Identification of potential urinary protein biomarkers in colorectal cancer: a pilot study using a proteomic approach

Colorectal cancer (CRC) is among the most diagnosed malignancies worldwide, and it is also the second leading cause of cancer-related deaths. Despite recent progress in screening programs, noninvasive accurate biomarkers are still needed in the CRC field. In this study, we evaluated and compared the urinary proteomic profiles of patients with colorectal adenocarcinoma and patients without cancer, aiming to identify potential biomarker proteins. Urine samples were collected from 9 patients with CRC and 9 patients with normal colonoscopy results. Mass spectrometry (label-free LC—MS/MS) was used to characterize the proteomic profile of the groups. Ten proteins that were differentially regulated were identified between patients in the experimental group and in the control group, with statistical significance with a p value ≤ 0.05. The only protein that presented upregulation in the CRC group was beta-2-microglobulin (B2M). Subsequent studies are needed to evaluate patients through different analysis approaches to independently verify and validate these biomarker candidates in a larger cohort sample. (AU)

Lipoma de recto prolapsado e incarcerado: caso clínico y análisis de la literatura / Prolapsed and incarcerated rectal lipoma: case report and literature review / Prolapso e encarceramento de lipoma do reto: caso clínico e análise da literatura

Los lipomas colónicos son tumores benignos poco frecuentes, extremadamente raros a nivel rectal. A pesar de ello, ocupan el segundo lugar en frecuencia detrás de los pólipos adenomatosos. Aunque la mayoría de los lipomas colorrectales son asintomáticos y se descubren incidentalmente, en ocasiones pueden ser sintomáticos y determinar complicaciones agudas que requieren tratamiento quirúrgico de urgencia. Estas formas de presentación pueden confundirse con las del cáncer colorrectal, constituyendo un desafío diagnóstico y terapéutico. Presentamos el caso de una paciente que consultó en emergencia por una gran masa dolorosa de aparición aguda a nivel del ano, resultando ser un lipoma rectal prolapsado a través del canal anal.

Colonic lipomas are infrequent benign tumors, extremely rare at the rectum. Nevertheless, they follow in frequency polyp adenomas. Even though most colorectal lipomas are asymptomatic and incidental, they can occasionally be symptomatic and develop acute complications that require urgent surgical treatment. This form of presentation can be confounded with colorectal cancer, therefore impairing diagnosis and treatment. We present the case of a female patient who came to the emergency room with an acute painful mass through the anus, that resulted in a prolapsed rectal lipoma.

Os lipomas colônicos são tumores benignos pouco frequentes, extremamente raros no nível retal. Apesar disso, ocupam o segundo lugar em frequência atrás dos pólipos adenomatosos. Embora a maioria dos lipomas colorretais sejam assintomáticos e descobertos incidentalmente, às vezes eles podem ser sintomáticos e levar a complicações agudas que requerem tratamento cirúrgico de emergência. Essas formas de apresentação podem ser confundidas com as do câncer colorretal, constituindo um desafio diagnóstico e terapêutico. Apresentamos o caso de um paciente que consultou na sala de emergência por uma grande massa dolorosa de início agudo ao nível do ânus, que acabou por ser um lipoma retal prolapsado pelo canal anal.

Estudo randomizado, aberto, utilizando protetor cutâneo em spray à base de terpolímero acrílico versus hidratante padrão na prevenção de radiodermatite aguda em pacientes com câncer de canal anal e reto / An open randomized study using a skin protector spray made of acrylic terpolymers versus and standardized moisturizer in preventing acute radiodermatitis in patients with anal and rectal cancer

Pacientes com câncer de canal anal e reto em tratamento por radioterapia apresentam alta prevalência de radiodermatite com descamação úmida, desfecho que causa impactos clínicos, econômicos e sociais. Estudos sobre a efetividade de produtos na prevenção das radiodermatites representam uma lacuna de conhecimento na área oncológica, podendo o seu desenvolvimento contribuir para a diminuição dos impactos negativos desse evento, do tempo ocioso do equipamento pela interrupção do tratamento e da possibilidade de falha local da doença. Objetivou-se analisar a efetividade do protetor cutâneo em spray à base de terpolímero acrílico na prevenção da radiodermatite com descamação úmida nos pacientes com câncer de canal anal e reto em comparação com um hidratante padronizado na instituição à base de Calendula officinalis L. e Aloe barbadensis. Ensaio clínico randomizado, aberto, em instituição única, referência nacional no tratamento de doenças oncológicas, com amostra 63 pacientes que foram randomizados nos grupos: experimental, com uso do protetor cutâneo em spray, e controle, usando o hidratante Dnativ Revita Derm. Os pacientes foram acompanhados na consulta de enfermagem, com cegamento do avaliador da pele quanto ao uso da intervenção. A escala de avaliação de pele utilizada foi a da Radiation Therapy Oncology Group. A coleta de dados ocorreu por meio dos formulários de avaliação inicial e subsequente, sendo o desfecho principal medido a ocorrência de radiodermatite com descamação úmida, e os secundários a ocorrência de interrupção temporária da radioterapia por radiodermatite, de eventos adversos aos produtos e de severidade da radiodermatite. As análises se deram por Intenção de Tratar e Protocolo, sendo utilizadas as estatísticas descritiva, analítica e inferenciais no tratamento dos dados, com nível de significância de ≤ 0,10. Pesquisa aprovada pelo Comitê de Ética sob parecer nº 5.322.985 e registrado no Clinical Trials sob número: NCT04067310T. A regressão logística binária mostrou que os participantes expostos ao protetor cutâneo em spray tiveram menor chance de apresentar a radiodermatite com descamação úmida quando comparados ao grupo controle. A redução absoluta do risco de radiodermatite foi de 18% no grupo experimental. A incidência geral de radiodermatite foi de 100%, sendo 36,5% graus mais severos. A incidência de radiodermatite Grau 1 foi maior no grupo experimental, enquanto os graus mais severos (Graus 3 e 4) tiveram maior incidência no grupo controle; 17,5% dos participantes tiveram interrupção da radioterapia por radiodermatite, variando de 3 a 15 dias, com média de seis dias interrompidos. Apesar de relevantes clinicamente, esses resultados sobre a interrupção temporária do tratamento e a severidade da radiodermatite não tiveram significância estatística. Foram considerados fatores de risco para a descamação úmida: sexo feminino, diagnóstico C.21 e C.21.8, altas doses de radioterapia (5400-6000cGy), tipo histológico carcinoma espinocelular, umidade antes e durante a radioterapia e uso de proteção íntima. Concluiu-se que o protetor cutâneo em spray é um produto efetivo na prevenção da radiodermatite com descamação úmida nos pacientes com câncer de canal anal e reto, afirmação que sustenta a tese defendida. Nesse sentido, os resultados podem orientar a revisão dos protocolos assistenciais de prevenção da radiodermatite utilizados pelo enfermeiro no âmbito da consulta de enfermagem em radioterapia, com vistas a reduzir os impactos no seguimento terapêutico e na qualidade de vida dos pacientes com câncer de canal anal e reto.

