Implementation of an organized colorectal cancer screening program through quantitative fecal immunochemical test followed by colonoscopy in an urban low-income community: Guidance and strategies

Abstract Fecal Immunochemical Test (FIT) followed by a colonoscopy is an efficacious strategy to improve the adenoma detection rate and Colorectal Cancer (CRC). There is no organized national screening program for CRC in Brazil. The aim of this research was to describe the implementation of an organized screening program for CRC through FIT followed by colonoscopy, in an urban low-income community of São Paulo city. The endpoints of the study were: FIT participation rate, FIT positivity rate, colonoscopy compliance rate, Positive Predictive Values (PPV) for adenoma and CRC, and the rate of complications. From May 2016 to October 2019, asymptomatic individuals, 50-75 years old, received a free kit to perform the FIT. Positive FIT (≥ 50 ng/mL) individuals were referred to colonoscopy. 10,057 individuals returned the stool sample for analysis, of which (98.2%) 9,881 were valid. Women represented 64.8% of the participants. 55.3% of individuals did not complete elementary school. Positive FIT was 7.8% (776/9881). The colonoscopy compliance rate was 68.9% (535/776). There were no major colonoscopy complications. Adenoma were detected in 63.2% (332/525) of individuals. Advanced adenomatous lesions were found in 31.4% (165/525). CRC was diagnosed in 5.9% (31/525), characterized as adenocarcinoma: in situ in 3.2% (1/31), intramucosal in 29% (9/31), and invasive in 67.7% (21/31). Endoscopic treatment with curative intent for CRC was performed in 45.2% (14/31) of the cases. Therefore, in an urban low-income community, an organized CRC screening using FIT followed by colonoscopy ensued a high participation rate, and high predictive positive value for both, adenoma and CRC.

Economic evaluations of colorectal cancer screening: A systematic review and quality assessment

Abstract Colorectal Cancer (CRC) is the third most common type of cancer worldwide and ranks second in mortality. Screening programs for early detection and treatment have been implemented in several countries. Economic evaluations are an important tool to support decision-making about reimbursement and coverage decisions in health systems and, therefore, to support efficient resource allocation. The article aims to review the up-to-date evidence on economic evaluations of CRC screening strategies. MEDLINE, EMBASE, Web of Science, SCOPUS, SciELO, Lilacs, CRD databases, and lists of references were reviewed to identify relevant literature regarding full economic evaluations of CRC screening in asymptomatic average-risk individuals over 40 years old. Searches were conducted with no restriction to language, setting, or date. Qualitative syntheses described CRC screening strategies and comparators (baseline context), study designs, key parameter inputs and incremental cost-effectiveness ratios. Seventy-nine articles were included. Most of the studies were from high-income countries and a third-party payer perspective. Markov models were predominantly used, although microsimulation has been increasingly adopted in the last 15 years. The authors found 88 different screening strategies for CRC, which differed in the type of technique, the interval of screening, and the strategy, i.e., isolated or combined. The annual fecal immunochemical test was the most predominant screening strategy. All studies reported cost-effective results in their scenarios compared to no screening scenarios. One-quarter of the publications reported cost-saving results. It is still necessary to develop future economic evaluations in Low- and Middle-Income Countries (LMICs), which account for the high burden of disease.

O intestino delgado é amplamente afetado na doença de Behçet: um acompanhamento de longo prazo dos sintomas gastrointestinais / Small bowel is largely affected in behçet's disease: a long-term follow-up of gastrointestinal symptoms

