Should preoperative chest computed tomography be performed in all patients with colorectal cancer?

AIM: This study evaluated the accuracy of chest computed tomography (CCT) in the preoperative staging of patients with potentially resectable colorectal cancer (CRC). An attempt was made to determine whether CCT has a significant influence on management and clinical outcome. METHOD: A review was conducted of all preoperative CCTs and X-rays performed in patients submitted to elective resection of CRC at our institution between 2005 and 2012. All scans were revised by an independent radiologist who was unaware of the circumstances of each case. The findings were classified as benign, malignant or indeterminate. Patients were followed for at least 12 months after surgery to assess the clinical evolution of any lesion found on CCT and the oncological outcome. RESULTS: Two hundred and twenty-three patients were included. The CCT showed normal or benign findings in 157 (70.4%) patients, a malignant lesion in 17 (7.6%), and an indeterminate lung lesion (ILL) in 49 (22%). Of the 30 patients with proven lung metastases, a plain X-ray detected lesions in only 11 (36.7%) patients. During the postoperative follow-up, 14 (28.6%) of the 49 patients with ILL demonstrated malignant progression of the lung lesions. Among all 223 patients, only six (2.7%) underwent lung resection. CONCLUSION: CCT is superior to plain X-ray for the detection of lung metastases. Despite the medical and financial implications of preoperative CCT, only a small number of patients will eventually undergo lung resection. We call into question the role of routine CCT in the staging of patients with CRC. A more selective approach, reserving CT for patients at high risk of lung metastases, is suggested.

Metabolic parameters in rats receiving different levels of oral glycerol supplementation.

The use of glycerol in the diets for animals is of interest because it is a residue of biodiesel production and rich in energy. Thus, this study aimed to evaluate metabolic and physiological parameters of rats receiving supplemental pure glycerol by gavage. We used 30 Wistar rats (initial weight 202.7 ± 29.98 g) receiving 0 (control/saline), 200, 400, 800 and 1600 mg glycerol/kg of body weight (bidistilled glycerine, 99.85% glycerol) beside food and water ad libitum for 28 days. We used a completely randomised design with five treatments and six replicates. At the end of the experiment, the animals were killed, and the results showed that there was no change (p > 0.05) in the intake and excretion of water, the average daily weight gain, dry matter, ash and crude protein in the carcass or plasma triacylglycerols. There was a beneficial effect (p < 0.05) up to a dose of 800 mg/kg glycerol on feed intake, percentage of carcass fat, plasma levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), high-density lipoprotein (HDLc) and low-/very low-density lipoprotein (LDLc + VLDLc). The levels of total cholesterol and glucose were increased with up to a dose of 800 mg/kg glycerol (but remained within the normal range); they were reduced with the dose of 1600 mg/kg. The total leucocyte count tended to be reduced, although it was within the reference values for rats. There were no renal or pancreatic lesions. In conclusion, glycerol presented as a safe supplement at the studied doses, even having some beneficial effects in a dose-dependent manner in rats.

DEFB1 gene 5' untranslated region (UTR) polymorphisms are marginally involved in inflammatory bowel disease in south Brazilians.

The possible association of three DEFB1 gene polymorphisms with susceptibility to develop ulcerative colitis (UC) and Crohn's disease (CD) was investigated in Brazilian patients and controls. Although a clear and strong association between functional 5'-UTR DEFB1 SNPs and susceptibility/protection to IBDs cannot be drawn, our results suggest a possible involvement of DEFB1 gene in inflammatory bowel diseases, especially with the colonic localization of Crohn's disease.

Human papillomavirus infection and colorectal cancer risk: a meta-analysis.

