the four polymorphisms on CRC prognosis was observed.Four haplotypes of MTNR1B SNPs were also associated with the 5-year OS.MTNR1B SNPs combined with CDKN2A and MGMT gene methylation status could be used to predict shorter CRC survival.CONCLUSION The novel genetic biomarkers combined with epigenetic biomarkers may be predictive tool for CRC prognosis and thus could be used to individualise treatment for patients with CRC.

Novel methylation gene panel in adjacent normal tissues predicts poor prognosis of colorectal cancer in Taiwan

BACKGROUND It is evident that current clinical criteria are suboptimal to accurately estimate patient prognosis.Studies have identified epigenetic aberrant changes as novel prognostic factors for colorectal cancer(CRC).AIM To estimate whether a methylation gene panel in different clinical stages can reflect a different prognosis.METHODS We enrolled 120 CRC patients from Tri-Service General Hospital in Taiwan and used the candidate gene approach to select six genes involved in carcinogenesis pathways.Patients were divided into two groups based on the methylation status of the six evaluated genes,namely,the<3 aberrancy group and≥3 aberrancy group.Various tumor stages were divided into two subgroups(local and advanced stages)on the basis of the pathological type of the following tissues:Tumor and adjacent normal tissues(matched normal).We assessed DNA methylation in tumors and adjacent normal tissues from CRC patients and analyzed the association between DNA methylation with different cancer stages and the prognostic outcome including time to progression(TTP)and overall survival.RESULTS We observed a significantly increasing trend of hazard ratio as the number of hypermethylated genes increased both in normal tissue and tumor tissue.The 5-year TTP survival curves showed a significant difference between the≥3 aberrancy group and the<3 aberrancy group.Compared with the<3 aberrancy group,a significantly shorter TTP was observed in the≥3 aberrancy group.We further analyzed the interaction between CRC prognosis and different cancer stages(local and advanced)according to the methylation status of the selected genes in both types of tissues.There was a significantly shorter 5-year TTP for tumors at advanced stages with the promoter methylation status of selected genes than for those with local stages.We found an interaction between cancer stages and the promoter methylation status of selected genes in both types of tissues.CONCLUSION Our data provide a significant association between the methylation markers in normal tissues with advanced stage and prognosis of CRC.We recommend using these novel markers to assist in clinical decision-making.

Differential DNA methylation analysis of SUMF2,ADAMTS5,and PXDN provides novel insights into colorectal cancer prognosis prediction in Taiwan

BACKGROUND Patients with colorectal cancer(CRC)undergo surgery,as well as perioperative chemoradiation or adjuvant chemotherapy primarily based on the tumor–node–metastasis(TNM)cancer staging system.However,treatment responses and prognostic outcomes of patients within the same stage vary markedly.The potential use of novel biomarkers can improve prognostication and shared decision making before implementation into certain therapies.AIM To investigate whether SUMF2,ADAMTS5,and PXDN methylation status could be associated with CRC prognosis.METHODS We conducted a Taiwan region cohort study involving 208 patients with CRC recruited from TriService General Hospital and applied the candidate gene approach to identify three genes involved in oncogenesis pathways.A methylation-specific polymerase chain reaction(MS-PCR)and Epi TYPER DNA methylation analysis were employed to detect methylation status and to quantify the methylation level of candidate genes in tumor tissue and adjacent normal tissue from participants.We evaluated SUMF2,ADAMTS5,and PXDN methylation as predictors of prognosis,including recurrence-free survival(RFS),progression-free survival(PFS),and overall survival(OS),using a Cox regression model and Kaplan–Meier analysis.RESULTS We revealed various outcomes related to methylation and prognosis.Significantly shorter PFS and OS were associated with the CpG_3+CpG_7 hypermethylation of SUMF2 from tumor tissue compared with CpG_3+CpG_7 hypomethylation[hazard ratio(HR)=2.24,95%confidence interval(CI)=1.03-4.85 for PFS,HR=2.56 and 95%CI=1.08-6.04 for OS].By contrast,a significantly longer RFS was associated with CpG_2 and CpG_13 hypermethylation of ADAMTS5 from normal tissue compared with CpG_2 and CpG_13 hypomethylation[HR(95%CI)=0.15(0.03-0.71)for CpG_2 and 0.20(0.04-0.97)for CpG_13].The relationship between the methylation status of PXDN and the prognosis of CRC did not reach statistical significance.CONCLUSION Our study found that CpG_3+CpG_7 hypermethylation of SUMF2 from tumor tissue was associated with significantly shorter PFS and OS compared with CpG_3+CpG_7 hypomethylation.CpG_2 and CpG_13 hypermethylation of ADAMTS5 from normal tissue was associated with a significantly longer RFS compared with CpG_2 and CpG_13 hypomethylation.These methylationrelated biomarkers which have implications for CRC prognosis prediction may aid physicians in clinical decision-making.