Patients' ongoing anal and rectal cancer radiotherapy exhibit a high prevalence of radiodermatitis with moist desquamation, impairing clinical, economic, and social outcomes. Clinical trials targeting product efficacy in preventing radiodermatitis are lacking in the current literature. These products could contribute to diminishing adverse effects, reducing equipment idle time by therapy interruption, and increasing the cure rate. Our goal is to evaluate the effectiveness of cutaneous spray based on acrylic terpolymers in preventing radiodermatitis with moist desquamation in patients with rectal or anal cancer. Spray effectiveness was defied against a standardized moisturizer in the institution made of Calendula officinalis L. and Aloe barbadensis extracts. An open, single-blind, randomized clinical study was conducted in a single institution, reference in national treatment in oncological diseases, with a sample size (n) of 63 patients. Patients were randomized into two groups: (i) experimental, using cutaneous protector spray; and (ii) control, using moisturizer Dnativ Revita Derm. RTOC's scale was used for evaluating skin condition. Data was collected in forms, which considered: (i) the primary outcome of radiodermatitis with moist desquamation occurrence; and (ii) the secondary outcome of radiotherapy interruption caused by radiodermatitis occurrence and severity, and product adverse effects. Analyses were performed by intention to treat and per protocol, using descriptive, analytical, and inferential statistics, with a significance level of ≤ 0.10 (α). Research was approved by the Ethics committee under approval nº 5.322.985 and registered in Clinical Trials under number NCT04067310T. Binary logistic regression demonstrated that patients exposed to cutaneous spray protector were less prone to develop radiodermatitis with moist desquamation compared to the control group. Absolute reduction in radiodermatitis risk was 18% in the experimental group. The radiodermatitis overall incidence was 100%, with 36.5% of higher severity. The incidence of grade 1 radiodermatitis was higher in the experimental group, while the more severe grades (3 and 4) had a higher incidence in the control group; 17.5% of the participants had an interruption of radiotherapy due to radiodermatitis, ranging from 3 to 15 days, with an average of six interrupted days. Despite being clinically relevant, these results regarding the temporary interruption of treatment and the severity of radiodermatitis were not statistically significant. Risk factors for moist desquamation were considered: female gender, diagnosis of C.21 and C.21.8, high radiation doses (5400 to 6000 cGy), histological type squamous cell carcinoma, humidity before and during radiotherapy, and use of intimate protection. In conclusion, the skin protector spray is an effective product in the prevention of radiodermatitis with moist desquamation in patients with anal and rectal cancer. In this sense, the results can guide the review of care protocols for the prevention of radiodermatitis used by nurses in the context of nursing consultations in radiotherapy to reduce the impacts on therapeutic follow-up and the quality of life of patients with cancer of the anal canal and straight.

Los pacientes con cáncer de canal anal y recto en tratamiento con radioterapia tienen una alta prevalencia de radiodermatitis con descamación húmeda, desenlace que genera impactos clínicos, económicos y sociales. Los estudios sobre la efectividad de los productos en la prevención de la radiodermatitis representan un vacío de conocimiento en el área de oncología y pueden contribuir para la reducción de los impactos negativos, el tiempo de inactividad de los equipos por interrupción del tratamiento y la posibilidad de falla local de la enfermedad. El objetivo de este estudio fue analizar la eficacia de un protector cutáneo en spray a base de terpolímero acrílico en la prevención de la radiodermatitis con descamación húmeda en pacientes con cáncer anal y rectal frente a una crema hidratante estandarizada de la institución a base de Calendula officinalis L. y Aloe barbadensis. Ensayo clínico aleatorizado, abierto, en una sola institución, referente nacional en el tratamiento de enfermedades oncológicas, con una muestra de 63 pacientes que fueron aleatorizados en grupos: experimental, utilizando spray protector para la piel, y control, utilizando Dnativ Revita Derm hidratante. Los pacientes fueron seguidos en la consulta de enfermería, cegándose el evaluador de piel en cuanto al uso de la intervención. La escala de valoración de la piel utilizada fue la del RTOC. Los datos se recopilaron mediante formularios de evaluación inicial y posterior, siendo el resultado principal medido la aparición de radiodermatitis con descamación húmeda y los resultados secundarios la interrupción temporal de la radioterapia debido a la radiodermatitis, los eventos adversos de los productos y la gravedad de la radiodermatitis. Los análisis fueron realizados por Intención de Tratar y Protocolo, utilizando estadística descriptiva, analítica e inferencial en el procesamiento de datos, con nivel de significación ≤ 0,10. Investigación aprobada por el Comité de Ética con dictamen nº 5.322.985 y registrada en Ensayos Clínicos con el número: NCT04067310T. La regresión logística binaria mostró que los participantes expuestos al protector de piel en aerosol tenían menos probabilidades de tener radiodermatitis con descamación húmeda en comparación con el grupo de control. La reducción absoluta del riesgo de radiodermatitis fue del 18 % en el grupo experimental. La incidencia global de radiodermatitis fue del 100%, siendo el 36,5% grados más graves. La incidencia de radiodermatitis Grado 1 fue mayor en el grupo experimental, mientras que los grados más severos (3 y 4) tuvieron mayor incidencia en el grupo control; El 17,5% de los participantes tuvo interrupción de la radioterapia por radiodermatitis, variando de 3 a 15 días, con un promedio de seis días de interrupción. A pesar de ser clínicamente relevantes, estos resultados en cuanto a la interrupción temporal del tratamiento y la gravedad de la radiodermatitis no fueron estadísticamente significativos. Se consideraron factores de riesgo para descamación húmeda: sexo femenino, diagnóstico C.21 y C.21.8, dosis altas (5400-6000cGy), carcinoma epidermoide de tipo histológico, humedad antes y durante la radioterapia y uso de protección íntima. Se concluyó que el spray protector de piel es un producto eficaz en la prevención de la radiodermatitis con descamación húmeda en pacientes con cáncer anal y rectal, afirmación que sustenta la tesis defendida. En ese sentido, los resultados pueden orientar la revisión de los protocolos de atención para la prevención de la radiodermitis utilizados por los enfermeros en el contexto de las consultas de enfermería en radioterapia, con el objetivo de reducir los impactos en el seguimiento terapéutico y en la calidad de vida de los pacientes con cáncer del canal anal y recto.

