Refractory diarrhea: A paraneoplastic syndrome of neuroblastoma.

Neuroblastoma (NB) is the most common extracranial solid tumor in children. Diarrheal NB is quite rare and is not easy to diagnose in the early stage. Six cases of diarrheal NB in our hospital treated from 1996 to 2006 were retrospectively analyzed, including characteristics such as electrolyte imbalance, pathologic features, vasoactive intestinal peptide (VIP) immunohistochemical staining results, treatment, and prognosis. All patients were boys with 3-8 loose or watery stools each day and routine fecal tests were normal. Abdominal tumors were identified by B-ultrasound. Drugs were ineffective. Three patients underwent surgery, and the remaining three patients received surgery and chemotherapy. Diarrhea stopped after treatment in five patients. Two patients died due to intractable hypokalemia. The tumor was located in the adrenal gland in four patients, in the upper retroperitoneum in one patient, and in the presacral area in one patient. Pathologic findings were NB and ganglioneuroblastoma. Five patients were at clinical stage I-II, and one was at stage III. Four patients survived (followed-up for 6 mo to 4 years). Immunohistochemical staining for VIP was positive. Refractory diarrhea is a paraneoplastic syndrome of NB and is rare. Patients aged 1-3 years who present with chronic intractable diarrhea should be followed closely. Intractable diarrhea, hypokalemia, and dysplasia are the initial clinical manifestations. Increased VIP is characteristic of this disease. Potassium supplementation plays a vital role in the treatment procedure, especially preoperatively. The prognosis of diarrheal NB is good following appropriate treatment.

Effectiveness of regional hyperthermia with chemotherapy for high-risk retroperitoneal and abdominal soft-tissue sarcoma after complete surgical resection: a subgroup analysis of a randomized phase-III multicenter study.

OBJECTIVE: To determine whether regional hyperthermia (RHT) in addition to chemotherapy improves local tumor control after macroscopically complete resection of abdominal or retroperitoneal high-risk sarcomas. BACKGROUND: Within the prospectively randomized EORTC 62961 phase-III trial, RHT and systemic chemotherapy significantly improved local progression-free survival (LPFS) and disease-free survival (DFS) in patients with abdominal and extremity sarcomas. That trial included macroscopically complete and R2 resections. METHODS: A subgroup analysis of the EORTC trial was performed and long-term survival determined. From 341 patients, 149 (median age 52 years, 18-69) were identified with macroscopic complete resection (R0, R1) of abdominal and retroperitoneal soft-tissue sarcomas (median diameter 10 cm, G2 48.3%, G3 51.7%). Seventy-six patients were treated with EIA (etoposide, ifosfamide, doxorubicin)+RHT (≥5 cycles: 69.7%) versus 73 patients receiving EIA alone (≥5 cycles: 52.1%, P=0.027). LPFS and DFS as well as overall survival were determined. RESULTS: RHT and systemic chemotherapy significantly improved LPFS (56% vs 45% after 5 years, P=0.044) and DFS (34% vs 27% after 5 years, P=0.040). Overall survival was not significantly improved in the RHT group (57% vs 55% after 5 years, P=0.82). Perioperative morbidity and mortality were not significantly different between groups. CONCLUSIONS: In patients with macroscopically complete tumor resection, RHT in addition to chemotherapy resulted in significantly improved local tumor control and DFS without increasing surgical complications. Within a multimodal therapeutic concept for abdominal and retroperitoneal high-risk sarcomas, RHT is a treatment option beside radical surgery and should be further evaluated in future trials.

Beyond stage I germ cell tumors: current status regarding treatment and long-term toxicities.