Verification of gene expression profiles for colorectal cancer using 12 internet public microarray datasets

AIM:To verify gene expression profiles for colorectal cancer using 12 internet public microarray datasets.METHODS:Logistic regression analysis was performed,and odds ratios for each gene were determined between colorectal cancer(CRC)and controls.Twelvepublic microarray datasets of GSE 4107,4183,8671,9348,10961,13067,13294,13471,14333,15960,17538,and 18105,which included 519 cases of adenocarcinoma and 88 normal mucosa controls,were pooled and used to verify 17 selective genes from 3 published studies and estimate the external generality.RESULTS:We validated the 17 CRC-associated genes from studies by Chang et al(Model 1:5 genes),Marshall et al(Model 2:7 genes)and Han et al(Model 3:5genes)and performed the multivariate logistic regression analysis using the pooled 12 public microarray datasets as well as the external validation.The goodnessof-fit test of Hosmer-Lemeshow(H-L)showed statistical significance(P=0.044)for Model 2 of Marshall et al in which observed event rates did not match expected event rates in subgroups of the model population.Expected and observed event rates in subgroups were similar,which are called well calibrated,in Models 1,3and 4 with non-significant P values of 0.460,0.194 and1.000 for H-L tests,respectively.A 7-gene model of CPEB4,EIF2S3,MGC20553,MS4A1,ANXA3,TNFAIP6and IL2RB was pairwise selected,which showed the best results in logistic regression analysis(H-L P=1.000,R2=0.951,areas under the curve=0.999,accuracy=0.968,specificity=0.966 and sensitivity=0.994).CONCLUSION:A novel gene expression profile was associated with CRC and can potentially be applied to blood-based detection assays.

Mutation analysis of 13 driver genes of colorectalcancer-related pathways in Taiwan Residents patients

AIM To investigate the driver gene mutations associatedwith colorectal cancer （CRC） in the Taiwan Residentspopulation.METHODS： In this study, 103 patients with CRCwere evaluated. The samples consisted of 66 menand 37 women with a median age of 59 years and anage range of 26-86 years. We used high-resolutionmelting analysis （HRM） and direct DNA sequencing tocharacterize the mutations in 13 driver genes of CRCrelatedpathways. The HRM assays were conductedusing the LightCycler？ 480 Instrument provided with the software LightCycler 480 Gene Scanning SoftwareVersion 1.5. We also compared the clinicopathologicaldata of CRC patients with the driver gene mutationstatus.RESULTS： Of the 103 patients evaluated, 73.79%had mutations in one of the 13 driver genes. Wediscovered 18 novel mutations in APC , MLH1 , MSH2 ,PMS2 , SMAD4 and TP53 that have not been previouslyreported. Additionally, we found 16 de novo mutationsin APC , BMPR1A , MLH1 , MSH2 , MSH6 , MUTYH andPMS2 in cancerous tissues previously reported in thedbSNP database; however, these mutations couldnot be detected in peripheral blood cells. The APCmutation correlates with lymph node metastasis（34.69% vs 12.96%, P = 0.009） and cancer stage（34.78% vs 14.04%, P = 0.013）. No association wasobserved between other driver gene mutations andclinicopathological features. Furthermore, having twoor more driver gene mutations correlates with thedegree of lymph node metastasis （42.86% vs 24.07%,P = 0.043）.CONCLUSION： Our findings confirm the importanceof 13 CRC-related pathway driver genes in the developmentof CRC in Taiwan Residents patients.