Pattern of rectal cancer recurrence following potentially curative surgical treatment

Survival in rectal cancer has been related mainly to clinical and pathological staging. Recurrence is the most challenging issue when surgical treatment of rectal cancer is concerned. This study aims to establish a recurrence pattern for rectal adenocarcinoma submitted to surgical treatment between June 2003 and July 2021. After applying the exclusion criteria to 305 patients, 166 patients were analyzed. Global recurrence was found in 18.7% of them, while 7.8% have had local recurrence. Recurrences were diagnosed from 5 to 92 months after the surgical procedure, with a median of 32.5 months. Follow-up varied from 6 to 115 months. Recurrence, in literature, is usually between 3 and 35% in 5 years and shows a 5-year survival rate of only 5%. In around 50% of cases, recurrence is local, confined to the pelvis. This study was consonant with the literature in most aspects evaluated, although a high rate of local recurrence remains a challenge in seeking better surgical outcomes. (AU)

Diagnosis of advanced disease in cases of colorectal cancer in a developing country

Objectives Colorectal cancer (CRC) is the second leading cause of cancer death in the world, with survival correlated with the extension of the disease at diagnosis. In many low-/middle-income countries, the incidence of CRC is increasing rapidly, while decreasing rates are observed in high-income countries. We evaluated the anatomopathological profile of 390 patients diagnosed with CRC who underwent surgical resection, over a six-year period, in the state of Paraíba, northeastern Brazil. Results Adenocarcinomas accounted for 98% of the cases of primary colorectal tumors, and 53.8% occurred in female patients. The average age of the sample was 63.5 years, with 81.8% of individuals older than 50 years of age and 6.4% under 40 years of age. The most frequent location was the distal colon; pT3 status was found in 71% of patients, and pT4 status, in 14.4%. Angiolymphatic and lymph-node involvements were found in 48.7% and 46.9% of the cases respectively. Distant metastasis was observed in 9.2% of the patients. Advanced disease was diagnosed in almost half of the patients (48.1%). The women in the sample had poorly-differentiated adenocarcinomas (p=0.043). Patients under 60 years of age had a higher rate of lymph-node metastasis (p=0.044). Tumor budding was present in 27.2% of the cases, and it was associated with the female gender, themucinous histological type, and the depth of invasion (pT3 and pT4). Conclusions We conclude that the diagnosis of advanced disease in CRC is still a reality, with a high occurrence of aggressive prognostic factors, which results in a worse prognosis. (AU)

Caracterización de enfermos operados de cáncer rectal. Hospital Universitario Clínico Quirúrgico Comandante Faustino Pérez Hernández / Characterization of patients operated of rectal cancer. Teaching Clinic-Surgical Hospital Faustino Pérez Hernández

RESUMEN Introducción: el cáncer de recto se considera una de las neoplasias más frecuentes del siglo XXI, con elevada mortalidad. Objetivo: caracterizar a los pacientes operados de cáncer rectal en el Hospital Universitario Clínico Quirúrgico Comandante Faustino Pérez Hernández, de Matanzas, entre enero de 2015 y diciembre de 2018. Materiales y métodos: se realizó un estudio observacional descriptivo. El universo fue de 97 pacientes de ambos sexos, operados de cáncer rectal. Se obtuvieron los datos de las historias clínicas individuales. Se analizaron variables como edad, sexo, localización específica del tumor, manifestaciones clínicas, características anatomopatológicas y estadios de la enfermedad, técnica quirúrgica empleada y complicaciones postoperatorias durante los primeros siete días. El método estadístico utilizado fue la distribución de frecuencia, en valores absolutos y porcentajes. Resultados: entre los pacientes operados de cáncer rectal, predominaron las personas de 70 a 79 años y el sexo masculino. El recto superior fue el sitio de mayor localización. El sangrado rectal, la expulsión de flemas y los cambios del hábito intestinal fueron los síntomas más frecuentes. El adenocarcinoma bien diferenciado fue la variedad histológica de mayor incidencia, y los estadios que prevalecieron fueron el II y el III. La técnica quirúrgica más empleada fue la resección anterior, y la complicación más frecuente la infección del sitio quirúrgico. Conclusiones: prevenir los factores de riesgo, sus causas predisponentes y desencadenantes, utilizar los medios diagnósticos convencionales y de avanzada. Detectar y tratar de forma temprana la enfermedad puede lograr mejor calidad de vida en estos pacientes (AU).