ABSTRACT Background Behçet's disease is a rare immune-mediated disorder that can affect the gastrointestinal tract. The prevalence and extension of small bowel involvement is largely unknown. Objective The aim of this study was to describe the small bowel lesions diagnosed by double-balloon enteroscopy (DBE) and to verify if these findings were associated to the presence of gastrointestinal symptoms and disease activity after long-term follow-up. Methods This study included 19 Behçet's disease patients who underwent DBE. After a mean follow-up of 15 years the endoscopic findings were associated to the presence of gastrointestinal symptoms, disease activity and current therapy through collection of electronic medical records. Results A total of 63.2% patients were female and the mean age was 37 years at the time of DBE. Mean disease duration at baseline was 24 years. 11 patients had no gastrointestinal symptoms and eight patients presented either abdominal pain, gastrointestinal bleeding or diarrhea. The average procedure time was 1 hour and 30 minutes and the ileum was achieved in all patients but one. Small bowel ulcers were diagnosed in 78.9%, with 63.1% of jejunal involvement. Two patients presented only small bowel edema and two were normal by DBE. Eight patients had concomitant gastric ulcers. Gastrointestinal symptoms prior to DBE were present in 36.8% of the patients and, after follow-up, all of them persisted with some of the symptoms. Bleeding was reported by three patients at baseline and persisted in only one patient. The frequency of treatment with steroids and immunomodulators was 31.6% and 57.9% at baseline, respectively, and 21% in both at the end of the follow-up. No patient was treated with biologics at the time of the DBE procedure and the current rate of biologic use is 21%. Conclusion Small bowel involvement in Behçet's disease was frequently demonstrated by DBE even in asymptomatic patients. Understanding clinical evolution of the disease over the years and the impact of such diagnosis still represents a challenge, possibly with the need for novel treatment.

RESUMO Contexto A doença de Behçet é uma doença imunomediada rara que pode afetar o trato gastrointestinal. A prevalência e extensão do envolvimento do intestino delgado é desconhecida. Objetivo O objetivo deste estudo foi descrever as lesões do intestino delgado diagnosticadas por enteroscopia de duplo balão (EDB) e verificar se esses achados estavam associados à presença de sintomas gastrointestinais e atividade da doença após seguimento de longo prazo. Métodos Este estudo incluiu 19 pacientes com doença de Behçet que foram submetidos a EDB. Após seguimento médio de 15 anos, os achados endoscópicos foram associados à presença de sintomas gastrointestinais, atividade da doença e terapia atual por meio de coleta de prontuário eletrônico. Resultados Um total de 63,2% dos pacientes eram do sexo feminino e a média de idade era de 37 anos no momento da EDB. A duração média da doença no início do estudo foi de 24 anos. 11 pacientes não apresentaram sintomas gastrointestinais e oito pacientes apresentaram dor abdominal, sangramento gastrointestinal ou diarréia. O tempo médio do procedimento foi de 1 hora e 30 minutos e o íleo foi atingido em todos os pacientes, exceto em um. Úlceras de intestino delgado foram diagnosticadas em 78,9%, sendo 63,1% de acometimento jejunal. Dois pacientes apresentaram apenas edema de intestino delgado e dois apresentaram EDB normais. Oito pacientes tinham úlceras gástricas concomitantes. Sintomas gastrointestinais prévios à EDB estavam presentes em 36,8% dos pacientes e, após o seguimento, todos persistiram com alguns dos sintomas. Sangramento foi relatado por três pacientes no início do estudo e persistiu em apenas um paciente. A frequência de tratamento com esteroides e imunomoduladores foi de 31,6% e 57,9% no início do estudo, respectivamente, e 21% em ambos ao final do seguimento. Nenhum paciente foi tratado com biológicos no momento da EDB e a taxa atual de uso de biológicos é de 21%. Conclusão O envolvimento do intestino delgado na doença de Behçet foi frequentemente demonstrado por EDB mesmo em pacientes assintomáticos. Compreender a evolução clínica da doença ao longo dos anos e o impacto de tal diagnóstico ainda representa um desafio, possivelmente com a necessidade de novos tratamentos.

Thylenetetrahydrofolate reductase gene polymorphisms and susceptibility to esophageal cancer: a case-control study / Polimorfismos do gene metilenotetrahidrofolato redutase e suscetibilidade ao câncer de esôfago: estudo caso-controle

