Fernando Castro-Poças

The importance of ultrasound findings in the study of anal pain

OBJECTIVE Endoanal ultrasonography can detect organic causes of anal pain without pathology on physical examination. The aim of this study is to evaluate the importance of endoanal ultrasonography in the diagnosis and therapeutic management of idiopathic and functional anal pain. MATERIAL AND METHODS Retrospective study, between 15 March 2005 and 15 June 2008, of all patients with proctalgia and normal examination or with alterations not responsible for anal pain at proctologic exam that have undergone an endoanal ultrasonography. RESULTS A total of 90 patients were analyzed, with a mean age of 50.5 years, 58% were female. Twenty-three patients had functional anal pain clinic criteria. Endoanal ultrasonography revealed alterations in 49% of patients. The primary findings were changes in sphincters in 14 patients, followed by anal sepsis in 12 patients, anal fissure in 10 patients, perirectal lesions in 6 patients and ulcer of the anal canal in 2 patients. Of the patients with sphincter defects, 5 patients had criteria of chronic anal pain. In this group of patients, no differences were found in manometric and defecographic results between the different ultrasound abnormalities. CONCLUSIONS The endoanal ultrasonography detected occult organic lesions to proctologic examination, in half the patients with anal pain. Ultrasound abnormalities were found in 22% of patients with functional anal pain. However, there was no correlation between ultrasound findings and physiological studies, and therefore could not find etiological or pathogenic factors of functional anal pain.

Predictive clinical model of tumor response after chemoradiation in rectal cancer

Survival improvement in rectal cancer treated with neoadjuvant chemoradiotherapy (nCRT) is achieved only if pathological response occurs. Mandard tumor regression grade (TRG) proved to be a valid system to measure nCRT response. The ability to predict tumor response before treatment may significantly have impact the selection of patients for nCRT in rectal cancer. The aim is to identify potential predictive pretreatment factors for Mandard response and build a clinical predictive model design. 167 patients with locally advanced rectal cancer were treated with nCRT and curative surgery. Blood cell counts in peripheral blood were analyzed. Pretreatment biopsies expression of cyclin D1, epidermal growth factor receptor (EGFR), vascular endothelial growth factor (VEGF) and protein 21 were assessed. A total of 61 single nucleotide polymorphisms were characterized using the Sequenom platform through multiplex amplification followed by mass-spectometric product separation. Surgical specimens were classified according to Mandard TRG. The patients were divided as: “good responders” (Mandard TRG1-2) and “poor responders” (Mandard TGR3-5). We examined predictive factors for Mandard response and performed statistical analysis. In univariate analysis, distance from anal verge, neutrophil lymphocyte ratio (NLR), cyclin D1, VEGF, EGFR, protein 21 and rs1810871 interleukin 10 (IL10) gene polymorphism are the pretreatment variables with predictive value for Mandard response. In multivariable analysis, NLR, cyclin D1, protein 21 and rs1800871 in IL10 gene maintain predictive value, allowing a clinical model design. Conclusion: It seems possible to use pretreatment expression of blood and tissue biomarkers, and build a model of tumor response prediction to neoadjuvant chemoradiation in rectal cancer.

Colon hemangiolymphangioma—a rare case of subepithelial polyp

An asymptomatic 64-year-old man without a relevant clinical history was referred for endoscopic colorectal cancer screening. In the colonoscopy, a polypoid lesion was identified, which was pediculated and measuring about 25 mm at the proximal transverse colon. The lesion was covered by normalappearing mucosa. We performed a miniprobe endoscopic ultrasonography, 12 MHz, which showed a polypoid morphology lesion, which heterogeneous and cystic, with various anechoic cavities separated by different thickness septa, being a part of them incomplete. The lesion was well delimited with regular boarders and located in the submucosa, with interface preservation with the adjacent layers. The size of the lesion was 27.1 by 20 mm. The patient required a definitive diagnosis. The endoscopic resection was performed with a hot snare. There were no complications. The patient is well with no additional colorectal lesions 2 years after the polyp’s resection. The macroscopic examination of the excised specimen showed a circumscribed round polyp, which is 25 mm in diameter, of soft consistency and covered by normal-appearing mucosa. The histological examination showed a lesion with capillary and lymphatic-type blood vessels in mucosa and submucosa; positivity for CD31 and D2-40 was expressed in the endothelial cells of lymphatic vessels. A definitive diagnosis of colon hemangiolymphangioma was made.