AIM: Human papillomavirus (HPV) infection is associated with cervical cancer, but whether it is involved in colorectal carcinogenesis is controversial. We conducted a meta-analysis to evaluate the association between HPV and colorectal adenocarcinoma. METHOD: A search of the MEDLINE database was performed using the MESH terms 'HPV', 'human papillomavirus', and 'colon cancer', 'rectal cancer', 'colorectal cancer'. The prevalence of HPV infection in colorectal cancer was estimated by pooling data from 16 studies (involving 1436 patients) published up to July 2012, taking into consideration methodological heterogeneity between studies. The association of HPV with colorectal cancer risk was estimated from case-control studies. RESULTS: The HPV overall prevalence was 31.9% (95% CI: 19.3-47.9). It was lowest in Europe (14.1%, 95% CI: 4.9-34.1) and highest in South America (60.8%, 95% CI: 42.7-76.4). Eight studies presented the results of HPV typing in 302 HPV-positive colorectal carcinomas. HPV 18 was the virus more frequently found in colorectal cancer cases from Asia (73.34%, 95% CI: 44.9-90.7) and Europe (47.3%, 95% CI: 34.5-60.4). In contrast, HPV 16 was more prevalent in colorectal tumours from South America (58.3%, 95% CI: 45.5-69.9). The analysis of five case-control studies showed an increase in colorectal carcinoma risk with HPV positivity (OR = 10.04; 95% CI: 3.7-27.5). CONCLUSION: The results provide quantitative evidence for an association between HPV infection and colorectal cancer risk.

Distal resection margins in rectal cancer specimens: differences in assessment between surgeons and pathologists and the influence of neoadjuvant chemoradiation.

To investigate the discrepancy between the distal resection margin (DRM) assessed by surgeons and pathologists, and the impact of neoadjuvant chemoradiotherapy (nCRT) on DRM. This study included 67 rectal cancer patients undergoing elective surgery. DRMs were assessed through four different techniques: in vivo subjective estimative, made by the surgeon before the rectal resection (by palpation and visual estimative); in vivo objective, measured with a ruler before the rectal transection; ex vivo objective, measured right after resection of the specimen; post-fixation objective measurement, conducted by the pathologist. The DRMs subjectively and objectively assessed by the surgeons were not significantly different (3.40 cm vs. 3.45 cm). There was a mean reduction in the length of DRMs of 35.6%, from 3.45 cm objectively measured by the surgeon to 2.20 cm measured by the pathologist. This difference was significant among patients that did not receive nCRT (3.90 cm vs. 2.30 cm, P < 0.001), but not among those who received nCRT (2.30 vs. 2.05 cm). Surgeons are accurate in assessing rectal cancer DRMs. There are significant differences between intraoperative measurements of DRMs and the final pathologic results. However, these differences are not seen when nCRT is used, a finding that may be useful when sphincter preservation is being considered.

Sentinel lymph node in patients with rectal cancer invading the anal canal.

BACKGROUND: To assess the feasibility of the sentinel lymph node procedure in patients with rectal cancer extending to the anal canal. METHODS: Between January 2005 and April 2008, 15 patients with adenocarcinoma of the rectum with direct invasion of the anal canal and no clinical evidence of inguinal involvement were prospectively enrolled in the study. The sentinel node procedure consisted of a combination of preoperative radiocolloid lymphoscintigraphy and intraoperative detection of the inguinal sentinel node with a gamma probe. Patent blue dye was also used to facilitate direct identification of the blue-stained lymph node. After removal, the sentinel node was studied by hematoxylin-eosin staining and immunohistochemistry. RESULTS: Detection and removal of inguinal sentinel nodes was possible in all patients. Four patients (26.7%) had sentinel nodes identified as positive for metastatic adenocarcinoma. All positive cases also had metastases detected in perirectal lymph nodes; three of them developed hepatic or pulmonary metastases within 6 months after surgery. Of the 11 patients with negative sentinel nodes, only four (36.4%) also presented metastatic perirectal lymph nodes. Although none of the negative cases developed late inguinal metastases, three developed systemic or pelvic recurrence within 12 months after surgery. CONCLUSIONS: The standardized procedure was highly effective in sampling inguinal sentinel nodes in very low rectal cancers, allowing the detection of subclinical metastatic disease. Although this technique can be potentially useful for a subgroup of patients with isolated inguinal metastases, it cannot be routinely recommended for patients with rectal tumors invading the anal canal at this moment.