ABSTRACT BACKGROUND: The enzyme methylenetetrahydrofolate reductase is engaged in DNA synthesis through folate metabolism. Inhibiting the activity of this enzyme increases the susceptibility to mutations, and damage and aberrant DNA methylation, which alters the gene expression of tumor suppressors and proto-oncogenes, potential risk factors for esophageal cancer. AIMS: This study aimed to investigate the association between methylenetetrahydrofolate reductase 677C>T and methylenetetrahydrofolate reductase 1298A>C polymorphisms and susceptibility to esophageal cancer, by assessing the distribution of genotypes and haplotypes between cases and controls, as well as to investigate the association of polymorphisms with clinical and epidemiological characteristics and survival. METHODS: A total of 109 esophageal cancer patients who underwent esophagectomy were evaluated, while 102 subjects constitute the control group. Genomic DNA was isolated from the peripheral blood buffy coat followed by amplification by polymerase chain reaction and real-time analysis. Logistic regression was used to assess associations between polymorphisms and the risk of developing esophageal cancer. RESULTS: There was no association for methylenetetrahydrofolate reductase 677C>T and methylenetetrahydrofolate reductase 1298A>C polymorphisms and haplotypes, with esophageal cancer susceptibility. Esophageal cancer patients carrying methylenetetrahydrofolate reductase 677TT polymorphism had higher risk of death from the disease. For polymorphic homozygote TT genotype, the risk of death significantly increased compared to wild-type genotype methylenetetrahydrofolate reductase 677CC (reference) cases (p=0.045; RR=2.22, 95%CI 1.02-4.83). CONCLUSIONS: There was no association between methylenetetrahydrofolate reductase 677C>T and methylenetetrahydrofolate reductase 1298A>C polymorphisms and esophageal cancer susceptibility risk. Polymorphic homozygote genotype methylenetetrahydrofolate reductase 677TT was associated with higher risk of death after surgical treatment for esophageal cancer.

RESUMO RACIONAL: A enzima metilenotetrahidrofolato redutase está envolvida na síntese de DNA através do metabolismo do folato. A inibição da sua atividade aumenta a suscetibilidade a mutações, danos e metilação aberrante do DNA, o que altera a expressão gênica de supressores tumorais e proto-oncogenes, potenciais fatores de risco para câncer de esôfago. OBJETIVOS: Investigar a associação entre os polimorfismos metilenotetrahidrofolato redutase 677C>T e metilenotetrahidrofolato redutase 1298A>C e a suscetibilidade ao câncer de esôfago, avaliando a distribuição de genótipos e haplótipos entre casos e controles, bem como investigar a associação de polimorfismos com características clínicas, epidemiológicas e sobrevida. MÉTODOS: Avaliaram-se 109 pacientes com câncer de esôfago submetidos à esofagectomia, enquanto 102 indivíduos constituaram o grupo controle. O DNA genômico do sangue periférico foi isolado e submetido à amplificação por reação em cadeia da polimerase em tempo real. A associação entre os polimorfismos e o risco de desenvolver câncer de esôfago foi avaliada por regressão logística. RESULTADOS: Não houve associação dos polimorfismos e haplótipos metilenotetrahidrofolato redutase 677C>T e metilenotetrahidrofolato redutase 1298A>C com a suscetibilidade ao câncer de esôfago. Pacientes com câncer de esôfago portadores do polimorfismo metilenotetrahidrofolato redutase 677TT apresentaram maior risco de morte pela doença. Para o genótipo TT homozigoto polimórfico, o risco de morte aumentou significativamente em comparação com os casos do genótipo selvagem metilenotetrahidrofolato redutase 677CC (referência) (p=0,045; RR=2,22, IC95% 1,02-4,83). CONCLUSÕES: Não houve associação entre os polimorfismos metilenotetrahidrofolato redutase 677C>T e metilenotetrahidrofolato redutase 1298A>C e o risco de suscetibilidade ao câncer de esôfago. O genótipo homozigoto polimórfico metilenotetrahidrofolato redutase 677TT associou-se a um maior risco de óbito após tratamento cirúrgico para câncer de esôfago.

