Mismatch repair system in colorectal cancer. Frequency, cancer phenotype, and follow-up.

INTRODUCTION AND AIMS: A frequent task in the study of colorectal carcinomas (CRC) is to identify tumors harboring deficient DNA mismatch repair systems (dMMR), which are associated with microsatellite instability. Given that there is scant information on those tumors in Mexican patients, our aim was to describe their frequency, clinical and pathologic characteristics, and results, which are necessary for future trials. MATERIALS AND METHODS: A consecutive series of CRC patients, treated and followed at a tertiary care center was performed. The clinical and pathologic variables and the risk of hereditary or familial cancer syndrome were retrieved. The original slides and hMLH1, hPMS2, hMSH2, hMSH6 immunohistochemistry were evaluated. Tumors with an absence of at least one protein were considered dMMR. Differences were contrasted, utilizing non-parametric tests. RESULTS: One hundred and forty-four patients were included, with a median age of 65 years. A total of 134/93% patients presented with sporadic CRC, 8/5.6% had a family history of CRC, and 2/1.4% met the diagnostic criteria for hereditary non-polyposis colon cancer, according to the Amsterdam and Bethesda criteria. dMMR tumors were found in 39 patients, distributed among the three groups. They were locally advanced (p<0.001), right-sided, had the mucinous phenotype, and harbored a Crohn's-like lymphoid reaction (all three features, p<0.04). Adjuvant or palliative chemotherapy was administered to 57 (39.6%), concomitant chemoradiotherapy to 24 (16.7%), but 63 (43.8%) patients received no additional treatment to surgery. Five-year follow-up was completed in 131 of the patients and the outcomes alive-with-disease or died-of-disease were more frequently observed in the proficient (pMMR) lesions. CONCLUSIONS: In the present pre-FOLFOX case series, outcomes were better in dMMR CRC than in proficient lesions.

Use of semiquantitative analysis in local recurrence of colorectal carcinoma with 18F-FDG PET/CT: A myth or a truth? / Uso de análisis semicuantitativo en la recidiva local del carcinoma colorrectal mediante PET/TC con 18F-FDG: ¿mito o realidad?

OBJECTIVE: Recurrence of colorectal cancer is mostly seen within the first 2 years after surgery. The most frequent site of recurrence is the postsurgical areas and its surroundings. The purpose of this study was to evaluate the usefulness of semiquantitative analysis of 18Fluorine fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in determining recurrence of colorectal carcinoma in the operation site. MATERIAL AND METHODS: Files of 35 patients with colorectal carcinoma (25 men, 10 women, mean age: 59.25±2.82 years, range: 27-80 years) who were treated with surgery and underwent FDG PET/CT scanning for restaging of colorectal carcinoma and showing increased FDG uptake in the postsurgical area, were retrospectively analysed. Besides calculating SUVmax of the areas showing FDG uptake, SUVmax of physiological colonic activity was also obtained and SUVmax of lesion/SUVmax of colonic wall (RSUVmax), was calculated. Characteristics of FDG uptake were classified according to histological analysis or clinical and imaging follow-up. RESULTS: In 17 of 35 patients (49%) the standard of reference for the final diagnosis was histologic analysis and in 18 (51%), final diagnosis was based on imaging and clinical follow-up. In 15 of 35 patients (43%) the etiology of increased FDG uptake was recurrence and in 20 (57%), FDG accumulation was observed due to benign etiology. The difference between the mean of the results of SUVmax in patients with recurrent disease and with no evidence of recurrence was statistically significant (P=.030). For SUVmax, a cut-off value for recurrence was calculated as 9.51 with a sensitivity of 80% and a specificity of 70%. In terms of RSUVmax results, a statistically significant difference was also observed between mean values in patients with recurrent disease and in those without (P=.002). ROC analysis demonstrated that the best predictive value of RSUVmax for recurrence was 1.75 with a sensitivity of 67% and specificity of 95%. CONCLUSIONS: Semiquantitative analysis of FDG PET/CT may be used in detecting recurrent disease of patients with colorectal carcinoma. Eliminating interfering physiological colonic activity in analysis may have an incremental effect on the success of this technique, by means of increasing the specificity.

