Clinical, histopathological, cytogenetic and prognostic differences between mucinous and nonmucinous colorectal adenocarcinomas.

OBJECTIVE: To assess the clinical and biological significance of histological typing of colorectal carcinomas. PATIENTS AND METHODS: The retrospective analysis of 142 consecutive patients who underwent surgical resection of a mucinous (MC; n = 27; 19%) or a nonmucinous (nMC; n = 115; 81%) colorectal adenocarcinoma was carried out. The two groups were compared in terms of the clinical features, p53 gene expression (antiserum CM1), proliferating cell nuclear antigen (PCNA) labeling index, DNA ploidy (by flow cytometry), histopathological features, prognosis and recurrence rate. RESULTS: The two types of tumors differed with respect to patient age, location, morphology, pattern of genetic lesions and type of tumor recurrences. Twenty-five percent of the patients with MC and 9% of those with nMC (p = 0.04) were under 50 years of age. The incidences of right MC and left MC were similar, while the majority of the nMC were located on the left side (p = 0.04). The MC were of higher grade and their margins more infiltrative than those of the nMC (p = 0.001 and p = 0.01, respectively), p53 nuclear staining was observed less frequently in the MC than in the nMC (30% vs 55%; p = 0.03). The PCNA labeling index was higher in the nMC (46% vs 21%; p = 0.05). We observed no significant differences with respect to tumor stage, incidence of vascular invasion or prevalence of lymphocytic infiltration. The prognosis was similar in both groups, although their recurrence patterns differed, with a tendency toward locoregional recurrence in the cases of MC. CONCLUSION: These findings suggest that, despite their similar prognoses, these two types of lesions are epidemiologically, phenotypically and genotypically different and, thus, result from distinct carcinogenic pathways.

Histopathologic prognostic score in colorectal adenocarcinomas.

OBJECTIVE: To analyze the prognostic value of a set of pathological variables after curative resection for large bowel adenocarcinoma and to test a prognostic score derived from factors with independent effect. PATIENTS AND METHODS: The study is based on data from 292 consecutive unselected patients (B-C Astler-Coller stages). Histopathological features were evaluated prospectively on the resected primary tumors. Relationship between these factors and risk of recurrence was assessed by a Cox's proportional regression analysis. RESULTS: Four variables retained independent prognostic significance: extent of bowel wall invasion, peritumoral lymphocytic infiltration, number of positive nodes and vascular invasion. A prognostic score based on the regression coefficients attained by such variables was developed. This system revealed four prognostic groups. Group I included 14% of patients, with 94% 5-year disease-free survival. These figures were: 35% and 60% in group II; 43% and 46% in group III; and 7% and 24.4% in group IV. Histopathologic score applied to bearers of Astler-Coller B2 tumors permitted the identification of two populations, one characterized by a low risk of relapse and another with high risk (p = 0.002). CONCLUSION: A prognostic score based in the evaluation of four histopathologic parameters concerning the tumor phenotype enables the identification of groups of patients at risk of relapse after curative resection for colorectal adenocarcinoma.

Pouch excision for recurrent serrated adenomas following restorative proctocolectomy for juvenile polyposis: report of a case.

PURPOSE: The study contained herein was undertaken to report the case of a patient with juvenile polyposis in whom multiple and rapid recurrence of mixed polyps, with progressive predominance of the adenomatous component, developed in a diverted ileoanal pouch. METHODS: The case of this patient with juvenile polyposis was reviewed. Despite regular surveillance and polypectomies, extensive and multiple recurrences of serrated polyps developed. RESULTS: Because the pouch was never cleared of polyps, a compromise to remove the pouch was decided on. Such a case has not been reported previously. CONCLUSION: Mixed juvenile polyposis may affect any level of the gastrointestinal tract. The ileal pouch and any rectal remnant may incidentally need surgical excision.

Bilateral gluteoplasty for fecal incontinence.

PURPOSE: This study describes our clinical experience with adynamic bilateral gluteoplasty in 20 patients with total fecal incontinence, in whom a sphincter repair had failed (n = 17) or was nonviable. METHODS: Between 1986 and 1995, 12 women and 8 men ranging in age from 15 to 58 (mean, 37) years underwent different techniques of adynamic gluteoplasty. The indications for the operation were congenital anomalies, denervation, or sphincter destruction. Postoperative evaluation was clinical (Pescatori grading; self-evaluation) and manometric. RESULTS: Morbidity was only related to wound infection (n = 7) requiring late reoperations for neosphincter repair (n = 5), anal stenosis (n = 2), and incisional hernia after colostomy closure (n = 1). Two other patients with no complications also had further surgery for tightening of the neosphincter; they had a successful outcome. Of the 17 evaluable patients, 9 (53 percent) achieved normal control or were graded as Pescatori A-1, A-2, B-1, or C-1, 1 (6 percent) as Pescatori C-2, and 7 (41 percent) as Pescatori C-3. Six patients (35 percent) judged their results as excellent, three (18 percent) as good, one (6 percent) as fair, and seven (41 percent) as bad. Eight patients are able to retain 200 ml of water instilled into the rectum for between five minutes and two hours. For the nine patients with better results, the mean +/- standard deviation of the differences between postgluteoplasty and pregluteoplasty anal pressures were 40 +/- 25 mmHg (resting pressure) and 122 +/- 85 mmHg (squeeze pressure). These findings demonstrate a tonic and voluntary activity of the plasty. The author's technique has less morbidity, and excellent or good results were achieved in 67 percent of the patients. Failures were attributable to suture disruption (n = 4), poor muscular contraction (n = 2), and intractable constipation (n = 1). CONCLUSIONS: Adynamic gluteoplasty is efficient for achieving good or very good continence status in a higher proportion of patients than with other adynamic muscle transfer procedures.

