Complete Clinical Response after Neoadjuvant Chemoradiation for Distal Rectal Cancer

Multimodality treatment of rectal cancer, with the combination of radiation therapy, chemotherapy, and surgery has become the preferred approach to locally advanced rectal cancer The use of neoadjuvant chemoradiation therapy (CRT) has resulted in reduced toxicity rates, significant tumor down-sizing and downstaging, better chance of sphincter preservation, and improved functional results A proportion of patients treated with neoadjuvant CRT may ultimately develop complete clinical response Management of these patients with complete clinical response remains controversial and approaches including radical resection, transanal local excision, and observation alone without immediate surgery have been proposed The use of strict selection criteria of patients after neoadjuvant CRT has resulted in excellent long-term results with no oncological compromise after observation alone in patients with complete clinical response Recurrences are detectable by clinical assessment and frequently amenable to salvage procedures

Nonoperative Approaches to Rectal Cancer: A Critical Evaluation

A neoadjuvant multimodality approach with chemoradiation therapy (CRT) is the preferred treatment strategy for most distal rectal cancers. Significant downstaging and complete pathologic response may develop after this strategy, and there is still controversy regarding the management of these patients. In this setting, a nonoperative approach has been suggested in select patients with complete clinical response after thorough clinical, endoscopic, and radiologic assessment. However, the assessment of these patients is not straightforward and remains complex. Available data regarding this approach are limited to a single institution`s experience from retrospective analyses. Standardization of the assessment of tumor response and the development of radiological/molecular tools may clarify the role of no immediate surgery in patients with complete clinical response after neoadjuvant CRT. Advances in radiation and medical oncology could potentially lead to significant improvements in complete tumor regression rates, leading to an increase in importance of a minimally invasive approach in patients with rectal cancer. Semin Radiat Oncol 21:234-239 (C) 2011 Elsevier Inc. All rights reserved.

Transanal Small Bowel Evisceration: An Unusual Presentation of Rectal Impalement

Traumatic transanal small bowel evisceration is a rare condition usually associated with suction injuries or blunt abdominal trauma. We report the first case of intestinal evisceration through the anus caused by penetrating trauma (rectal impalement). Additionally, we performed a literature review of all English language articles since 1970 concerned with traumatic transanal small bowel evisceration. Mechanisms of injury and the surgical management are discussed.

Transanal Endoscopic Microsurgery for Residual Rectal Cancer After Neoadjuvant Chemoradiation Therapy Is Associated With Significant Immediate Pain and Hospital Readmission Rates

BACKGROUND: Transanal endoscopic microsurgery may represent appropriate diagnostic and therapeutic procedure in selected patients with distal rectal cancer following neoadjuvant chemoradiation. Even though this procedure has been associated with low rates of postoperative complications, patients undergoing neoadjuvant chemoradiation seem to be at increased risk for suture line dehiscence. In this setting, we compared the clinical outcomes of patients undergoing transanal endoscopic microsurgery with and without neoadjuvant chemoradiation. METHODS: Thirty-six consecutive patients were treated by transanal endoscopic microsurgery at a single institution. Twenty-three patients underwent local excision after neoadjuvant chemoradiation therapy for rectal adenocarcinoma, and 13 patients underwent local excision without any neoadjuvant treatment for benign and malignant rectal tumors. Chemoradiation therapy included 50.4 to 54Gy and 5-fluorouracil-based chemotherapy. All patients underwent transanal endoscopic microsurgery with primary closure of the rectal defect. Complications (immediate and late) and readmission rates were compared between groups. RESULTS: Overall, median hospital stay was 2 days. Immediate (30-d) complication rate was 44% for grade II/III complications. Patients undergoing neoadjuvant chemoradiation therapy were more likely to develop grade II/III immediate complications (56% vs 23%; P = .05). Overall, the 30-day readmission rate was 30%. Wound dehiscence was significantly more frequent among patients undergoing neoadjuvant chemoradiation therapy (70% vs 23%; P = .03). Patients undergoing neoadjuvant chemoradiation therapy were at significantly higher risk of requiring readmission (43% vs 7%; P = .02). CONCLUSION: Transanal local excision with the use of endoscopic microsurgical approach may result in significant postoperative morbidity, wound dehiscence, and readmission rates, in particular, because of rectal pain secondary to wound dehiscence. In this setting, the benefits of this minimally invasive approach either for diagnostic or therapeutic purposes become significantly restricted to highly selected patients that can potentially avoid a major operation but will still face a significantly morbid and painful procedure.