Hepatitis autoinmune y cáncer de colon: una asociación inusual. Caso clínico y revisión de la literatura / A case of an unusual association of autoimmune hepatitis and colon cancer: report and literature review

Resumen Introducción: la hepatitis autoinmune idiopática (HAI) es una enfermedad crónica que predomina en mujeres, con episodios de actividad y remisión, favoreciendo la fibrosis hepática. El 40% de los pacientes presenta historia familiar de enfermedades autoinmunes. Al parecer, es mediada por la interacción antígeno-anticuerpo; sin embargo, su causa es desconocida. Se conoce la asociación frecuente de HAI con cáncer hepatobiliar; menos frecuente con linfomas, cáncer de piel y cáncer de colon; y casi inexistente con síndromes hereditarios de cáncer de colon. Este caso debutó con HAI y sangrado rectal causado por poliposis adenomatosa familiar (PAF) y adenocarcinoma de colon sigmoide. Caso clínico: mujer de 51 años con HAI de 1 año de evolución manejada con prednisolona y azatioprina. Se realizó una colonoscopia total por anemia en la que se encontraron múltiples pólipos entre 5 y 10 mm y 1 de 30 mm sésil, ulcerado, en colon sigmoide. Se realizó una polipectomía endoscópica múltiple que reportó un adenoma tubulovelloso con displasia de alto y bajo grado en varios pólipos y un adenocarcinoma de bajo grado en el pólipo del sigmoide. Los estudios de extensión fueron negativos para metástasis. Se realizó una repleción nutricional prequirúrgica, luego una colectomía subtotal y una procto-ileoanastomosis con ileostomía de protección. La patología de pieza quirúrgica mostró un adenocarcinoma de colon de bajo grado y adenomas tubulares y tubulovellosos con displasias de alto y bajo grado. Discusión y conclusiones: La asociación de HAI con PAF y cáncer colorrectal (CC) es infrecuente. Es conocida la correlación de HAI con cáncer hepatobiliar (asociado con cirrosis), linfomas, cáncer de piel y otros desórdenes autoinmunes. El pronóstico es malo y no puede establecerse una correlación clara con moduladores inmunes.

Abstract Introduction: Idiopathic autoimmune hepatitis (IAH) is a chronic disease that occurs predominately in women, has episodic activity and remission, and favors hepatic fibrosis. Forty percent of patients have family histories of autoimmune diseases. It is apparently mediated by antigen-antibody interaction, but its causes are unknown. IAH is frequently associated with hepatobiliary cancer, less frequently with lymphomas, skin cancer and colon cancer and very rarely with hereditary colon cancer syndrome. This case debuted IAH and rectal bleeding caused by familial adenomatous polyposis (FAP) and adenocarcinoma of the sigmoid colon. Clinical case: The patient was a 51-year-old woman who had had IAH for one year which had been managed with prednisolone and azathioprine. A total colonoscopy, performed because of anemia, found multiple polyps that measured 5 and 10 mm and one ulcerated 30 mm sessile polyp in the sigmoid colon. A multiple endoscopic polypectomy revealed a tubulovillous adenoma with high and low grade dysplasia in several polyps and a low grade adenocarcinoma in the sigmoid polyp. Tests and examinations for metastasis were negative. Following presurgical nutritional repletion, a subtotal colectomy was performed and an ileal pouch-anal anastomosis with protective ileostomy was created. The pathology of the surgical specimen showed low grade adenocarcinoma of the colon and tubular and tubulovillous adenomas with high and low grade dysplasia. Discussion and conclusions: Association of IAH with familial adenomatous polyposis (FAP) and colorectal cancer (CC) occurs infrequently although associations of IAH with hepatobiliary cancer associated with cirrhosis, lymphomas, skin cancer and other autoimmune disorders are well-known. The prognosis is bad and no clear correlation with immune modulators can be established.

Combined Hepatic and Pulmonary Metastasectomies From Colorectal Carcinoma. Data From the Prospective Spanish Registry 2008-2010.