ABSTRACT Introduction: rectal cancer is considered one of the most frequent neoplasia of the 21st century, with high mortality. Objective: to characterize patients who underwent rectal cancer surgery at the Teaching Clinic-Surgical Hospital Faustino Pérez Hernández, of Matanzas, between January 2015 and December 2018. Materials and methods: a descriptive observational study was carried out. The universe was 97 patients of both sexes, who underwent a rectal cancer surgery. Data were obtained from individual medical records. Variables such as age, sex, specific tumor location, clinical manifestations, anatomopathologic characteristics and stages of the disease, surgical technique used and post-surgery complications during the first seven days were analyzed. The statistical method used was the frequency distribution, in absolute values and percentages. Results: people aged 70-79 years and men predominated among patients with rectal cancer. The upper rectum was the site of most common location. Rectal bleeding, phlegm expulsion, and changes in bowel habit were the most frequent symptoms. Well-differentiated adenocarcinoma was the most prevalent histological variety, and the stages that prevailed were II and III. The most commonly used surgical technique was anterior resection, and the most common complication was surgical site infection. Conclusions: to prevent risk factors, their predisposing causes and triggers; to use conventional and advanced diagnostic means. Early detection and treatment of the disease can achieve better quality of life in these patients (AU).

Perianastomotic cyst following rectosigmoidectomy due to adenocarcinoma of the proximal rectum: a case report / Cisto perianastomótico pós-retossigmoidectomia por adenocarcinoma dereto alto: relato de caso

ABSTRACT The implantation cyst occurs from the imprisonment and subsequent proliferation of the colonic mucosa below the submucosa during mechanical stapling. The understanding and definition of the evaluation protocol of these lesions is important, since they can generate the need for a new complex surgical procedure and cause anxiety in patients and surgeons. This case reports the occurrence of a subepithelial lesion in follow-up imaging of a patient who underwent videolaparoscopic rectosigmoidectomy for adenocarcinoma of the proximal rectum, submitted to an endoscopic attempt to drain/detangle the lesion and subsequent histopathological analysis showing colic mucosa without changes. In line with Katsumata,it is suggested to asymptomatic patients without alteration of the CEA or suspicious imaging signs a follow up with periodic imaging methods. For symptomatic patients with normal CEA, or whose lesions are growing at follow-up exams, it is suggested to continue with the investigation, with biopsy and/or effluent sample for histopathological study in addition to an attempt at symptomatic resolution. Finally, in the presence of an alteration in CEA, despite symptoms, it is suggested that the lesion be managed as a suspected local tumor recurrence.

RESUMO O cisto de implantação ocorre a partir do aprisionamento e subsequente proliferação da mucosa colônica abaixo da submucosa durante o grampeamento mecânico. A compreensão e definição do protocolo de avaliação dessas lesões é importante, pois podem gerar a necessidade de um novo procedimento cirúrgico complexo e causar ansiedade em pacientes e cirurgiões. Este caso relata a ocorrência de uma lesão sub-epitelial na imagem de seguimento de um paciente submetido à retossigmoidectomia por via videolaparoscópica devido a adenocarcinoma do reto proximal, submetido a uma tentativa endoscópica de drenar/remover a lesão e subsequente análise histopatológica mostrando a mucosa cólica sem alterações. De acordo com Katsumata, sugere-se que pacientes assintomáticos sem alteração do CEA ou sinais de imagem suspeitos tenham um seguimento com métodos de imagem periódicos. Para pacientes sintomáticos com CEA normal, ou cujas lesões mostrem crescimento nos exames de seguimento, sugere-se continuar a investigação, com biópsia e / ou amostra de efluente para estudo histopatológico, além de uma tentativa de resolução sintomática. Finalmente, na presença de uma alteração no CEA, apesar dos sintomas, sugere-se que a lesão seja tratada como uma suspeita de recorrência local do tumor.

A rectal gastrointestinal stromal tumor - a plea for neoadjuvant imatinib and TAMIS / Tumor estromal gastrointestinal no reto - um caso de uso de imatinibe neoadjuvante e TAMIS

Abstract Here we describe an infrequent case of gastrointestinal stromal tumor of the rectum in a 57 year-old man with spindle cell neoplasm probably gastrointestinal stromal tumor and CT scan showed tumor from the anterior rectal wall and offered abdominoperineal resection for the same. The patient was started on imatinib and had a significant reduction in symptoms. The patient was reassessed with the CT scan, which showed a reduction in tumor size and Transanal minimally invasive surgery was planned for the patient. Use of imatinib prior to surgical resection to attain the reduced size of the tumor within the limit of resection is an attractive approach. Since tumor development can happen rapidly again after substantial tumor shrinkage, the best time to operate depending on resectability and the maximum therapeutic outcome remains divisive.

Resumo No presente estudo, os autores descrevem um caso raro de tumor estromal gastrointestinal no reto em um homem de 57 anos que se apresentou com neoplasia de células fusiformes, com provável tumor estromal gastrointestinal. A tomografia computadorizada demonstrou tumor na parede anterior do reto e foi sugerida sua ressecção abdominoperineal. O paciente iniciou tratamento com imatinibe e apresentou uma redução significativa nos sintomas. O paciente foi reavaliado por tomografia computadorizada, que evidenciou redução do tamanho do tumor; portanto, foi indicada cirurgia transanal minimamente invasiva. O tumor era ressecável e foi necessário um extenso acompanhamento para romper o órgão, de forma a alcançar a ressecção máxima; caso contrário, o tumor estromal gastrointestinal também seria irressecável. O uso de imatinibe antes da ressecção cirúrgica para reduzir o tamanho do tumor dentro do limite de ressecção é uma abordagem interessante. Como o tumor pode se crescer rapidamente após ser substancialmente reduzido, a literatura ainda apresenta controvérsias quanto ao melhor momento para operar e quanto ao melhor desfecho terapêutico.

