Young patients with benign anal diseases and rectal bleeding: should a colonoscopy be performed?

BACKGROUND AND AIM: There is no consensus whether a colonoscopy should be recommended for patients under 50 years of age who present with both anal bleeding and benign anal diseases. The aim of this study is to evaluate the effectiveness of colonoscopy to detect neoplastic lesions in this specific group of patients. METHODS: A prospective study analyzing the results of colonoscopies performed in patients younger than 50 years of age who reported a rectal bleeding and also had a diagnosis of benign anal disease at first clinical visit. RESULTS: One hundred and eighty-seven consecutive patients were prospectively included in this study. In 35 patients (18.7%), adenomatous polyps were diagnosed. Thirty-seven percent of those lesions (13 cases) were further classified as either advanced adenomas or serrated adenomas. The prevalence of adenomas was 14.6% among patients under the age of 40 and 20% among those between 40 and 50 years of age. Thirty-one percent of the adenomas (11 cases) were located in the right colon, without any other concomitant lesion in the distal colon. In addition, an unsuspected case of sigmoid carcinoma was diagnosed. CONCLUSION: The performance of colonoscopy in young patients with benign anal diseases and hematochezia resulted in a high rate of detection of neoplastic lesions. The method might be considered as a valid strategy of investigation in this frequent clinical situation.

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.

Lymph node retrieval after preoperative chemoradiotherapy for rectal cancer.

BACKGROUND: Current guidelines recommend the assessment of at least 12 lymph nodes for rectal cancer staging. Preoperative chemoradiotherapy may affect lymph node yield in this malignancy. This study investigated the impact of neoadjuvant chemoradiotherapy on the number of lymph nodes retrieved from rectal cancer patients. METHODS: An analysis of 162 rectal cancer patients who underwent curative surgery between 2005 and 2010. Seventy-one patients with stage II or III tumors received preoperative chemoradiotherapy. Using multivariate analysis, we assessed the correlation between clinicopathologic variables and number of retrieved lymph nodes. We also evaluated the association between survival and number of lymph nodes obtained. RESULTS: On multivariate analysis, preoperative chemoradiotherapy was the only variable to independently affect the number of lymph nodes obtained. The mean number of lymph nodes was 14.2 in patients treated with preoperative chemoradiotherapy and 19.4 in those not treated (P < 0.001). In the chemoradiotherapy group, 29.6 % of patients had fewer than 12 lymph nodes obtained compared with 9.9 % in the primary surgery group (P = 0.003). After chemoradiation, the number of retrieved lymph nodes was inversely correlated with tumor regression grade. Results showed that 5-year overall and disease-free survival were similar whether the patient had 12 or more nodes retrieved or not. CONCLUSIONS: Preoperative chemoradiotherapy reduces the lymph node yield in rectal cancer. The number of retrieved lymph nodes is affected by degree of histopathologic response of the tumor to chemoradiation. Thus, number of lymph nodes should not be used as a surrogate for oncologic adequacy of resection after neoadjuvant chemoradiotherapy for rectal cancer.

Fibrin glue in the management of complex anal fistula / Uso da cola de fibrina no tratamento da fistula anal complexa

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 Crohn's 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 percent). Among the 27 patients who failed to heal, 9 (33.3 percent) were diagnosed within the first postoperative month. In 13 patients (48.1 percent) the failure of treatment occurred in the period between 1 and 3 months, in 3 patients (11.1 percent) between 3 and 6 months, and in 2 patients (7.4 percent) 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.

