c-Myc overexpression is strongly associated with metaplasia-dysplasia-adenocarcinoma sequence in the esophagus.

We aim to determine the expression of the proto-oncogene c-Myc in patients with Barrett's esophagus (BE) and esophageal adenocarcinoma, and to evaluate the prevalence of such expression in relation to the metaplasia-dysplasia-adenocarcinoma sequence. BE develops as a result of a severe esophageal mucosa injury from gastroesophageal reflux. BE is a premalignant lesion and plays an important role in the development of esophageal adenocarcinoma. Several genetic alterations have been identified in the process that transforms a normal cell into a tumorous one. In the development of human tumors, one of the most important genes is the proto-oncogene c-Myc. The c-Myc protein expression was determined by immunohistochemical analysis in four different groups: 31 patients with normal tissue, 43 patients with BE without dysplasia, 11 patients with dysplasia in BE and 37 patients with esophageal adenocarcinoma. The material was obtained from esophageal biopsies or the dissection of patient esophagectomy specimens. Demographic and endoscopic data (sex, age, race and intestinal metaplasia extension), and morphologic and histopathologic tumor characteristics (deep tumor invasion, lymph node status, and tumor differentiation) were analyzed. The c-Myc expression was assessed using the Immunoreactive Scoring System (IRS). Overexpression of c-Myc was found in only 9.6% of normal tissue specimens, 37.2% of Barrett's esophagus, 45.5% of BE patients with dysplasia and 73% of adenocarcinoma samples, with significant statistical difference among these groups. No correlation was identified when the c-Myc expression was compared with morphologic and histologic tumor features or endoscopic data. However, linear correlation of c-Myc overexpression along the metaplasia-dysplasia-adenocarcinoma sequence was observed. This study demonstrates a significant increase in the expression of c-Myc in Barrett's esophagus, dysplasia and adenocarcinoma in relation to the control group, as well as a linear progression of this gene expression in this sequence. These results point out the importance of this marker in the development of esophageal adenocarcinoma from BE.

Prognostic value of p53 protein expression and vascular endothelial growth factor expression in resected squamous cell carcinoma of the esophagus.

The most common genetic alterations found in a wide variety of cancers are p53 tumor suppressor gene mutations. p53 appears to be a nuclear transcription factor that plays a role in the control of cell proliferation, apoptosis, and the maintenance of genetic stability. Angiogenesis is a critical process in solid tumor growth and metastasis. Vascular endothelial growth factor (VEGF), a recently identified growth factor with significant angiogenic properties, may be a major tumor angiogenesis regulator. Few studies have investigated the association between p53 and VEGF expressions and prognosis in esophageal carcinoma. Forty-seven specimens resected from patients with stage II and III squamous cell carcinoma (SCC) of the esophagus were studied using immunohistochemical staining. VEGF and p53 expressions were observed in 40% and 53% of the tumors, respectively. The p53 and VEGF staining statuses were coincident in only 21% of the tumors, and no significant correlation was found between p53 and VEGF statuses. No clinicopathologic factors were significantly correlated with p53 or VEGF expression. No significant association between p53 and VEGF expressions and poor prognosis was found. In conclusion, p53 and VEGF were not correlated with prognosis in patients with stage II and III SCC of the esophagus.

Survival and prognostic factors in patients with resected epidermoid oesophageal carcinoma.

To determine long-term survival of patients with thoracic oesophageal tumor who underwent resection, and to identify possible associated prognostic factors, 58 patients underwent oesophagectomy alone (group A) and 16 combined with neo-adjuvant chemoradiotherapy (group B). Univariate and multivariate analysis of prognostic factors were performed for age, depth of oesophageal wall tumour penetration, node involvement, type of resection, TNM stage and degree of tumour differentiation. Long-term survival rates at 1-5 years were 81% versus 89%; 56% versus 67%; 30% versus 67%; 12% versus 44%; and 0% versus 33% for group A and B, respectively (P = 0.0543, NS). Univariate analysis revealed only depth of invasion (P = 0.0076) and TNM stage (P = 0.0452) as isolated prognostic factors for long-term survival and multivariate analysis did not demonstrate any independent factor. Despite the small number of cases, neoadjuvant chemoradiotherapy seems to improve prognosis as well as to allow resection in a greater number of cases due to tumor downstaging.

Induction of esophageal carcinogenesis by diethylnitrosamine and assessment of the promoting effect of ethanol and N-nitrosonornicotine: experimental model in mice.