Linfangioma quístico de recto-sigmoides en un hospital público de Lima, Perú: reporte de caso / Cystic lymphangioma of the rectum-sigmoid in a public hospital in Lima-Peru: case report

RESUMEN Los linfangiomas son lesiones benignas que se deben a una malformación del desarrollo en el sistema linfático que ocurre durante la etapa embrionaria. Son más frecuentes en niños. Pueden encontrarse en cavidad abdominal, siendo la afectación del tracto gastrointestinal en forma ocasional. La presentación clínica es variada, dependiendo de la localización de los linfangiomas, pudiendo tener formas asintomáticas y, en ocasiones, presentarse con dolor abdominal, alteraciones del hábito defecatorio, rectorragia, etc. El diagnóstico se realiza por endoscopía, imágenes auxiliares y se confirma por medio de histología. Presentamos un caso de linfangioma quístico de recto-sigmoides que tuvimos en nuestro hospital; la paciente se presentó con proctalgia, alternancia evacuatoria y rectorragia intermitente. Examen físico sin alteraciones significativas. Durante la colonoscopía, a nivel de recto y sigmoides, se encontró múltiples lesiones protruidas, a modo de protuberancias, cuya superficie era lisa, trasluciente y de coloración azulada, con algunos orificios pseudodiverticulares, a predominio de recto. En la ultrasonografía endoscópica se observó, a nivel del recto, engrosamiento de la submucosa con múltiples imágenes anecoicas, microquísticas, algunas de ellas con tabiques finos. El diagnóstico definitivo se realizó mediante histopatología, que describe conductos linfáticos dilatados, rodeados de células endoteliales, hallazgos consistentes con linfangioma quístico de recto-sigmoides.

ABSTRACT Lymphangiomas are benign lesions due to a developmental malformation in the lymphatic system that occurs during the embryonic stage. They are more frequent in children. They can be found in the abdominal cavity, being the involvement of the gastrointestinal tract occasionally. The clinical presentation is varied, depending on the location of the lymphangiomas, and may have asymptomatic forms and, occasionally, present with abdominal pain, changes in defecation, rectal bleeding, etc. The diagnosis is made by endoscopy, auxiliary images and is confirmed by histology. We present a case of cystic rectal-sigmoid lymphangioma that we had in our hospital; the patient presented with proctalgia, alternating evacuation and intermittent rectal bleeding. Physical examination was without significant alterations. During the colonoscopy, at the level of the rectum and sigmoids, multiple protruded lesions were found, whose surface was smooth, translucent and bluish in color, with some pseudodiverticular holes, predominantly of the rectum. Endoscopic ultrasound revealed thickening of the submucosa at the level of the rectum with multiple anechoic, microcystic images, some of them with fine septa. The definitive diagnosis was made by histopathology, which describes dilated lymphatic ducts, surrounded by endothelial cells, findings consistent with cystic rectal-sigmoid lymphangioma.

Metástases Cutâneas e Neoplasia de Reto: Relato de Caso / Cutaneous Metastasis and Rectum Neoplasia: Case Report / Metástasis Cutáneas y Neoplasia Rectal: Relato de Caso

Introdução: As metástases cutâneas são as neoplasias que acometem a derme ou o tecido celular subcutâneo e podem ser um indicador de neoplasia desconhecida de mau prognóstico. Metástases cutâneas em adenocarcinoma de reto são consideradas raras. Relato do caso: Mulher de 80 anos de idade, hipertensa e diabética, apresentou dor abdominal e hematoquezia, relatando histórico familiar de câncer. Realizou colonoscopia com resultado de biópsia para adenocarcinoma. Um ano depois, recebeu terapia neoadjuvante e radioterapia concomitante por quatro meses, com boa resposta ao tratamento. Porém, relatou lesão mandibular de crescimento rápido, com o trato gastrointestinal como sítio primário de acordo com a biópsia. Em tomografias de reavaliação, foram diagnosticados também vários nódulos diminutos em tecido subcutâneo de abdome inferior, mama e pulmão. Foi realizada nova biópsia dos nódulos de mama e imuno--histoquímica, procedimentos que sugeriram o reto como sítio primário das lesões. Sendo assim, foi iniciada quimioterapia paliativa e a paciente apresentou resposta satisfatória das lesões cutâneas logo no segundo ciclo do tratamento antineoplásico. O projeto foi aprovado pelo Comitê de Ética em Pesquisa do Hospital Pompeia sob número de parecer 311.052. Conclusão: Este caso enfatiza que lesões na pele de crescimento progressivo ou sem resposta após terapia convencional podem ser a primeira manifestação de câncer visceral avançado e devem ser apropriadamente investigadas. Dessa forma, fica claro que, por meio de um diagnóstico precoce, é possível mudar o prognóstico da doença e o seu tratamento.

Introduction: Skin metastases are neoplasms that affect the dermis or subcutaneous cell tissue and may be an indicator of an unknown neoplasm with a poor prognosis. Skin metastases in rectal adenocarcinoma are considered rare. Case report: An 80-year-old woman, hypertensive and diabetic, had abdominal pain and hematochezia, reporting a family history of cancer. Colonoscopy was performed with biopsy results for adenocarcinoma. One year later, she received neoadjuvant therapy and concomitant radiation therapy for four months, with good response to treatment. However, she reported a fast-growing mandibular lesion, with the gastrointestinal tract as the primary site according to the biopsy. In reassessment CT scans, several small nodules in subcutaneous tissue of the lower abdomen, breast and lung were also diagnosed. A new biopsy of the breast nodules and immunohistochemistry were performed, procedures that suggested the rectum as the primary site of the lesions. Therefore, palliative chemotherapy was started and the patient presented a satisfactory response to skin lesions in the second cycle of antineoplastic treatment. The project was approved by the Institutional Review Board of Hospital Pompeia through report the opinion nº 311.052. Conclusion: This case emphasizes that progressive or unresponsive skin lesions after conventional therapy can be the first manifestation of advanced visceral cancer and should be properly investigated. Thus, it is clear that, through an early diagnosis, it is possible to change the prognosis of the disease and its treatment.

