Department of Colorectal Surgery

Yukihide Kanemitsu, Shunsuke Tsukamoto, Konosuke Moritani, Yasuyuki Takamizawa, Manabu Inoue

Introduction

The Department of Colorectal Surgery deals with colorectal cancer and allied malignancies in the colon and rectum. Liver metastasis from colorectal cancer is treated in cooperation with the Department of Hepatobiliary and Pancreatic Surgery. Lung metastasis from colorectal cancer is also treated in cooperation with the Department of Thoracic Surgery. Although surgery is still the main treatment modality for colorectal cancer, multidisciplinary treatments including radiotherapy and chemotherapy are important in advanced cancer. We have multidisciplinary meetings with the Department of Gastrointestinal Medical Oncology, the Department of Endoscopy, the Department of Diagnostic Radiology, and the Department of Pathology and Clinical Laboratories every week, and decide the treatment strategy with a multidisciplinary team (MDT) before treatment is performed.

The Team and What We Do

Even with the continuing COVID-19 crisis, we perform more than 500 surgeries per year, and provide the best treatment for each individual case, ranging from minimally-invasive surgery such as laparoscopic surgery to expansion surgery such as resection of adjacent or metastatic organs (Table 1). For rectal cancer, we started robot-assisted surgery in 2014, and had performed a total of more than 400 surgeries by July 2022, achieving excellent results with an extremely low complication rate. In terms of surgical approach selection, the percentage of robot-assisted surgeries is increasing significantly. On the other hand, we also handle many difficult-to-resect recurrent pelvic cancers, and are involved in abdominal and pelvic sarcoma surgery in collaboration with other departments.

We have a weekly conference with the Endoscopy Department to discuss and decide on diagnosis and treatment. In addition, a multidisciplinary team (MDT) meeting is held once a week, in which colorectal surgeons, liver surgeons, oncologists, radiologists, and pathologists participate to determine the best treatment plan.

Table 1

Research activities

The results of the primary analyses of the multicenter randomized controlled trials “The Significance of Adjuvant Chemotherapy after Resection of Liver Metastases in Colorectal Cancer” (JCOG0603) and “The Significance of Resection of Primary Tumors in Stage IV Unresectable Colorectal Cancer” (JCOG1007) were published in the Journal of Clinical Oncology.

With the support of the Japan Agency for Medical Research and Development (AMED) "Research Project for Utilization of 8K and Other High-Definition Imaging Data," a national project to develop a new remote surgery-assisted laparoscopic surgery system using 8K technology and to study the utilization of high-definition imaging data, is being conducted in collaboration with NHK Engineering Systems, Inc and NHK. The results of remote surgical guidance of laparoscopic colorectal cancer radical surgery using a combination of an 8K camera and 5G communication between Narita and Kyoto in an experimental animal model using a pig showed that the texture, color, and impression of the space inside the abdominal cavity were close to the actual image, and that the electronically magnified images obtained by using an electronic zoom device together with the 8K camera showed less deterioration in image quality, making it optimal for medical treatment. In addition, the electronically magnified image with the electronic zoom device enabled surgical guidance with accurate and delay-free annotation, in addition to surgical images with a sense of reality (high realism) optimized and enhanced for medical treatment.

Clinical trials

Our department plays a central role in conducting multi-institutional clinical trials in Japan. Y. Kanemitsu is a representative of the Colorectal Cancer Group of the Japan Clinical Oncology Group (JCOG). Our department is currently participating in ten JCOG studies as shown below.

1. JCOG1502C: A Global Study to Evaluate the Potential Benefit of Adjuvant Chemotherapy for Small Bowel Adenocarcinoma

2. JCOG1503C: Efficacy of aspirin for stage III colorectal cancer: a randomized double-blind placebo-controlled trial

3. JCOG1612: Single-arm confirmatory trial of the adjuvant chemoradiation for the patients with the high-risk rectal submucosal invasive cancer after the local resection

4. JCOG1801: A randomized controlled trial comparing surgery plus adjuvant chemotherapy with preoperative chemoradiotherapy followed by surgery plus adjuvant chemotherapy for locally recurrent rectal cancer

5. JCOG1805: A randomized controlled trial to examine efficacy of adjuvant chemotherapy for stage II colorectal cancer patients at high risk of developing recurrence according to T-stage and three selected pathological factors.

