Claudio Tarta

Massive zosteriform cutaneous metastasis from rectal carcinoma.

Abstract.A 44-year-old man presented with a large and rapidly growing skin lesion approximately six months after resection of a rectal carcinoma. The lesion measured 40 cm in size, extended from the suprapubic area to the proximal half of the left groin, and showed a particular zosteriform aspect. Biopsy confirmed a metastatic skin adenocarcinoma. Cutaneous metastases from rectal cancer are very uncommon. Their gross appearance is not distinctive, although the skin tumors are usually solid, small (less than 5 cm) and painless nodules or papules. Early biopsies for suspicious skin lesions are needed in patients with a history of colorectal cancer.

Identification of patients at-risk for Lynch syndrome in a hospital-based colorectal surgery clinic.

AIM To determine the prevalence of a family history suggestive of Lynch syndrome (LS) among patients with colorectal cancer (CRC) followed in a coloproctology outpatient clinic in Southern Brazil. METHODS A consecutive sample of patients with CRC were interviewed regarding personal and family histories of cancer. Clinical data and pathology features of the tumor were obtained from chart review. RESULTS Of the 212 CRC patients recruited, 61 (29%) reported a family history of CRC, 45 (21.2%) were diagnosed under age 50 years and 11 (5.2%) had more than one primary CRC. Family histories consistent with Amsterdam and revised Bethesda criteria for LS were identified in 22 (10.4%) and 100 (47.2%) patients, respectively. Twenty percent of the colorectal tumors had features of the high microsatellite instability phenotype, which was associated with younger age at CRC diagnosis and with Bethesda criteria (P < 0.001). Only 5.3% of the patients above age 50 years had been previously submitted for CRC screening and only 4% of patients with suspected LS were referred for genetic risk assessment. CONCLUSION A significant proportion of patients with CRC were at high risk for LS. Education and training of health care professionals are essential to ensure proper management.

FIBRIN GLUE IN THE MANAGEMENT OF COMPLEX ANAL FISTULA

CONTEXT Management of complex anal fistulas is associated with the risk of sphincter injury and fecal incontinence. In recent years, fibrin glue has emerged as an alternative sphincter-preserving treatment for anal fistulas. To date, however, there is no consensus about the efficacy of the method. OBJECTIVE To specifically evaluate the fibrin glue injection in the management of complex cryptoglandular anal fistulas. METHODS We studied a series of patients with complex anal fistulas treated with fibrin glue between January 2005 and January 2007. Only patients with fistulas of cryptoglandular origin were analyzed. Patients with fistulas related to Crohns disease, HIV or previous surgery were excluded from the study. Under spinal anesthesia, the fistulas were curetted and injected with fibrin glue. After treatment, patients were followed-up for 12 months. RESULTS Thirty-two patients were enrolled in the study. Two patients were lost to follow-up and were excluded. Out of the remaining 30 patients, only three healed successfully (10%). Among the 27 patients who failed to heal, 9 (33.3%) were diagnosed within the first postoperative month. In 13 patients (48.1%) the failure of treatment occurred in the period between 1 and 3 months, in 3 patients (11.1%) between 3 and 6 months, and in 2 patients (7.4%) between 6 and 9 months after surgery. No treatment-related complications were observed. CONCLUSIONS In this series, fibrin glue treatment for complex cryptoglandular anal fistulas achieved a very low healing rate. Our results do not support the use of fibrin glue as a first-line treatment for patients with this type of fistula.