Introducción: Las metástasis cutáneas son neoplasias que afectan la dermis o el tejido subcutáneo y pueden ser un indicador de neoplasia desconocida con mal pronóstico. Las metástasis cutáneas en el adenocarcinoma rectal se consideran raras. Relato del caso: Una mujer de 80 años, hipertensa y diabética, presentaba dolor abdominal y hematoquecia, e informaba antecedentes familiares de cáncer. La colonoscopia se realizó con resultados de biopsia para adenocarcinoma. Un año después, recibió terapia neoadyuvante y radioterapia concomitante durante cuatro meses, con buena respuesta al tratamiento. Sin embargo, informó una lesión mandibular de rápido crecimiento, con el tracto gastrointestinal como el sitio primario según la biopsia. En las tomografías de reevaluación, también se diagnosticaron varios nódulos pequeños en el tejido subcutáneo de la parte inferior del abdomen, mama y pulmón. Se realizó una nueva biopsia de los nódulos mamarios y la inmunohistoquímica, procedimientos que sugirieron el recto como el sitio primario de las lesiones. Por lo tanto, se inició la quimioterapia paliativa y el paciente presentó una respuesta satisfactoria a las lesiones cutáneas en el segundo ciclo de tratamiento antineoplásico. El proyecto fue aprobado por el Comité de Ética e Investigación del Hospital Pompéia a través del dictamen número 311.052. Conclusión: Este caso enfatiza que las lesiones cutáneas progresivas o que no responden después de la terapia convencional pueden ser la primera manifestación de cáncer visceral avanzado y deben investigarse adecuadamente. Por lo tanto, está claro que, a través de un diagnóstico temprano, es posible cambiar el pronóstico de la enfermedad y su tratamiento.

Tumores ano-rectales del músculo liso / Smooth muscle ano-rectal tumors

Introducción: Los tumores ano-rectales del musculo liso son raros, la relación respecto de los de recto es de 0.1%, presentándose con un rango entre 40-70 años. El objetivo es analizar una serie de pacientes, el tratamiento empleado y actualización bibliográfica. Material y Método: Sobre una base de datos retrospectiva entre enero de 1983 y diciembre de 2018, sobre 421 pacientes operados por cáncer recto-anal, fueron extraídos 6 que correspondieron a tumores del musculo liso. Resultados: Correspondieron al sexo femenino 4, con edades entre 49 y 75 años (57.5 años); 4 de localización rectal, de ellos 3 fueron leiomiosarcoma, y 2 anales (leiomioma). En 2 se obtuvo diagnostico preoperatorio de certeza por punción mediante Tru-Cut. De 3 pacientes con leiomiosarcoma, a 2 se les realizo cirugía radical y al restante biopsia. Los 2 resecados recidivaron a los 6 meses y al año. Los 3 fallecieron entre los 2 y 16 meses por progresión de la enfermedad. La paciente con diagnóstico de leiomioma rectal, operada mediante cirugía radical, se encuentra sin recidiva a 18 meses. Los 2 pacientes resecados localmente por leiomioma de ano, presentaron en el postoperatorio absceso y fistula extraesfinteriana, uno de ellos con incontinencia severa. Ambos fueron re-operados y se encuentran asintomáticos, libres de recidiva a los 36 y 60 meses. Discusión: Los tumores del músculo liso ano-rectal son infrecuentes y presentan síntomas inespecíficos. La biopsia preoperatoria es imperiosa a fin de establecer una adecuada estrategia quirúrgica. Los malignos tienen alto índice de recidiva y mortalidad. (AU)

Introduction: Smooth muscle ano-rectal tumors are rare; the relation with respect to the rectum is 0.1%, in a patient's age range between 40-70 years. The objective is the analysis of a series of patients, the treatment used and bibliographic update. Material and method: On a retrospective, database between January 1983 and December 2018. About 421 patients operated for rectum-anal cancer, of which 6 corresponded to smooth muscle tumors. Results: Four were female, with ages between 49 and 75 years (57.5 years average); 4 were of rectal location, of which 3 were leiomyosarcoma, and 2 anal (leiomyoma). In two, a preoperative diagnosis of certainty was obtained by Tru-Cut. Two out of 3 patients with leiomyosarcoma, underwent radical surgery and the remaining one a biopsy. The two resected relapsed at 6 months and at one year. All 3 died between 2 and 16 months due to disease progression. The patient diagnosed with rectal leiomyoma, operated by radical surgery, is without recurrence at 18 months. The 2 patients resected locally for anus leiomyoma showed abscess and extrasphincteric fistula in the postoperative period, one of them with severe incontinence. Both were re-operated and are asymptomatic, free of recurrence at 36 and 60 months. Discussion: Ano-rectal smooth muscle tumors are uncommon and have nonspecific symptoms. Preoperative biopsy is imperative in order to establish an appropriate surgical strategy. Malignant tumors have a high rate of recurrence and mortality. (AU)

Opciones terapéuticas en el cáncer de recto inferior. Actualización / Therapeutic options in lower rectal cancer. Upgrade

Motiva esta presentación el hecho que desde el Relato "Opciones terapéuticas del Cáncer de Recto Inferior" en el año 2008 han pasado 10 años y por supuesto aparecieron algunos progresos y cambios. Se conoce gran heterogeneidad genética debido que puede desarrollarse por diferentes vías. Nuevos fármacos han aparecido para lograr terapia eficiente. La clasificación clínica TNM fue actualizada en el año 2018. Los métodos de diagnóstico siguen teniendo vigencia. La resección local endoanal se presenta como una conducta factible con resultados favorables debido al progreso instrumental. Combinado con R/T y Q mostró excelentes resultados ("Watch and Wait"). La escisión total de mesorecto sigue ocupando un lugar importante. En la amputación abdomino perineal debemos incluir la resección de ambos músculos elevadores del ano. La cirugía laparoscópica ocupa cada vez más lugar siendo tan segura como la convencional. Se adjuntan los algoritmos terapéuticos. Continuarán las investigaciones para mejorar los resultados. (AU)