Evidence for an association of human papillomavirus infection and colorectal cancer.

AIM: To investigate the presence of human papillomavirus (HPV) in colorectal carcinomas and the correlation of the viral infection with prognostic factors for the disease outcome. METHODS: Seventy-two patients with primary colorectal adenocarcinoma were studied. From each patient two tissue samples were collected: one sample of the tumor and one sample of normal colorectal tissue from an area located 15 cm away from the tumor. Samples of colorectal mucosa obtained from 30 individuals without malignant disease were also studied as control group. Tissues were initially analyzed through MY/GP nested polymerase chain reaction (PCR) and through GP5+/GP6+ auto-nested PCR. Specific primer sets targeting the E6/E7 region of the HPVs 6, 11, 16, 18, 31, 33, 45 were used for typing. Direct DNA sequencing was conducted to confirm positive PCR results. RESULTS: HPV DNA was detected in colorectal specimens of 60 patients with cancer (83.3%), but in none of the tissues from the non-malignant control group (p<0.001). Twenty-three cancer patients had HPV DNA detected in both the tumor and the matched normal tissue, 23 had HPV only in the tumor, and 14 had HPV only in the normal colorectal tissue. HPV16 was the viral type most frequently detected, being present in 41 out of 60 positive cases (68.3%). No correlation between the presence of the virus and specific prognostic predictors for the disease outcome was observed. CONCLUSION: HPV is present in the colon and rectum of most patients with colorectal adenocarcinoma, suggesting that this virus may be related to the pathogenesis of colorectal cancer.

Sentinel lymph node in carcinoma of the anal canal: a review.

AIMS: To review the studies investigating the efficacy of the sentinel lymph node (SLN) procedure in anal canal carcinoma and to evaluate its potential role in guiding a more selective approach for patients with the malignancy. METHODS: A literature search in the PubMed database was preformed using the key words "sentinel lymph node" and "anal cancer". All indexed original articles (except case reports) on the SLN procedure in cancer of the anal canal were analysed. RESULTS: There are five published series to date. Eighty-four patients were studied. Rates of SLN detection and removal ranged from 66 to 100% of patients investigated. Nodal metastases were found in 7.1 to 42% of cases. No serious complications were reported. CONCLUSIONS: The technique has proven to be safe and effective in sampling inguinal SLNs. The detection of occult metastases in clinically unsuspicious nodes represents an important improvement in the process of staging these patients, which has not been possible with any other method of diagnosis. Although SLN procedure is still in an early phase of investigation in this type of cancer, it emerges as an objective method to guide individual therapeutic decisions.

von Willebrand factor antigen levels in plasma of patients with malignant breast disease.

von Willebrand factor (vWF) is a protein that mediates platelet adherence to the subendothelium during primary hemostasis. High plasma vWF concentrations have been reported in patients with various types of cancer, such as head and neck, laryngeal and prostatic cancer, probably representing an acute phase reactant. In the present study we determined the plasma levels of vWF antigen (vWF:Ag) by quantitative immunoelectrophoresis in 128 female patients with breast cancer as well as in 47 women with benign breast disease and in 27 healthy female controls. The levels of vWF:Ag were 170.7 +/- 78 U/dl in patients with cancer, 148.4 +/- 59 U/dl in patients with benign disease and 130.6 +/- 45 U/dl in controls (P<0.005). We also detected a significant increase in the levels of vWF:Ag (P<0.0001) in patients with advanced stages of the disease (stage IV = 263.3 +/- 113 U/dl, stage IIIB = 194.0 +/- 44 U/dl) as compared to those with earlier stages of the disease (stage I = 155.3 +/- 65 U/dl, stage IIA = 146.9 +/- 75 U/dl). In conclusion, vWF levels were increased in plasma of patients with malignant breast disease, and these levels correlated with tumor progression.

[Magnifying colonoscopy in the diagnosis of colorectal carcinoma invading the submucosa in familial adenomatous polyposis]. / Colonoscopia com magnificação de imagem no diagnóstico de carcinoma colorretal invasivo da submucosa na polipose adenomatosa familiar.