Development of a warning score for early detection of colorectal anastomotic leakage:Hype or hope?

BACKGROUND Colorectal anastomotic leakage(CAL),a severe postoperative complication,is associated with high morbidity,hospital readmission,and overall healthcare costs.Early detection of CAL remains a challenge in clinical practice.However,some decision models have been developed to increase the diagnostic accuracy of this event.AIM To develop a score based on easily accessible variables to detect CAL early.METHODS Based on the least absolute shrinkage and selection operator method,a predictive classification system was developed[Early ColoRectAL Leakage(E-CRALL)score]from a prospective observational,single center cohort,carried out in a colorectal division from a non-academic hospital.The score performance and CAL threshold from postoperative day(POD)3 to POD5 were estimated.Based on a precise analytical decision model,the standard clinical practice was compared with the E-CRALL adoption on POD3,POD4,or POD5.A cost-minimization analysis was conducted,on the assumption that all alternatives delivered similar health-related effects.RESULTS In this study,396 patients who underwent colorectal resection surgery with anastomosis,and 6.3%(n=25)developed CAL.Most of the patients who developed CAL(n=23;92%)were diagnosed during the first hospital admission,with a median time of diagnosis of 9.0±6.8 d.From POD3 to POD5,the area under the receiver operating characteristic curve of the E-CRALL score was 0.82,0.84,and 0.95,respectively.On POD5,if a threshold of 8.29 was chosen,87.4%of anastomotic failures were identified with E-CRALL adoption.Additionally,score usage could anticipate CAL diagnosis in an average of 5.2 d and 4.1 d,if used on POD3 and POD5,respectively.Regardless of score adoption,episode comprehensive costs were markedly greater(up to four times)in patients who developed CAL in comparison with patients who did not develop CAL.Nonetheless,the use of the E-CRALL warning score was associated with cost savings of€421442.20,with most(92.9%)of the savings from patients who did not develop CAL.CONCLUSION The E-CRALL score is an accessible tool to predict CAL at an early timepoint.Additionally,ECRALL can reduce overall healthcare costs,mainly in the reduction of hospital costs,independent of whether a patient developed CAL.

Effects of the number of neoadjuvant therapy cycles on clinical outcomes, safety, and survival in patients with metastatic colorectal cancer undergoing metastasectomy

The controversial outcomes in patients with metastatic colorectal cancer(mCRC)highlight the need for developing effective systemic neoadjuvant treatment strategies to improve clinical results.The optimal treatment cycles in patients with mCRC for metastasectomy remain undefined.This retrospective study compared the efficacy,safety,and survival of cycles of neoadjuvant chemotherapy/targeted therapy for such patients.Sixty-four patients with mCRC who received neoadjuvant chemotherapy/targeted therapy following metastasectomy were enrolled between January 2018 and April 2022.Twenty-eight patients received 6 cycles of chemotherapy/targeted therapy,whereas 36 patients received≥7 cycles(median,13;range,7–20).Clinical outcomes,including response,progression-free survival(PFS),overall survival(OS),and adverse events,were compared between these two groups.Of the 64 patients,47(73.4%)were included in the response group,and 17(26.6%)were included in the nonresponse group.The analysis revealed chemotherapy/targeted therapy cycle and pretreatment serum carcinoembryonic antigen(CEA)level as independent predictors of the response as well as overall survival and chemotherapy/targeted therapy cycle as an independent predictor of progression(all p<0.05).Furthermore,our results revealed shorter operation time,lower estimated operative blood loss,higher response rate,lower progression rate,and higher survival rate in≥7 cycles of chemotherapy/targeted therapy group(all p<0.05),but no statistical differences in adverse events were observed between the two groups(all p>0.05).The median OS and PFS were 48 months(95%CI,40.855–55.145)and 28 months(95%CI,18.952–37.48)in the≥7-cycle group and 24 months(95%CI,22.038–25.962)and 13 months(95%CI,11.674–14.326)in the 6-cycle group,respectively(both p<0.001).The oncological outcomes in the≥7-cycle group were significantly better than those in the 6-cycle group,without significant increases in adverse events.However,prospective randomized trials are mandatory to confirm the potential advantages of cycle numbers of neoadjuvant chemotherapy/targeted therapy.