6. JCOG1901: An intergroup phase III study of combination therapy with everolimus and lanreotide versus everolimus monotherapy for unresectable or recurrent gastroenteropancreatic neuroendocrine tumor

7. JCOG2004: Randomized Phase II Study of Bevacizumab plus FOLFIRI versus Ramucirumab plus FOLFIRI versus Aflibercept plus FOLFIRI for Metastatic Colorectal Cancer after failure of First-line chemotherapy with Fluoropyrimidine and Oxaliplatin to Explore Predictive Biomarker

8. JCOG2006: A randomized phase II study comparing preoperative adjuvant chemotherapy with mFOLFOX6 versus FOLFOXIRI for resectable locally advanced colon cancer

9. JCOG2010: Single-arm confirmatory trial of the total neoadjuvant therapy and watch and wait strategy for the patients with low rectal cancer

10. JCOG2014: Randomized phase III study of bi-weekly trifluridine/tipiracil plus bevacizumab vs trifluridine/tipiracil alone for chemorefractory metastatic colorectal cancer

11. FANTASTIC study: A phase II study to evaluate the safety and efficacy of modified-FOLFOXIRI and a potential novel biomarker-driven strategy using ctDNA for CRC, after resection of oligometastases.

Education

In the resident doctor education, under the supervision of a supervising physician, the residents are trained not only in the acquisition and improvement of skills, but also in a series of medical procedures such as judgment of the indications for surgery, selection of surgical techniques, postoperative management, working as a primary surgeon or assistant surgeon after gaining experience, and postoperative treatment. In addition, we actively instruct resident doctors in the preparation of reports and papers for various research groups and conferences. As part of these efforts, video conferences to review surgical techniques and research conferences to check the progress of research and provide guidance are held regularly.

Future prospects

Although Japan has been leading the world in the development of newAlthough Japan has been leading the world in the development of new drugs such as irinotecan and oxaliplatin, it is far behind in the development of molecular targeted drugs. While the gap is being filled by international collaborative clinical trials, there is no guarantee that innovative new drugs will continue to dramatically improve treatment outcomes of cancer patients in the future. Therefore, it is a big but important challenge for clinical oncologists to think and act strategically. Outside of Japan, novel studies using the data from many clinical trials and the data from specimen examination have been carried out one after another. We believe that all the specialists involved in colorectal cancer treatment must work together with their wisdom and experience in order to improve treatment outcomes. We will reconfirm the department’s research policy that a clinical question is reviewed by all participants and an answer is obtained from a randomized controlled trial, and continue to actively promote clinical trials in the future.

 

• Development of a new laparoscopic surgical system using 8K Super Hi-Vision technology

 

At the National Cancer Center Hospital (NCCH), a national research project working on the development of a new laparoscopic surgical system and the utilization of high definition image data using 8K Super Hi-Vision technology has been initiated. With this project, further improvement of the treatment outcome of patients with colorectal cancer is expected in the future.

List of papers published

Journal

1. Ohue M, Fujita S, Mizusawa J, Kanemitsu Y, Hamaguchi T, Tsukamoto S, Noura S, Yasui M, Itoh M, Shiomi A, Komori K, Watanabe J, Akazai Y, Shiozawa M, Yamaguchi T, Bandou H, Katsumata K, Moriya Y. Preoperative and postoperative prognostic factors of patients with stage II/III lower rectal cancer without neoadjuvant therapy in the clinical trial (JCOG0212). Japanese journal of clinical oncology, 52:114-121, 2022

2. Tsukamoto S, Kuchiba A, Moritani K, Shida D, Katayama H, Yorikane E, Kanemitsu Y. Laparoscopic surgery using 8 K ultra-high-definition technology: Outcomes of a phase II study. Asian journal of endoscopic surgery, 15:7-14, 2022

3. Tsutsui K, Ogata D, Tsukamoto S, Moritani K, Mori T, Namikawa K, Takahashi A, Kanemitsu Y, Yamazaki N. Post-Immunotherapy Robotic-Assisted Resection for Primary Anorectal Melanoma: A Case Report. Case reports in oncology, 15:56-61, 2022

4. Tsubokura M, Adegawa Y, Kojima M, Tanosaki R, Ohtake R, Kase Y, Iwashita N, Kasane M, Nakabayashi S, Takeuchi S, Kato K, Boku N, Kanemitsu Y, Okusaka T, Fujimoto H, Yonemori K, Ishiki H, Kawamura K, Satomi E, Matsushita H. Adverse effects of cell-free and concentrated ascites reinfusion therapy for malignant ascites: a single-institute experience. BMC cancer, 22:268, 2022

5. Kudose Y, Shida D, Ahiko Y, Nakamura Y, Sakamoto R, Moritani K, Tsukamoto S, Kanemitsu Y. Evaluation of Recurrence Risk After Curative Resection for Patients With Stage I to III Colorectal Cancer Using the Hazard Function: Retrospective Analysis of a Single-institution Large Cohort. Annals of surgery, 275:727-734, 2022