Ressecção endoscópica sob imersão d'água de pequenos tumores neuroendócrinos retais / Underwater endoscopic mucosal resection for small rectal neuroendocrine tumors

ABSTRACT BACKGROUND: A common site of neuroendocrine tumors (NETs) is the rectum. The technique most often used is endoscopic mucosal resection with saline injection. However, deep margins are often difficult to obtain because submucosal invasion is common. Underwater endoscopic mucosal resection (UEMR) is a technique in which the bowel lumen is filled with water rather than air, precluding the need for submucosal lifting. OBJECTIVE: This study aimed to evaluate the efficacy and safety of UEMR for removing small rectal neuroendocrine tumors (rNETs). METHODS: Retrospective study with patients who underwent UEMR in two centers. UEMR was performed using a standard colonoscope. No submucosal injection was performed. Board-certified pathologists conducted histopathologic assessment. RESULTS: UEMR for small rNET was performed on 11 patients (nine female) with a mean age of 55.8 years and 11 lesions (mean size 7 mm, range 3-12 mm). There were 9 (81%) patients with G1 rNET and two patients with G2, and all tumors invaded the submucosa with only one restricted to the mucosa. None case showed vascular or perineural invasion. All lesions were removed en bloc. Nine (81%) resections had free margins. Two patients had deep margin involvement; one had negative biopsies via endoscopic surveillance, and the other was lost to follow-up. No perforations or delayed bleeding occurred. CONCLUSION: UEMR appeared to be an effective and safe alternative for treatment of small rNETs without adverse events and with high en bloc and R0 resection rates. Further prospective studies are needed to compare available endoscopic interventions and to elucidate the most appropriate endoscopic technique for resection of rNETs.

RESUMO CONTEXTO: Um local comum de tumores neuroendócrinos (TNEs) é o reto. A técnica mais utilizada é a ressecção endoscópica da mucosa com injeção de solução salina. No entanto, as margens profundas costumam ser difíceis de ressecar porque a invasão da submucosa é comum. A ressecção endoscópica sob imersão d'água (RESI) é uma técnica em que o lúmen intestinal é preenchido com água em vez de ar, evitando a necessidade de elevação submucosa. OBJETIVO: Este estudo teve como objetivo avaliar a eficácia e segurança da RESI para a remoção de pequenos TNEs retais (rTNEs). MÉTODOS: Estudo retrospectivo com pacientes que realizaram RESI em dois centros. RESI foi realizada usando um colonoscópio padrão. Nenhuma injeção submucosa foi realizada. Patologistas certificados conduziram avaliação histopatológica. RESULTADOS: RESI foi realizada para pequenos rTNEs em 11 pacientes (nove mulheres) com média de idade de 55,8 anos e 11 lesões (tamanho médio de 7 mm, variando de 3-12 mm). Havia 9 (81%) pacientes com G1 rTNEs e dois pacientes com G2, sendo que todos os tumores invadiam a submucosa sendo apenas um restrito a mucosa. Nenhum caso mostrou invasão vascular ou perineural. Todas as lesões foram removidas em bloco. Nove (81%) ressecções tiveram margens livres. Dois pacientes tiveram envolvimento de margens profundas; um teve biópsias negativas por meio de vigilância endoscópica e o outro perdeu o acompanhamento. Não ocorreram perfurações ou sangramento tardios. CONCLUSÃO: A RESI parece ser uma alternativa eficaz e segura para o tratamento de pequenos rTNEs sem eventos adversos e com altas taxas de ressecção em bloco e R0. Mais estudos prospectivos são necessários para comparar as intervenções endoscópicas disponíveis e para elucidar a técnica endoscópica mais adequada para ressecção de rTNEs.

Endoscopy infection control strategy during the COVID-19 pandemic: experience from a tertiary cancer center in Brazil

OBJECTIVES: Strategic planning for coronavirus disease (COVID-19) care has dominated the agenda of medical services, which have been further restricted by the need for minimizing viral transmission. Risk is particularly relevant in relation to endoscopy procedures. This study aimed to describe a contingency plan for a tertiary academic cancer center, define a strategy to prioritize and postpone examinations, and evaluate the infection rate among healthcare workers (HCWs) in the endoscopy unit of the Cancer Institute of the State of São Paulo (ICESP). METHODS: We created a strategy to balance the risk of acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and to mitigate the effects of postponing endoscopic procedures in oncological patients. A retrospective analysis of prospectively collected data on all endoscopies between March and June 2020 compared with those during the same period in 2019 was carried out. All HCWs were interviewed to obtain clinical data and SARS-CoV-2 test results. RESULTS: During the COVID-19 outbreak, there was a reduction of 55% in endoscopy cases in total. Colonoscopy was the most affected modality. The total infection rate among all HCWs was 38%. None of the senior digestive endoscopists had COVID-19. However, all bronchoscopists had been infected. One of three fellows had a serological diagnosis of COVID-19. Two-thirds of all nurses were infected, whereas half of all technicians were infected. CONCLUSIONS: In this pandemic scenario, all endoscopy services must prioritize the procedures that will be performed. It was possible to maintain some endoscopic procedures, including those meant to provide nutritional access, tissue diagnosis, and endoscopic resection. Personal protective equipment (PPE) seems effective in preventing transmission of COVID-19 from patients to digestive endoscopists. These measures can be useful in planning, even for pandemics in the future.