Contexto: O manejo das fistulas anais complexas está associado ao risco de lesão esfincteriana e incontinência fecal. Recentemente, a cola de fibrina surgiu como uma alternativa de tratamento conservador de esfíncter para as fístulas anais, porém até o momento não se chegou a um consenso quanto à eficácia do método. Objetivo: Avaliar o uso da cola de fibrina especificamente no tratamento de fístulas anais complexas de origem criptoglandular. Métodos: Foram estudados pacientes com fístulas anais complexas tratados com cola de fibrina entre janeiro de 2005 e janeiro de 2008. Somente pacientes com fístulas de origem criptoglandular foram analisados, sendo excluídos pacientes com fístulas relacionadas à doença de Crohn, ao HIV ou à cirurgia prévia. Sob anestesia espinhal, as fistulas eram curetadas, sendo após preenchidas com cola de fibrina. Depois do tratamento, os pacientes eram acompanhados por 12 meses. Resultados: Trinta e dois pacientes foram incluídos no estudo. Dois pacientes foram perdidos durante o seguimento pós-operatório, sendo excluídos. Dos 30 pacientes remanescentes, apenas 3 tiveram suas fistulas cicatrizadas (10 por cento). Com relação aos 27 pacientes nos quais não houve cicatrização, em 9 pacientes (33,3 por cento) a falha do tratamento foi diagnosticado nos primeiros 30 dias após a cirurgia, em 13 (48,8 por cento) entre 1 e 3 meses, em 3 (11,1 por cento) entre 3 e 6 meses e em 2 pacientes (7,4 por cento) entre 6 e 9 meses após a cirurgia. Não foram observadas complicações relacionadas ao tratamento. Conclusões: Nesta série, o tratamento das fístulas anais complexas de origem criptoglandular com cola de fibrina atingiu um índice muito baixo de cicatrização. Estes resultados não permitem a indicação da cola de fibrina como tratamento de primeira escolha para pacientes com esse tipo de fístula.

Lack of correlation between p53 codon 72 polymorphism and anal cancer risk.

AIM: To investigate the potential role of p53 codon 72 polymorphism as a risk factor for development of anal cancer. METHODS: Thirty-two patients with invasive anal carcinoma and 103 healthy blood donors were included in the study. p53 codon 72 polymorphism was analyzed in blood samples through polymerase chain reaction-restriction fragment length polymorphism and DNA sequencing. RESULTS: The relative frequency of each allele was 0.60 for Arg and 0.40 for Pro in patients with anal cancer, and 0.61 for Arg and 0.39 for Pro in normal controls. No significant differences in distribution of the codon 72 genotypes between patients and controls were found. CONCLUSION: These results do not support a role for the p53 codon 72 polymorphism in anal carcinogenesis.

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 Crohn's 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.

Carcinoma basocelular perianal: relato de caso e revisão da literatura / Perianal basal cell carcinoma: case report and literature review

O Carcinoma basocelular (CBC) é a mais freqüente das neoplasias epiteliais, localizando-se preferencialmente em áreas expostas ao sol. A ocorrência deste tumor na região perianal é extremamente rara. Neste artigo, relatamos um caso de CBC perianal. Apresentamos também uma revisão da literatura médica sobre o tema, salientando as características clínicas e histopatológicas, bem como o tratamento preconizado para esse tipo de tumor.

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.

pRB expression in esophageal mucosa of individuals at high risk for squamous cell carcinoma of the esophagus.

AIM: To investigate the pRb expression in a large group of patients with history of chronic exposure to the main risk factors for development of squamous cell carcinoma of the esophagus. METHODS: One hundred and seventy asymptomatic individuals at high risk for esophageal squamous cell carcinoma (consumption of more than 80 g of ethanol and 10 cigarettes/d for at least 10 years) underwent upper gastrointestinal endoscopy with biopsies of the esophageal mucosa. As a control group, specimens of esophageal mucosa obtained from 20 healthy subjects were also studied. Immunohistochemical assessment of the tissues was performed using a monoclonal antibody anti-pRB protein. RESULTS: Absence of the pRB staining, indicating loss of RB function, was observed in 33 (19.4%) of the individuals at risk for esophageal cancer, but in none of the healthy controls (P < 0.02). Loss of pRb expression increased in a stepwise fashion according to the severity of the histological findings (P < 0.005): normal mucosa (11/97 or 11.3%), chronic esophagitis (17/60 or 28.3%), low-grade dysplasia (3/10 or 30%), high-grade dysplasia 1/2 or 50%) and squamous cell carcinoma (1/1 or 100%). CONCLUSION: Our findings suggest that abnormal expression of the pRB protein may be implicated in the process of esophageal carcinogenesis. Additional studies are warranted to define the role of the pRB protein as a biomarker for development of esophageal squamous cell carcinoma in individuals at high risk for this malignancy.