Stapled haemorrhoidopexy transiently decreases rectal compliance and sensitivity

Aim Stapled haemorrhoidopexy may damage the anorectal musculature and its sensorimotor function. Most studies have not used a barostat for the measurement of compliance. This study aimed to investigate the effect of stapled haemorrhoidopexy on rectal compliance and sensitivity. Method After Ethical Committee approval, we studied 10 male patients (mean age 33.8 years) with third- or fourth-degree haemorrhoids. Rectal compliance and sensitivity were measured with a 600-ml bag and an electronic barostat. Volunteers were submitted to two consecutive rectal distension protocols, including continuous distension at 2, 4 and 6 months after stapled haemorrhoidopexy. Intraluminal volume and pressure were recorded, including the first rectal sensation, desire to defecate and onset of rectal pain. Another group of 10 male control patients (mean age 24.9 years) with pilonidal sinus and no haemorrhoids was also included in the study. Results Two months after stapled haemorrhoidopexy, rectal compliance decreased (7.1 +/- 0.2 vs 5.3 +/- 0.1, 6.4 +/- 0.1 vs 5.1 +/- 0.1 and 5.6 +/- 0.2 vs 4.7 +/- 0.1 ml/mmHg for first rectal sensation, desire to defecate and rectal pain, respectively; P < 0.05). The sensitivity threshold volume did not change for the first sensation but decreased significantly for the desier to defecate and pain (p < 0.05) (116.8 +/- 13.8 vs 148.4 +/- 14.61, 251.1 +/- 8.9 vs 185.8 +/- 8.6 and 293.3 +/- 16.6 vs 221.2 +/- 6.0 ml for first rectal sensation, desire to defecate and rectal pain, respectively). Four and 6 months after surgery, rectal compliance and sensitivity returned to levels similar to those in the basal period. Muscle tissue was found in only three of the 10 resected doughnuts. Controls remained without any change in rectal compliance and sensitivity. Conclusion Stapled haemorrhoidopexy transiently decreases rectal compliance and sensitivity threshold in young male patients.

Postembryonic Development of Rectal Pads in Bees (Hymenoptera, Apidae)

The morphology and development of the digestive tract of insects has been extensively studied, but little attention has been given to the development of the rectal pads. These organs are responsible for absorption of water and salts. In insects where they occur, there are usually six ovoid rectal pads located in the medial-anterior portion of the rectum. The rectal pad has three types of cells: principal, basal, and junctional. The arrangement of these three cell types delimits an intrapapillary lumen. The aim of the current study is to describe the development of the rectal pads during postembryonic development of Melipona quadrifasciata anthidioides and Melipona scutellaris. Specimens were analyzed at the following developmental stages: white-, pink-, brown-, and black-eyed pupae, and adult workers. The development of the rectal pad begins as a thickening of the epithelium in white-eyed pupae at 54 hr. At this stage, there is neither a basal cell layer nor intrapapillary lumen. The basal layers begin to form in the pink-eyed pupa and are completely formed at the end of the development of the brown-eyed pupa. In the brown-eyed pupal stage, the intrapapillary lumen is formed and the junctional cells are positioned and completely differentiated. Necrotic and apoptotic cell death were detected along with cell proliferation in the whole rectum during pupal development, suggesting that the development of the rectal pads involves cell proliferation, death, and differentiation. The rectal pads originate only from the ectoderm. Anat Rec, 292:1602-1611, 2009. (C) 2009 Wiley-Liss, Inc.

Angioleiomioma de cavidade nasal: relato de um caso e revisão de literatura

Leiomioma de cavidade nasal e seios paranasais é raro. Ele constitui menos de 1% de todos os leiomiomas do corpo humano. Isto se deve à escassez de células musculares no nariz. Estas neoplasias podem ser classificadas em três grupos: leiomioma, angiomioma e leiomioma epitelióide. Somente 15 casos de angiomioma foram encontrados na literatura. O tratamento de escolha é a excisão cirúrgica. Um novo caso e a revisão da literatura são apresentados.