It is known that some nitrosamines preferably affect particular organs because of their organospecificity. Diethylnitrosamine (DEN) is one of the most powerful nitrosamines for experimentally inducing esophagus cancer. The present study aimed to evaluate the rate and type of epithelial lesions induced by DEN in mice. We also assessed the role of alcohol and N-nitrosonornicotine (NNN) as promoters of this carcinogenesis. A total of 208 female mice (Mus musculus) were allocated to five experimental groups: group 1, water only (controls); group 2, DEN + water; group 3, DEN + NNN; group 4, DEN + 6% alcohol solution; group 5, DEN + NNN + 6% alcohol solution. Animals in groups 2, 3, 4 and 5 received DEN (0.04 ml/l) three times per week, and during the following 4 days they received the other solutions. NNN was provided at a final concentration of 30 mg/l. The overall experimental period was 180 days. At the end of this time, the animals were killed and their esophagus was dissected for macro- and microscopic analysis. There was no significant difference in relation to the size of the esophagus and to the average DEN intake by the animals (p > 0.05). A statistically significant difference (p < 0.0001) was observed between controls and all other experimental groups. There was no significant difference among experimental groups treated with carcinogens (p > 0.05). The average incidence of cancer was 85.4%. The experimental model used in the present study is a very potent indicator of esophagus cancer. Owing to the high incidence for cancer observed in the present study, it was not possible to assess the effect of alcohol and NNN as inducers for the development of esophageal cancer.

Alternative surgical treatment for complex enterocutaneous fistula.

A retrospective analysis on the clinical-surgical handling of patients with enterocutaneous fistula (ECF) was performed, where an alternative surgical technique was discussed: intestinal bypass. Fistula with draining over 500 ml/24 h, which were present in 13 patients, were classified as high debit. We defined as complex, the fistula with multiple orifices, high defect of the abdominal wall or through the mesh. The population studied consisted of 25 patients, 11 male, in a total of 34 ECF and mean age of 41.9 years. At clinical treatment with TPN for high debit ECF, 2 patients (16.6%) were cured, another 2 died and 8 (66.8%) needed surgical treatment. The surgery cured 7 patients (77.7%) with high debit ECF but 2 (22.3%) died. In the patients with low debit ECF, TPN cured 2 patients (40%) but failed in another 3 (60%). All patients with low debit ECF resolved with surgical treatment.

Efficacy of computed axial tomography in the evaluation of the involvement of the respiratory tract in patients with squamous cell carcinoma of esophagus.

Squamous cell carcinoma of the esophagus is endemic in Rio Grande do Sul, the most southern state of Brazil, where the incidence reaches 27 out of 100,000 inhabitants per year. Palliative treatments, surgical or nonsurgical, impose lower mortality and lower costs. The choice of the best treatment for each patient depends on the neoplasia staging, and the local involvement of the tracheobronchial tree by tumor characterizes incurability. Computed axial tomography (CAT) is indicated, but remarkable contradictions were found in the literature. We studied 134 patients, diagnosed with esophageal squamous cell carcinoma, who underwent computed tomography and fiberoptic bronchoscopy (gold standard) performed with an uniform technique. An accuracy of 85.1% was obtained when computed tomography was compared with bronchoscopy with regard to impingement, displacement and invasion of trachea and bronchi. In conclusion, there is no statistically significant difference between computed tomography and fiberoptic bronchoscopy in the evaluation of tracheobronchial involvement by squamous cell carcinoma of the esophagus (p < 0.05).

Laparoscopic approach to wandering spleen: a case report and an update to the question.

Wandering spleen is seldom seen in everyday situations, and its prevalence is not well defined in the literature. Its causes are not precisely known, and there is controversy over its management. A 34-year-old woman experienced low-intensity abdominal pain associated with a palpable hypogastric mass, which was confirmed by imaging studies to be a wandering spleen. Because of ureteral compression, a surgical approach was decided upon, and videolaparoscopic splenectomy was chosen. This technique, comments about specific technical issues, and other treatment options presented in the literature are discussed. Videolaparoscopic splenectomy has excellent surgical results, both functional and aesthetic.

The influence of reperitonization on the induction of formation of intraperitoneal adhesions by a polypropylene mesh prosthesis. An experimental study in rats.

The correction of groin hernias has increasingly been performed by transperitoneal videolaparoscopic methods, using a polypropylene mesh. This could lead to an increased incidence of adhesion formation. The incidence of adhesions induced by mesh placement and the influence of reperitonization was observed on 40 male adult Wistar rats. Adhesions were significantly more common on the groups in which the prosthesis was placed (59% vs 95%; p = 0.01), as well as on the groups in which reperitonization was performed (58% vs 100%; p = 0.03). The results suggest that polypropylene mesh placement and reperitonization are each independent factors in the induction of adhesions formation.