Approximately 20% to 40% of patients with germ-cell tumors (GCT) will need advanced medical treatment because of relapse or initial metastatic disease. The survival and recommended treatment for men with metastatic disease varies according to histology, primary and metastatic sites, and the level of prechemotherapy tumor markers. For patients with a good prognosis, three cycles of bleomycin, etoposide, and cisplatin (BEP) or four cycles of etoposide, and cisplatin are recommended. For patients with intermediate- and poor prognosis, four cycles of bleomycin, etoposide, and cisplatin remains the preferred treatment option, although a switch to a more intensive regimen can be considered a new alternative. A major advance in salvage therapy for GCT in the last 5 years was the development of a new risk classification system. Initial salvage treatment includes both high-dose chemotherapy and standard-dose chemotherapy. There is clear consensus that patients with residual masses larger than 1 cm should undergo postchemotherapy retroperitoneal lymph node dissection (PC-RPLND); however, the role of PC-RPLND in patients with serologic and radiographic complete response to first-line chemotherapy is controversial. The rationale for PC-RPLND in patients with small residual masses is discussed, and only a small minority of advanced nonseminoma GCT (NSGCT) patients are suitable candidates for observation after first-line chemotherapy. Post-treatment long-term toxicity has emerged as an important issue for GCT survivors. Examples of late effects are secondary nongerm-cell cancers and cardiovascular disease, which represent the most severe and potentially life-threatening effects of cancer treatment. Follow-up of cancer survivors should include recommendations for maintaining a healthy lifestyle to reduce the risk of serious long-term and late effects of treatment.

Retroperitoneal schwannomas: dilemmas in diagnostic approach and therapeutic management.

INTRODUCTION: Schwannomas are rare tumors arising from Schwan cells of the peripheral nerve sheath. The majority of the cases are sporadic and familial clustering is often observed in association with von Rechlinghausen's disease. Cases of intrasacral (osseous) and spinal tumors have also been described. Histologically, schwannomas are distinguished by the presence of areas of high and low cellularity called Antoni A and B tissue, respectively. CLINICAL PRESENTATION: Clinical features are highly non-specific and depend on the location and size of the lesion, with abdominal pain and neurological deficit being the most common abnormalities. Radiological studies are fundamental in the diagnostic evaluation of RSs. THERAPEUTIC MANAGEMENT: Despite recent research on the therapeutic strategies against RS, surgical resection appears the only potentially curative approach. Unfortunately, a mere minority of patients is eligible to undergo surgical intervention. In addition, surgical removal of RS does not necessarily guarantee patient's long-term survival. Laparoscopic approach and enucleation of the tumor have been suggested as well. Alternative therapies, such as radio- and chemotherapy often proved insufficient. The aim of this review was to evaluate the results of surgical treatment for RS with special reference to the extent of its histological spread and to analyze the recent literature in order to provide an update on the current concepts of therapeutic management of this entity.

Ovarian metastasis is associated with retroperitoneal lymph node relapses in women treated for colorectal peritoneal carcinomatosis.

PURPOSE: To analyze the patterns of recurrence and the prognostic impact of ovarian metastases (OM) in a population of women with colorectal peritoneal carcinomatosis (CRPC) treated with curative intent. METHODS: Data from all consecutive women with CRPC who underwent curatively intended complete cytoreductive surgery (CRS) plus intraperitoneal chemotherapy at our institution were retrieved from a prospective database. A bilateral oophorectomy or a complementary unilateral oophorectomy was systematically performed during CRS. RESULTS: From 1994 to 2009, among 105 women who underwent CRS plus intraperitoneal chemotherapy for CRPC, 62 (60 %) had OM. Women with and without OM had comparable peritoneal cancer index (PCI) scores (10 vs. 12, respectively, p = 0.09). After a median follow-up of 60 (range 5-145) months, median overall survival of women with OM did not differ statistically from that of women without OM (respectively, 36 and 40 months; p = 0.75). Relapses occurred in 82 % of the patients, distributed similarly between the two groups except for retroperitoneal lymph node recurrence, which occurred in 19 patients (18 %), including 18 with OM. The only predictive factor for a retroperitoneal relapse was a history of OM (p = 0.0012). CONCLUSIONS: Retroperitoneal lymph node recurrence seems to be linked to OM originating from colorectal cancer and could worsen the prognosis. A systematic lymphadenectomy could be evaluated in women with isolated OM or very limited peritoneal carcinomatosis to analyze the incidence of invaded lymph nodes and study its potential benefit on survival.

Peritoneal sarcomatosis: is there a subset of patients who may benefit from cytoreductive surgery and hyperthermic intraperitoneal chemotherapy?