Angiogenesis in advanced colorectal adenocarcinoma with special reference to tumoral invasion

BACKGROUND Angiogenesis is a crucial step in tumor growth and progression. Its quantification by microvessel counting has a prognostic value in several types of malignancies and recently has been appraised in gastrointestinal tumors. AIM To assess the prognostic significance of microvessel quantification in colorectal carcinomas, studying its association with hematogenous metastases, survival and clinicopathological variables such as size, histologic differentiation and depth of tumoral invasion. PATIENTS/METHODS Forty eight patients with colorectal adenocarcinoma were included in this study. Histologic sections of invasion tumoral margin (4 microns) were analyzed and endothelined microvessels were immunostained with monoclonal mouse Von Willebrand Factor (anti-FVIII). The microvessel count was performed from the identification of the area with increased microvessel density--hot spots--and results of the mean in five of these fields. RESULTS The cut-off microvessel count was 14 microvessels/0.785 mm2, which divided the sample into hypovascular and hypervascular groups. While 2/8 (25%) tumors with muscularis propria invasion were classified as hypervascular, 11/15 (73%) tumors with serosa or perivisceral fat were classified as hypervascular. However, a non-significant statistical association was found between the angiogenesis quantification, hematogenous metastases, survival and clinicopathological variables such as size and histologic differentiation of the tumor. CONCLUSIONS The findings of significantly increase of microvessel count in conformity with tumoral invasion depth supports the hypothesis that tumor progression might be related to angiogenesis. Although angiogenesis is an important step in the tumoral growth and during the metastatization process, other factors can be implicated.

Colonoscopia com magnificação de imagem no diagnóstico de carcinoma colorretal invasivo da submucosa na polipose adenomatosa familiar

O desenvolvimento da colonoscopia com magnificacao de imagem possibilitou o estudo detalhado da mucosa colonica e o diagnostico diferencial entre lesoes neoplasicas e nao-neoplasicas, a partir da observacao dos pit patterns. Os resultados sao comparaveis a estereomicroscopia, sendo possivel, assim, presumir o diagnostico histologico. Foi realizada colonoscopia com magnificacao de imagem em paciente portadora de polipose adenomatosa familiar, demonstrando-se com este metodo, a diversidade de lesoes polipoides benignas e as apresentacoes morfologicas do câncer colorretal precoce. Nesta paciente, a avaliacao por magnificacao (videocolonoscopio FUJINON 410 - CM ¾ 40X), combinada a cromoscopia com indigo carmine 0,4%, demonstrou ampla variedade de lesoes distribuidas por todo o colon: lesao de espalhamento lateral no ceco com padrao IIIL + IV, polipos subpediculados e sesseis distribuidos pelo colon com padrao tipo IIIL, polipo subpediculado no colon transverso com diâmetro aproximado de 2,0 cm e padrao IV + V, lesoes plano-elevadas tipo IIIL e no colon sigmoide lesao IIa + IIc, com padrao V de Kudo. A avaliacao dos pit patterns de lesoes no colon transverso e sigmoide permitiu o diagnostico endoscopico de lesao com invasao de submucosa.The development of colonoscopy with image magnification has enable to study the colonic mucosa in detail and to do differential diagnosis between neoplastic and non-neoplastic lesions from the observation of pit patterns. The results are comparable to stereomicroscopy being possible to predict the histologic diagnosis. In a patient with familial adenomatous polyposis magnifying colonoscopy was performed and this method demonstrated a wide variation of benign polypoid lesions and the morphological features of early colorectal cancer. In this patient, the evaluation by image magnification, together with indigo carmin 0.4% chromoscopy, showed a wide variety of lesions in the colon and rectum: laterally spreading tumor in the cecum, with IIIL + IV pits, subpediculate polyp in the transverse colon with approximately 2.0 cm diameter and IV + V pits, flat elevated lesions IIIL type, and in the sigmoid colon IIa + IIc lesion with V type of Kudos classification were observed. The evaluation of pit patterns of the lesions in the transverse and sigmoid colon has enable to do the endoscopic diagnosis of the lesion with submucosal invasion.The development of colonoscopy with image magnification has enable to study the colonic mucosa in detail and to do differential diagnosis between neoplastic and non-neoplastic lesions from the observation of pit patterns. The results are comparable to stereomicroscopy being possible to predict the histologic diagnosis. In a patient with familial adenomatous polyposis magnifying colonoscopy was performed and this method demonstrated a wide variaton of benign polypoid lesions and the morphological features of early colorectal cancer. In this patient, the evaluation by image magnification, together with indigo carmin 0,4% chromoscopy, showed a wide variety of lesions in the colon and rectum: laterally spreading tumor in the cecum, with IIIL + IV pits, subpediculate polyp in the transverse colon with approximately 2,0 cm diameter and IV + V pits, flat elevated lesions IIIL type, and in the sigmoid colon IIa + IIc lesion with V type of Kudos classification were observed. The evaluation of pit patterns of the lesions in the transverse and sigmoid colon has enable to do the endoscopic diagnosis of the lesion with submucosal invasion.