INTRODUCTION: Resection of both liver and lung metastases from colorectal carcinoma (CRC) is a standard of care in selected patients with oligometastatic disease. We present here the analysis of the subgroup of patients undergoing combined surgery from the Spanish Group of Surgery of Pulmonary Metastases (PM) from Colorectal Carcinoma (GECMP-CCR-SEPAR). METHODS: We analyze characteristics, survival and prognostic factors of patients undergoing combined resection from March-2008 to February-2010 and followed-up during at least 3 years, from the prospective multicenter Spanish Registry. RESULTS: A total of 138 patients from a whole series of 543 cases from 32 thoracic surgery units underwent both procedures. Seventy-seven (43.8%) resected liver metastases were synchronic with colorectal tumor. Median disease specific survival (DSS) from first pulmonary metastasectomy was 48.9 months, being three and 5-year DSS 65.1% and 41.7%, respectively. From CRC-surgery median DSS was 97.2 months, with 3 and 5-year DSS rates of 96.7% and 77%, respectively. Five-year DSS from pulmonary metastasectomy was 41.7% for patients with combined resection and 52.4% for those without hepatic involvement (P=.04). Differences disappeared when considering DSS from colorectal surgery. Carcinoembrionary antigen (CEA) before lung surgery over 10mg/dl and bilateral PM were independent prognostic factors for survival (hazard ratio 2.4 and 2.5, respectively). CONCLUSIONS: Patients with resection of PM of CRC with history of resected hepatic metastases presented significantly lower disease specific survival rates than those undergoing pulmonary metastasectomy alone. CEA before lung surgery and bilateral PM associated worse prognosis.

Riesgo aumentado de lesiones colónicas preneoplásicas en acromegalia: estudio multicéntrico caso control. Resultados preliminares / Increased risk of pre-cancerous bowel lesions in acromegaly: Multicentre case-control study. Preliminary results

Introducción: El riesgo de desarrollar neoplasias colónicas en pacientes acromegálicos y su relación directa con los niveles elevados de GH/IGF-1 no están bien establecidos y continúan siendo motivo de controversia en la literatura mundial. El objetivo de este trabajo fue evaluar el riesgo de desarrollar lesiones neoplásicas avanzadas (LNA) (adenomas mayores a 1 cm, componente velloso mayor del 75% y/o displasia de alto grado), en pacientes con acromegalia, comparado con un grupo control. Materiales y métodos: Estudio multicéntrico caso-control retrospectivo. Ciento treinta y siete pacientes con acromegalia que realizaron videocolonoscopia (VCC) fueron incluidos inicialmente, aunque solo 69 cumplieron criterios de inclusión. Sesenta y dos controles fueron obtenidos: por cada caso (paciente con acromegalia) 2 «controles¼ fueron seleccionados aleatorizadamente e igualados por edad y sexo. El riesgo se expresó en odds ratio (OR) y su correspondiente intervalo de confianza (IC) del 95%. La significación estadística fue considerada una p < 0,05. Resultados: De los 69 pacientes con VCC completa y datos adecuados para su análisis, 28 presentaron VCC positiva con hallazgos de pólipos (40%) y 41 VCC negativa o normal (60%). Dentro del grupo con VCC positiva, 14 presentaron LNA (20%) y solo un paciente presentó diagnóstico de cáncer colorrectal. Para el análisis caso-control se incluyó a 31 pacientes frente al grupo control (n = 62) que cumplieron con los criterios de inclusión. La presencia de pólipos colónicos, adenomas y LNA en los pacientes con acromegalia fue de 19/31 (61,9%), 14/31 (45,16%) y 10/31 (32,25%), y en el grupo control de 18/62 (29,03%), 11/62 (17,74%) y 4/62 (6,45%), respectivamente. El riesgo de adenomas y LNA fue mayor en el grupo de acromegalia en comparación con el grupo control, siendo ambos resultados estadísticamente significativos: adenomas OR 2,54 (IC 1,22-5,25) p = 0,005, LNA OR: 7,3 (2,4-25), p = 0,00. Conclusión: La acromegalia se asocia a un mayor riesgo de lesiones colónicas preneoplásicas. Este hallazgo justifica el cribado con VCC al diagnóstico en pacientes con acromegalia.

