Caio Sergio Rizkallah Nahas

Squamous-Cell Carcinoma of the Rectum: A Rare but Curable Tumor

PurposeThis study was designed to evaluate one institution’s experience with treatment outcomes for rectal squamous-cell carcinoma.MethodsUsing our prospective Colorectal Database, we identified patients diagnosed with rectal squamous-cell carcinoma at our institution between 1983 and 2005. Pathology was rereviewed, tumor immunophenotype was compared to control cases of anal squamous-cell carcinoma and rectal adenocarcinoma, treatment modalities and outcomes were analyzed.ResultsTwelve patients were identified (10 females median age, 58xa0years). Median distal extent of tumors was 7 (range, 5–8) cm from the anal verge. Treatment included chemotherapy only (nu2009=u20091), chemoradiation only (nu2009=u20092), induction chemotherapy followed by chemoradiation and surgery (nu2009=u20092), chemoradiation followed by surgery (nu2009=u20095), and surgery followed by chemoradiation (nu2009=u20092). The chemotherapy regimen was 5-fluorouracil-based. Radiotherapy total dose was 50.4xa0Gy (1.8xa0Gy/day, daily × 5) external iliac and inguinal nodes were not included in the radiation field. Complete clinical responders to chemoradiation (nu2009=u20092) received no further treatment. All seven partial responders underwent surgery; six had complete pathologic response; nodal status in two of six was unknown because they had local excision. Immunophenotypical analysis showed similar keratin expression profile between rectal squamous-cell carcinoma (nu2009=u20095) and rectal adenocarcinoma (nu2009=u20095), which is different from anal squamous-cell carcinoma (nu2009=u200910). All patients were alive without evidence of disease at follow-up (median follow-up, 2.6 (range, 0.5–16)xa0years).ConclusionsOur data suggest that most patients treated with upfront chemoradiation therapy followed by surgery did well. Sphincter-preserving surgery is usually feasible. Clinical judgment of tumor response after chemoradiation is not completely reliable. Immunohistochemistry suggests a common cellular origin for rectal squamous-cell carcinoma and rectal adenocarcinoma, which is different from anal squamous-cell carcinoma.

Screening anal dysplasia in HIV-infected patients: is there an agreement between anal pap smear and high-resolution anoscopy-guided biopsy?

PURPOSE: The purpose of this study was to analyze the agreement between anal Pap smear and high-resolution anoscopy-guided biopsy in diagnosing anal dysplasia in HIV-infected patients. METHODS: We conducted cross-sectional analysis of HIV-infected patients receiving anal dysplasia screening as part of routine care. Agreement between measures was estimated by weighted kappa statistics, using a three-tiered cytologic and histologic grading system (normal, low-grade dysplasia, and high-grade dysplasia). Estimates of sensitivity, specificity, and predictive values were calculated using a two-tiered cytologic and histologic grading system (“without dysplasia” and “with dysplasia of any grade”). Estimates were also calculated for the detection of high-grade dysplasia. RESULTS: During a one-year period, 222 patients underwent 330 anal Pap smears followed by high-resolution anoscopy-guided biopsies. There were 311 satisfactory Pap smears with concurrent biopsies. Considering histology the standard, the frequency of anal dysplasia was 46%. Kappa agreement between anal Pap smear and biopsy was 0.20. For detection of anal dysplasia of any grade, anal Pap smear showed sensitivity of 61%, specificity of 60%, positive predictive value of 56%, and negative predictive value of 64%. For high-grade dysplasia, anal Pap smear showed sensitivity of 16% and specificity of 97%. CONCLUSION: Anal Pap smears alone were not sensitive enough to rule out anal dysplasia. We recommend that high-resolution anoscopy-guided biopsy be incorporated as a complementary screening test for anal dysplasia in high-risk patients. Following baseline high-resolution anoscopy, these individuals could be followed with serial anal cytology to dictate the need for future high-resolution anoscopy-guided biopsies.

Positron Emission Tomography Detection of Distant Metastatic or Synchronous Disease in Patients with Locally Advanced Rectal Cancer Receiving Preoperative Chemoradiation