Evaluation of serum carcinoembryonic antigen monitoring in the follow-up of colorectal cancer patients with metastatic lymph nodes and a normal preoperative serum level.

The value of serial serum carcinoembryonic antigen (CEA) assay in the follow-up of colorectal cancer patients with metastatic lymph nodes and normal (< or = 5 ng/ml) preoperative CEA levels, was examined in this study. Thirty-eight patients were studied and compared with 22 patients with elevated CEA levels. The overall sensitivity of CEA for the diagnosis of recurrence was 36%. Postoperative CEA was strongly influenced by the site of recurrence. CEA monitoring showed the best results in patients who developed hepatic metastases (sensitivity 60%, specificity 94%, positive predictive value 60%, and negative predictive value 94%), and was ineffective for the detection of locoregional or pulmonary metastases. The results indicate that elevation of CEA in the postoperative course of these patients is an indicator of the presence of hepatic metastases. Postoperative CEA monitoring should not be omitted in Dukes C patients with normal preoperative levels, and is more reliable for the detection of liver metastases.

[A comparative study on the prognostic value of the nuclear expression of protein p53 vis-à-vis histopathology in colorectal cancer]. / Estudio comparativo sobre el valor predictivo de la expresión nuclear de la proteína p53 frente a la histopatología en el cáncer colorrectal.

OBJECTIVE: To determine the predictive value of p53 nuclear overexpression in comparison with established prognostic pathological features in colorectal adenocarcinoma. PATIENTS AND METHODS: 61 patients operated on for cure between January 1989 an December 1991 were included. Expression of p53 protein was examined by immunohistochemistry in paraffin-embedded sections. Tumor localization, depth of bowel wall involvement, lymph nodes metastasis, vascular invasion and PCNA Labelling index were studied in all patients. RESULTS: Nuclear staining was detected in 27 (44.2%) cases. Positivity was more frequent in tumors with venous invasion and in rectal cancer. p53-positive tumours exhibited a higher likelihood of relapse and lower survival. After adjustment for the other covariates, p53 overexpression was the only factor showing independent prognostic significance on the risk of recurrence. None of the factors analysed evinced independent significant relationship with the risk of death. CONCLUSION: Nuclear p53 protein overexpression is closely related to the development of postoperative recurrences and has higher predictive value than standard pathological variables.

Prediction of recurrence in B-C stages of colorectal cancer by p53 nuclear overexpression in comparison with standard pathological features.

This study investigated the predictive value of p53 nuclear overexpression on recurrence of colorectal adenocarcinomas compared with established prognostic pathological features. Sixty-one paraffin-embedded sections from primary tumours were examined by immunohistochemistry. Specific nuclear staining was detected in 27 (44.2%) cases. Positivity was more frequent in tumours with venous invasion (76.9%) (P = 0.06) and in rectal cancer (68.4%) (P = 0.06). After a median observation time of 46 months, p53-positive tumours exhibited a higher percentage of recurrence (40.7% vs 11.7%) (P = 0.03), and a higher likelihood of relapse at 5-year follow-up (46% vs 13%) (P = 0.006). Among the pathological variables analysed, only the extent of bowel wall invasion showed a relationship with recurrence. After adjustment for the other covariates in a Cox's regression model, p53 overexpression was the only factor showing independent prognostic significance (hazard ratio: 4.96; 95% Confidence Interval (CI): 1.47-16.71) (P = 0.012). The results of this study show that nuclear p53 protein overexpression has higher predictive value than standard pathological variables.

[The ultrashort bowel syndrome: the surgical treatment of an exceptional case]. / Síndrome de intestino ultracorto: tratamiento quirúrgico de un caso excepcional.

An exceptional case of a 16-year-old boy who accidentally lost all of the small bowel (except the proximal 5 cm. of jejunum), and also 10 cm of transverse colon and a small part of the middle and upper rectum, is presented. After suffering severe medical complications derived from prolonged and uninterrupted total parenteral nutrition for more than one year, with no oral intake except fluids, the patient underwent intestinal lengthening of all the residual bowel up to the sigmoid colon, with antiperistaltic anastomosis and sigmoid J pouch with myotomy. Several months after the operation the patient returned to his normal activities and is fed with a free-diet, complemented or not with nocturnal enteral and parenteral feeding, depending on the circumstances and weight variations. Lengthening of the large bowel together with the rest of surgical gestures here performed has not been published previously.