3D echoendoscopy and miniprobes for rectal cancer staging

BACKGROUND rectal cancer staging using rigid probes or echoendoscopes has some limitations. The aim of the study was to compare rectal cancer preoperative staging using conventional endoluminal ultrasonography with three-dimensional endoscopic ultrasonography and miniprobes. MATERIALS AND METHODS sixty patients were included and evaluated with: a) a conventional echoendoscope (7.5 and 12 MHz); b) miniprobes (12 MHz); and c) the Easy 3D Freescan software for three-dimensional endoscopic ultrasonography. The reference or gold standard was conventional endoluminal ultrasonography in all cases and pathological assessment for those without preoperative therapy. The differences in T and N staging accuracy in both longitudinal and circumferential extension were evaluated. RESULTS with regard to T staging, conventional endoluminal ultrasonography had an accuracy of 85% (compared to pathological analysis), and the agreement between miniprobes vs conventional endoluminal ultrasonography (kappa = 0.81) and three-dimensional endoscopic ultrasonography vs conventional endoluminal ultrasonography (k = 0.87) was significant. In addition, miniprobes had an accuracy of 82% and three-dimensional endoscopic ultrasonography had a higher accuracy (96%). With regard to N staging, conventional endoluminal ultrasonography had an accuracy of 91% with a sensitivity of 78%. However, the agreement between miniprobes and conventional endoluminal ultrasonography and three-dimensional endoscopic ultrasonography and conventional endoluminal ultrasonography (k = 0.70) was lower. Interestingly, miniprobes had a lower accuracy of 81% whereas three-dimensional endoscopic ultrasonography had an accuracy of 100% without any false negative. No false positives were observed in any of the techniques. Accuracy for T and N staging was not influenced by longitudinal or circumferential extensions of the tumor in all types of endoscopic ultrasonography analyzed. CONCLUSIONS miniprobes and especially three-dimensional endoscopic ultrasonography may be relevant during rectal cancer staging.

Portal Vein Aneurysm Mimicking a Liver Nodule

liver and the pancreatic head, apparently adjacent to the portal vein trunk, with positive Doppler sign (Fig. 1). At this point, the lesion was considered to be of vascular nature, and as the patient refused magnetic resonance imaging (MRI) due to claustrophobia, an abdominal computed tomography (CT) scan was performed, describing a normal liver and a portal vein trunk aneurysm with a 35-mm diameter, without thrombosis or compression of adjacent structures (Fig. 2). After multidisciplinary discussion, conservative management with clinical and Doppler ultrasound surveillance of complications such as thrombosis or compression of structures was proposed to the patient, and no such events occurred during 1 year of follow-up. Portal vein aneurysms, defined as a portal vein diameter exceeding 19 mm in cirrhotic patients and 15 mm in noncirrhotic ones, are extremely rare, with about 200 cases published, most being extrahepatic [1]. A proportion is believed to be congenital due to incomplete regression of the right primitive distal vitelline vein, explaining its presence in patients with no history of cirrhosis, pancreatitis, abdominal trauma or malignancy [2]. Half of the patients present with nonspecific abdominal pain and less than 10% have a serious complication, with spontaneous rupture being unfrequently reported [1]. Abdominal Doppler ultrasound and especially CT and MRI are helpful for the diagnosis, evaluation and determining of the exact location of the aneurysm.

Mediastinal Mass in a Patient with Colorectal Cancer: A Diagnostic Challenge

The differential diagnosis of mediastinal masses involves many benign and malignant conditions, such as lymphadenopathies and cystic lesions. Metastatic mediastinal adenopathies are usually due to lung, esophagus, and stomach cancer and, rarely, due to colorectal cancer. Gastrointestinal duplication cysts are uncommon inherited lesions usually diagnosed during childhood and may involve the esophagus in 20% of cases. In adults, they are usually asymptomatic and diagnosed incidentally. We report the case of a 54-year-old male who recently underwent sigmoidectomy due to an obstructive colon adenocarcinoma. Staging computed tomography scan showed a hypodense lesion in the posterior mediastinum suggestive of metastatic adenopathy. Endoscopic ultrasound revealed a homogeneous and hypoechogenic lesion with intramural location in the upper esophagus, suggestive of a duplication esophageal cyst. Given the oncologic background and to exclude metastatic disease, endoscopic ultrasound-guided fine needle aspiration was performed, and a mucinous fluid was aspirated. The cytologic examination supported the ultrasonographic diagnostic hypothesis. This case highlights the role of endoscopic ultrasound in the differential diagnosis of mediastinal masses, particularly in oncologic patients, in order to rule out more ominous lesions.