Neoplasias associadas ao carcinoma epidermóide do esôfago / Neoplasms associated to esophageal epidermoid carcinoma

INTRODUÇÄO. O carcinoma epidermóide de esôfago (CEE) tem uma importante associaçäo com neoplasias do trato aerodigestivo e, provavelmente, compartilham dos mesmos fatores de risco. Além destes, outras neoplasias podem estar associadas com o carcinoma de esôfago. OBJETIVO. Analisar, retrospectivamente, pacientes com carcinoma epidermóide de esôfago tratados pelo Grupo de Cirurgia do Esôfago, Estômago e Intestino Delgado (GCEEID) do Hospital de Clínicas de Porto Alegre (HCPA), no período de janeiro/88 a junho/95, os quais tinham neoplasias associadas ao CEE. PACIENTES E MÉTODOS. Dentre os 261 pacientes estudados, 19 (7,28 por cento) tinham neoplasia associada ao CEE. Dez pacientes apresentaram tumores sincrônicos e 9, metacrônicos. O sexo predominante foi o masculino, com 17 casos. A média de idade ficou em 62,52 anos no momento do diagnóstico da neoplasia esofágica. RESULTADOS. Os tumores aerodigestivos, na sua totalidade carcinomas escamosos, representaram o tipo histológico predominante da neoplasia associada em 68,42 por cento dos casos. O sítio mais freqüente da neoplasia aerodigestiva associada foi a árvore respiratória (53,8 por cento), seguido da cavidade oral e orofaringe (23 por cento) e laringe (23 por cento). Dos 19 pacientes, 12 eram tabagistas e nove ingeriam bebidas alcoólicas regularmente. Para o tratamento do CEE, optou-se por cirurgia em seis pacientes. A neoplasia associada foi tratada com cirurgia radical em 11 pacientes e radioterapia em cinco. Surpreendentemente, foram diagnosticados quatro casos (21 por cento) de adenocarcinomas gßstricos associados ao CEE, tratados com cirurgia radical em três pacientes. CONCLUSÄO. Os autores ressaltam a importância do estadiamento criterioso dos pacientes com CEE devido a associaçäo significativa com outras neoplasias, principalmente com tumores aerodigestivos. Alertam para o seguimento desses pacientes e discutem a possibilidade de fatores de risco comuns: fumo e álcool. Nesta casuística, encontrou-se associaçäo importante com neoplasias gástricas.

Delayed cervical anastomosis of the esophagus for esophageal carcinoma.

BACKGROUND: The surgical approach for patients with advanced epidermoid esophageal carcinoma should provide an effective palliative effect with morbidity ratio as low as possible. Anastomotic leakage is a frequent complication and may be responsible for both early and late morbidity and, therefore, we assessed the role of delayed cervical esophagovisceral anastomosis technique in relation to the incidence of anastomotic complications. METHODS: Eight patients (Group 1) and 12 patients (Group 2) submitted to one-stage or two-stage operation, respectively, were selected by an intraoperative assessment by the surgeon, considering mainly tissue blood flow of the replacement organ after its placement in the cervical region. RESULTS: In Group 1 anastomotic dehiscence was observed in 37.5% of patients, while in Group 2 no cases of dehiscence occurred (p = 0.049). However, the postoperative mortality rate did not differ between the two groups (12.5% versus 0%, NS). CONCLUSION: When organ viability is uncertain, esophagovisceral anastomosis is best done by two-stage operation, since it decreases the incidence of anastomotic leak.

[Neoplasms associated with esophageal epidermoid carcinoma]. / Neoplasias associadas ao carcinoma epidermóide do esôfago.

INTRODUCTION: The esophageal epidermoid cancer has an important association with aerodigestive tract neoplasms and possibly share the same risk factors. Furthermore, other neoplasms can be associated with esophagus cancer. OBJECTIVE: To analyze retrospectively the patients with esophageal epidermoid cancer (EEC) and associated neoplasms, treated by the Esophagus Stomach and Small Intestine Group of Surgery at Hospital de Clinicas de Porto Alegre from January 1988 to June 1995. PATIENTS AND METHODS: Nineteen (7.28%) of the 261 studied patients had associated neoplasms to the EEC. Ten patients presented synchronic tumours and 9 metachronic ones. The predominant sex was the masculine with 17 cases. The mean age was 62.52 years in the moment of the esophageal cancer diagnostic. RESULTS: The aerodigestive tumours, squamous carcinomas in totality, represented the predominant associated neoplasm histological type in 68.42% of the cases. The most frequent associated aerodigestive tumours site was the respiratory tract (53.8%), followed by the oral cavity and oropharynx (23%) and larynx (23%). In our sample, twelve patients were smokers and 9 were alcohol abusers. In relation to the EEC treatment, surgery was performed in 6 patients. The associated neoplasm was treated with radical surgery in 11 patients and radiotherapy in 5. Surprisingly 4 cases (21%) of gastric adenocarcinoma associated to the EEC were diagnosed, treated with radical surgery in 3 patients. CONCLUSION: The authors call attention to the importance of a criterial staging as well as the follow up in patients with EEC owing to the significant association with others neoplasms, principally with aerodigestive tumours, and discuss the common risk factors possibility: tobacco and alcohol use. Important association with gastric neoplasms were found in this casuistry.