Postoperative ileus: Impact of pharmacological treatment,laparoscopic surgery and enhanced recovery pathways

Almost all patients develop postoperative ileus (POI) after abdominal surgery.POI represents the single largest factor influencing length of stay (LOS) after bowel resection,and has great implications for patients and resource utilization in health care.New methods to treat and decrease the length of POI are therefore of great importance.During the past decade,a substantial amount of research has been performed evaluating POI,and great progress has been made in our understanding and treatment of POI.Laparoscopic procedures,enhanced recovery pathways and pharmacologic treatment have been introduced.Each factor has substantially contributed to decreasing the length of POI and thus LOS after bowel resection.This editorial outlines resource utilization of POI,normal physiology of gut motility and pathogenesis of POI.Pharmacological treatment,fast track protocols and laparoscopic surgery can each have significant impact on pathways causing POI.The optimal integration of these treatment options continues to be assessed in prospective studies.

Efficacy and safety of transnasal butorphanol for pain relief after anal surgery

AIM:To compare the analgesic properties and efficacy of transnasal butorphanol with intramuscular meperidine after anal surgery.METHODS: Sixty patients who underwent fistulectomy were enrolled in the study from January 2006 to December 2007. They were randomly divided into transnasal butorphanol (n=30) or intramuscular meperidine (n=30) treatment groups. Assessment of postoperative pain was made using a visual analogue scale (VAS). The VAS score was recorded 6 h after the completion of surgery, before receiving the first dose of analgesic, 60 min after analgesia and the next morning. Any adverse clinical effects such as somnolence, dizziness, nausea or vomiting were recorded. Satisfaction with narcotic efficacy, desire to use the particular analgesic in the future and any complaints were recorded by patients using questionnaires before being discharged.RESULTS: Forty-two men and eighteen women were included in the study. There were no significant differences in VAS scores between the groups within 24 h. Length of hospital stay and the incidence of adverse effects between the groups were similar. In addition, most patients were satisfied with butorphanol nasal spray and wished to receive this analgesic in the future, if needed.CONCLUSION: Butorphanol nasal spray is effective for the relief of pain after fistulectomy. However, it offered patients more convenient usage and would be suitable for outpatients.

Robotic surgery for rectal cancer: A systematic review of current practice

AIM: To give a comprehensive review of current litera-ture on robotic rectal cancer surgery.METHODS: A systematic review of current literature via PubMed and Embase search engines was per-formed to identify relevant articles from january 2007 to november 2013. The keywords used were: "robotic surgery", "surgical robotics", "laparoscopic computer-assisted surgery", "colectomy" and "rectal resection". RESULTS: After the initial screen of 380 articles, 20 pa-pers were selected for review. A total of 1062 patients(male 64.0%) with a mean age of 61.1 years and body mass index of 24.9 kg/m2 were included in the review.Out of 1062 robotic-assisted operations, 831(78.2%) anterior and low anterior resections, 132(12.4%) in-tersphincteric resection with coloanal anastomosis, 98(9.3%) abdominoperineal resections and 1(0.1%) Hart-mann's operation were included in the review. Robotic rectal surgery was associated with longer operative time but with comparable oncological results and anastomotic leak rate when compared with laparoscopic rectal surgery. CONCLUSION: Robotic colorectal surgery has con-tinued to evolve to its current state with promising re-sults; feasible surgical option with low conversion rate and comparable short-term oncological results. The challenges faced with robotic surgery are for more high quality studies to justify its cost.