Ressecção da mucosa endoscópica sob imersão dágua para lesões colorretais não pediculadas. Um estudo prospectivo de braço único / Underwater endoscopic mucosal resection for non-pedunculated colorectal lesions. a prospective single-arm study

ABSTRACT BACKGROUND: Underwater endoscopic mucosal resection (UEMR) has emerged as a revolutionary method allowing resection of colorectal lesions without submucosal injection. Brazilian literature about this technique is sparse. OBJECTIVE: The aim of this study was evaluate the efficacy and safety of UEMR technique for removing non-pedunculated colorectal lesions in two Brazilian tertiary centers. METHODS: This prospective study was conducted between June 2016 and May 2017. Naïve and non-pedunculated lesions without signs of submucosal invasion were resected using UEMR technique. RESULTS: A total of 55 patients with 65 lesions were included. All lesions, except one, were successfully and completely removed by UEMR (success rate 98.5%). During UEMR, two cases of bleeding were observed (3.0%). One patient had abdominal pain on the day after resection without pneumoperitoneum. There was no perforation or delayed bleeding. CONCLUSION: This study supports the existing data indicating acceptable rates of technical success, and low incidence of adverse events with UEMR. The results of this Brazilian study were consistent with previous abroad studies.

RESUMO CONTEXTO: A ressecção endoscópica da mucosa sob imersão d'água (REMS) surgiu como um método revolucionário que permite a ressecção de lesões colorretais sem injeção submucosa. A literatura brasileira sobre essa técnica é escassa. OBJETIVO: A finalidade deste estudo foi avaliar a eficácia e segurança da técnica REMS na remoção de lesões colorretais não pediculadas em dois centros terciários brasileiros. MÉTODOS: Este estudo prospectivo foi realizado entre junho de 2016 e maio de 2017. As lesões sem tentativa de ressecção prévia, não pediculadas e sem sinais de invasão submucosa foram ressecadas pela técnica REMS. RESULTADOS: Um total de 55 pacientes com 65 lesões foram incluídos. Todas as lesões, exceto uma, foram removidas com sucesso e completamente por REMS (taxa de sucesso de 98,5%). Durante a REMS, foram observados dois casos de sangramento (3,0%). Uma paciente apresentou dor abdominal no dia seguinte à ressecção sem pneumoperitônio. Não houve perfuração ou sangramento tardio. CONCLUSÃO: Este estudo apoia os dados existentes, indicando taxas aceitáveis de sucesso técnico e baixa incidência de eventos adversos com a REMS. Os resultados deste estudo brasileiro foram consistentes com estudos internacionais prévios.

Long-term survival analysis after endoscopic stenting as a bridge to surgery for malignant colorectal obstruction: comparison with emergency diverting colostomy