6. Kataoka K, Yamada T, Taniguchi H, Ikeda M, Yamazaki K, Kanemitsu Y. A ctDNA-driven multidisciplinary treatment strategy for resectable colorectal cancer -what surgical oncologists should know. European journal of surgical oncology: the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology, 48:1-2, 2022

7. Kataoka K, Fujita S, Inomata M, Takii Y, Ohue M, Shiozawa M, Akagi T, Ikeda M, Tsukamoto S, Tsukada Y, Ito M, Ikeda S, Ueno H, Shida D, Kanemitsu Y. Challenges needed to be overcome in multi-institutional surgical trials: accumulated experience in the JCOG Colorectal Cancer Study Group (CCSG). Japanese journal of clinical oncology, 52:103-107, 2022

8. Shinto E, Ike H, Ito M, Takahashi K, Ohue M, Kanemitsu Y, Suto T, Kinugasa T, Watanabe J, Hida JI, Itabashi M, Ozawa H, Nozawa H, Kobayashi H, Hashiguchi Y, Hase K, Sugihara K. Optimizing nodal and staging classification in low rectal cancers with lateral node metastasis: multicentre retrospective cohort study. BJS open, 6:2022

9. Katsumata K, Enomoto M, Ishizaki T, Fujita S, Kanemitsu Y, Ito M, Shiomi A, Komori K, Ohue M, Ota M, Akazai Y, Shiozawa M, Yamaguchi T, Bando H, Sekimoto M, Kobatake T, Machida R, Akasu T, Moriya Y. Risk factors for surgical site infection and association of surgical site infection with survival of lower rectal cancer patients without clinical lateral pelvic lymph node metastasis (clinical Stage II/III): Analysis of data from JCOG0212. Clinical & experimental metastasis, 38:459-466, 2021

10. Kanemitsu Y, Shimizu Y, Mizusawa J, Inaba Y, Hamaguchi T, Shida D, Ohue M, Komori K, Shiomi A, Shiozawa M, Watanabe J, Suto T, Kinugasa Y, Takii Y, Bando H, Kobatake T, Inomata M, Shimada Y, Katayama H, Fukuda H. Hepatectomy Followed by mFOLFOX6 Versus Hepatectomy Alone for Liver-Only Metastatic Colorectal Cancer (JCOG0603): A Phase II or III Randomized Controlled Trial. Journal of clinical oncology: official journal of the American Society of Clinical Oncology, 39:3789-3799, 2021

11. Katayama H, Inomata M, Mizusawa J, Nakamura K, Watanabe M, Akagi T, Yamamoto S, Ito M, Kinugasa Y, Okajima M, Takemasa I, Okuda J, Shida D, Kanemitsu Y, Kitano S. Institutional variation in survival and morbidity in laparoscopic surgery for colon cancer: From the data of a randomized controlled trial comparing open and laparoscopic surgery (JCOG0404). Annals of gastroenterological surgery, 5:823-831, 2021

12. Saito S, Akagi T, Katayama H, Wakabayashi M, Inomata M, Yamamoto S, Ito M, Kinugasa Y, Egi H, Munakata Y, Kokuba Y, Bando H, Yasui M, Ikeda M, Nakajima K, Shida D, Kanemitsu Y, Kitano S. Identification of patient subgroups with unfavorable long-term outcomes associated with laparoscopic surgery in a randomized controlled trial comparing open and laparoscopic surgery for colon cancer (Japan Clinical Oncology Group Study JCOG0404). Annals of gastroenterological surgery, 5:804-812, 2021

13. Takamaru H, Saito Y, Sekiguchi M, Yamada M, Sakamoto T, Matsuda T, Sekine S, Ochiai H, Tsukamoto S, Shida D, Kanemitsu Y. Endoscopic Resection Before Surgery Does Not Affect the Recurrence Rate in Patients With High-Risk T1 Colorectal Cancer. Clinical and translational gastroenterology, 12:e00336, 2021

14. Kitamura K, Shida D, Sekine S, Ahiko Y, Nakamura Y, Moritani K, Tsukamoto S, Kanemitsu Y. Comparison of model fit and discriminatory ability of the 8th edition of the tumor-node-metastasis classification and the 9th edition of the Japanese classification to identify stage III colorectal cancer. International journal of clinical oncology, 26:1671-1678, 2021

15. K, Takashima A, Kanemitsu Y. Comparison of model fit and discriminatory ability of M category as defined by the 7th and 8th editions of the tumor-node-metastasis classification of colorectal cancer and the 9th edition of the Japanese classification. Cancer medicine, 10:6937-6946, 2021

