Rectal cancer: local recurrence after surgery without radiotherapy.

PURPOSE: This study was designed to assess the local recurrence rate and prognostic factors for local recurrence in patients undergoing curative anterior or abdominoperineal resections without radiotherapy. METHODS: From January 1980 to December 1996, 514 consecutive patients underwent curative resections for rectal cancer. We excluded those with preoperative radiotherapy (n = 23), postoperative radiotherapy (n = 27), local resection (n = 36), and 11 (2.1 percent) patients who died postoperatively. The remaining 417 patients (249 males) with a median age of 64 (range, 21-90) years were analyzed. For upper third lesions, mesorectal tissue was excised down to at least 5 cm below the tumor. Total mesorectal excision was performed for lower and middle tumors. Postoperative chemotherapy was limited to patients with Stage III lesions. Median follow-up (and 95 percent confidence interval) was (5.2 4.3-5.9) years, with 87.7 percent of patients followed up longer than 24 months. Local recurrence was defined as any recurrence within the field of resection, regardless of the presence or absence of distant metastasis. RESULTS: Five-year local recurrence rate(and 95 percent confidence interval) was 9.7 (6.4-13) percent, with a median time to diagnosis of 15 (10-23) months. Local recurrence rates in Stages I, II, and III were: 3.1, 4.1, and 24.1 percent, respectively (P < 0.0001). In relation to node status, local recurrence rates were N0, 4.1 (1.7-6.5) percent; N1, 12.6 (4.6-20.6) percent; N2, 32.1 (12.1-52.1) percent; and N3, 59.3 (22.5-96.1) percent; (P < 0.00001). Lower third tumors had a higher local recurrence rate than middle and upper third tumors: 17.9, 7.1, and 5.1 percent, respectively (P = 0.002). Adjusted by stage, this difference was maintained only in Stage III tumors. Among lower tumors, those at 6 and 7 cm from the anal verge had a lower local recurrence rate than those below 6 cm (6.7 vs. 26.2 percent, respectively; P = 0.02). Accidental rectal perforation at or near the tumor site occurred in 12 cases (2.9 percent), showing a strong correlation with local recurrence (P < 0.0001). Multivariate analysis showed significant higher risk for lower third tumors (hazard ratio, 2.98) and positive nodes (hazard ratio, 4.78). CONCLUSIONS: Appropriate surgery without irradiation achieves excellent local control in N0 rectal cancers. Node metastasis, lower third localization (especially below 6 cm), and accidental rectal perforation at or near the tumor site are significantly associated with a higher local recurrence rate.

Lipoid proteinosis of the small bowel.

We describe a 65-year-old-man who presented with acute gastrointestinal bleeding secondary to massive submucosal deposits of hyaline material in the small bowel. The histochemical and ultrastructural features of the hyaline substance were typical of lipoid proteinosis, a rare cutaneous disorder in which, to our knowledge, symptomatic compromise of internal organs has not been described previously. The patient was later found to have mild but characteristic mucocutaneous lesions of lipoid proteinosis, as well as asymptomatic deposits in other gastrointestinal sites. Our case documents that severe visceral involvement may occur in lipoid proteinosis, even in previously undiagnosed patients with mild cutaneous manifestations of the disease.

Antigenic markers of hepatocellular carcinoma.

One hundred thirty-five hepatocellular carcinomas were examined for the presence of antigenic tumor markers by the avidin-biotin-peroxidase complex method. Ninety-seven were from the US and 38 came from Argentina. The following markers were tested: alpha-fetoprotein (AFP), alpha-1-antitrypsin (AAT), hepatitis B surface antigen (HBsAg), hepatitis B core antigen (HBcAg), hepatitis D delta antigen (HD delta Ag), and Mallory's bodies (MB). In the US cases, AFP was present in 43%, AAT in 41%, HBsAg in 17%, and MB in 48%. Both HBcAg and HD delta Ag were absent. In the cases from Argentina, AFP was found in 26% and AAT in 18%. None of the other antigens were seen. Thirteen US tumors expressed three antigens and two four antigens simultaneously. This study reveals in humans a heterogenous expression of antigens by neoplastic hepatocytes with geographic differences, possibly due to multiple factors such as alcohol consumption or prevalence of hepatitis B infection.

Concanavalin A binding sites in fetal, adult, transitional, and malignant rectosigmoid mucosa.