Imunofenótipo e evolução de câncer de mama: comparação entre mulheres muito jovens e mulheres na pós-menopausa

OBJETIVO: avaliar características clínicas, patológicas e moleculares de carcinomas mamários em mulheres muito jovens em comparação a tumores de mulheres na pós-menopausa. MÉTODOS: foram selecionados 106 casos de câncer de mama de mulheres jovens e 130 casos de mulheres pós-menopausa. Foram analisados dados clínicos (idade ao diagnóstico, estadiamento, ocorrência de metástases, tempo de sobrevida global e livre de doença), anátomo-patológicos (tamanho do tumor, tipo e grau histológico do tumor primário) e marcadores moleculares (receptores de estrógeno e progesterona, HER2, p53, p63, citoqueratinas 5 e 14 e EGFR) com uso da imunoistoquímica empregando microarranjo de tecido. Foi analisada a relação entre as características clínico-patológicas, imunoistoquímicas e de sobrevidas global e livre de doença. RESULTADOS: as pacientes muito jovens apresentaram maior frequência de nuliparidade (p=0,03), maior diâmetro dos tumores (p<0,000), estadiamento clínico mais avançado (p=0,01), maior número de linfonodos positivos (p=0,001) e tumores pouco diferenciados (p=0,004). A maioria das pacientes jovens recebeu tratamento com quimioterapia (90,8%) e radioterapia (85,2%) e em menor proporção com tamoxifeno (31,5%), comparado às mulheres na pós-menopausa. Observamos baixa positividade para o receptor de estrógeno (49,1%; p=0,01) e alta positividade para a proteína HER2 (28,7%; p=0,03) nas mulheres jovens. O fenótipo triplo-negativo foi observado em 29,6% no grupo jovem e em 20% nas mulheres na pós-menopausa. Os tumores de fenótipo basal foram mais frequentes nas mulheres jovens (50%). As metástases sistêmicas ocorreram em 55,3% dos casos nas jovens e em 39,2% nas idosas. As sobrevidas global e livre de doença em cinco anos foram, respectivamente, 63 e 39% para as mulheres jovens e 75 e 67% para o grupo de mulheres na pós-menopausa. CONCLUSÕES: carcinomas mamários de mulheres muito jovens têm características clínicas, patológicas e moleculares mais agressivas quando comparadas às mulheres acima de 50 anos.

Carcinomas mamários de tipo basal: perfil clínico-patológico e evolutivo

OBJETIVO: Investigar a frequência de carcinomas mamários de fenótipo basal em uma série de tumores triplo-negativos (TTN), definidos pela negatividade para receptores de estrógeno (RE), de progesterona (RP) e HER2. MÉTODOS: Selecionamos 140 TTN, obtendo-se características clínico-patológicas e sobrevida. Microarranjo de tecido (2 cilindros de cada tumor) foi construído e submetido à imunoistoquímica para RE, RP, HER2, citoqueratinas (Cks) 5 e 14, EGFR, p63 e p53. Consideramos carcinomas de fenótipo basal os tumores negativos para RE, RP e HER2, e positivos para CK5. RESULTADOS: Encontramos 105 carcinomas de fenótipo basal entre 140 TTN (frequência=75%). A idade média das pacientes foi de 54,8 anos, sendo que 34,3% estavam na pré-menopausa. A maioria dos tumores foi classificada como carcinoma ductal invasor de alto grau. Os TTN exibiram positividade para CK5 (75,0%), CK14 (29%), EGFR (36,4%), p63 (28,6%) e p53 (67,1%). Estadiamento avançado da doença foi observado em 52 pacientes (50%), com diâmetro tumoral maior que 5 cm em 41 casos (39%) e metástases axilares em 61 casos (59,2%). Seguimento clínico foi obtido em 89 pacientes (média=51 meses). Destas, 45 pacientes (50,5%) evoluíram sem doença; 6 (6,7%) estavam vivas com doença e 38 (42,6%) morreram pelo câncer. Recidiva sistêmica ocorreu em 42 pacientes (47,1%), sendo pulmões, cérebro e ossos os principais sítios de metástases. As médias das sobrevidas global e livre de doença foram de 36 e 28 meses, respectivamente. CONCLUSÕES: Nosso estudo confirma comportamento clínico agressivo e elevada frequência dos carcinomas de fenótipo basal entre os TTN, semelhante ao descrito em casuísticas norte-americanas e europeias.

Immunohistochemical expression of p53, p16 and hTERT in oral squamous cell carcinoma and potentially malignant disorders