BackgroundPatients with locally advanced rectal cancer may present with synchronous distant metastases. Choice of optimal treatment—neoadjuvant chemoradiation versus systemic chemotherapy alone—depends on accurate assessment of distant disease. Wexa0prospectively evaluated the ability of [18F]fluorodeoxyglucose ([18F]FDG) positron emission tomography (PET) to detect distant disease in patients with locally advanced rectal cancer who were otherwise eligible for combined modality therapy (CMT).MethodsNinety-three patients with locally advanced rectal cancer underwent whole-body [18F]FDG PET scanning 2–3 weeks before starting CMT. Sites other than the rectum, mesorectum, or the area along the inferior mesenteric artery were considered distant and were divided into nine groups: neck, lung, mediastinal lymph node (LN), abdomen, liver, colon, pelvis, peripheral LN, and soft tissue. Two nuclear medicine physicians blinded to clinical information used PET images and a five-point scale (0–4) to determine certainty of disease. A score greater than 3 was considered malignant. Confirmation was based on tissue diagnosis, surgical exploration, and subsequent imaging.ResultsAt a median follow-up of 34 months, the overall accuracy, sensitivity, and specificity of PET in detecting distant disease were 93.7%, 77.8%, and 98.7% respectively. Greatest accuracy was demonstrated in detection of liver (accuracyxa0=xa099.9%, sensitivityxa0=xa0100%, specificityxa0=xa098.8%) and lung (accuracyxa0=xa099.9%, sensitivityxa0=xa080%, specificityxa0=xa0100%) disease; PET detected 11/12 confirmed malignant sites in liver and lung. A total of 10 patients were confirmed to have M1 stage disease. All 10 were correctly staged by pre-CMT PET; abdominopelvic computed tomography (CT) scans accurately detected nine of them.ConclusionBaseline PET in patients with locally advanced rectal cancer reliably detects metastatic disease in liver and lung. PET may play a significant role in defining extent of distant disease in selected cases, thus impacting the choice of neoadjuvant therapy.

Prevalence of Perianal Intraepithelial Neoplasia in HIV-Infected Patients Referred for High-Resolution Anoscopy

PurposeThis study was designed to describe perianal disease in a cohort of HIV-infected patients referred for high-resolution anoscopy.MethodsA retrospective chart review was performed on 52 HIV-infected patients referred for high-resolution anoscopy from 2001 to 2005. All patients underwent anal canal and perianal high-resolution anoscopy in the office with biopsy of suspicious areas. Patients with high-grade intraepithelial perianal lesions underwent multiple biopsies under general anesthesia in the operating room to rule out malignancy.ResultsOf the 52 patients, 19 (37 percent) had perianal abnormalities noted on high-resolution anoscopy and underwent punch biopsy. The mean duration of known HIV infection in these 19 patients (15 males) was 10.6 years, with 17 on highly active antiretroviral therapy for the last 3-month period. Mean CD4 count was 371 cells/μl. Office perianal biopsies diagnosed two patients with invasive squamous-cell carcinoma and nine with high-grade squamous intraepithelial lesion. Seven of the nine patients with perianal high-grade squamous intraepithelial lesion on office biopsy were submitted to multiple biopsies under general anesthesia. One of these seven had an occult perianal squamous-cell carcinoma.ConclusionsPerianal disease was common in this group of HIV-infected patients; 11 patients (21 percent of total) were diagnosed with squamous-cell carcinoma or high-grade squamous intraepithelial lesion. Because only 19 patients had clinically suspicious perianal lesions biopsied, this may be an underestimate. Our data suggest that anal canal neoplasia often is accompanied by perianal disease and illustrates the need for biopsy of any suspicious perianal lesions.

Outcomes of Immediate Internal Pudendal Artery Perforator Flap Reconstruction for Irradiated Abdominoperineal Resection Defects

BACKGROUND: There are many previous reports for using the internal pudendal artery perforator flap in vulvovaginal reconstruction; however, reports of this flap for perineal reconstruction after abdominoperineal excision of the rectum are scarce. OBJECTIVE: The purpose of this study was to evaluate the outcomes of immediate internal pudendal artery perforator flap reconstruction for irradiated abdominoperineal resection defects. DESIGN: This was a prospective case series. SETTINGS: This flap could represent a step forward over other perineal flap approaches or primary closure. PATIENTS: A total of 73 consecutive patients with anorectal tumors were included. INTERVENTIONS: The study included immediate perineal reconstruction using 122 internal pudendal artery perforator flaps after abdominoperineal excision of the rectum. MAIN OUTCOME MEASURES: Dimensions of the perineal defect (in centimeters squared), hospital stay (days), healing time (days), and postoperative complications (Clavien–Dindo grades) were measured. RESULTS: The means of the perineal defect, hospital stay, and healing time were 51.62u2009cm2, 15.94 days, and 38.52 days. The higher the patient BMI, the longer healing time (p = 0.02); Clavien–Dindo complications grades III to IV were greater in patients with perineal defect ≥60u2009cm2 (p = 0.03; OR = 10.56); postoperative complications were higher both in patients with anal squamous cell carcinoma (p = 0.005; OR = 6.09) and in patients with comorbidities (p = 0.04; OR = 2.78); hospital stay (p= 0.001) and healing time (p < 0.001) were higher in patients who had postoperative complications. The complete perineal wound healing at 12 weeks was achieved by 95% of patients, and our 30-day mortality rate was 4%. LIMITATIONS: As a nonrandomized study, our results have to be interpreted with caution. CONCLUSIONS: Multiple previously described advantages associated with internal pudendal artery perforator flap were also observed here, reinforcing the idea that it is reliable, versatile, and a useful option for perineal reconstruction after abdominoperineal excision of the rectum. Therefore, we propose that this flap could be considered as the first choice for perineal reconstruction in selected patients with moderate and some large defects after abdominoperineal excision of the rectum. See Video Abstract at http://links.lww.com/DCR/A367.