We studied mucin histochemistry in 25 rectosigmoid adenocarcinomas and in the transitional mucosa adjacent to these tumors using standard techniques for the detection of neutral and acid sialomucins and sulfomucins and the paradoxical concanavalin A (Con A) stain. This histochemical procedure selectively detects residues of mannose in glycoproteins exposed to brief steps of oxidation and reduction. Those techniques were also used to study histologically normal mucosa of specimens with carcinoma, normal rectosigmoid mucosa of patients without inflammatory or neoplastic bowel disease, hyperplastic rectal polyps, and rectosigmoid mucosa of human fetuses. Normal mucosa and hyperplastic polyps mainly contained sulfomucins and did not display Con A binding activity with any of the variants of the stain. In contrast, fetal, transitional, and malignant mucosa predominantly showed sialomucins and although not reactive with the standard Con A sequence, displayed binding activity for the lectin after short oxidative-reductive steps. These results provide further evidence that transitional and malignant mucosa produce markedly abnormal mucins whose histochemical patterns represent a re-emergence of the fetal type found during development. The principles of the paradoxic Con A reaction may be applied to unmask lectin binding activity in apparently unreactive sites.

[Gastric carcinoid polyp and type A atrophic gastritis]. / Pólipo carcinoide gástrico y gastritis atrófica tipo A.

Three cases of gastric carcinoid polypi associated to atrophic gastritis and high levels of seric gastrin, are presented. One of the cases was a multiple micropolyposis the literature regarding this association is reviewed and the therapy discussed. Tumors of greater than 2 cm have to be considered potentially malignant and be treated likewise. The treatment of the micropolyposis is not well established.

Maternal vascular lesions in placentae of small-for-gestational-age infants.

Placentae from 140 term pregnancies were studied. Seventy-four were from uncomplicated pregnancies in which the neonates were within the normal weight range for their gestational age. The remaining 66 placentae were from pregnancies whose infants were small for gestational age (SGA). In eight cases of this latter group a curettage of placental bed was performed during caesarean section. Maternal arterial vessels with absence of trophoblastic migration were observed in basal decidua and basal plate, and acute atherosis in parietal decidua, basal decidua and basal plate, all of them in cases of the SGA group. Furthermore, chronic vasculitis-like lesions were observed in the parietal decidua of three cases from the SGA group and in two others of the control group. No vascular lesions were found in cases of the control group when an infant's birthweight was above the 25th percentile of the normal ponderal range. Atheromatous-like lesions have been described in placental bed arteries in pre-eclampsia, systemic lupus erythematosus and SGA infants: this type of vasculopathy has also been described in rejection of renal transplants. Moreover, lesions similar to those found in chronic vasculitis were also described in the latter pathological entity. It is suggested that these vasculopathies may represent different steps of the same lesion. On the other hand, they may also be the expression of a maternal immunological attack on placental tissues causing a deficit of placentation, low birthweight being the consequence of this deficit.

A nodule of adrenocortical tissue within a human placenta: light microscopic and immunocytochemical findings.

A case of adrenocortical tissue within a human placenta is described, this being the second example of such a phenomenon. Immunocytochemistry showed that the adrenal tissue reacted positively for DHEA-S but negatively for 17-OH progesterone and cortisol. This suggests that the heterotopic adrenal tissue resembled metabolically the fetal zone of the adrenal cortex.

Tumores gastricos malignos. Analisis de nuestra experiencia y factores de prognostico. / Malignant gastric tumors. Analysis of our experience and prognostic factors

Se presentan 351 casos de tumores gastricos malignos tratados en la decada 19701.516 carcinomas tratados. Trece perteneutiles para este estudio. El 95,3% fueron carcinomas y solo el 4,6% sarcomas, entre estos ultimos predominaron los linfosarcomas (2,8%). La incidencia del carcinoma temprano fue del 11,2%. Tumores del munongastrico fueron detectados en 7 oportunidades (2,1%). El grado de penetracion del tumor en la pared del estomago P < 0,003, la presencia de ganglios linfaticos regionales positivos p < 0,003, y el tipo histologico segun Lauren p < 0,005, resultaron parametros significativamente utiles para efectuar el pronostico. Las clasificaciones de Broders p < 0,3125 y Borman P < 0,002 fueron menos utiles en este sentido. Un 75% de los tumores pudieron ser resecados con criterio radical. La mortalidad global de la serie fue del 16% e incluye gastrectomia total, subtotal y polar superior. En las intervenciones paliativas se elevo al 24,2%. En los ultimos 5 anos estas cifras descendieron en forma importante; al 4,4% la mortalidad global y al 3,7% y 3,8% para la gastrectomia subtotal y respectivamente. Los motivos de estos resultados favorables figuran en el trabajo

Tumores gastricos malignos. Analisis de nuestra experiencia y factores de prognostico. / Malignant gastric tumors. Analysis of our experience and prognostic factors