Total fecal incontinence--a new method of gluteus maximus transposition: preliminary results and report of previous experience with similar procedures.

Since 1986, different procedures of gluteus maximus transposition have been performed, by one of the authors, in 10 patients with total anal incontinence not amenable to sphincter repair, due to congenital anomalies (four), sphincteric denervation (three) or after severe trauma (three). Variable degrees of long-lasting fecal control were obtained in all but one patient, with great improvement in six. Difficulties for achieving a closed anus without muscular tension of the neosphincter, together with the morbidity associated with anal wound infection, determined the reasons for the successive use of different techniques (Biström, Hentz, Schoamaker) until the authors, in 1990, designed a new procedure (Devesa). Although the reported experience with this technique described here is limited to only four patients, our impression is that the method is easier, has less morbidity, and achieves better short-term functional results, derived from a thick, tension-free neosphincter.

Value of follow-up in the management of recurrent colorectal cancer.

The purpose of this article was to study the effectiveness of a prospective follow-up programme in patients after curative surgery for colorectal cancer. Of the initial 151 selected patients, 61 (40%) developed a recurrence in whom only six cases (10%) of potentially curable recurrent lesions were detected. The first clues to recurrence in the 61 patients were history or physical examination in 49%, a rising CEA in 29% and a positive imaging finding in 10%, being difficult to decide which test first signalled a recurrent cancer in an additional 11%. Endoscopy and CEA determinations were the most rewarding investigations. CEA was a sensitive means of identifying disseminated recurrent disease and liver metastases compared with liver function tests or liver ultrasound every 3 months. Endoscopy was useful in the diagnosis of local recurrences. However no follow-up test was capable of detecting recurrent colorectal cancer when it might still have been curable. As a direct result of this follow-up programme 15 patients (23%) underwent re-exploration. No symptomatic patients were candidates for curative re-operation. Of the asymptomatic patients six (four colonic and two rectal cancers) (19.5%) were re-resected for cure. Only three of these were alive and without evidence of disease, 40, 43 and 69 months later so that long term survivors after curative re-resection represent only 5% of all patients with recurrences (7.2% of the recurrent colonic cancer and 3% of the rectal cancer). Our follow-up programme did not permit us to alter the incidence of disseminated recurrent disease, and the effectiveness of the curative re-resection represents an increase of only 1.3% in the global 5-year survival rates for colorectal cancer. Our study does not demonstrate any great value of 'classical' postoperative follow-up programme.

[Intestinal fistula in Crohn disease]. / Fístulas intestinales en la enfermedad de Crohn.

The treatment of patients with Crohn's disease (CD) presenting intestinal fistulas is debated. A retrospective analysis was made of the treatment of 26 patients with Crohn's disease who had a total of 37 fistulas: 28 internal and 9 external. In 19 patients the fistulas were single and in 7 multiple; in most patients the fistula originated on the terminal ileum. Crohn's disease was ileal in 10 patients, ileocolonic in 15 and exclusively colonic in 1, and the evolution of the disease from the onset of symptoms to the appearance of the fistula was a mean of 5.8 years. The diagnosis, except for two patients in whom it was an operative finding, was based on the clinical examination and radiology studies. All the patients, except for four with asymptomatic internal fistulas, underwent medical treatment as needed. Six patients required only medical treatment, and the rest, 16, received medical and surgical treatment. Surgical treatment consisted basically of resection of the intestinal segment affected by the fistula, with or without anastomosis. The operative mortality was 0% and the morbidity was 25%, the most frequent complication being infection of the surgical wound. All the patients with external fistulas required surgical treatment. In every case the fistula was single. The treatment of internal fistulas in conditioned by the symptoms the response to medical treatment and the presence or not of associated pathology. Asymptomatic patients or those who responded to medical treatment had single fistulas.

Colorectal cancer. The bases for a comprehensive follow-up.

The purpose of this article was to review the effectiveness of follow-up in patients with colorectal cancer submitted to curative treatment. A comprehensive follow-up involves rational initial management of the primary tumor, knowledge of prognostic factors, selection of the patient to be followed, determination of the time for follow-up, use of the most appropriate tests for early diagnosis of recurrence, and eventual curative treatment. The updated answers to all these questions are given through an extensive review of the world literature and confronted with the authors' experience of eight years of follow-up in a series of 170 colorectal cancer patients treated for cure. Although the future might be more promising, past world experience suggests only a few patients could be saved. It is concluded that there is no place for incomplete and disperse screening tests, and only comprehensive, intensive, and very well-coordinated follow-up programs should be undertaken if better results are hoped to be achieved.