Raul Cutait

Restaging of colorectal cancer based on the identification of lymph node micrometastases through immunoperoxidase staining of CEA and cytokeratins.

The present study was performed to identify tumor cells in lymph nodes from colorectal adenocarcinomas considered free of disease by the classic hematoxylin-eosin stain, based on the detection of the carcinoembryonic antigen (CEA) and cytokeratins in neoplastic epithelial cells. For this purpose, 603 lymph nodes from 46 lesions were stained by the peroxidase-antiperoxidase technique. Tumor cells were detected in 22 nodes from 12 patients, mainly in the subcapsular sinuses, permitting a restaging of these patients into two groups: those now considered to have metastatic disease and those free of metastases. However, the 5-year follow-up showed no statistical differences in survival between the two groups.

Abdominoperineal endoanal pull-through resection

Abdominoperineal endoanal pull-through resection with colorectal anastomosis was performed on 728 patients—primarily those with chagasic megacolon and cancer of the rectum. Intestinal continuity was reestablished through immediate anastomosis (Swenson procedure) in 229 patients and through delayed anastomosis (Cutait-Turnbull procedure) in 499. Comparative studies showed: that the incidence of leakage was 31.9 percent in immediate and only 2.2 percent in delayed anastomosis; that presacral infection occurred in 27.9 percent in immediate and in 6.8 percent in delayed anastomosis; that stenosis was observed in 4.4 percent in immediate and 1.8 percent in delayed anastomosis; that mortality was 6.1 percent in immediate and 2.2 percent in delayed anastomosis; that anal continence was good in both procedures and that sexual disturbances were rare in benign and frequent in malignant lesions in both procedures. The final conclusion is that, in abdominoperineal endoanal pull-through resection with colorectal anastomosis, complications and mortality are less frequent in delayed than in immediate anastomosis and that continence and sexual behavior are identical in both procedures.

Surgery of chagasic megacolon

AbstractChagas disease is an endemic clinical entity caused byTrypanosoma cruzi,a parasite that is transmitted to humans by the hematophagic Triatominae insects. It affects several million persons in Latin America, mostly in Brazil, Argentina, Chile, Paraguay, and Bolivia. Megacolon, the most common complication of intestinal trypanosomiasis, results in severe constipation, for which surgery is indicated. A variety of procedures have been proposed for the correction of this disabling condition including sigmoidectomy, abdominal rectosigmoidectomy, left colectomy, and subtotal colectomy. On long-term follow-up, however, these operations have proved to be inadequate in a significant number of cases, apparently due to preservation of the dyskinetic rectum which continues to act as a functional obstacle to the progression of the fecal bolus. On the other hand, pull-through operations, which include the removal of all or almost all of the dyskinetic rectum, or the exclusion of the rectum, as in the Duhamel-Haddad operation, have been demonstrated to be superior.nThe abdominoperineal endoanal pull-through resection with delayed colorectal anastomosis and the Duhamel-Haddad operation are the most accepted procedures in Brazil and other Latin American countries; their technical details are illustrated. Functional results are satisfactory. Anal continence is normal in the vast majority of cases and sexual disturbances are rare. Routine treatment of 2 main complications—fecaloma and volvulus of the sigmoid colon—are discussed.RésuméLa maladie de Chagas est une entité clinique endémique provoquée par le Trypanosome cruzi, parasite transmis aux hommes par les insectes Triatominae hématophagi. Elle affecte plusieurs millions dindividus en Amérique Latine, surtout au Brésil, en Argentine, au Chile, au Paraguay, et au Bolivie. Le mégacôlon, complication la plus courante de la trypanosomiase intestinale se traduit par une constipation grave pour laquelle la chirurgie est indiquée. Différents procédés ont été proposés pour corriger cet état invalidant comprenant sigmoïdectomie, rectosigmoïdectomie, colectomie gauche, et colectomie subtotale. Un bon nombre de ces interventions se sont avérées inadaptées dans les suites à long terme ce qui est apparemment dû à la conservation du rectum dyskinétique qui continue à agir comme obstacle fonctionnel à la progression des selles. Par ailleurs, les interventions par retournement qui comprennent lablation soit totale soit subtotale du rectum dyskinétique ou son exclusion comme dans lintervention de Duhamel-Haddad, se sont avérées meilleures. La résection abdominopérinéale par retournement avec anastomose colorectale retardée et lintervention de Duhamel-Haddad sont les processus les plus couramment employés au Brésil et dans les autres pays dAmérique Latine; les détails techniques sont illustrés. Les résultats fonctionnels sont satisfaisants. La continence est normale dans la plus grande majorité des cas et les troubles sexuels sont rares. Le traitement systématique des 2 complications principales, fécalome et volvulus du côlon sigmoïde, sont discutées.ResumenLa enfermedad de Chagas es una entidad clínica de carácter endémico transmitida al ser humano por insectos triatomídeos. Afecta a varios millones de personas en América Latina, principalmente en Brasil, Argentina, Chile, Paraguay, y Bolivia. El megacolon es una de las complicaciones más comunes de esta enfermedad. La cirugia esta indicada en la gran mayoría de los casos y tiene como propósito principal curar el severo estreñimiento que afecta a la mayoría de los pacientes. Entre los procedimientos quirúrgicos que han sido propuestos, la sigmoidectomía, la rectosigmoidectomía abdominal, la colectomía izquierda, y la colectomía total han demostrado ser ineficaces, en un número significativo de casos, en el seguimiento a largo plazo, ciertamente porque en estos procedimientos se preserva el recto disquinético, el cual continúa actuando como un obstáculo funcional al avance del bolo fecal. Por el contrario, las operaciones de tipo “pull-through” han demostrado mayor efectividad, en virtud de que incluyen la resección de la totalidad o de la casi totalidad del recto disquinético, o su exclusión, como en la operación de Duhamel-Haddad. La resección abdominoperineal con “pull-through” endoanal y la operación de Duhamel-Haddad son los 2 procedimientos de preferencia en Brasil y en las naciones latinoamericanas. Se ilustran sus detalles técnicos. La continencia anal queda normal en la mayoría de los casos operados y la disfunción sexual es rara. Se discute el tratamiento rutinario de otras 2 complicaciones—el fecaloma y el vólvulos del sigmoide.