Se presentan 351 casos de tumores gastricos malignos tratados en la decada 19701.516 carcinomas tratados. Trece perteneutiles para este estudio. El 95,3% fueron carcinomas y solo el 4,6% sarcomas, entre estos ultimos predominaron los linfosarcomas (2,8%). La incidencia del carcinoma temprano fue del 11,2%. Tumores del munongastrico fueron detectados en 7 oportunidades (2,1%). El grado de penetracion del tumor en la pared del estomago P < 0,003, la presencia de ganglios linfaticos regionales positivos p < 0,003, y el tipo histologico segun Lauren p < 0,005, resultaron parametros significativamente utiles para efectuar el pronostico. Las clasificaciones de Broders p < 0,3125 y Borman P < 0,002 fueron menos utiles en este sentido. Un 75% de los tumores pudieron ser resecados con criterio radical. La mortalidad global de la serie fue del 16% e incluye gastrectomia total, subtotal y polar superior. En las intervenciones paliativas se elevo al 24,2%. En los ultimos 5 anos estas cifras descendieron en forma importante; al 4,4% la mortalidad global y al 3,7% y 3,8% para la gastrectomia subtotal y respectivamente. Los motivos de estos resultados favorables figuran en el trabajo

Granulomatosis linfomatoidea del pulmon. A proposito de dos casos. / Lymohomatoid granulomatosis of the lung.Apropos of 2 cases

Se presentan 2 casos de granulomatosis linfomatoidea del pulmon.El diagnostico se establecio por biopsia-reseccion de las lesiones. El tratamiento se realizo con quimioterapia (ciclofosfamida) en un caso y corticoideoterapia mas quimioterapia (ciclofosfamida) e irradiacion, en el otro La evolucion de ambos fue mala, falleciendo a los 3 y 15 meses del diagnostico respectivamente. Se efectuan consideraciones sobre la afeccion, la que constituye una vasculitis granulomatosa, de etiologia desconocida e incierta.Presenta semajanzas clinicas con la granulomatosis de Wegener, pero se diferencia de esta por presentar frecuentemente lesiones del sistema nervioso central y piel y por la ausencia de glomerulonefritis y/o lesiones del tracto respiratorio superior. El curso clinico es agresivo y frecuentemente fatal a corto plazo. El papel de los corticoides, citostaticos e irradiacion en el tratamiento esta aun en controversia

Granulomatosis linfomatoidea del pulmon. A proposito de dos casos. / Lymohomatoid granulomatosis of the lung.Apropos of 2 cases

Se presentan 2 casos de granulomatosis linfomatoidea del pulmon.El diagnostico se establecio por biopsia-reseccion de las lesiones. El tratamiento se realizo con quimioterapia (ciclofosfamida) en un caso y corticoideoterapia mas quimioterapia (ciclofosfamida) e irradiacion, en el otro La evolucion de ambos fue mala, falleciendo a los 3 y 15 meses del diagnostico respectivamente. Se efectuan consideraciones sobre la afeccion, la que constituye una vasculitis granulomatosa, de etiologia desconocida e incierta.Presenta semajanzas clinicas con la granulomatosis de Wegener, pero se diferencia de esta por presentar frecuentemente lesiones del sistema nervioso central y piel y por la ausencia de glomerulonefritis y/o lesiones del tracto respiratorio superior. El curso clinico es agresivo y frecuentemente fatal a corto plazo. El papel de los corticoides, citostaticos e irradiacion en el tratamiento esta aun en controversia

Chronic villitis of unknown aetiology in placentae of idiopathic small for gestational age infants.

Placentae from 63 term pregnancies were studied. Of these, 19 were from normal pregnancies in which the neonates were within the normal weight range for their gestational age. The remaining 44 placentae were from pregnancies in which the infants were small for their gestational age (SGA). A chronic villitis was found in 68 per cent of all placentae. In the control group this lesion was present in 26 per cent but a mean of only 1.2 per cent of villi in these cases was inflamed. In the SGA group 86 per cent of placentae showed a chronic villitis and in these an average of 10 per cent of the villi were inflamed. Lymphocytic infiltrates in basal plate anchoring villi were observed in 48 of the 63 placentae and there were no differences among the various groups. Vascular lesions were found, similar to those described in placental bed arteries in preeclampsia and more recently in biopsies of the placental bed of SGA infants and in the decidua of mothers with systemic lupus erythematosus: this type of vasculopathy has also been described in rejection of renal transplants. It is suggested that the cellular infiltrate around and inside anchoring villi and free villi in cases of chronic villitis may represent the histological hallmark of an immunological reaction between mother and fetus rather than a response to infection.