16. Kasuga K, Yamada M, Shida D, Tagawa T, Takamaru H, Sekiguchi M, Sakamoto T, Uraoka T, Sekine S, Kanemitsu Y, Saito Y. Treatment outcomes of endoscopic submucosal dissection and surgery for colorectal neoplasms in patients with ulcerative colitis. United European gastroenterology journal, 9:964-972, 2021

17. Tanabe T, Shida D, Boku N, Yoshida T, Tsukamoto S, Takashima A, Kanemitsu Y. Primary Tumor-Related Complications Among Patients With Unresectable Stage IV Colorectal Cancer in the Era of Targeted Therapy: A Competing Risk Regression Analysis. Diseases of the colon and rectum, 64:1074-1082, 2021

18. Ahiko Y, Shida D, Nakamura Y, Imaizumi J, Takamizawa Y, Moritani K, Tsukamoto S, Kanemitsu Y. Preoperative Nutritional Scores as Host-Related Prognostic Factors for Both Overall Survival and Postoperative Complications in Patients With Stage II to III Colorectal Cancer. Diseases of the colon and rectum, 64:1222-1231, 2021

19. Nakamura Y, Shida D, Boku N, Yoshida T, Tanabe T, Takamizawa Y, Takashima A, Kanemitsu Y. Lymphocyte-to-C-Reactive Protein Ratio Is the Most Sensitive Inflammation-Based Prognostic Score in Patients With Unresectable Metastatic Colorectal Cancer. Diseases of the colon and rectum, 64:1331-1341, 2021

20. Moritani K, Shida D, Kanemitsu Y, Shunsuke T, Hamaguchi T, Shimada Y. Surveillance of patients with stage I or II colorectal cancer in Japan: a JCOG study group questionnaire survey. Japanese journal of clinical oncology, 51:1761-1764, 2021

21. Nishizawa Y, Nishigori H, Tsukada Y, Sasaki T, Tsukamoto S, Kanemitsu Y, Nakano D, Yamaguchi T, Otsuka K, Nakamura T, Shiomi A, Iwasaki N, Tamura H, Wakabayashi M, Nomura S, Ito M. A multicentre confirmatory single-arm trial of the safety and efficacy of a transanal drain for prevention of anastomotic leakage after surgery for rectal cancer. Colorectal disease: the official journal of the Association of Coloproctology of Great Britain and Ireland, 23:3196-3204, 2021

22. Ueno H, Kajiwara Y, Ajioka Y, Sugai T, Sekine S, Ishiguro M, Takashima A, Kanemitsu Y. Histopathological atlas of desmoplastic reaction characterization in colorectal cancer. Japanese journal of clinical oncology, 51:1004-1012, 2021

23. Yokota T, Saito Y, Takamaru H, Sekine S, Nakajima T, Yamada M, Sakamoto T, Taniguchi H, Kushima R, Tsukamoto S, Shida D, Kanemitsu Y, Matsuda T. Spontaneous Regression of Mismatch Repair-Deficient Colon Cancer: A Case Series. Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association, 19:1720-1722.e3, 2021

24. Inoue A, Murata K, Komori T, Takeda T, Fujii M, Yamaguchi T, Yamaguchi T, Masuishi T, Shiota T, Morita S, Suzuki Y, Ito M, Kanemitsu Y, Shiozawa M, Yasui M, Kagawa Y, Sugihara K. Open versus laparoscopic surgery for primary appendiceal tumors: a large multicenter retrospective propensity score-matched cohort study in Japan. Surgical endoscopy, 35:5515-5523, 2021

25. Kanemitsu Y, Shitara K, Mizusawa J, Hamaguchi T, Shida D, Komori K, Ikeda S, Ojima H, Ike H, Shiomi A, Watanabe J, Takii Y, Yamaguchi T, Katsumata K, Ito M, Okuda J, Hyakudomi R, Shimada Y, Katayama H, Fukuda H. Primary Tumor Resection Plus Chemotherapy Versus Chemotherapy Alone for Colorectal Cancer Patients With Asymptomatic, Synchronous Unresectable Metastases (JCOG1007; iPACS): A Randomized Clinical Trial. Journal of clinical oncology: official journal of the American Society of Clinical Oncology, 39:1098-1107, 2021

26. Yonemaru J, Hashimoto T, Takayanagi D, Naka T, Yatabe Y, Kanemitsu Y, Shiraishi K, Sekine S. NTRK fusion-positive colorectal cancer in Japanese population. Pathology international, 71:355-359, 2021