The use of colorectal self-expanding metal stents (SEMS) as bridge therapy for malignant colorectal obstruction was first reported more than 20 years ago. However, its use remains controversial. Objective: In this study, we aimed to compare the long-term survival of patients with potentially resectable malignant colorectal obstruction who had undergone colorectal SEMS placement and emergency surgery. Methods: This study was a retrospective analyses. Patients who received treatment between 2009 and 2017 were included. According to the eligibility criteria, 21 patients were included in the SEMS group and 67 patients were included in the surgical group.. Results: The majority of the patients in the SEMS group were female (57.1%), whereas the majority of those in the surgical group were male (53.7%). The median follow-up time was 60 months for both groups with the same interquartile range of 60 months. There was no difference in the overall survival rate (log rank p=0.873) and disease-free survival rate (log rank p=0.2821) in the five-year analysis. There was no difference in local recurrence rates (38.1% vs. 22.4%, p=0.14) or distant recurrence rates (33.3% vs. 50.7%, p=0.16) in the SEMS and the surgical groups. Technical and clinical success rates of endoscopic stenting were 95.3% and 85.7%, respectively. There were no immediate adverse events (AEs). Severe AEs included perforation (14.3%), silent perforation (4.7%), reobstruction (14.3%), and bleeding (14.3%). Mild AEs included pain (42.8%), tenesmus (9.5%), and incontinence (4.76%). The limitations of this study was retrospective and was conducted at a single center. Conclusions: No differences in disease-free and overall survival rates were observed in the five-year analysis of patients with resectable colorectal cancer who had undergone SEMS placement or colostomy for the treatment of malignant colorectal obstruction. Patients in the SEMS group had a higher rate of primary anastomosis and a lower rate of temporary colostomy than did those in the surgery group.

Validation of classic and expanded criteria for endoscopic submucosal dissection of early gastric cancer: 7 years of experience in a Western tertiary cancer center

OBJECTIVE: Our aim was to evaluate the Japan Gastroenterological Endoscopy Society criteria for endoscopic submucosal resection of early gastric cancer (EGC) based on the experience in a Brazilian cancer center. METHODS: We included all patients who underwent endoscopic submucosal resection for gastric lesions between February 2009 and October 2016. Demographic data and information regarding the endoscopic resection, pathological report and follow-up were obtained. Statistical calculations were performed with Fisher's exact test and chi-square tests, with 95% confidence intervals. RESULTS: In total, 76% of the 51 lesions were adenocarcinomas, 16% were adenomas, and 8% had other diagnoses. The average size was 19.9 mm (±11.7). The average procedure length was 113.9 minutes (±71.4). The complication rate was 21.3%, with only one patient who needed surgical treatment (transmural perforation). Among the adenocarcinomas, 39.5% met the classic criteria for curability, 31.6% met the expanded criteria and 28.9% met the criteria for noncurative resection. Analysis of the indication criteria and curability revealed differences among cases with "only-by-size" expanded criteria (64.28%), other expanded criteria (40%) and classic criteria (89.47%), with a p-value of 0.049. During follow-up (15.8 months; ±14.3), 86.1% of the EGC patients had no recurrence. When well-differentiated and poorly differentiated lesions or lesions included in the classic and expanded criteria were compared, there were no differences in recurrence. The noncurative group presented a higher recurrence rate than the classic group (p=0.014). CONCLUSION: These results suggest that the Japanese endoscopic submucosal resection criteria might be useful for endoscopic treatment of EGC in Western countries.

Caracterização dos fenótipos de mucina podem prever a recorrência do câncer gástrico precoce após a mucosectomia endoscópica / Characterization of the mucin phenotype can predict gastric cancer recurrence after endoscopic mucosal resection

ABSTRACT BACKGROUND: Endoscopic mucosal resection is still considered an accepted treatment for early gastric cancer for selected cases. Histopathologic criteria for curative endoscopic resection are intramucosal well-differentiated adenocarcinoma, lateral and deep margins free of tumor, no histological ulceration, and no venous or lymphatic embolism. A 5% local recurrence rate has been described even when all the above-mentioned criteria are met. On the other hand, antigen expression by tumoral cells has been related to the biological behavior of several tumors. OBJECTIVE: To evaluate whether early gastric cancer mucin immunoexpression, p53 and Ki-67, can predict recurrence after endoscopic mucosal resection, even when standard histopathologic criteria for curative measures have been attempted. METHODS: Twenty-two patients with early gastric cancer were considered to have been completely resected by endoscopic mucosal resection. Local recurrence occurred in 5/22 (22.7%). Immunohistochemical study was possible in 18 (81.8%) resected specimens. Patients were divided in two groups: those with and those without local recurrence. They were compared across demographic, endoscopic, histologic data, and immunohistochemical factors for MUC2, MUC5a, CD10, p53, and Ki-67. RESULTS: Mucin immunoexpression allowed a reclassification of gastric adenocarcinoma in intestinal (10), gastric (2), mixed (4), and null phenotypes (2). Mixed phenotype (positive for both MUC2 and MUC5a) was found in 80% of cases in the local recurrence group, while the intestinal type (positive MUC2 and negative MUC5a) was found in 76.9% of cases without local recurrence (P=0.004). Other observed features did not correlate with neoplastic recurrence. CONCLUSION: The mixed phenotype of early gastric adenocarcinoma is associated with a higher probability of local recurrence after endoscopic mucosal resection.