Background: The risk of developing cancerous lesions in the colon of acromegaly patients and their direct relationship with elevated growth hormone (GH) and insulin-like growth factor-1 (IGF-1) levels is not well established, and is still controversial in the international literature. The objective of this study was to evaluate the risk of developing advanced neoplastic lesions (ALN: greater than 1 cm adenomas, villous component greater than 75% and/or high grade dysplasia) in patients with acromegaly compared to a control group. Materials and methods: A multicentre, retrospective case-control study was conducted initially on 137 patients with acromegaly (cases) who underwent videocolonoscopy (VCC), although only 69 met inclusion criteria. Sixty-two controls were obtained, and for each case two "controls" were randomly selected and matched by age and gender. Risk was expressed as odds ratio (OR) and its corresponding 95% con"dence interval (CI). P values < .05 were considered statistical significantly. Results: Of the 69 acromegaly patients with a completed VCC and adequate data for their analysis, 28 had a positive VCC with findings of polyps (40%), and 41 VCC negative with no lesions (60%). Within the group with positive VCC, 14 were ALN (20%) and one a colorectal cancer. In the case-control analysis, 31 cases were to be analysed against the control group (n = 62). The presence of colonic polyps, adenomas, and ALN in patients with acromegaly was 19/31 (61.9%), 14/31 (45.16%), and 10/31 (32.25%), respectively, and in the control group, it was 18/62 (29.03%), 11/62 (17.74%), and 4/62 (6.45%), respectively. The risk of adenomas and ALN was higher in the acromegaly group compared to the control group: adenomas OR: 2.54 (95% CI 1.22-5.25) P=.005, ALN OR: 7.3 (2.4-25) P=.00. Conclusion: This preliminary case control study showed an increased risk of pre-cancerous colprectal lesions in patients with acromegaly, supporting the VCC screening at diagnosis.

Colitis ulcerosa y su relación con el desarrollo de carcinoma colorrectal / Ulcerous colitis and its relationship with the development of carcinoma

Se presentó un caso de un paciente con colitis ulcerativa de varios años de evolución con un cuadro de oclusión intestinal por un adenocarcinoma de colon izquierdo. Durante el acto quirúrgico se constató la presencia de una tumoración en el ángulo esplénico del colon. Se realizó hemicolectomía izquierda con colostomía tipo Hartman(AU)

A case of a patient with ulcerative colitis is presented with several years of evolution with a picture of intestinal occlusion by a left colon adenocarcinoma. During the surgery, a tumor was observed in the splenic angle of the colon. Left hemicolectomy was done with Hartman type colostomy

Metástasis hepática sincrónica de cáncer colorrectal / Synchronous liver metastases of colorectal cancer

El cáncer colorrectal representa 9,7% de todos los cánceres con 1,4 millones de nuevos casos diagnosticados cada año en el mundo 19-31% de los pacientes desarrollan metástasis hepáticas de cáncer colorrectal y 23-38% desarrollan enfermedad extrahepática1 15-25% se presentarán de forma sincrónica y 25-40% serán metacrónicas2.La resección quirúrgica es el único tratamiento potencial-mente curativo, en el caso de las metástasis sincrónicas, se debate si se deben resecar simultáneamente, antes o después del tumor primario.

Colorectal cancer (CRC) accounts for 9.7% of all cancers with 1.4 million new cases diagnosed each year. 19–31% of CRC patients develop colorectal liver metastases, and 23–38% develop extra-hepatic disease1 . 15-25% will be presented synchronously and 25-40% will metachronously2 . Surgical resection is the only potentially curative treatment and, in the case of synchronous metastases, the debate is whether to resect simultaneously, before or after the primary tumor.

Aetiology and prevalence of post-colonoscopy colorrectal cancer. / Etiología y prevalencia de los cánceres colorrectales poscolonoscopia.