The aim of this presentation is to update the one written in 2008 "Low rectal cancer therapeutic options" since some progress and changes have appeared after ten years. Great genetic heterogeneity is known because it can develop in different pathways. New drugs have appeared to achieve efficient therapy. The TNM clinical classification was updated in 2018. The diagnosis methods are still in effect. Endoanal local resection is presented as feasible behavior with favorable results due to instrumental progress. Combined with R/T and Ch showed excellent results (Watch and Wait). The total mesorectal continues to occupy an important place. The resection of both elevator muscles of anus must be included in the abdominoperineal amputation. Laparoscopic surgery is increasingly in place, being as safe as the conventional. Therapeutic algorithms are attached. Research will continue to improve results. (AU)

Síndrome da ressecção anterior do reto: fatores preditivos / Predictive factors of low anterior resection syndrome following anterior resection of the rectum

RESUMO Objetivo: identificar fatores preditivos da síndrome da ressecção anterior do reto (SRAR) que podem contribuir para o seu diagnóstico e tratamento precoces. Métodos: estudo de coorte retrospectivo de pacientes submetidos à ressecção anterior do reto entre 2007 e 2017 no Serviço de Coloproctologia do Hospital de Clínicas da Universidade Federal do Paraná. Foram realizadas análises de curva ROC (Receiver Operating Characteristic Curve Analysis) ou COR (Característica de Operação do Receptor) para identificar os fatores preditivos da SRAR. Resultados: foram incluídos 64 pacientes com dados completos. A idade dos homens foi de 60,1±11,4 anos e 37,10% eram do sexo masculino. Vinte pacientes (32,26%) apresentaram SRAR. Os sintomas mais relatados foram evacuação incompleta (60%) e urgência (55%). Na análise univariada, a distância da anastomose à margem anal (p<0,001), terapia neoadjuvante (p=0,0014) e confecção de ileostomia no momento da ressecção (p=0,0023) foram preditivos da SRAR. Análise da curva ROC mostrou um ponto de corte de 6,5cm na distância da anastomose à margem anal como preditor da SRAR. Conclusão: distância entre anastomose e margem anal, história de terapia neoajuvante e confecção de estoma são condições que podem ajudar a predizer o desenvolvimento da SRAR. A orientação e o envolvimento na educação do paciente, bem como, o manejo precoce podem reduzir potencialmente o impacto desses sintomas na qualidade de vida dos pacientes.

ABSTRACT Objective: to identify predictors of low anterior resection syndrome (LARS) that can contribute to its early diagnosis and treatment. Methods: we conducted a retrospective cohort study of patients undergoing anterior resection of the rectum between 2007 and 2017 in the Coloproctology Service of the Federal University of Parana Clinics Hospital. We performed Receiver Operating Characteristic Curve (ROC) analysis to identify LARS predictive factors. Results: we included 64 patients with complete data. The men's age was 60.1±11.4 years and 37.10% were male. Twenty patients (32.26%) had LARS. The most reported symptoms were incomplete evacuation (60%) and urgency (55%). In the univariate analysis, the distance from the anastomosis to the anal margin (p<0.001), neoadjuvant therapy (p=0.0014) and ileostomy at the time of resection (p=0.0023) were predictive of LARS. The ROC curve analysis showed a 6.5cm cut-off distance from the anastomosis to the anal margin as a predictor of LARS. Conclusion: distance between the anastomosis and the anal margin, neoadjuvant therapy history and preparation of stoma are conditions that can help predict the development of LARS. Guidance and involvement in patient education, as well as early management, can potentially reduce the impact of these symptoms on patients' quality of life.

Leiomiosarcoma rectal: reporte de un caso / Rectal leiomyosarcoma: a case report

Introducción: Los leiomiosarcomas (LMS) son tumores raros del tubo digestivo, corresponden a neoplasias malignas originadas de células de músculo liso, representando sólo el 0,1% del total. La localización rectal se da en el 11% de los LMS, aunque representan menos del 1% de los tumores malignos colón- icos. En nuestro medio también es una patología de baja frecuencia. Objetivo: Exponer método diagnóstico, tratamiento, y resultado quirúrgico en paciente con LMS rectal. Caso Clínico: Paciente mujer, 53 años, atendida en el Hospital Padre Hurtado, gran tabáquica, que se presentó con un cuadro de 1 año de evolución de dolor perianal, defecación laboriosa y 3 episodios de rectorragia. Al examen físico presentaba al tacto rectal a 4 cm del margen anal una masa de ±2 cm de superficie irregular y de consistencia pétrea. Se realizó colonoscopía objetivando la masa tumoral y tomando biopsia la que se informó como LMS rectal, incluyendo resultados de inmunohistoquímica. Siguiendo con el estudio se realizó TAC y RNM. Se decide la intervención quirúrgica realizándose una resección anterior baja, sin incidentes durante la cirugía y con un buen postoperatorio. Conclusión: El leiomiosarcoma es de extrema baja frecuencia en nuestro país, con sólo pocos casos reportados. La confirmación diagnóstica es con biopsia e inmunohistoquímica. La cirugía sugerida en la literatura es la resección anterior baja, la que se realiza en este caso con buenos resultados. (AU)

