Paulo de Carvalho Contu

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.

A administração perioperatória de simbióticos em pacientes com câncer colorretal reduz a incidência de infecções pós-operatórias: ensaio clínico randomizado duplo-cego

OBJECTIVE to evaluate the effect of perioperative administration of symbiotics on the incidence of surgical wound infection in patients undergoing surgery for colorectal cancer. METHODS We conducted a randomized clinical trial with colorectal cancer patients undergoing elective surgery, randomly assigned to receive symbiotics or placebo for five days prior to the surgical procedure and for 14 days after surgery. We studied 91 patients, 49 in the symbiotics group (Lactobacillus acidophilus 108 to 109 CFU, Lactobacillus rhamnosus 108 to 109 CFU, Lactobacillus casei 108 to 109 CFU, Bifi dobacterium 108 to 109 CFU and fructo-oligosaccharide (FOS) 6g) and 42 in the placebo group. RESULTS surgical site infection occurred in one (2%) patient in the symbiotics group and in nine (21.4%) patients in the control group (p=0.002). There were three cases of intraabdominal abscess and four cases of pneumonia in the control group, whereas we observed no infections in patients receiving symbiotics (p=0.001). CONCLUSION the perioperative administration of symbiotics significantly reduced postoperative infection rates in patients with colorectal cancer. Additional studies are needed to confirm the role of symbiotics in the surgical treatment of colorectal cancer.Objective to evaluate the effect of perioperative administration of symbiotics on the incidence of surgical wound infection in patients undergoing surgery for colorectal cancer. Methods We conducted a randomized clinical trial with colorectal cancer patients undergoing elective surgery, randomly assigned to receive symbiotics or placebo for five days prior to the surgical procedure and for 14 days after surgery. We studied 91 patients, 49 in the symbiotics group (Lactobacillus acidophilus 108 to 109 CFU, Lactobacillus rhamnosus 108 to 109 CFU, Lactobacillus casei 108 to 109 CFU, Bifi dobacterium 108 to 109 CFU and fructo-oligosaccharide (FOS) 6g) and 42 in the placebo group. Results surgical site infection occurred in one (2%) patient in the symbiotics group and in nine (21.4%) patients in the control group (p=0.002). There were three cases of intraabdominal abscess and four cases of pneumonia in the control group, whereas we observed no infections in patients receiving symbiotics (p=0.001). Conclusion the perioperative administration of symbiotics significantly reduced postoperative infection rates in patients with colorectal cancer. Additional studies are needed to confirm the role of symbiotics in the surgical treatment of colorectal cancer.

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

Expression of gastrin-releasing peptide receptor in epidermoid carcinoma of the anal canal.

Gastrin-releasing peptide is a neuroendocrine homolog of bombesin that demonstrated important growth-stimulatory effects in various types of cancer. High levels of expression of gastrin-releasing peptide receptors (GRPR) has been found in different malignancies, and the studies exploring the therapeutic use of GRPR antagonists have shown promising results. Our aim was to determine the GRPR expression in epidermoid carcinoma of the anal canal and discuss its potential clinical applications. We performed immunohistochemical analysis for GRPR on formalin-fixed and paraffin-embedded tumor samples obtained from 35 patients with anal cancer. As a control group, we analyzed 24 samples of nonmalignant anal tissues (hemorrhoidectomy specimens). GRPR expression was evaluated using a semiquantitative approach according to the intensity and distribution of staining. All analyzed tissues, except 1 control sample, showed positive GRPR immunoexpression. GRPR was strongly expressed in 54% of cancer specimens as compared with only 12% of the control specimens (P<0.003). In tumors, the receptor showed a diffuse and homogenous pattern of distribution within the specimens. In contrast, control specimens showed a focal pattern of staining restricted to the basal half of the epithelium. In conclusion, we demonstrated that GRPR is highly expressed in epidermoid carcinoma of the anal canal, suggesting this receptor might have a role in anal carcinogenesis. Our results provide a basis for exploiting GRPR as a target for diagnostic and therapeutic purposes in the anal cancer.

Expression of C-Reactive Protein in Rectal Cancer

Background The possible involvement of inflammation on colorectal carcinogenesis has potential prognostic, preventive and therapeutic implications. We investigated immunohistochemically whether C-reactive protein is expressed in human primary rectal adenocarcinoma and assessed its relationship with clinicopathological findings. Methods Ninety-one rectal cancer samples and 22 normal control samples were immunohistochemically analysed. Results Cell accumulation of C-reactive protein was observed in 65 (71%) out of 91 patients with rectal adenocarcinoma and in all 22 control cases (p < 0.01). No significant difference was observed regarding to clinicopathological features or survival rates, but a linear correlation between the positivity proportion of C-reactive protein and Dukes-Turnbull stage (p = 0.005) was observed. Conclusions These data suggest that C-reactive protein might play a role in rectal carcinogenesis, but seems not to affect prognosis. Additional studies are warranted in larger population samples.

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.