Magnifying colonoscopy: interobserver agreement in the assessment of colonic pit patterns and its correlation with histopathological findings

Background and study aimsMagnifying colonoscopy (MC) is recognized as an aid to the differential diagnosis between neoplastic and nonneoplastic lesions. This study evaluated interobserver agreement of experienced endoscopists in the assessment of colonic pit patterns through the Kudo’s classification and correlated morphological aspects with histopathological findings.Materials and methodsA total of 213 magnification chromoendoscopic pictures of colonic lesions were collected from 161 consecutive patients and presented to three independent observers who expressed opinion about predominant pit pattern. All lesions were excised and sent for histopathological study.ResultsKappa statistics showed that the general agreement index with respect to the aspects of the pits was good among the three observers (0.561). Regarding prediction of histopathology according to the pit pattern diagnosis, overall accuracy was 84%, sensitivity was 91.4%, specificity was 67.2%, positive predictive value was 86.6%, and negative predictive value was 79.3%.ConclusionAlthough the interobserver reproducibility of the colonic pit pattern is good for experienced endoscopists, MC must not be used to replace the histopathological analysis, since it does not differentiate with the necessary safety neoplastic from nonneoplastic lesions.

Hereditary nonpolyposis colorectal cancer identification and surveillance of high-risk families

Hereditary nonpolyposis colorectal cancer is an autosomal dominant condition caused by highly penetrant gene mutations. It is characterized by increased susceptibility for a specific group of cancer, mainly colorectal cancer. The syndrome originates from the inheritance of mutations in DNA mismatch repair genes. The most commonly affected genes in hereditary nonpolyposis colorectal cancer are hMLH1 and hMSH2. Their deficient expression renders the cell susceptible to the accumulation of many molecular defects, a condition which can be evaluated by the instability in sections of base repeats in the genoma known as microsatellite instability. The molecular detection of hereditary nonpolyposis colorectal cancer is possible in most of the highly suspicious cases. Genetic tests for hereditary nonpolyposis colorectal cancer also allow characterization of the individual that bears the mutation within a family. The high cost and restricted availability of these tests hamper their use for every person presenting colorectal cancer. Due to this fact, some clinical criteria have been developed by a hereditary nonpolyposis colorectal cancer international organization to select families with a high probability of carrying the mutation. Once families at risk are identified, they are encouraged to join a screening program that aims at early detection of hereditary nonpolyposis colorectal cancer-related cancers, increasing the possibility of its prevention and early detection.