BACKGROUND: Unlike novel molecular-targeted therapies for metastatic gastrointestinal stromal tumors (GIST), conventional treatments for peritoneal sarcomatosis (PS) are mostly ineffective. As with carcinomatosis of epithelial origin, a rationale base supports an aggressive locoregional treatment of PS, but the use of CRS and HIPEC in this setting is still controversial. We assessed the outcome of clinically and pathologically homogeneous subsets of patients with PS uniformly treated by cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS: A prospective database of 37 patients who underwent CRS and close-abdomen HIPEC with cisplatin and doxorubicin or mitomycin-C was reviewed. PS originated from GIST (pre-imatinib era) in 8 patients, uterine leiomyosarcoma (ULS) in 11, retroperitoneal liposarcoma (RPLP) in 13, and other sarcoma in 5. RESULTS: CRS was macroscopically complete in 28 patients (75.7%). Operative mortality was 3.7% and morbidity 21.6%. After median follow-up of 104 (range, 1-131) months, peritoneal disease progression occurred in 16 patients, distant metastases in 5, and both in 13. For all patients, median overall survival was 26.2 months; 7 patients were alive at 46-130 months (ULS, n = 4; RPLP, n = 2; GIST, n = 1). RPLP had the best overall survival (median, 34 months) but 100% peritoneal relapse; GIST had dismal overall, local-regional-free and distant-free survival; ULS had the higher proportion of long survivors and best local-regional-free survival. CONCLUSIONS: Overall, results of CRS and HIPEC did not compare favorably to those of conventional therapy. In a subgroup analysis, the combined approach did not change GIST and RPLS natural history. The interesting results with ULS may warrant further investigations.

Neuroblastoma: treatment outcome after incomplete resection of primary tumors.

PURPOSE: For International Neuroblastoma Staging System (INSS) stages III or IV neuroblastoma (intermediate or high risk), complete excision of the primary tumor is not always feasible. Most current studies on the treatment outcome of these patients have reported on the complete excision status. The aim of this study is to review the treatment outcome after the incomplete resection. METHODS: The medical records of 37 patients that underwent incomplete resection between January 1986 and December 2005 were reviewed retrospectively. Incomplete resection was assessed by review of the operative notes and postoperative computerized tomography. Age, gender, tumor location, INSS stage, N-myc gene copy number, pre- and postoperative therapy, and treatment outcome were reviewed. The treatment outcome was evaluated according to the postoperative treatment protocol in the high-risk group. RESULTS: Intermediate-risk patients were treated with conventional chemotherapy, isotretinoin (ITT) and interleukin-2 (IL-2). High-risk patients were treated with peripheral blood stem cell transplantation (PBSCT), ITT, and IL-2 (N = 11). Before the introduction of PBSCT, the high-risk patients were also treated with the conventional chemotherapy (N = 19). Intermediate-risk patients (N = 5) currently have no evidence of disease (NED). For the high-risk patients (N = 32), 19 patients were treated with chemotherapy alone; 15 patients died of their disease while four patients currently have an NED status. Eight of 11 patients that underwent PBSCT are currently alive. CONCLUSIONS: For intermediate risk, conventional chemotherapy appears to be acceptable treatment. However, for high-risk patients, every effort should be made to control residual disease including the use of myeloablative chemotherapy, differentiating agents and immune-modulating agents.

Long term survival in anti-Hu associated adult neuroblastoma.

We report on a young lady suffering from adult neuroblastoma and anti-Hu associated paraneoplastic encephalomyelitis (PEM) with a tumour free survival of nine years up to now. Treatment included tumour surgery, radiation, high dose chemotherapy, and stem cell transplantation. Serological testing demonstrated a marked decline in anti-Hu antibody titres under therapy, and subsequent disappearance of the antibody 31 months after second tumour resection.

Aggressive recurrence after radiofrequency ablation of liver neoplasms.

Radiofrequency ablation is considered safe for inoperable liver neoplasms; with small lesions the rate of success is very high, the local recurrence is marginal and generally suitable for a retreatment. We have little information about the possibility of rapid regrowth of the tumor after a response judged as complete. We present four patients, affected by primary (3 patients) and metastatic (1 patient) uninodular cancer. All the lesions were small, superficial and well suited for surgery, but were treated by radiofrequency ablation elsewhere. The early instrumental evaluations stated a complete result in all the patients. Cancer regrowth was diagnosed at 3, 4, 6 and 12 months after radiofrequency ablation, always starting from the treated lesion. In case 1 the whole right lobe was involved together with a controlateral multinodular recurrence; cases 2 and 3 presented an extensive liver and parietal wall involvement; while in the fourth patient a diffuse biliary colonization was observed. Only 1 patient was suitable for surgery; the others died 6, 2 and 4 months, respectively, after recurrence. Recurrence after radiofrequency ablation may show an aggressive evolution precluding any possibility of cure. Radiofrequency ablation must not be considered a suitable alternative to surgery in patients with a low surgical risk.