BACKGROUND: Colonoscopy is the gold standard for the detection and prevention of colorectal cancer (CRC). However, some individuals are diagnosed with CRC soon after a previous colonoscopy. AIMS: To evaluate the rate of new onset or missed CRC after a previous colonoscopy and to study potential risk factors. METHODS: Patients in our endoscopy database diagnosed with CRC from March 2004 to September 2011 were identified, selecting those with a colonoscopy performed within the previous 5years. Medical records included age, gender, comorbidities and colonoscopy indication. Tumour characteristics studied were localization, size, histological grade and TNM stage and possible cause. These patients were compared with those diagnosed with CRC at their first endoscopy (sporadic CRC-control group). RESULTS: A total of 712 patients with CRC were included; 24 patients (3.6%) had undergone colonoscopy within the previous 5 years (50% male, 50% female, mean age 72). Post-colonoscopy CRCs were attributed to: 1 (4.2%) incomplete colonoscopy, 4 (16.6%) incomplete polyp removal, 1 (4.2%) failed biopsy, 8 (33.3%) 'missed lesions' and 10 (41.7%) new onset CRC. Post-colonoscopy CRCs were smaller in size than sporadic CRCs (3.2cm vs. 4.5cm, P<.001) and were mainly located in the proximal colon (63% vs. 35%, P=.006); no difference in histological grade was found (P=.125), although there was a tendency towards a lower TNM stage (P=.053). CONCLUSIONS: There is a minor risk of CRC development after a previous colonoscopy (3.6%). Most of these (58.4%) are due to preventable factors. Post-colonoscopy CRCs were smaller and mainly right-sided, with a tendency towards an earlier TNM stage.

Metástasis esplénica solitaria en una paciente con adenocarcinoma colorrectal / Splenic metastases secondary to colorrectal carcinoma

Introduction: Splenic metastases are unusual, arising in less than 1 percent of all metastases. Splenic metastases from colorrectal carcinoma is considered excepcional. If present, they generally occur in concert with disseminated disease. Case report: We present a case of 78 year old man operated of colon tumor by right hemicolectomy. Nine months after first surgical, CT scan showed metastases in spleen, splenectomy was performed.

Introducción: Las metástasis esplénicas son inusuales, representando menos del 1 por ciento de todas las metástasis. Que este tipo de localización secundaria sea ocasionado por carcinomas colorrectales puede considerarse como algo excepcional. Cuando se presentan generalmente lo hacen en el contexto de una enfermedad diseminada. Caso clínico: Presentamos el caso de un varón de 78 años de edad que fue intervenido de un carcinoma colorrectal mediante hemicolectomía derecha. nueve meses después de la primera cirugía el escáner muestra metástasis en el bazo, por lo que se realizó una esplenectomía.

Efficacy and complications in the use of self-expanding colonic stents: an analysis of 15 years' experience.

OBJECTIVE: To analyze the efficacy and safety of the procedure for placing self-expanding stents in the colon. To evaluate the factors associated with complications. To analyze the dose of radiation delivered in the procedure. MATERIAL AND METHODS: This was a retrospective descriptive study of 478 procedures done at a single center to place self-expanding metallic stents in the colon. A total of 423 nitinol stents and 79 stainless steel stents were placed. We included all colonic obstructions, of which 446 had malignant causes and 8 had benign causes. We excluded patients with intestinal perforation, severe colonic bleeding, short life expectancy, or lesions located less than 5 cm from the anus. We collected the dosimetric data and analyzed the technical success, clinical success, and complications during follow-up. RESULTS: The procedure was a technical success in 92.26% of cases (n=441) and a clinical success in 78.45% (n=375); complications occurred during follow-up in 18.5% of cases. Complications occurred more frequently with the stainless steel stents than with the nitinol stents (OR: 3.2; 95% CI: 1.8-5.7). The mean value of the dose area product was 35 Gy*cm(2). When instead of being done by the interventional radiologist working together with an endoscopist the procedure was done exclusively by the interventional radiologist, the time under fluoroscopy (p=0.001), dose area product (p=0.029), and kinetic energy released per unit mass (p=0.001) were greater. CONCLUSION: The procedure for placing self-expanding colonic stents is efficacious and safe with an acceptable rate of complications. The doses of radiation delivered were low, and the radiation doses and time under fluoroscopy were lower when the procedure was done together with an endoscopist.