Metástase endotraqueal e endobrônquica de adenocarcinoma de cólon

Endotracheal and endobronchial dissemination from a colon cancer is an excedingly rare event. The authors report a case of an endotracheal and endobronchial metastatic lesion presenting clinically 10 years after treatment of the primary tumor.

Human papillomavirus detected in a colonic metastasis of cervical adenocarcinoma.

In this letter, we report a case of a 57-year-old woman referred to our Coloproctology Division with symptoms of progressive constipation and a colonoscopy showing a rigid stenosis of the sigmoid colon, without any mucosal lesion. She had a history of a radical hysterectomy, performed 5 years earlier, due to a well-differentiated villoglandular cervical adenocarcinoma (Fig 1a). After a preoperative workup without additional findings, she underwent a sigmoid resection. Histopathologic examination of the surgical specimen revealed a well-differentiated glandular malignant tumor (3 9 3 cm) within the intestinal wall (Fig. 1b), without extension to the mucosal layer, but showing tumor emboli within subserosal vessels (Fig 1c). This glandular pattern was very similar to that previously seen in the cervical adenocarcinoma. Immunohistochemical analysis of the tumor confirmed the diagnosis of adenocarcinoma originating in the cervix. The immunohistochemical profile was as follows: strong intensity staining for CEA, CA125 and CK7 in 100 % of the tumor cells; strong staining for CK20 in 70 % of the cells; and negative staining for p53, k-ras and progesterone receptor. Considering the well-known etiological correlation of human papillomavirus (HPV) and cervical cancer, we decided to analyze tumor tissues through MY/GP-nested polymerase chain reaction (PCR) and through GP5?/ GP6? auto-nested PCR. Specific primer sets targeting the E6/E7 region of the HPVs 16, 18, 33, 45 were used for typing. The molecular analyses revealed the presence of HPV18 in both the primary cervical adenocarcinoma and the metastatic tumor. Metastatic lesions involving the colon are rare, being usually related to carcinomas of the breast and kidney or to melanoma. Colonic metastases of cervical cancers are exceedingly rare. To date, there are only 9 cases reported in the literature (eight squamous carcinomas) [1–5]. There is only one report of a cervical adenocarcinoma metastasizing to the large bowel, which also involved the sigmoid colon with extension to the subserosa [5]. HPV has been definitely implicated in the process of cervical carcinogenesis. Its role in development of primary colorectal cancer has also been demonstrated [6]. Some authors have reported the identification of HPV deoxyribonucleic acid (DNA) in bone, lung, liver and lymph node metastasis from squamous cell carcinoma of the cervix [4]. However, to the best of our knowledge, the present article is the first to report the detection of HPV within a metastastic adenocarcinoma of the cervix involving the colon. Our findings confirm the importance of HPV in cervical carcinogenesis and reinforce prior data indicating that viral integration into host cell DNA represents a crucial step for development of the malignant phenotype and tumor dissemination. A. P. Damin G. Agnes Laboratory of Molecular Biology, Federal University of Health Science of Porto Alegre, Porto Alegre, Brazil

Carcinoma basocelular perianal: relato de caso e revisão da literatura

Basal Cell Carcinoma (BCC) is the most common skin cancer. It is preferentially found in sun-exposed areas and it is extremely rare at perianal region. In this article, we report a case of perianal BCC. In addition, we present a review of the medical literature on this subject, outlining clinical and histologic characteristics of this type of tumor as well as the choices of treatment.