Efficacy of superficial and deep regional hyperthermia combined with systemic chemotherapy and radiotherapy in metastatic melanoma.

BACKGROUND AND OBJECTIVE: Response rates of cutaneous-subcutaneous or lymph node metastases of melanoma to systemic chemotherapy are rather low. We report our clinical experience with superficial and deep regional hyperthermia in combination with radiotherapy and/or chemotherapy with carboplatin. PATIENTS/METHODS: We treated 15 patients with metastatic melanoma (6 men, 9 women; age 39-84 years, mean age 60 years) by using superficial or deep regional hyperthermia produced by electromagnetic energy. Superficial hyperthermia was delivered to skin or lymph node metastases in combination with radiochemotherapy in 12 patients, while deep regional hyperthermia was administered with an annular array applicator to lymph node metastases either in combination with radiochemotherapy (1 patient) or with carboplatin alone (2 patients). The clinical response was assessed by clinical evaluation and/or computer tomography and/or ultrasonography at monthly intervals. RESULTS: Both superficial and deep regional hyperthermia was well tolerated. We observed 5 complete local remissions (34%), 6 partial local remissions (40%) and 2 patients with stable disease (13%). The best results were obtained in cutaneous or retroperitoneal metastases. CONCLUSIONS: Local response can be achieved in inoperable metastatic melanoma using superficial or deep regional hyperthermia in combination with radiochemotherapy or chemotherapy.

Response to neoadjuvant chemotherapy combined with regional hyperthermia predicts long-term survival for adult patients with retroperitoneal and visceral high-risk soft tissue sarcomas.

PURPOSE: To determine the efficacy of neoadjuvant chemotherapy combined with regional hyperthermia (RHT) for local tumor control and overall survival (OS) in adult patients with retroperitoneal or visceral (RP/V) high-risk soft tissue sarcomas (HR-STS). PATIENTS AND METHODS: From 1991 to 1997, 58 patients with HR-STS at RP/V sites were prospectively treated with four cycles of etoposide, ifosfamide, and doxorubicin combined with RHT followed by surgery, adjuvant chemotherapy, and radiation. RESULTS: Objective response rate assessable in 40 patients was 13% (five partial responses). Including minor responses (n = 8), the radiographic response rate was 33%. The pathologic response rate assessable in 26 patients after surgical resection was 42%. Median OS was 31 months. At a median observation time of 74 months, 5-year probability of local failure-free survival (LFFS), distant metastasis-free survival, event-free survival, and OS were 25%, 51%, 20%, and 32%, respectively. Averaged minimum temperatures (T(min)) and time-averaged temperatures achieved in 50% (T(50)) and 90% (T(90)) of all measured tumor sites differed significantly between responders and nonresponders (T(min), 39.3 degrees C v 38.0 degrees C; P =.002; T(50), 40.9 degrees C v 40.3 degrees C; P =.038; T(90), 40.1 degrees C v 39.3 degrees C; P =.017). At 5-year follow-up, probability of LFFS (59% v 0%; P <.001) and OS (60% v 10%; P <.001) was significantly in favor of patients responding to neoadjuvant thermochemotherapy. CONCLUSION: Response to neoadjuvant chemotherapy combined with RHT is predictive for an improved local tumor control resulting in a long-term survival benefit for patients with HR-STS at unfavorable RP/V sites; however, the impact of RHT has to be defined in a randomized phase III trial.

Clinical usefulness of determining the rate of thermal clearance within heated tumors.