RESUMO CONTEXTO: A ressecção endoscópica da mucosa é tratamento aceito para o tratamento do câncer gástrico precoce em casos selecionados. Os critérios histopatológicos favoráveis à ressecção endoscópica curativa são adenocarcinomas intramucosos, bem diferenciados, com margens lateral e profunda livres, ausência de ulceração ou de embolização angiolinfática. Taxas de recorrência local próximas a 5% têm sido descritas mesmo quando se cumprem tais critérios. Por outro lado, a expressão antigênica por células tumorais tem sido relacionada com o comportamento biológico de diversos tumores. OBJETIVO: Avaliar se a imunoexpressão de mucinas, p53 e Ki-67 podem predizer a recorrência tumoral após mucosectomia endoscópica no câncer gástrico precoce, mesmo se critérios de cura histopatológicos forem atingidos. MÉTODOS: Vinte e dois pacientes com critérios de cura para ressecção endoscópica e sumetidos a mucosectomia foram selecionados. A recorrência local ocorreu em 5/22 (22,7%). O estudo imunohistoquímico foi realizado em 18 (81,8%) espécimens. Os pacientes foram divididos em grupos com e sem recorrência local. Foram comparados quanto a dados demográficos, endoscópicos, histológicos e fatores imunohistoquímicos para MUC2, MUC5A, CD10, p53, e Ki-67. RESULTADOS: A imunoexpressão de mucinas permitiu a reclassificação dos adenocarcinomas gástricos em intestinal (10), gástrico (2), e de fenótipo misto (4) e nulo (2). Os fenótipos mistos (positivos tanto para MUC2 quanto para MUC5A) foram encontrados em 80% dos casos no grupo de recorrência local, enquanto tipos intestinais (MUC2 positivo e MUC5A negativo) foram identificados em 76,9% dos casos sem recorrência (P=0,004). Os outros fatores observados não se relacionaram com a recorrência tumoral. CONCLUSÃO: O fenótipo misto do câncer gástrico precoce está associado a maior probabilidade de recorrência local após a mucosectomia.

Strongyloides stercoralis hyperinfection: an unusual cause of gastrointestinal bleeding / Hiperinfecção por Strongyloides stercoralis: uma causa incomum de hemorragia digestiva

SummaryStrongyloidiasis is a parasitic disease that may progress to a disseminated form, called hyperinfection syndrome, in patients with immunosuppression. The hyperinfection syndrome is caused by the wide multiplication and migration of infective larvae, with characteristic gastrointestinal and/or pulmonary involvement. This disease may pose a diagnostic challenge, as it presents with nonspecific findings on endoscopy.

ResumoHiperinfecção por Strongyloides stercoralis: uma causa incomum de hemorragia digestiva A estrongiloidíase é uma parasitose que pode evoluir para uma forma disseminada, denominada síndrome de hiperinfecção, nos pacientes em estados de imunossupressão. A síndrome de hiperinfecção é ocasionada pela grande multiplicação e migração de larvas infectantes, com envolvimento gastrointestinal e/ou pulmonar característico. Essa doença pode representar um desafio diagnóstico, pois apresenta- se em achados inespecíficos à endoscopia.

