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.

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.

[A comparative study on the prognostic value of the nuclear expression of protein p53 vis-à-vis histopathology in colorectal cancer]

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.

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.

[Intestinal fistula in Crohn disease]

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.