Between June 1987 and June 1988, 28 patients (28 tumors) with liver, retroperitoneal, intrapelvic, or superficial tumors were treated with hyperthermia combined with radiotherapy and/or chemotherapy. Hyperthermia was administered once or twice a week for 30-60 min per session, up to a total of 2-11 sessions, with an 8-MHz RF capacitive heating device. Blood flow in the tumors was evaluated from the rate of thermal clearance (TCR) using the bio-heat transfer equation. The TCR was measured in the middle of the first heating session and at the end of the last heating session by turning off the output power of the heating device. For 9 patients, contrast-enhanced CT scans were taken and CT numbers at the centers of tumors were measured before and after the entire course of hyperthermia. Changes in TCR were closely related to average tumor center temperature, changes in CT number, and tumor response. When smaller and more superficial tumors were treated by hyperthermia combined with radiotherapy and/or chemotherapy that consisted of many heating sessions and during which a high average tumor center temperature was achieved, a better tumor response was obtained. The better the tumor response, the higher the local control rate became. The cause-specific survival rate of patients who achieved good tumor responses was higher than that of patients who showed poor tumor responses. Changes in TCR and CT number in heated tumors were useful and important indicators of tumor response to hyperthermia.

Comprehensive treatment of advanced neuroblastoma involving autologous bone marrow transplant.

Encouraging results are reported with high-dose chemotherapy and total body irradiation followed by autologous bone marrow transplantation in the treatment of advanced neuroblastoma. However, relapse remains a significant problem. We used high-dose chemotherapy, surgery, intraoperative radiation and an autologous bone marrow transplant treated in vitro to remove tumor cells followed by 13-cis-retinoic acid to treat 36 children with advanced neuroblastoma. This comprehensive treatment appears to improve the survival rate of patients with advanced neuroblastoma, including those with N-myc amplification and bony involvement. The disease-free survival rate was 66% (95% confidence interval, 49-84%) at 3 years. All patients who received 13-cis-retinoic acid developed cheilitis, but no bone marrow depression occurred in these patients. Five patients developed hemolytic uremic syndrome (HUS) post-transplant. This may have been related to the procedure used for total body irradiation. Patients who had their kidneys shielded during this procedure did not develop this syndrome. Patients who received local irradiation at the primary site showed no evidence of relapse in this region, indicating that such therapy may help to prevent a relapse. These data suggest a high rate of 3 year disease-free survival with this treatment strategy. The nonrandomized nature of the study and use of multiple modalities precludes analysis of the specific contribution of each.

Effects of intraoperative hyperthermia on canine sciatic nerve: histopathologic and morphometric studies.

Failure to achieve local control in the treatment of pelvic and retroperitoneal tumours results in a high rate of recurrences. The objective of intraoperative hyperthermia (IOHT) is to enhance the effect of intraoperative radiation therapy and to increase local tumour control. The tolerance of peripheral nerves to heat may limit the heat dose that can be applied to tumours. Histopathologic and histomorphometric changes of canine sciatic nerve after 60-min IOHT were studied in three groups of five dogs each for temperatures of 43, 44 and 45 degrees C. IOHT was performed using a water-circulating hyperthermia device with a multichannel thermometry system on surgically exposed sciatic nerve. Histopathologic and histomorphometric studies were done immediately, 3 weeks and 12 months after IOHT. Histologic changes observed immediately after treatment were minimal but at 3 weeks following 60-min 45 degrees C IOHT both axon and myelin loss and an increase in endoneurial fibrous tissue were observed. Twelve months after treatment a statistically significant decrease in axon, myelin and small vessel percentages as well as an increase in endoneurial and epineural connective tissue were observed for dog treated to 45 degrees C. Dog treated to 44 degrees C for 60 min had similar statistically significant but less severe changes. Twelve months after 43 degrees C IOHT for 60 min, nerve fibres appeared normal and endoneurial connective tissue was only increased mildly around small and medium-sized vessels. These results suggest that temperatures to the peripheral nerve > 44 degrees C for 60 min are likely to cause significant histopathologic changes that can be found 12 months after treatment. A hypothesis of the mechanism of heat injury to peripheral nerves was developed.

[A case of aortoduodenal fistula following radiotherapy of retroperitoneal metastatic disease].

A new case of aortoduodenal fistula was added to the five cases previously reported in the literature, in which malignancy and/or its treatments could be implicated. This 67 year-old woman, six years previously had been placed on a therapy including irradiation on the pelvis for cancer of uterine cervix. For this time she underwent a radiotherapy completed in a total dose of 55.6 Gy combined with hyperthermia and chemotherapy for retroperitoneal metastatic disease with excellent response. Three months later she had hematemesis followed by melena and deteriorated to hemorrhagic shock. Emergent aortography detected contrast extravasation from the aorta with subsequent opacification of the duodenum, and immediate intraaortic balloon occlusion was done, but she died soon thereafter. Postmortem examination revealed the fistula from the aorta just above the bifurcation to a 2 by 1.5 cm. area of the posterior wall of the third portion of the duodenum. Accentuated arteriosclerosis in locally irradiated portion of the aorta, obstruction of small arteries from organized thrombus and hyaline necrosis in the wall of the fistulous tract were defined without evidence of tumor invasion. Based upon the findings of the patient reported herein, radiation might be another possible etiologic factor in aortoduodenal fistula, as well as tumor invasion per se.