Type 2 Autoimmune Pancreatitis: A Challenge in the Differential Diagnosis of a Pancreatic Mass

Introduction: Autoimmune pancreatitis is a rare entity of unknown etiology that can mimic pancreatic cancer and whose diagnosis involves clinical, serological, imagiological, and histological findings. There are two types of autoimmune pancreatitis: type 1, in which the pancreas is involved as one part of a systemic immunoglobulin G4-related disease, and type 2, generally without immunoglobulin G4-positive cells and without systemic involvement. Case: We report the case of a 45-year-old female, who underwent an abdominal magnetic resonance imaging for etiological study of a solid liver lesion, which revealed a tail pancreatic mass. Laboratory analyses showed normal levels of immunoglobulin G4 and negative antinuclear antibodies. Endoscopic ultrasound revealed a homogeneous and hypoechogenic lesion in the pancreatic tail with a “sausage-like” appearance. Endoscopic ultrasound-guided fine needle aspiration was inconclusive and the patient underwent a laparoscopic distal pancreatectomy. Histopathology examination confirmed the diagnosis of type 2 autoimmune pancreatitis. Conclusion: This case highlights the challenge in the diagnostic approach of a pancreatic mass, particularly in distinguishing benign from malignant disease.

Rectal follicular lymphoma

Dear Editor: Colonoscopy was performed to a 65-year-old female with tenesmus that showed, in the distal rectum, a bulging lesion of 3 cm covered with normal appearance mucosa. We performed an endoscopic ultrasonography (EUS) that showed a polypoid morphology lesion, heterogeneous, mainly hypoechoic, located in the deep mucosa and submucosa layers; the lesion was well delimited with regular borders and occupied one third of the rectum circumference. There was no sure diagnosis, being most likely a fibrolipoma, a granular cell tumor, a neuroendocrine tumor, or a fibrovascular polyp. It was proposed to the patient to perform a transanal resection or an EUS with fine needle aspiration. She accepted the transanal resection. She had history of a nodal non-Hodgkin lymphoma treated 3 years before with rituximab, cyclophosphamide, vincristine, and prednisolone and a surgical treatment of urogenital prolapse 1 year before using a plastic prosthesis. The histopathologic examination revealed a rectal follicular lymphoma, grade one. The staging procedures showed no other site of disease. Discussion

Neuroendocrine Rectal Tumors: Main Features and Management

The incidence of neuroendocrine tumors of the rectum has been increasing in the last decades, partly due to improved investigation. They are mostly well-differentiated small tumors with a rather good overall prognosis. In the last few years, some aspects of neuroendocrine tumors have been evolving. In 2010, the World Health Organization proposed a new classification, indicating that these tumors, as a category, should be considered malignant. Afterwards the European Neuroendocrine Tumor Society published their guidelines for the management of colorectal neoplasms. Treatment algorithm is mainly based on tumor size and grading and, in general, well-differentiated rectal tumors <2 cm can be endoscopically resected. Endorectal ultrasound plays a particularly important role by accurately assessing tumor size and depth of invasion prior to resection. There are no specific recommendations on the optimal endoscopic resection method, but data from recent studies suggests that modified endoscopic mucosal resection techniques and endoscopic submucosal dissection have superior complete resection rates.

Endoscopic Ultrasound and Anal Pain: The Key to Diagnosis

A 73-year-old male patient with a history of pulmonary tuberculosis in childhood, a gastric adenocarcinoma (intestinal type) T1N0M0 (TNM classification), submitted to a partial gastrectomy Roux-en-Y, 10 years before, and a T1 lowgrade papillary bladder urothelial carcinoma treated with a transurethral resection and epirubicin, 1 year before, reported anal pain and fever for the last 5 days. The patient denied diarrhea, hematochezia or weight loss. In the anoscopy a painful bulging lesion with 2--3 cm was detected in distal rectum. Anorectal endoscopic ultrasonography (EUS) showed a heterogeneous, irregular lesion in