Molecular markess of mucosa harboring gastric adenoass

Context Gastric adenoma is a precursor lesion of the adenocarcinoma. Objective To characterize gastric adenomas according to the mucin immunoexpression and to evaluate the immunoexpression of p53, p16ink4a, BCL-2, cyclin D, Ki-67, in the adenoma and in the gastric mucosa harboring adenoma. Methods Forty gastric specimens from 20 patients were classified as intestinal (MUC2 - goblet cell mucin) or foveolar (MUC5AC - gastric-foveolar mucin) adenomas. Immunohistochemistry was performed using streptavidin-biotin-complex method. Results Twelve (60%) patients were men. The mean age was 67.9 ± 12.9 years-old. Intestinal adenomas were detected in 13 (65%) patients and gastric type in 7 (35%). Low-grade dysplasia was present in 13 (65%) of the adenomas, high-grade in 3 (15%), and adenocarcinoma within the polyp in 4 (20%). Six (30%) patients had synchronous adenocarcinoma. p53 immunoexpression was observed in 6/20 (30%) of adenomas, and in 2/6 (33.3%) of synchronous tumors. There was an association between p53 immunoexpression and intestinal type of adenoma/tumor, P = 0.04. There was no association between p16ink4a, Bcl-2, cyclin D and Ki-67 and adenoma clinicopathological characteristics. Conclusion Immunohistochemistry may be useful to classify the adenomas subtypes and may define the pathway of adenoma to carcinoma sequence. .

Contexto Adenoma gástrico é uma lesão precursora do adenocarcinoma. Objetivo Melhor caracterizar os adenomas de acordo com a imunoexpressão de mucinas e avaliar a imunoexpressão de p53, p16ink4a, BCL-2, cyclin D, Ki-67, nos adenomas e na mucosa gástrica adjacente. Métodos Quarenta espécimes gástricos provenientes de 20 pacientes portadores de adenomas foram classificados como do tipo intestinal (MUC2 – mucina presente nas células caliciformes) ou gástrico (MUC5AC – mucinas de padrão foveolar). Realizou-se imunoistoquímica para p53, p16ink4a, BCL-2, cyclin D e Ki-67 pelo método do complexo da estreptavidina-biotina. Resultados Doze (60%) pacientes eram homens e a média de idade foi de 67,9 ± 12,9 anos. Os adenomas foram classificados como do tipo intestinal em 13 (65%) pacientes e do tipo gástrico em 7 (35%). Displasia (neoplasia intraepitelial) de baixo grau estava presente em 13 (65%), displasia de alto grau em 3 (15%), e adenocarcinoma no pólipo adenomatoso em 4 (20%) pacientes. Observou-se immunoexpressão do p53 em 6/20 (30%) adenomas, e em 2/6 (33,3%) dos tumores sincrônicos. Houve associação entre imunoexpressão do p53 e adenoma/tumor tipo intestinal, P = 0.04. Não houve associação entre imunoexpressão do p16ink4a, Bcl-2, ciclina D e Ki-67 e as características clinicopatológicas dos adenomas. Conclusão Imunoistoquímica pode ser utilizada para caracterizar os subtipos de adenoma e talvez indicar o caminho de carcinogênese. .

Colangiografia endoscópica retrograda com o endoscópio de duplo balão em paciente submetido à gastrectomia total em Y de Roux / Endoscopic retrograde cholangiography with double-balloon endoscope in patient with a Roux-en-y total gastrectomy

A endoscopia de duplo-balão tornou-se impor»tante procedimento na avaliação endoscópica das afecções do intestino delgado. Sua capacidade de intubação profunda ampliou suas indicações para o acesso de órgãos cirurgicamente deriva»dos e com a anatomia alterada. Os autores rela»tam caso de paciente de 56 anos, submetido àgastrectomia total com reconstrução em "Y" de Roux por câncer gástrico que evoluiu com cole»docolitíase, em que foi realizada colangiografia endoscópica retrógrada com papilotomia e re»moção dos cálculos com o uso do enteroscópio de duplo-balão.

Enteroscopia de duplo-balão para diagnóstico de linfomas do intestino delgado: relatos de caso / double-balloon enteroscopy to diagnose small bwel lymphomas: case reports

Os linfomas do intestino delgado são entidades raras e seu diagnóstico é muitas vezes difícil. Recentemente, a enteroscopia de duplo-balão foi idealizada com o objetivo de aprimorar o diagnóstico de doenças que afetam o intestino delgado, permitindo também a realização de biópsias em todo o trajeto desse órgão. Neste artigo, apresentam-se 3 casos diagnosticados como linfomas de intestino delgado através da técnica de enteroscopia de duplo-balão