Oral carcinogenesis is a multi-step process. One possible step is the development of potentially malignant disorders known as leukoplakia and erytroplakia. The objective of this study was to use immunohistochemistry to analyze the patterns of expression of the cell-cycle regulatory proteins p53 and p16INK4a in potentially malignant disorders (PMD) of the oral mucosa (with varying degrees of dysplasia) and in oral squamous cell carcinomas (OSCC) to correlate them with the expression of telomerase (hTERT). Fifteen PMD and 30 OSCC tissue samples were analyzed. Additionally, 5 cases of oral epithelial hyperplasia (OEH) were added to analyze clinically altered mucosa presenting as histological hyperplasia without dysplasia. p53 positivity was observed in 93.3% of PMD, in 63.3% of OSCC and in 80% of OEH. Although there was no correlation between p53 expression and the grade of dysplasia, all cases with severe dysplasia presented p53 suprabasal immunoexpression. p16INK4a expression was observed in 26.7% of PMD, in 43.3% of OSCC and in 2 cases of OEH. The p16INK4a expression in OEH, PMD and OSCC was unable to differentiate non-dysplastic from dysplastic oral epithelium. hTERT positivity was observed in all samples of OEH and PMD and in 90% of OSCC. The high hTERT immunoexpression in all three lesions indicates that telomerase is present in clinically altered oral mucosa but does not differentiate hyperplastic from dysplastic oral epithelium. In PMD of the oral mucosa, the p53 immunoexpression changes according to the degree of dysplasia by mechanisms independent of p16INK4a and hTERT.

Expressão da proteína erbB-2 e dos receptores de hormônios na transição das regiões in situ para invasora de tumores da mama

OBJETIVOS: avaliar a expressão de erbB-2 e dos receptores hormonais para estrógeno e progesterona (RE/RP) nas regiões de transição entre as frações in situ e invasoras de neoplasias ductais da mama (CDIS e CDI, respectivamente). MÉTODOS: oitenta e cinco casos de neoplasias mamárias, contendo regiões contíguas de CDIS e CDI, foram selecionados. Espécimes histológicos das áreas de CDIS e de CDI foram obtidos através da técnica de tissue microarray (TMA). As expressões da erbB-2 e dos RE/RP foram avaliadas por meio de imunoistoquímica convencional. A comparação da expressão da erbB-2 e dos RE/RP nas frações in situ e invasoras da mama foi realizada com emprego do teste de McNemar. Os intervalos de confiança foram determinados em 5% (p=0,05). Foram calculados coeficientes de correlação intraclasse (ICC) para avaliar a concordância na tabulação cruzada da expressão de erbB-2 e RE/RP nas frações de CDIS e CDI. RESULTADOS: a expressão da erbB-2 não diferiu entre as áreas de CDIS e CDI (p=0,38). Comparando caso a caso suas áreas de CDIS e CDI, houve boa concordância na expressão da erbB-2 (coeficiente de correlação intraclasse, ICC=0,64), dos RP (ICC = 0,71) e dos RE (ICC = 0,64). Considerando apenas tumores cujo componente in situ apresentasse áreas de necrose (comedo), o ICC para erbB-2 foi de 0,4, comparado a 0,6 no conjunto completo de casos. Os ICC não diferiram substancialmente daqueles obtidos com o conjunto completo de espécimes em relação aos RE/RP: para RE, ICC=0,7 (versus 0,7 no conjunto completo), e para RP, ICC=0,7 (versus 0,6 no conjunto completo). CONCLUSÕES: nossos achados sugerem que as expressões de erbB-2 e RE/RP não diferem nos componentes contíguos in situ e invasivo em tumores ductais da mama.

Survival and quality of life of patients with oral and oropharyngeal cancer at 1-year follow-up of tumor resection

OBJECTIVE: This study aimed to assess the survival and life quality evolution of patients subjected to surgical excision of oral and oropharyngeal squamous cell carcinoma. MATERIAL AND METHODS: Forty-seven patients treated at a Brazilian healthcare unit specialized in head and neck surgery between 2006 and 2007 were enrolled in the study. The gathering of data comprised reviewing hospital files and applying the University of Washington Quality of Life (UW-QOL) questionnaire previously and 1 year after the surgery. Comparative analysis used Poisson regression to assess factors associated with survival and a paired t-test to compare preoperative and 1-year postoperative QOL ratings. RESULTS: 1 year after surgery, 7 patients were not found (dropout of the cohort); 15 had died and 25 fulfilled the UW-QOL again. The risk of death was associated with having regional metastasis previously to surgery (relative risk=2.18; 95% confidence interval=1.09-5.17) and tumor size T3 or T4 (RR=2.30; 95%CI=1.05-5.04). Survivors presented significantly (p<0.05) poorer overall and domain-specific ratings of quality of life. Chewing presented the largest reduction: from 74.0 before surgery to 34.0 one year later. Anxiety was the only domain whose average rating increased (from 36.0 to 70.7). CONCLUSIONS: The prospective assessment of survival and quality of life may contribute to anticipate interventions aimed at reducing the incidence of functional limitations in patients with oral and oropharyngeal cancer.