Médicos residentes podem realizar com segurança e eficiência técnicas de Milligan-Morgan, Ferguson e grampeadores no tratamento cirúrgico das hemorróidas?

BACKGROUND: Surgery for symptomatic hemorrhoids is needed in almost 10% of the patients. Although, literature about the surgical management of hemorrhoidal disease is vast, data concerning hemorrhoidectomy or hemorrhoidopexy performed by training residents is limited. AIM: To analyze the results of these procedures in a teaching institution. METHODS: Data from all patients who underwent surgical treatment for hemorrhoids from 1995 to 2007 in a single institution were retrospectively analyzed. Residents supervised by assisting doctors performed all procedures. Techniques were compared based on operative time, hospital stay, morbidity, and long-term efficacy. RESULTS: Three hundred thirty three patients were included in the study, 182 males (54.6%), with a mean age of 45.3 years (± 12.02). Third degree hemorrhoids were the main indication (81.7%). Milligan-Morgan was the most commonly performed procedure (57%), followed by Ferguson and stapled hemorrhoidopexy. Mean operative time was significantly lower in the stapled hemorrhoidopexy group when compared to the open and closed procedures: 49,4 ± 29.3 min vs. 61.1 ± 26.5 and 67.1 ± 28.3, respectively (p=0.0034). There was no statistically significant difference among the groups regarding postoperative complications or reoperation rate. Length of stay was significantly higher in the Milligan-Morgan group when compared to Ferguson and stapled hemorrhoidopexy (1.41 ± 0.86 days vs. 1.19 ± 0.43 vs. 1.16 ± 0.37 respectively). Symptomatic recurrence, reoperation rates and band ligation usage were similar among groups. CONCLUSION: Residents under supervision can perform Milligan-Morgan, Ferguson and stapled hemorrhoidopexy with low incidence of complications and good long-term results. Stapled hemorrhoidopexy technique was associated with a shorter operative time, while Milligan-Morgan correlated with a longer length of stay.

Excisão total do mesorreto por laparoscopia

INTRODUCAO: O tratamento cirurgico do câncer do reto passou por grande refinamento tecnico apos a incorporacao da excisao total do mesorreto. A possibilidade de tratamento por laparoscopia ainda permanece como motivo de controversia. Assim, uma revisao atualizada do assunto e pertinente para ajudar a orientar a conduta aos pacientes com esse tumor. METODO: Foram consultadas as bases de dados disponiveis pelo Medline/Pubmed, Scielo e Lilacs cruzando os seguintes unitermos: câncer colorretal, laparoscopia, cirurgia. CONCLUSAO: Ate a presente data, ainda permanece motivo de controversia se o tratamento do câncer de reto deve ser realizado de forma rotineira por laparoscopia. Nao existem dados na literatura que suportem a realizacao minimamente invasiva da excisao total do mesorreto para o tratamento do câncer de reto fora de protocolo de pesquisa, especialmente pela ausencia de indices de sobrevida e de recidiva local com pelo menos cinco anos de seguimento.

The use of PET/PET CT in the Management of Colorectal Cancer

Positron emission tomography (PET) is considered a potentially useful diagnostic tool in the management of a variety of malignancies. It has been used for staging, evaluating recurrent and metastatic disease and tumoral response to neoadjuvant therapy, and providing prognostic information. However, some data are available about its definitive role in the colorectal cancer (CRC) population. In this chapter, the most recent evidence and future perspectives are presented for [18F]fluorodeoxyglucose PET in managing patients with CRC.

Positron emission tomography detection of distant metastatic or synchronous disease in patients with locally advanced rectal cancer receiving preoperative chemoradiation (Annals of Surgical Oncology DOI: 10.1245/s10434-007-9626-y)

Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA Department of Nuclear Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA Department of Epidemiology & Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA Department of Gastroenterology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA