Cáncer colorrectal. Variantes génicas en la vía de señalización BMP y ancestría en población mexicana / Colorectal cancer. Genetic variants in BMP signaling pathway and ancestry in the Mexican population

Resumen Introducción: Variantes génicas relacionadas con la vía de señalización de las proteínas morfogenéticas óseas (BMP2, BMP4, GREM1, SMAD7) se han asociado a cáncer colorrectal, principalmente en poblaciones caucásicas. Objetivo: Describir la asociación de variantes en miembros de la vía BMP en población mexicana, caracterizada por su ancestría indoamericana y caucásica. Métodos: Se realizó el genotipado de 1000 casos de cáncer colorrectal y 1043 individuos de control reclutados en la Ciudad de México, Monterrey y Torreón mediante la plataforma Sequenom. Con análisis univariados y multivariados se estudiaron las asociaciones entre cáncer colorrectal y variantes. Resultados: Las variantes rs4444235, rs12953717 y rs4939827 replicaron la asociación con la neoplasia (p ≤ 0.05). La ascendencia caucásica mostró asociación con el tumor. Conclusiones: El estudio mostró las asociaciones entre cáncer colorrectal y las variantes SMAD7 y BMP4, así como con el componente caucásico de la mezcla étnica.

Abstract Introduction: Genetic variants related to bone morphogenetic proteins (BMP2, BMP4, GREM1, SMAD7) signaling pathway have been associated with colorectal cancer, mainly in Caucasian populations. Objective: To describe the association of variants in members of the BMP signaling pathway in a Mexican population, characterized by its indigenous American and Caucasian ancestry. Methods: Genotyping of 1,000 colorectal cancer cases and 1,043 control individuals recruited in Mexico City, Monterrey, and Torreón was carried out using the Sequenom platform. Associations between colorectal cancer and variants were studied with univariate and multivariate analyses. Results: Variants rs4444235, rs12953717 and rs4939827 replicated the association with the neoplasm (p ≤ 0.05). Caucasian ancestry showed association with the tumor. Conclusions: The study replicated the associations between colorectal cancer and SMAD7 and BMP4 variants, with an association being observed with the Caucasian component of the ethnic mix.

Colorectal cancer. Genetic variants in BMP signaling pathway and ancestry in the Mexican population.

INTRODUCTION: Genetic variants related to bone morphogenetic proteins (BMP2, BMP4, GREM1, SMAD7) signaling pathway have been associated with colorectal cancer, mainly in Caucasian populations. OBJECTIVE: To describe the association of variants in members of the BMP signaling pathway in a Mexican population, characterized by its indigenous American and Caucasian ancestry. METHODS: Genotyping of 1,000 colorectal cancer cases and 1,043 control individuals recruited in Mexico City, Monterrey, and Torreón was carried out using the Sequenom platform. Associations between colorectal cancer and variants were studied with univariate and multivariate analyses. RESULTS: Variants rs4444235, rs12953717 and rs4939827 replicated the association with the neoplasm (p ≤ 0.05). Caucasian ancestry showed association with the tumor. CONCLUSIONS: The study replicated the associations between colorectal cancer and SMAD7 and BMP4 variants, with an association being observed with the Caucasian component of the ethnic mix.

INTRODUCCIÓN: Variantes génicas relacionadas con la vía de señalización de las proteínas morfogenéticas óseas (BMP2, BMP4, GREM1, SMAD7) se han asociado a cáncer colorrectal, principalmente en poblaciones caucásicas. OBJETIVO: Describir la asociación de variantes en miembros de la vía BMP en población mexicana, caracterizada por su ancestría indoamericana y caucásica. MÉTODOS: Se realizó el genotipado de 1000 casos de cáncer colorrectal y 1043 individuos de control reclutados en la Ciudad de México, Monterrey y Torreón mediante la plataforma Sequenom. Con análisis univariados y multivariados se estudiaron las asociaciones entre cáncer colorrectal y variantes. RESULTADOS: Las variantes rs4444235, rs12953717 y rs4939827 replicaron la asociación con la neoplasia (p ≤ 0.05). La ascendencia caucásica mostró asociación con el tumor. CONCLUSIONES: El estudio mostró las asociaciones entre cáncer colorrectal y las variantes SMAD7 y BMP4, así como con el componente caucásico de la mezcla étnica.

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) delivered via a modified perfusion system for peritoneal carcinomatosis of colorectal origin.

BACKGROUND AND PURPOSE: The long-term survival of patients with peritoneal carcinomatosis of colorectal origin has been achieved with cytoreductive surgery, which removes all macroscopic implants, combined with hyperthermic intraperitoneal chemotherapy (HIPEC). The current technology for administering intraperitoneal heated chemotherapy is expensive and, for some institutions, unaffordable. We conducted this study to assess the temperature stability provided by a modified, inexpensive system, to offer a simple and low cost alternative to the standard HIPEC delivery equipment. METHODS: Ten patients with histologically diagnosed peritoneal metastases of adenocarcinoma or pseudomyxoma peritonei underwent cytoreductive surgery and received HIPEC with 5-fluorouracil for 90 min, delivered via our modified system. The temperature was recorded from two probes: one in the inflow catheter and one in the outflow catheter. The intra-abdominal temperature was monitored meticulously to maintain it at between 41 and 42 °C. RESULTS: All patients underwent cytoreductive surgery and HIPEC using our modified delivery system. Temperature stability was achieved in all patients, with a mean of 41.4°. There were no thermal injuries associated with any of the ten perfusions. The mean hospital stay was 15 days and the median survival was 30 months. CONCLUSION: Analysis of this data demonstrates that the uniform delivery of HIPEC at 41° with this modified system is feasible and safe. The outcome of the patients treated with cytoreductive surgery and HIPEC with this modified system compares favorably to other published series. Its low cost and simple design will give more patients with peritoneal carcinomatosis access to this treatment.

Thrombocytosis as a predictor of distant recurrence in patients with rectal cancer.

BACKGROUND AND AIMS: Thrombocytosis is frequently observed in patients with malignancy. We undertook this study to determine the prognostic value of thrombocytosis in patients with rectal cancer. METHODS: We performed a retrospective study of patients undergoing low anterior resection for rectal cancer between January 2000 and March 2007. Preoperative platelet count was measured before surgery. Postoperative platelets were determined 1 month after surgery. Two-tailed p values <0.05 were considered statistically significant. RESULTS: One hundred sixty three patients with rectal cancer were included in the study. Preoperative platelet count >350,000 was found in 8% of patients. Postoperative platelet count >350,000 was found in 6% of patients. Distant metastases were found in 17 patients (10.4%). Significant variables in the multivariate analyses were preoperative platelets >350,000 (p = 0.001), postoperative platelets >350,000 (p = 0.002), carcinoembryonic antigen >13 ng/dL (p = 0.003). Patients with preoperative platelet count <350,000 showed a 5-year survival rate of 81%, whereas patients with platelet count >350,000 had a 25-month survival [95% confidence interval (CI): 20-26]; p <0.001. Patients with postoperative platelets <350,000 showed a 5-year survival rate of 80%, whereas patients with platelets >350,000 showed a 3-year survival rate of 37.5% (p <0.05). CONCLUSIONS: Pre- or postoperative platelet count >350,000 is associated with poor survival in patients with rectal cancer. The measurement of platelets is a clinical marker useful to define the prognosis for patients with rectal cancer.

Risk factors for anastomotic leakage after preoperative chemoradiation therapy and low anterior resection with total mesorectal excision for locally advanced rectal cancer.

BACKGROUND: Risk factors for anastomotic leakage after preoperative chemoradiation plus low anterior resection and total mesorectal excision remain uncertain. OBJECTIVE: To analyze, the associated risk factors with colorectal anastomosis leakage following preoperative chemo-radiation therapy and low anterior resection with total mesorectal excision for rectal cancer. MATERIALS AND METHODS: Between January 1992 and December 2000, 92 patients with rectal cancer were treated with 45 Gy of preoperative radiotherapy and bolus infusion of 5-FU 450 mg/m2 on days 1-5 and 28-32, six weeks later low anterior resection was performed. Univariate analysis was performed as to find the risk factors for colorectal anastomotic leakage. RESULTS: There were 48 males and 44 females, mean age was 55.8 years. Mean tumor location above the anal verge was 7.4 +/- 2.6 cm. Preoperative mean levels of albumin and lymphocytes were 3.8 g/dL and 1,697/microL, respectively. Mean distal margin was 2.9 +/- 1.4 cm. Multivisceral resection was performed in 11 patients (13.8%), 32 patients (35%) had diverting stoma. Mean preoperative hemorrhage was 577 +/- 381 mL, and 27 patients (24%) received blood transfusion. Ten patients (10.9%) had anastomotic leakage. No operative mortality occurred. Risk factors for anastomotic leakage were: gender (male) and tumor size > 4 cm. Three patients of the group without colostomy required a mean of six days in the unit of intensive care; mean time of hospital stay of patients with and without protective colostomy was 12.4 +/- 4.5 days vs. 18.3 +/- 5.2 days (p = 0.01). CONCLUSION: In male patients with rectal adenocarcinoma measuring > 4 cm, treated by preoperative chemoradiotherapy + low anterior resection with total mesorectal excision, a diverting stoma should be performed to avoid major morbidity due to anastomotic leak.

Risk factors for anastomotic leakage after preoperative chemoradiation therapy and low anterior resection with total mesorectal excision for locally advanced rectal cancer / Factores de riesgo para la fuga anastomótica después de quimio-radioterapia preoperatoria y resección anterior baja con excisión total de mesorrecto para cáncer de recto localmente avanzado

Background. Risk factors for anastomotic leakage after preoperative chemoradiation plus low anterior resection and total mesorectal excision remain uncertain. Objective. To analyze, the associated risk factors with colorectal anastomosis leakage following preoperative chemo-radiation therapy and low anterior resection with total mesorectal excision for rectal cancer. Materials and methods. Between January 1992 and December 2000, 92 patients with rectal cancer were treated with 45 Gy of preoperative radiotherapy and bolus infusion of 5-FU 450 mg/m² on days 1-5 and 28-32, six weeks later low anterior resection was performed. Univariate analysis was performed as to find the risk factors for colorectal anastomotic leakage. Results. There were 48 males and 44 females, mean age was 55.8 years. Mean tumor location above the anal verge was 7.4 ± 2.6 cm. Preoperative mean levels of albumin and lymphocytes were 3.8 g/dL and l,697/mL, respectively. Mean distal margin was 2.9 ± 1.4 cm. Multivisceral resection was performed in 11 patients (13.8%), 32 patients (35%) had diverting stoma. Mean preoperative hemorrhage was 577 ± 381 mL, and 27 patients (24%) received blood transfusion. Ten patients (10.9%) had anastomotic leakage. No operative mortality occurred. Risk factors for anastomotic leakage were: gender (male) and tumor size > 4 cm. Three patients of the group without colostomy required a mean of six days in the unit of intensive care; mean time of hospital stay of patients with and without protective colostomy was 12.4 ± 4.5 days vs. 18.3 ± 5.2 days (p = 0.01). Conclusion. In male patients with rectal adenocarcinoma measuring > 4 cm, treated by preoperative chemoradiotherapy + low anterior resection with total mesorectal excision, a diverting stoma should be performed to avoid major morbidity due to anastomotic leak.

Antecedentes. Los factores de riesgo para la fuga de anastomosis colo-rectal después de quimio-radioterapia preoperatoria con excisión total de mesorrecto permanecen aún inciertos. Objetivo. Analizar los factores de riesgo asociados con la fuga o filtración de anastomosis colorrectal que sigue a la terapia de radiación química y a la extirpación anterior baja con total excisión mesorrectal para el cáncer rectal. Materiales y métodos. Entre enero de 1992 y diciembre de 2000, 92 pacientes con cáncer rectal fueron tratados con 45 Gy de radioterapia preoperativa e infusión del bolo de 5'FU450 mg/m² administrados los días 1-5 y del 28-32; seis semanas más tarde, se realizó la extirpación anterior baja. Se llevó a cabo un análisis univariado en cuanto a encontrar los factores de riesgo de la fuga anastomótica colorrectal. Resultados. Se trató a 48 varones y 44 mujeres cuya media etaria fue de 55.8 años. La localización media del tumor arriba del borde anal fue de 7.4 ± 2.6 cm. Los niveles medios preoperativos de albúmina y linfocitos fueron de 3.8 g/dL y 1,697/mL, respectivamente. El margen distal medio fue de 2.9 ± 1.4 cm. La extirpación multivisceral fue realizada en 11 pacientes (13.8%); 32 pacientes (35%) tuvieron una colostomía derivativa. La hemorragia preoperativa media fue de 577 ± 381 mL, y 27 pacientes (24%) recibieron transfusión sanguínea. Diez pacientes (10.9%) tuvieron fuga anastomótica. No hubo ningún deceso quirúrgico. Los factores de riesgo para la fuga anastomótica fueron: el género (masculino) y el tamaño del tumor > 4 cm. Tres pacientes del grupo sin colostomía requirieron una media de seis días en la UTI (Unidad de Terapia Intensiva); el promedio media de la duración hospitalaria de pacientes con y sin colostomía protectiva fue de 12.4 ± 4.5 días contra 18.3 ± 5.2 días (p = 0.01). Conclusión. En pacientes masculinos con adenocarcinoma rectal que mide > 4 cm, tratados mediante radioterapia química preoperativa + extirpación anterior baja con excisión total mesorrectal, debería realizarse una abertura que se desvíe a fin de evitar una mayor mortalidad debida a fuga anastomótica.

Prognostic significance of circumferential margin involvement in rectal adenocarcinoma treated with preoperative chemoradiotherapy and low anterior resection.

INTRODUCTION: Histologic examination of circumferential margins is an important predictor of local and distant relapse in non-radiated rectal cancer. However, for patients who received preoperative chemoradiotherapy this role has not yet been addressed. METHODS: From January 1995 to December 1997, 61 patients with rectal adenocarcinoma located between 0 and 10 cm from anal verge with invasion into perirectal fat assessed by rectal ultrasound were included. All patients received 45 Gy + bolus infusion of 5-FU (450 mg/m(2)/days 1-5, 28-33 of RT); 4-6 weeks later, surgery was performed. Circumferential margin was assessed (<2 mm was considered as positive). Five-year survival was calculated by Kaplan-Meier method and comparison of groups with log-rank test. Multivariate Cox regression analysis was performed to find risk factors affecting local control and survival. RESULTS: There were 35 males and 26 females, mean age 60.3 years. Twelve patients (19.7%) had circumferential margin involvement. Median follow-up was 44 months. Overall local recurrence was observed in 6 of 61 patients (9.8%); in patients without circumferential margin involvement this was 8%, whereas it was 16% in those with circumferential margin involvement (P = 0.33). Distant recurrence was observed in 22% of patients without circumferential margin involvement; conversely, it was 58.3% in those with involvement (P = 0.02). Five-year survival of patients without circumferential resection involvement margin was 81%, while it was 42% in patients with circumferential involvement (P = 0.006). CONCLUSIONS: In patients with rectal cancer treated by preoperative chemoradiation plus total mesorectal excision (TME) and sphincter saving surgery, circumferential margin involvement is associated with high incidence of distant recurrence and cancer-related death.

Composite pelvic exenteration: is it worthwhile?

BACKGROUND: In locally advanced pelvic cancer, tumor fixation to the bony pelvis is regarded as unresectable and often inoperable. Few data exist regarding the futility or utility of pelvic exenteration with en bloc resection of involved portions of the bony pelvis. METHODS: Thirty-four of 625 patients undergoing radical pelvic procedures had an en bloc resection of pelvic organs with portions of the bony pelvis. There were 19 female and 15 male patients, and the median age was 59 years. Primary neoplasms included 19 rectal, 6 cervicouterine, 4 anal, 3 vaginal, 1 sarcoma, and 1 penile. All but three patients underwent preoperative pelvic irradiation. Pelvic exenterations were posterior in 7 patients, anterior in 3, supralevator in 3, and total in 21 patients. Pelvic bony resections included portions of the sacrum-coccyx in 18 patients, ischium in 5, pubic symphysis in 4, and ischial pubic rami in 4, and hemipelvectomy was performed in 3. RESULTS: Surgical morbidity occurred in 67.6% (23) of 24 patients. Median follow-up was 37 months. Pelvic or perineal tumor recurrence was concurrent with distant metastases in 9 patients (26.4%); 6 (17.6%) had only distant relapse, and 2 (5.8%) died with local recurrence alone. Overall cancer-related mortality rate was 50%. Five-year overall and cancer-specific survival rates were 44% and 52%, respectively. CONCLUSIONS: Substantial survival can be accomplished for patients whose tumors are fixed to limited portions of the bony pelvis. These procedures are still associated with substantial morbidity, but operative mortality is infrequent.

Prognostic significance of retrieved lymph nodes per specimen in resected rectal adenocarcinoma after preoperative chemoradiation therapy.

BACKGROUND: Histologic examination of a regional lymphadenectomy specimen ordinarily should include 12 or more lymph nodes. However, in specimens from patients who received preoperative chemoradiotherapy this number has not yet been established. METHODS: From January 1990 to December 2000, 210 patients with rectal adenocarcinoma located between 0 and 10 cm from anal verge with invasion into perirectal fat, tethered or fixed to the pelvis, diagnosed by computed tomography (CT) scan and/or rectal ultrasound were included. All patients received 45 Gy+bolus infusion of 5-FU (450 mg/m2/days 1-5, 28-33 of RT) 4-8 weeks after surgery was performed. Specimens were mapped and sliced. Lymph nodes were studied under clearing or manual techniques. Five-year survival was calculated by Kaplan-Meier method and comparison of groups with log-rank test. Multivariate Cox regression analysis was performed to find risk factors affecting local control and survival. RESULTS: There were 126 males and 84 females; mean age was 55.2 years. Low anterior resection was performed in 112 patients, abdominoperineal resection in 85, and pelvic exenteration in 13. Total retrieved lymph nodes numbered 2,554, of which 252 contained metastasis. The group was divided into patients with 1-10 retrieved lymph nodes (n=119) and patients with > or = 11 retrieved lymph nodes (n=91). Median follow-up was 49 months. Local recurrence was as follows: 15% in patients with specimens containing 1-10 lymph nodes and conversely 7.4% in those with > or = 11 (p=0.01). Five-year survival of patients with 1-10 lymph nodes was 48%, whereas for those with > or = 11 lymph nodes it was 69% (p=0.02). CONCLUSIONS: Retrieval of at least 11 lymph nodes in the surgical specimen is not only a powerful tool to properly stage patients with rectal adenocarcinoma treated with preoperative chemoradiotherapy and surgery, but it is also of prognostic relevance in that 5-year survival and local recurrence were better in this group of patients.

Anal sphincter preservation in locally advanced low rectal adenocarcinoma after preoperative chemoradiation therapy and coloanal anastomosis.

BACKGROUND AND OBJECTIVES: Standard treatment of rectal adenocarcinoma located 3-6 cm above anal verge is abdominoperineal resection. The objective was to evaluate feasibility, morbidity, and functional results of anal sphincter preservation after preoperative chemoradiation therapy and coloanal anastomosis in patients with rectal adenocarcinoma located between 3 and 6 cm above the anal verge. METHODS: This study included 17 males and 15 females with a mean age of 54.8 +/- 15.4 years. Tumors were located at a mean of 4.7 +/- 1.1 cm above the anal verge. The mean tumor size was 4.6 +/- 1.5 cm. All patients received the scheduled treatment. Twenty-two patients underwent coloanal anastomosis with the J pouch; 10 underwent straight anastomosis. Average surgical time was 328.7 +/- 43.8 min, and the average intraoperative hemorrhage was 471.5 +/- 363.6 ml. The mean distal surgical margin was 1.3 +/- 0.6 cm. Five patients (15.6%) received a blood transfusion. RESULTS: Major complications included coloanal anastomotic leakage (three); pelvic abscess (three), and coloanal stenosis (two). Tumor stages were as follows: T0-2,N0,M0 = 12; T3,N0,M0 = 9; T1-3,N+,M0 = 9, and T1-3,N0-3,M+ = 2. Diverting stomas were closed in 30 patients. Median follow-up was 25 months. Recurrences occurred in four patients and were local and distant (n = 1) and distant (n = 3). Anal sphincter function was perfect (n = 20), incontinent to gas (n = 3), occasional minor leak (n = 2), frequent major soiling (n = 3), and colostomy (n = 2). CONCLUSIONS: In patients with locally advanced rectal cancer located 3-6 cm from anal verge who are traditionally treated with abdominoperineal resection, preservation of anal sphincter after preoperative chemoradiation therapy plus complete rectal excision with coloanal anastomosis is feasible and is associated with acceptable morbidity and no mortality.

Multivisceral resection for colon cancer.

BACKGROUND: There is a lack of appropriate information in regard to the optimal treatment for colon cancer infiltrating neighboring organs. OBJECTIVES: The objective of this study is to analyze treatment results and to identify the risk factors of death by cancer in these patients. METHODS: A retrospective analysis of 40 patients with colon cancer infiltrating neighboring organs without distant metastases was carried out. Patterns of recurrence and 5-year survival were analyzed. RESULTS: The study included 20 males and 20 females with a median age of 51.5 years. Primary tumor location was as follows: right colon (n = 15); transverse colon (n = 5); left colon (n = 7), and sigmoid (n = 13). In 17 patients, the colon tumor infiltrated the abdominal wall alone or together with neighboring organs and in 23 patients, one or more neighboring organs were infiltrated. Eleven patients (27.5%) developed postoperative complications. Two patients (5%) died during the postoperative period. Microscopic tumor infiltration was demonstrated in 29 patients (72.5%). Tumor stage was as follows: T3,N0 (n = 8); T3,N+ (n = 3); T4,N0 (n = 16), and T4,N+ (n = 13). Overall 5-year survival was 45%. Multivariate analysis shows that the unfavorable risk factors for 5-year survival were neoplastic cell infiltration to neighboring organs, age > 50 years, and lymph node metastases. CONCLUSIONS: The main risk factors for cancer-related failure are neoplastic infiltration to neighboring organs, age > 50 years, and lymph node metastases. In T4 colon cancer, the recurrence pattern was found at local, peritoneal, and distant sites.

[Usefulness of scintigraphy images with 111In-CYT-103 in the diagnosis of colonic and rectal recurrence]. / Utilidad de las imágenes centelleográficas con 111In.CYT-103 en el diagnóstico de recurrencia del cáncer de colon y recto.

OBJECTIVE: To determine the effectiveness of radioimmunoscintigraphy (RIC) with 111In-CYT-103 in detecting the extension of malignant disease in patients surgically treated for colorectal adenocarcinoma under suspicion of recurrence in comparison to CT scan (computed tomography) and exploratory laparotomy. DESIGN: Prospective and observational study. MATERIAL AND METHODS: A total of 26 patients under suspicion of recurrence, with a total of 31 lesions. All the patients had performed the following studies with GT, RIC with 111In-CYT-103, exploratory laparotomy and histopathology. RESULTS: A sensitivity of 96.8%, and specificity of 77.8%, and accuracy of 92% were found for the RIC. CT scan had a sensitivity, specificity and accuracy of 71.5%, 88.8%, and 75.7%, respectively in extrahepatic lesions. When both methods are combined, results shows an increment in sensitivity. Hepatic lesions were present in 50% of the patients; a sensitivity of 85%, a specificity of 92%, and accuracy of 89% for RIC and sensitivity, specificity and accuracy of 92% for the CT. CONCLUSION: The results of clinical studies with 111In-CYT-103 in detecting the occurrence of colorectal carcinoma provided additional information, making this method a valuable complementary test that contributes to patient management.

Formalin instillation for refractory radiation-induced hemorrhagic proctitis.

BACKGROUND AND OBJECTIVES: Radiation proctitis is a common complication after pelvic irradiation. One to five percent of these patients will develop intractable or massive hemorrhagic radiation proctitis that will require repeated hospital admissions and blood transfusions. We evaluated the benefits of instillation of 4% formalin in the management of refractory hemorrhagic radiation-induced proctitis. METHODS: From January 1998 to May 1999, 20 female patients who failed with administration of topical steroids and/or mesalazine were treated with 500 ml of 4% formalin instilled into the rectum in 50-ml aliquots. RESULTS: Median age was 58 years. Eighteen patients had cervical cancer and two, endometrial cancer. These patients received a mean of 7,500 rads to the pelvis. The symptoms began at a mean of 8 months after termination of radiotherapy. Median time of symptomatic rectal hemorrhage was 8 months. Median of blood units previously transfused was six (range: 2-11). Hemorrhage immediately ceased after the 4% formalin instillation in 17 patients. Three patients required formalin instillation repetition with success in one. Overall success was 90%. Median follow-up was 20 months. Five patients had moderate pelvic pain after instillation and one developed rectosigmoideal necrosis that required resection plus Hartmann procedure. Two patients developed rectovaginal fistula and required colostomy, and one thereafter, required abdominoperineal resection en bloc with the posterior wall of the vagina due to pelvis sepsis. CONCLUSIONS: Rectal instillation of 4% formalin is a simple, inexpensive, and efficient treatment for refractory hemorrhagic radiation proctitis.

Utilidad de las imágenes centelleográficas con 111In. CYT-103 en el diagnóstico de recurrencia del cáncer de colon y recto / Usefulness of scintigraphy images with 111In-CYT-103 in the diagnosis of colonic and rectal recurrence

OBJECTIVE: To determine the effectiveness of radioimmunoscintigraphy (RIC) with 111In-CYT-103 in detecting the extension of malignant disease in patients surgically treated for colorectal adenocarcinoma under suspicion of recurrence in comparison to CT scan (computed tomography) and exploratory laparotomy. DESIGN: Prospective and observational study. MATERIAL AND METHODS: A total of 26 patients under suspicion of recurrence, with a total of 31 lesions. All the patients had performed the following studies with GT, RIC with 111In-CYT-103, exploratory laparotomy and histopathology. RESULTS: A sensitivity of 96.8, and specificity of 77.8, and accuracy of 92 were found for the RIC. CT scan had a sensitivity, specificity and accuracy of 71.5, 88.8, and 75.7, respectively in extrahepatic lesions. When both methods are combined, results shows an increment in sensitivity. Hepatic lesions were present in 50 of the patients; a sensitivity of 85, a specificity of 92, and accuracy of 89 for RIC and sensitivity, specificity and accuracy of 92 for the CT. CONCLUSION: The results of clinical studies with 111In-CYT-103 in detecting the occurrence of colorectal carcinoma provided additional information, making this method a valuable complementary test that contributes to patient management.

[Multivariate analysis of risk factors associated with dehiscence of colorectal anastomosis after anterior or lower anterior resection for sigmoid or rectal cancer]. / Análisis multivariado de factores de riesgo asociados a dehiscencia de la anastomosis colorrectal después de una resección anterior o anterior baja por cáncer del sigmoides o del recto.

INTRODUCTION: Clinical anastomotic leakage remains a major problem after anterior or low anterior resection for rectal or sigmoid cancer. OBJECTIVE: To analyze risk factors associated with this complication. MATERIAL AND METHODS: From January 1992 to December 2000, 232 anterior or low anterior resections were performed. An univariate and multivariate analysis were performed as to find the risk factors. RESULTS: There were 122 females and 110 males, mean age was 58.5 +/- 14.1. Tumors were located as follows: low third (n = 10), middle third (n = 104), upper third (n = 52) and sigmoid (n = 66). Ninety-two patients received preoperative radiotherapy +/- chemotherapy. Twenty-six (11.6%) had diabetes mellitus, 52 (22.4%) hypertension and 31 (13.4%) mixed cardiopathy. Forty-six patients (19.8%) had > 90% of tumor obstruction. Mean levels of serum albumin and lymphocytes were 3.7 +/- .62 g/L y de 2,026 +/- 1,576/mm3, respectively. Tumors mean distance from the anal verge was 10.2 +/- 6.7 cm. Colorectal anastomoses were performed with the following techniques: double stapled (n = 92), single stapled (n = 85) and manual (n = 55). Multivisceral resection was performed in 29 patients (12.5%); a diverting colostomy was performed in 54 patients (23.2%). Mean intraoperative haemorrhage was 505.3 +/- 393.5 mL. Mean operative time was 267.4 +/- 83 min. Sixty patients (27.2%) received blood transfusion. Mean tumor size was 4.8 +/- 2.6 cm. Tumor stage was as follows: T0-, T2, N0 (n = 60), T3, T4, N0 (n = 103), any T, N+ (n = 55) y T3-4, N+, M+ (n = 14). Nineteen patients (8.1%) developed clinical anastomotic leakage. No operative mortality was observed. Adverse risk factors for clinical anastomotic leakage were: gender (male), preoperative albumin levels < 3 g/L, preoperative tumor obstruction (> 90%) and distance of the anastomosis from the anal verge (< 7 cm). CONCLUSIONS: In patients with these adverse risk factors a diverting colostomy or ileostomy should be performed, as to avoid fecal peritonitis.

Morbidity and mortality following abdominoperitoneal resection for low rectal adenocarcinoma

Antecedentes y objetivos. El tratamiento estándar del cáncer del recto localizado entre 0 y 8 cm del margen anal es la resección abdominoperineal (RAP), se asocia a una alta morbimortalidad. El objetivo de éste estudio fue el analizar la morbilidad, mortalidad y recurrencias asociadas a este procedimiento. Material y métodos. Durante 1995 y 1999 a 137 pacientes se les efectuó RAP por cáncer del recto localizado entre 0 y 8 cm del margen anal. Las variables se analizaron mediante la prueba de Ji cuadrada. Se efectuó un análisis de regresión logística para encontrar las variables que afectaron la infección perineal y los patrones de recurrencia. Resultados. Fueron 78 hombres y 59 mujeres, con un promedio de edad de 57.4 ñ 14.6 años. El promedio de la hemorragia intraoperatoria fue de 739 ñ 547 mL; 51 pacientes (37.2 por ciento) ameritaron hemotransfusión; 72 pacientes recibieron radioterapia preoperatoria; 22 recibieron quimio-radioterapia postoperatoria; 21 quimio-radioterapia preoperatoria y 22 sólo RAP. 17 pacientes (12.4 por ciento) presentaron complicaciones mayores y 47 (34.3 por ciento) menores. Veinte pacientes (14.6 por ciento) tuvieron infección en la herida perineal; los factores asociados a esta complicación fueron: la radioterapia preoperatoria ñ quimioterapia y la edad mayor a 55 años. La mortalidad operatoria fue de 0.7 por ciento. La mediana de seguimiento fue de 32 meses. Cuarenta y siete pacientes (34.5 por ciento) tuvieron recurrencia, 12 local (8.8 por ciento) y 35 a distancia. La supervivencia a cinco años del grupo fue de 75 por ciento. Conclusión. La RAP es un procedimiento asociado con una alta morbilidad, pero con baja mortalidad. La causa de morbilidad más frecuente fue la infección de la herida perineal, influenciada por la administración de radioterapia preoperatoria ñ quimioterapia y por la edad (>55 años). Sin embargo, este tratamiento combinado se asocia a una baja tasa de recurrencias locales.

Linfangioma quístico del mesenterio: análisis clínico, radiológico y morfológico / Cystic mesenteric lymphangioma: clinical, radiological and histopathological features

Antecedentes: los linfangiomas quísticos del mesenterio (LQM) son neoplasias benignas raras, que pueden confundirse con tumores originados en otros órganos de la cavidad abdominal. Objetivo: mostrar las características clínicas, radiológicas y morfológicas de un caso de LQM. Material y método: masculino de 17 años de edad, que inició su padecimiento 17 días antes a su ingreso con dolor en fosa iliaca derecha, náusea, vómito, fiebre y un tumor abdominal. Inicialmente se diagnosticó como apendicitis aguda, en el transoperatorio le encontraron un tumor en el mesenterio y sólo le efectuaron apendicectomía. El paciente fue enviado a un centro especializado. En la tomografía axial computada de abdomen se encontró un tumor quístico que se interpretó como cistadenoma del páncreas. Se sometió a laparotomía exploradora, en la que se encontró tumor retroperitoneal multiquístico que infiltraba el mesenterio del colon derecho, el duodeno, el yeyuno proximal y la cabeza del páncreas. Se efectuó pancreatoduodenectomía con hemicolectomía derecha. En el postoperatorio desarrolló colestasis intrahepática por la administración de nutrición parenteral endovenosa con recuperación al discontinuarla. El paciente fue egresado sin complicaciones al 15§ día de posoperatorio. El estudio histopatológico correspondió a un LQM. A un año de seguimiento se encuentra asintomático. Conclusión: el LQM debe ser incluido en el diagnóstico diferencial de los tumores quísticos intraabdominales. Debido a las localizaciones que presenta este tumor, el cirujano debería planificar la cirugía adecuada para evitar complicaciones porque este tratamiento es curativo.

The surgeon as prognostic factor for local recurrence and survival in the anal sphincter preservation for mid-rectal cancer

Antecedentes y objetivo. Los factores pronósticos en el cáncer del recto dependen principalmente del estadio del tumor. Sin embargo, es importante evaluar el papel del cirujano como parte de estos factores pronósticos que afectan la recurrencia local y la supervivencia en un grupo de pacientes con cáncer del tercio medio del recto tratados en un hospital de referencia comparados contra pacientes tratados en hospitales generales. Material y métodos. De enero de 1980 a diciembre de 1995, se analizaron retrospectivamente 82 pacientes con cáncer del tercio medio del recto que fueron tratados con resección anterior baja. Cuarenta y dos enfermos fueron antendidos en un centro de referencia (Grupo I) y 40 en hospitales generales (grupo II). Se efectuó un análisis multivariado de factores riesgo. Resultados. Fueron 42 hombres y 40 mujeres, con edad promedio de 55.8 ñ 14.9 años. No se encontraron diferencias entre los dos grupos estudiados respecto a: edad, sexo, estadio, grado de diferenciación, número de ganglios positivos, infiltración a órganos adyacentes y administración de quimio y/o radioterapia postoperatoria. Diferencias signficativas fueron encontradas en el número de ganglios estudiados por espécimen y en el seguimiento postoperatorio. La mediana de seguimiento del grupo fue de 49 meses. Los pacientes del grupo I tuvieron un 9.5 por ciento de recurrencia local vs. 50 por ciento de los del grupo II (P=0.0001). La supervivencia a cinco años de los pacientes del grupo I fue de 63 por ciento vs 54 por ciento del II (p=0.04). Los factores pronósticos que afectaron favorablemente la recurrencia local y a la supervivencia dependen principalmente del cirujano y del estadio del tumor