Changes in ruminal fermentation and mineral serum level in animals kept in high temperature environments

In order to evaluate the effect of environmental temperature on ruminal fermentation and on mineral levels of growing ruminants, it was used 12 male calves (initial average weight 82.9 ± 7.7 kg, 100 days of age), were employed in a randomized block design (by weight) experiment, with repeated weight measurement and two environmental temperatures: thermoneutral (24ºC) and heat-stressed (33ºC), during 38 days. The animals exposed to 33ºC presented lower dry matter ingestion, lower T3 (triiodothyronine) serum level, higher ammoniacal nitrogen (NH3-N) level in the rumen liquid, and higher rectal and body temperatures during all the experimental period when compared to the animals kept in thermoneutral environment (24ºC). The animals kept under heat stress environment (33ºC) presented higher calcium serum level, which was the highest on 31st day and the lowest on the 38th day of the experiment; phosphorus level was the lowest during all the experimental period; sodium level was lower on the 17th, 31st and 38th experimental days. Potassium and zinc levels were lower after 24 days; copper level was lower until the 24th day; magnesium level was higher until the 17th day, if compared to the ones from the animals kept in thermoneutral environment (24ºC). The heat-stressed animals presented higher levels of ammoniacal nitrogen in the ruminal liquid and a decrease in the phosphorus, sodium, potassium and zinc serum levels. These results show the necessity of changes on feed management to ruminants in temperatures over the thermal comfort limits so that performance loss is decreased.

Evolução dos doentes com citologia oncótica alterada e colposcopia anal normal

A citologia anal vem sendo usada para rastreamento do carcinoma anal e suas lesões precursoras nas populações de risco. Quando o raspado do canal anal mostra alterações citológicas está indicada o exame com colposcópio e ácido acético para identificar e realizar biópsia para confirmar o achado. Poucos estudos mostram o seguimento dos doentes tratados de condilomas acuminados perianais. Temos usado os métodos em associação e encontrado lesões subclínicas em metade dos doentes, cujo exame proctológico não revelava doença HPV induzida. Essas lesões são tratadas com tópicos. Entretanto, algumas citologias estavam alteradas e a colposcopia anal não revelou doença HPV induzida. O objetivo deste estudo foi observar o comportamento dessas lesões no seguimento semestral, durante 12 meses, e avaliar se a periodicidade da reavaliação foi suficiente para evitar o aparecimento das lesões de alto grau ou superior. Encontramos 58 (21%) entre 273 doentes nessas condições. As reavaliações de 22 deles após um ano mostraram que as colposcopias permaneceram normais em 17 (74%), sendo que em cinco (22%) a citologia voltou aos padrões normais e 12 (52%) persistiram com alterações. Os outros seis (26%) desenvolveram lesões clínicas ou subclínicas provocadas pelo HPV. As contagens de linfócitos T CD4 dos doentes HIV-positivos foram inferiores nos doentes cujas lesões progrediram. Os resultados permitiram concluir que as alterações podem progredir ou regredir neste grupo distinto de doentes, sendo relacionada à imunidade, e que o intervalo de seis meses é suficiente para cada reavaliação.

Linfoma ileal primário como uma causa de intussuscepção ileocecal recorrente

INTRODUÇÃO: A intussuscepção ocorre quando um segmento proximal do intestino invagina para dentro do lúmen do segmento distal adjacente. Esta patologia é relativamente comum em crianças, sendo geralmente idiopática, diferentemente do que é evidenciado em adolescentes e adultos, os quais apresentam uma causa orgânica comprovada na maioria dos casos. O linfoma intestinal como etiologia desta patologia é extremamente raro. RELATO DE CASO: Um paciente de 16 anos, masculino, referindo dor abdominal em quadrante inferior direito há 36 horas associada a vômitos e fezes com sangue vivo compareceu em nosso serviço. O exame físico se apresentava dentro da normalidade exceto por uma massa palpável no quadrante inferior direito. A ultra-sonografia abdominal revelou intussuscepção ileocecal. A colonoscopia demonstrou uma massa protuberante proveniente do orifício da válvula ileocecal que foi reduzida, tendo o paciente um alívio completo dos sintomas. Três semanas após, o paciente retornou ao nosso hospital com recorrência dos sintomas. Uma laparotomia exploradora foi realizada evidenciando uma massa polipóide no íleo terminal com intussuscepção para dentro do ceco. Uma colectomia direita ampliada foi realizada. Após exame patológico da peça e estadiamento tumoral, um linfoma de Burkitt primário foi diagnosticado. A recuperação pós-operatória não apresentou intercorrências e o paciente foi encaminhado para quimioterapia adjuvante.