Bcl-2 expression in rectal cancer

BACKGROUD: Proteins involved in apoptosis process seem to play an important role in colorectal carcinogenesis AIM: To determine the prevalence of bcl-2 protein immunohistochemical expression and its relation with clinical and histopathological variables of rectal adenocarcinoma. PATIENTS AND METHODS: One hundred and thirty-two patients operated at "Hospital de Clínicas de Porto Alegre", Porto Alegre, RS, Brazil, between 1988 and 1999 were studied through immunohistochemical reaction using a monoclonal antibody anti-bcl-2 on formalin-fixed, paraffin-embedded tissue samples RESULTS: The prevalence of bcl-2 protein was 29.5 percent. There was a significant increased number of positive bcl-2 cases among women as compared to men. There was no significant association between bcl-2 and age, tumour site, histological grade, mucin production, depth of invasion, lymphatic involvement, distant metastasis or stage, despite a trend showing decreased immunoreactivity to bcl-2 among poorly and moderately differentiated tumours, as well as disseminated disease CONCLUSIONS: Analysis of bcl-2 protein expression in tumour tissues, as well as other oncoproteins, may have a role in predict therapeutic response and prognosis of colorectal cancer. However, the potential use of bcl-2 protein assessment in the clinical set for management of rectal cancer remains to be determined.

RACIONAL: As proteínas envolvidas no processo de apoptose parecem desempenhar papel importante na carcinogênese colorretal. OBJETIVOS: Determinar a prevalência da expressão imunoistoquímica da proteína bcl-2 e sua relação com variáveis clínicas e histopatológicas do câncer de reto. PACIENTES E MÉTODOS: Cento e trinta e dois pacientes operados no Hospital de Clínicas de Porto Alegre, RS, entre 1988 e 1999 foram estudados através de reação imunoistoquímica, utilizando um anticorpo monoclonal anti-bcl-2 em amostras teciduais fixadas em formalina e parafinizadas. RESULTADOS: A prevalência da proteína bcl-2 foi de 29,5 por cento. Houve aumento significativo no número de casos bcl-2 positivo entre mulheres quando comparado aos homens. Não houve associação significativa entre bcl-2 e idade, sítio do tumor, grau histológico, produção de muco, profundidade de invasão, envolvimento linfático, metástases distantes ou estágio, apesar de uma tendência demonstrando imunorreatividade ao bcl-2 diminuída entre os tumores pouco e moderadamente diferenciados, bem como para doença disseminada. CONCLUSÕES: A análise da expressão da proteína bcl-2 em tecidos tumorais, bem como outras oncoproteínas, pode ter um papel em predizer a resposta terapêutica e o prognóstico do câncer colorretal. Entretanto, o uso potencial da avaliação da proteína bcl-2 na prática clínica no manejo do câncer de reto permanece a ser determinado.

Bcl-2 expression in rectal cancer.

BACKGROUND: [corrected] Proteins involved in apoptosis process seem to play an important role in colorectal carcinogenesis AIM: To determine the prevalence of bcl-2 protein immunohistochemical expression and its relation with clinical and histopathological variables of rectal adenocarcinoma. PATIENTS AND METHODS: One hundred and thirty-two patients operated at "Hospital de Clínicas de Porto Alegre", Porto Alegre, RS, Brazil, between 1988 and 1999 were studied through immunohistochemical reaction using a monoclonal antibody anti-bcl-2 on formalin-fixed, paraffin-embedded tissue samples RESULTS: The prevalence of bcl-2 protein was 29.5%. There was a significant increased number of positive bcl-2 cases among women as compared to men. There was no significant association between bcl-2 and age, tumour site, histological grade, mucin production, depth of invasion, lymphatic involvement, distant metastasis or stage, despite a trend showing decreased immunoreactivity to bcl-2 among poorly and moderately differentiated tumours, as well as disseminated disease CONCLUSIONS: Analysis of bcl-2 protein expression in tumour tissues, as well as other oncoproteins, may have a role in predict therapeutic response and prognosis of colorectal cancer. However, the potential use of bcl-2 protein assessment in the clinical set for management of rectal cancer remains to be determined.