Downstaging of a rectal gastrointestinal stromal tumor by neoadjuvant imatinib therapy allowing for a conservative surgical approach

Gastrointestinal stromal tumor (GIST) is a recently recognized pathology that originates from the interstitial cells of Cajal1 and is the most common mesenchymal neoplasm of the gastrointestinal tract. Although surgery is the only treatment available, it is only possible in approximately half of the cases2. This malignancy is characterized by a high risk of metastatic relapse, specifically in the liver and peritoneum. Imatinib mesylate, a tyrosine kinase inhibitor that inhibits c-kit signal transduction, is often used as a treatment for metastatic GIST. n nNeoadjuvant therapy is defined as a treatment administered prior to the main (usually surgical) treatment for a particular neoplasm. It is used not only to eliminate circulating tumor cells but also to reduce the size of the tumor, thereby facilitating surgery and perhaps increasing the chance of organ preservation. Since imatinib results in significant tumor shrinkage in at least 50% of treated patients,3,4 its use as a neoadjuvant treatment is logical.

Importância prognóstica da invasão neural no câncer colorretal: estudo imunoistoquímico com a proteína S-100

Among the anatomopathological variables related to the prognosis for patients with colorectal cancer, neural invasion remains little studied. OBJECTIVE: To evaluate whether neural invasion in patients with colorectal cancer in Dukes stages B and C could be considered to be an independent prognostic factor, by means of univariate and multivariate analysis. METHODS: Ninety-seven patients who underwent operations with curative intent by the same surgical team were followed up for a minimum period of five years and were studied. Patients who received adjuvant treatment were excluded. The surgical specimens were stained with hematoxylin-eosin (HE) and immunohistochemical techniques for S-100 protein analysis, with the aim of comparing the two techniques for detecting neural invasion. Accuracy, specificity, sensitivity and positive and negative predictive values were analyzed for HE in relation to S-100 protein. Comparison between the incidence of neural invasion and tumor recurrence was made by using the chi-squared test. Survival and disease-free survival were studied by univariate analysis. A significance level of 5% (p £ 0.05) was established for all the tests adopted. RESULTS: The HE technique presented weak ability to detect neural invasion and was inadequate for this analysis in colorectal cancer patients. The survival and disease-free survival curves for patients with neural invasion, investigated by means of immunostaining for S-100 protein, were significantly worse, thus identifying this histological characteristic as having independent prognostic value (p = 0.0003 and p = 0.0002, respectively). There was significantly more tumor recurrence among patients who presented neural invasion (p = 0.0010). CONCLUSION: The results from the present study allow the conclusion that, among colorectal cancer patients, neural invasion was shown to be an independent variable that gave additional prognostic information regarding patients in stages B, C and C2 of the Dukes and Astler-Coller classifications, respectively.

Câncer em doença de Crohn: relato de caso

ABSTRACT: Although Crohn’s disease (CD) is associated with an increased risk for developing cancer, there are less than 150cases reported in the world literature. Main risk factors include early onset, a long period of disease, chronic fistulous diseaseand excluded bowel presence. Case report. MCAN, 53 years old, female, white, has been submitted to a right ileocolectomy at theage of 17, due to bowel obstruction caused by distal ileum CD. A year ago, she presented a new obstructive episode and atlaparotomy a tumor mass was identified in the ileocolic anastomosis. Pathology confirmed a mucinous adenocarcinoma. Discussion.The majority of patients with CD who develop intestinal cancer have in common the following items: cancer installs many yearsafter the first symptoms, in around 80% of the cases after 20 years of the CD diagnosis; bowel obstruction is the main problem;lesions are very aggressive, and only 10% of the patients remain two years free of the disease.Key words: Crohn disease; cancer.

Diagnóstico e manejo do câncer gástrico familiar

Embora a neoplasia gastrica maligna constitua-se numa das principais causas de mortalidade por câncer, as bases moleculares desta enfermidade permanecem ainda pouco compreendidas. Recentemente, a identificacao de lesoes gastricas difusas ocorrendo em familias com padrao de transmissao tipicamente mendeliano, resultou no achado de um evento molecular unico: mutacoes no gene da caderina-E. Esta entidade foi denominada câncer gastrico hereditario. Apesar de rara, a sua identificacao deve ser suspeitada na pratica clinica, ja que e possivel detectar-se casos precoces de câncer nestas familias em alto risco. Como a analise mutacional do gene da caderina-E so e realizada em pouquissimos centros no mundo, e importante tentar identificar estas familias por meio de criterios de facil acesso para qualquer profissional de saude. Este trabalho comenta os criterios sugeridos pelo International Gastric Cancer Linkage Consortium (IGCLC), propostos em 1999, alem de tentar estabelecer algumas diretrizes para o rastreamento das pessoas em risco.