Oxaliplatin-induced severe anaphylactic reactions in metastatic colorectal cancer: Case series analysis

AIM: To investigate oxaliplatin-induced severe anaphylactic reactions (SAR) in metastatic colorectal cancer in a retrospective case series analysis and to conduct a systemic literature review. METHODS: During a 6-year period from 2006 to 2011 at Kaohsiung Veterans General Hospital, a total of 412 patients exposed to oxaliplatin-related chemotherapy were retrospectively reviewed. Relevant Englishlanguage studies regarding life-threatening SAR following oxaliplatin were also reviewed in MEDLINE and PubMed search. RESULTS: Eight patients (1.9%, 8 of 412 cases) were identified. Seven patients were successful resuscitated without any sequelae and one patient expired. We changed the chemotherapy regimen in five patients and rechallenged oxaliplatin use in patient 3. Twenty-three relevant English-language studies with 66 patients were reported. Patients received a median of 10 cycles of oxaliplatin (range, 2 to 29). Most common symptoms were respiratory distress (60%), fever (55%), and hypotension (54%). Three fatal events were reported (4.5%). Eleven patients (16%) of the 66 cases were rechallenged by oxaliplatin. CONCLUSION: SAR must be considered in patients receiving oxaliplatin-related chemotherapy, especially in heavily pretreated patients. Further studies on the mechanism, predictors, preventive methods and management of oxaliplatin-related SAR are recommended.

Thymoquinone suppresses migration of Lo Vo human colon cancer cells by reducing prostaglandin E2 induced COX-2 activation

AIM To identify potential anti-cancer constituents in natural extracts that inhibit cancer cell growth and migration.METHODS Our experiments used high dose thymoquinone(TQ) as an inhibitor to arrest Lo Vo(a human colon adenocarcinoma cell line) cancer cell growth, which was detected by cell proliferation assay and immunoblotting assay. Low dose TQ did not significantly reduce Lo Vo cancer cell growth. Cyclooxygenase 2(COX-2) is an enzyme that is involved in the conversion of arachidonic acid into prostaglandin E2(PGE2) in humans. PGE2 can promote COX-2 protein expression and tumor cell proliferation and was used as a control.RESULTS Our results showed that 20 μmol/L TQ significantly reduced human LoV o colon cancer cell proliferation. TQ treatment reduced the levels of p-PI3 K, p-Akt, p-GSK3β, and β-catenin and thereby inhibited the downstream COX-2 expression. Results also showed that the reduction in COX-2 expression resulted in a reduction in PGE2 levels and the suppression of EP2 and EP4 activation. Further analysis showed that TG treatment inhibited the nuclear translocation of β-catenin in LoV o cancer cells. The levels of the cofactors LEF-1 and TCF-4 were also decreased in the nucleus following TQ treatment in a dose-dependent manner. Treatment with low dose TQ inhibited the COX-2 expression at the transcriptional level and the regulation of COX-2 expression efficiently reduced LoV o cell migration. The results were further verified in vivo by confirming the effects of TQ and/or PGE2 using tumor xenografts in nude mice.CONCLUSION TQ inhibits LoV o cancer cell growth and migration, and this result highlights the therapeutic advantage of using TQ in combination therapy against colorectal cancer.

Role of surgical intervention in managing gastrointestinal metastases from lung cancer

AIM:To investigate the clinicopathological characteristics of late-stage lung cancer patients with gastrointestinal(GI)-tract metastases,focusing on therapeutic options and outcomes.METHODS:Our institution(the National Taiwan University Hospital) diagnosed 8159 patients with lung cancer between 1987 and 2008,of which 21 developed symptomatic GI metastases.This study reviewed all of the patients' information,including survival data,pathological reports,and surgical notes.RESULTS:The most common histological type of lung cancer was adenocarcinoma,and 0.26% of patients with lung cancer developed GI metastases.The median duration from lung cancer diagnosis to GI metastases was three months(range,0-108 mo),and the average time from diagnosis of GI metastasis to death was 2.8 mo.Most patients with symptomatic gastric and/or duodenal metastases exhibited GI bleeding and were diagnosed by panendoscopy.In contrast,small bowel metastases typically presented as an acute abdomen and were not diagnosed until laparotomy.All patients with small bowel or colonic metastases underwent surgical intervention,and their perioperative mortality was 22%.Our data revealed a therapeutic effect in patients with solitary GI metastasis and a favorable palliative effect on survival when metastases were diagnosed preoperatively.In patients with multiple GI metastases,the presentation varied according to the locations of the metastases.CONCLUSION:Surgical treatment is worthwhile in a select group of patients with bowel perforation or obstruction.Physicians should be more alert to symptoms or signs indicating GI metastases.