Introduction: Leiomyosarcomas (LMS) are rare digestive tract tumors. It is a malignant tumor originated from smooth muscle cells, representing only 0.1% of the total. Rectal location is given in 11% of LMS, however, they represent less than 1% of all malignant colon tumors. It is a very infrequent tumor in our medium. Objective: Show the diagnostic method, treatment, and surgical result. Case Presentation: A 53-year-old female, treated in Padre Hurtado Hospital, heavy smoker, presented with a 1-year history of perianal pain, difficulty during defecation, and three episodes of rectal bleeding. Digital rectal examination showed a mass 4 cm from the anal margin of approximately 2 cm, of irregular surface, and very hard consistency. A colonoscopy was performed, objectivating the tumoral mass and taking a biopsy which was informed as a rectal LMS, including immunohistochemistry results. Continuing with the study, a CT-Scan and MRI were performed. Treatment of choice was surgery; a low anterior resection was carried out with no incidents during the surgery and a favorable post-operatory. LMS is extremely infrequent in our country, with only a few cases reported. Conclusion: Diagnostic confirmation is made through biopsy and immunohistochemistry. Surgery suggested by literature is low anterior resection, which was carried out in this case with good results. (AU)

Tumores de reto: diagnóstico e tratamento / Rectal tumors: diagnosis and treatment

Introdução: A incidência de câncer retal tem aumentado na última década. O adenocarcinoma de reto, vasta maioria dos cânceres retais, é uma doença com o diagnóstico relativamente simples e de desfecho positivo através de tratamento e diagnóstico precoces. Métodos: Revisamos na literatura o diagnóstico e o tratamento. O estudo foi realizado de forma qualitativa, por meio de revisão de literatura, tendo como fonte principal artigos científicos disponibilizados em diversas bases de dados. Resultados: O diagnóstico é realizado pela anamnese, exame físico e exames de imagem. A base do tratamento de tumores potencialmente ressecáveis é a cirurgia enquanto que a quimiorradioterapia neoadjuvante apresenta papel importante em casos de invasão transmural. Conclusão: O tratamento curativo do câncer retal baseia-se no procedimento cirúrgico. Neste sentido, deve-se conhecer todos os passos de estadiamento e avaliação, a fim de aumentar as chances de ressecção curativa.

Introduction: The incidence of rectal cancer is increasing in the past decade. Rectal adenocarcinoma, the majority of rectal cancers, is a relatively simple disease in terms of diagnosis and with a positive outcome through right treatment and early diagnosis. Methods: We have reviewed the diagnosis and treatment in the academic literature. The study was carried out in a qualitative way, through a literature review, having as main source scientific articles available in several databases. Results: The diagnosis of this pathology must be established associating physical examination, anamnesis and image exams. The baseline of treatment of potentially resectable tumors is surgery while neoadjuvant chemoradiotherapy plays an important role in transmural invasion. Conclusion: The curative treatment of rectal cancer is based on the surgical procedure. In this sense, it is necessary to know all steps of staging and evaluation, in order to increase the chances of curative resection.

De la resección abdominoperineal a las técnicas conservadoras de esfínteres en la cirugía laparoscópica del cáncer del recto / From abdominoperineal resection to conservative techniques of interest in relation to laparoscopic surgery for rectal cancer

Introducción: la principal regla en el manejo del cáncer del recto es la cura oncológica y el mantenimiento de la calidad de vida. El advenimiento de la cirugía laparoscópica ha tenido un impacto en la cirugía gastrointestinal en los últimos 20 años. Tres décadas después de su original descripción por Heald, la escisión total del mesorrecto se ha convertido en la regla de oro para la resección curativa del cáncer del recto. Objetivos: revisar las diferentes opciones técnicas de las que se dispone en la actualidad para el tratamiento laparoscópico del cáncer del recto, mediante la descripción de sus resultados, ventajas y desventajas. Métodos: se realizó una revisión en las bases de datos bibliográficas accesibles por Infomed, que incluyó artículos que trataran el tema en español e inglés, mediante los descriptores de DeCS y MeSH. Resultados: el cáncer del último tercio del recto plantea un cambio significativo para el cirujano. La resección abdominoperineal ha sido considerada como la regla de oro para el tratamiento de los adenocarcinomas situados en el tercio medio y bajo del recto. Sin embargo, con el incremento del conocimiento de la enfermedad, el desarrollo de las técnicas quirúrgicas, la mejor instrumentación, y el uso de la radioquimioterapia preoperatoria, se ha llegado a un cambio en el tratamiento del cáncer de recto que va de la resección abdominoperineal con colostomía permanente a la cirugía preservadora del esfínter mediante las técnicas mínimamente invasivas. Conclusiones: la cirugía conservadora de esfínteres para el cáncer del recto mediante las técnicas mínimamente invasivas es posible en la mayoría de los pacientes con unos resultados a largo plazo iguales a los de la resección abdominoperineal(AU)

Introduction: the main rule for the management of rectal cancer is oncologic cure and the maintenance of quality of life. The advent of laparoscopic surgery has had an impact on gastrointestinal surgery over the last 20 years. Three decades following its original description by Heald, total mesorectal excision has become the gold standard for the curative resection of rectal cancer. Objectives: To review the different technical options currently available for the laparoscopic treatment of rectal cancer, by describing their outcomes, advantages and disadvantages. Methods: A review was performed in the bibliographical databases accessible from Infomed, including articles on the topic written in Spanish and English, using DeCS and MeSH descriptors. Results: Cancer of the lower third of the rectum signifies a fundamental change for the surgeon. Abdominoperineal resection has been considered as the gold standard for the treatment of adenocarcinomas located in the middle and lower rectum. However, with increased knowledge of the disease, the development of surgical techniques, better instrumentation, and the use of preoperative radiochemotherapy, a change has been achieved in treating rectal cancer, which goes from abdominoperineal resection with permanent colostomy to conservative surgery of the sphincter using minimal invasive techniques. Conclusions: The conservative surgery of the sphincters for rectal cancer by minimal invasive techniques is possible to be performed in most patients, with long-term results similar to those of the abdominoperineal resection(AU)