The development of colonoscopy with image magnification has enable to study the colonic mucosa in detail and to do differential diagnosis between neoplastic and non-neoplastic lesions from the observation of pit patterns. The results are comparable to stereomicroscopy being possible to predict the histologic diagnosis. In a patient with familial adenomatous polyposis magnifying colonoscopy was performed and this method demonstrated a wide variation of benign polypoid lesions and the morphological features of early colorectal cancer. In this patient, the evaluation by image magnification, together with indigo carmin 0.4% chromoscopy, showed a wide variety of lesions in the colon and rectum: laterally spreading tumor in the cecum, with IIIL + IV pits, subpediculate polyp in the transverse colon with approximately 2.0 cm diameter and IV + V pits, flat elevated lesions IIIL type, and in the sigmoid colon IIa + IIc lesion with V type of Kudo's classification were observed. The evaluation of pit patterns of the lesions in the transverse and sigmoid colon has enable to do the endoscopic diagnosis of the lesion with submucosal invasion.

Detection of human papillomavirus DNA in squamous cell carcinoma of the esophagus by auto-nested PCR.

The aim of the present study was to investigate the presence of human papillomavirus (HPV) in surgical specimens of esophageal squamous cell carcinoma. One hundred and sixty-five paraffin-embedded specimens of esophageal carcinoma were analyzed through high-sensitivity auto-nested polymerase chain reaction (PCR) using the consensus GP5+/GP6+ primer. Twenty-six specimens of esophageal mucosa without malignant disease were also studied as a control group. Two different specific primer sets targeting the E6 region of the HPVs 16 and 18 were used for typing. Direct DNA sequence analysis was conducted to confirm positive PCR results. HPV DNA was detected in 26 esophageal carcinomas (15.75%), but in none of the benign esophageal specimens (P < 0.05). Out of the 26 positive cases, 24 were HPV-16 and one was HPV-18. One tumor contained both HPV-16 and -18 DNA. Positive PCR results were confirmed by the amplified viral sequences. Our findings suggest that the presence of either HPV-16 or -18 might be related to development of the malignant phenotype in the esophagus.

Massive zosteriform cutaneous metastasis from rectal carcinoma.

A 44-year-old man presented with a large and rapidly growing skin lesion approximately six months after resection of a rectal carcinoma. The lesion measured 40 cm in size, extended from the suprapubic area to the proximal half of the left groin, and showed a particular zosteriform aspect. Biopsy confirmed a metastatic skin adenocarcinoma. Cutaneous metastases from rectal cancer are very uncommon. Their gross appearance is not distinctive, although the skin tumors are usually solid, small (less than 5 cm) and painless nodules or papules. Early biopsies for suspicious skin lesions are needed in patients with a history of colorectal cancer.

von Willebrand factor antigen levels in plasma of patients with malignant breast disease

von Willebrand factor (vWF) is a protein that mediates platelet adherence to the subendothelium during primary hemostasis. High plasma vWF concentrations have been reported in patients with various types of cancer, such as head and neck, laryngeal and prostatic cancer, probably representing an acute phase reactant. In the present study we determined the plasma levels of vWF antigen (vWF:Ag) by quantitative immunoelectrophoresis in 128 female patients with breast cancer as well as in 47 women with benign breast disease and in 27 healthy female controls. The levels of vWF:Ag were 170.7 + or - 78 U/dl in patients with cancer, 148.4 + or - 59 U/dl in patients with benign disease and 130.6 + or - 45 U/dl in controls (P<0.005). We also detected a significant increase in the levels of vWF:Ag (P<0.0001) in patients with advanced stages of the disease (stage IV = 263.3 + or - 113 U/dl, stage IIIB = 194.0 + or - 44 U/dl) as compared to those with earlier stages of the disease (stage I = 155.3 + or - 65 U/dl, stage IIA = 146.9 + or - 75 U/dl). In conclusion, vWF levels were increased in plasma of patients with malignant breast disease, and these levels correlated with tumor progression