Cambios en la distribución de la frecuencia topográfica del carcinoma colorrectal. Análisis de los últimos 10 años / Changes on topographic location of colorectal cancer. Review of 10 years experience

Antecedentes: En las últimas décadas se han referido cambios en la distribución topográfica del carcinoma colorrectal (CCR) con un aumento del mismo en los segmentos proximales y una disminución en los distales. Objetivos: Determinar la distribución topográfica actual del CCR y comparar un grupo actual (1996-2006) con otro anterior (1979-1989) y con la bibliografia. Lugar de aplicación: Medio sanatorial de la Ciudad de Buenos Aires. Población y Métodos: Estudio retrospectivo de dos grupos de pacientes. El primero está constituido por 636 enfermos, 344 (54 por ciento) hombres y 292 (46 por cientos) mujeres con una mediana de edad de 66 años y rango de 28 a 89 (Grupo I). Para comparar se utilizó un grupo anterior constituido por 371 pacientes, operados entre 1979 y 1989 (Grupo II) integrado por 210 (57 por ciento) mujeres y 161 (43 por ciento) hombres con una mediana de edad de 72 años con rango de 28 a 96. Para la comparación de ambos grupos se utilizó la prueba de Chi Cuadrado. Se consideró p = 0.05. Resultados: Con cáncer en el colon proximal en el Grupo I hubieron 258 (55 por ciento) pacientes mientras que en el Grupo II fueron 128 (35 por ciento). Y en el colon distal fueron 206 (45 por ciento) pacientes en el Grupo I, con respecto a 243 (65 por ciento) pacientes en el Grupo II. Esto muestra una diferencia estadísticamente significativa con una p = 0.00 y demuestra un predominio en la última década de un 10 por ciento a favor de los carcinomas del colon derecho con respecto al izquierdo y de un 20 por ciento cuando se correlacionan ambos grupos. Para el recto los resultados de esta serie comparados con la bibliografía Argentina muestra una disminución del 13 por ciento en la incidencia. Conclusiones: Los resultados de éste trabajo concuerdan con la mayoría de la bibliografía en cuanto que hay un aumento del carcinoma del colon derecho y una disminución del izquierdo...

Background: In last decades changes in the distribution of colorectal cancer (CRC) has been described, with an increase in the proximal and a decrease in the distal location. Objectives: To determine the current anatomic distribution of CRC, and to compare a current group (1996-2006) with a previous group (1979-1989), and with the bibliography. Setting: Private practice Clinic in Buenos Aires. Patients and Methods: Retrospective study of two groups of patients. Group I: 636 patients, 344 (54 per cent) males and 292 (46 per cent) females, median age: 66 (range, 28-89) years. Group II: 371 patients, operated on betweeen 1979 and 1989, 210 (57 per cent) females and 161 (43 per cent) males, median age: 72 (range, 28-96) years. To compare both groups Chi square test were used. P < 0.05 was considered significant. Results: In the proximal segment of Group I there were 258 (55 per cent) patients, while in Group II were 128 (35 per cent). In the distal colon there were 206 (45 per cent) patients in Group I, and 243 (65 per cent) in Group II (P = 0.00). That distribution shows in the last decade a 10 per cent predominance of right colon carcinomas, compared to left carcinomas, and a 20 per cent when both groups correlate. Rectal carcinomas showed a 13 per cent decrease of incidence comparing to that of the Argentine bibliography. Conclusions: The results of this study agree with most authors in the bibliography with regard to an increase in right colon and a decrease in left colon cancer. Furthermore, it shows a decrease in the incidence of rectal cancer comparing to historical series. Probably, the causes are related to changes in the diet, hormonal factors, and sedentary lifestyle. The practical importance of this change in colon cancer is to reaffirm the need for using methods of screening the whole colon, and not only the distal part of it.