[Multiple malignant schwannoma treated with a multidisciplinary therapy--a case report].

A 32-year-old man, complaining of an abdominal mass, was admitted to hospital where, on undergoing examination, the mass, which had spread widely through the abdominal cavity and the retroperitoneal space, was diagnosed as a malignant schwannoma with a liver metastasis. Thus, a multidisciplinary treatment was initiated and a remission was achieved. Later, however, he developed a multiple, local recurrence and died forty months after onset of his clinical symptoms. Since the prognosis of patients with a malignant schwannoma that do not undergo radical surgery is extremely poor, the authors emphasize the necessity of research for an effective adjuvant therapy.

[Clinical use of combined radiation and hyperthermia therapy at the National Cancer Center Hospital].

At the National Cancer Center Hospital, Tokyo, hyperthermia combined with radiation was started in February 1982. At first BSD-1000 was introduced into clinical practice, followed by Thermotron RF-8 which utilizes radio frequency and then Aloka HMS-020 which utilizes microwaves. This study involved a total of 116 evaluable patients (128 lesions) from a series of patients treated by hyperthermia during a 4-year period up to March 1986. The sites of the tumors were the lower extremities in 7 patients, upper abdomen in 18, pelvic cavity in 18 patients and superficial in 82. Among 82 superficial lesions 34 were classified as showing CR and another 23 as showing PR, with a response rate of 69.5%. In 7 patients with tumors of the lower extremities none was classified as having CR or PR, the response rate being 0%. Eighteen upper abdominal tumors showed a response rate of 16.7%, with 1 of them being categorized as showing CR and 2 as showing PR. Eighteen pelvic tumors showed a response rate of 27.8%, with 1 of them being categorized as showing CR and 4 as showing PR. In 3 patients with tumors of thoracic cavity none was classified as having CR or PR, the response rate being 0%.

Retrorectal tumores in adults: a report of five cases

Foram estudados cinco casos de tumors retro-retais quanto ao quadro clínico, métodos complementares para o diagnóstico e possibilidades do tratamento cirúrgico. O doente mais jovem tinha 19 anos de idade e o mais idoso 57, com média de 40 anos. Três pacientes eram do sexo feminino e dois do masculino. A queixa mais freqüente era obstipaçäo e desconforto hipogástrico, com duraçäo de um a dois anos. Um dos pacientes mencionava massa de aumento progressivo na regiäo sacral desde o nascimento. Em todos os pacientes o toque retal demonstrava a presença de tumor retro-retal e a retossigmoidoscopia era normal. Todos os pacientes apresentavam "spina bifida", demonstrada no Raio X simples do abdome e sinais de compressäo extrínsica do reto, dos ureteres pélvicos e da bexiga, evidenciados no enema opaco e na urografia excretora. A tomografia computadorizada e a ultra-sonografia determinaram, em um caso em que foram empregadas, o caráter sólido, o tamanho e as relaçöes topográficas do tumor. Quatro pacientes foram submetidos à excisäo completa do tumor. O acesso foi abdominal em um, sacral em dois e abdomino-perineal em um paciente. Um paciente foi submetido à radioterapia como única forma de tratamento, devido ao grande tamanho do tumor, tendo sido estabelecido o diagnóstico através de biopsia. Os diagnósticos histológicos foram: teratoma benigno (dois casos), linfangioma (um caso), hemangiopericitoma (um caso) e neurilemona (um caso). Os pacientes submetidos à cirurgia foram seguidos por um a cinco anos, näo se observando recidiva do tumor. Os resultados funcionais foram satisfatórios em quatro e um paciente apresentou incontinência para fezes líquidas. O paciente submetido à radioterapia apresenta-se bem após dois anos, com diminuiçäo significativa da massa tumoral e melhora das condiçöes gerais