10例直肠基底细胞样鳞状细胞癌组织化学及免疫组化观察

目的探讨直肠基底细胞样鳞状细胞癌(BSCC)的组织化学、免疫组化特征及在病理诊断中的作用。方法收集10例直肠BSCC分别作HE、组织化学及免疫组化染色,同时收集10例典型鳞状细胞癌(SCC)作对照。结果BSCC主要由密集的小细胞组成,排列成实体小叶状及假腺样(筛网状),并见粉刺样坏死及基底膜样物质沉积(PAS ),8例BSCC均见不同分化程度的鳞状细胞癌成分,2例见局灶性鳞状细胞分化。免疫组化基底细胞样成分Ker(AE1/AE3)、Ker14、PCNA、LM及P53均阳性,Ker19,8例基底细胞样成分及4例伴随鳞癌成分同时阳性;Syn仅2例BSCC阳性,10例SCCKer(AE1、AE3)均阳性,6例Ker14弱阳性,4例Ker19弱阳性。10例BSCC和BCC其S100、CgA、NSE及SMA均阴性。结论BSCC是鳞状细胞癌独特的组织学类型,进行组织化学及免疫组化染色有助于BSCC诊断及鉴别诊断。     

Tumeur stromale rectale : à propos d’une observation

Gastro-intestinal stromal tumors are uncommon mesenchymal tumors. There are localized preferentially in the stomach. The rectal localization is exceedingly rare. Through a new case of rectal stromal tumour as well as a review of the literature, we propose to focus on clinical, radiological and therapeutic particularities of this rare entity.     

A study on planning organ at risk volume for the rectum using cone beam computed tomography in the treatment of prostate cancer

In this study, we analyzed planning organ at risk volume (PRV) for the rectum using a series of cone beam computed tomographies (CBCTs) acquired during the treatment of prostate cancer and evaluated the dosimetric effect of different PRV definitions. Overall, 21 patients with prostate cancer were treated radically with 78 Gy in 39 fractions had in total 418 CBCTs, each acquired at the end of the first 5 fractions and then every alternate fraction. The PRV was generated from the Boolean sum volume of the rectum obtained from first 5 fractions (PRV-CBCT-5) and from all CBCTs (PRV-CBCT-All). The PRV margin was compared at the superior, middle, and inferior slices of the contoured rectum to compare PRV-CBCT-5 and PRV-CBCT-All. We also compared the dose received by the planned rectum (Rectum-computed tomography [CT]), PRV-CBCT-5, PRV-CBCT-All, and average rectum (CBCT-AV-dose-volume histogram [DVH]) at critical dose levels. The average measured rectal volume for all 21 patients for Rectum-CT, PRV-CBCT-5, and PRV-CBCT-All was 44.3 ± 15.0, 92.8 ± 40.40, and 121.5 ± 36.7 cm³, respectively. For PRV-CBCT-All, the mean ± standard deviation displacement in the anterior, posterior, right, and left lateral directions in centimeters was 2.1 ± 1.1, 0.9 ± 0.5, 0.9 ± 0.8, and 1.1 ± 0.7 for the superior rectum; 0.8 ± 0.5, 1.1 ± 0.5, 1.0 ± 0.5, and 1.0 ± 0.5 for the middle rectum; and 0.3 ± 0.3; 0.9 ± 0.5; 0.4 ± 0.2, and 0.5 ± 0.3 for the inferior rectum, respectively. The first 5 CBCTs did not predict the PRV for individual patients. Our study shows that the PRV margin is different for superior, middle, and the inferior parts of the rectum, it is wider superiorly and narrower inferiorly. A uniform PRV margin does not represent the actual rectal variations during treatment for all treatment fractions. The large variation in interpatient rectal size implies a potential role for adaptive radiotherapy for prostate cancer.     

Utility of reassessment after neoadjuvant therapy and difficulties in interpretation

We describe the main tools for MR assessment of the response of rectal cancer tumors after chemotherapy, before surgery. In locally advanced cases of rectal and lower rectal cancer, MR is useful in allowing the treatment strategy to be adjusted, enabling conservative surgery to be performed if the patient responds well. The different types of response (fibrous, desmoplastic and colloid), their appearances and difficulties in MR interpretation are described. We describe the features and performance of MR after neoadjuvant therapy for T and N staging, assessment of circumferential resection margin and diffusion weighted imaging. Quantitative (change in tumor volume) and qualitative (grade of tumor response) MR assessment can distinguish good responders from poor responders.     

Pseudoaneurysm rupture causing hemoperitoneum following rectal impalement injury: A case report

IntroductionAlthough vascular anatomy of the rectum is complex, pseudoaneurysm followed by massive hemoperitoneum after rectal impalement injury is extremely rare.Case presentationA 43-year-old man presented with abdominal distension. One day earlier, he had undergone sigmoid loop colostomy for rectal implement injury at a local hospital. After the operation, he had become hemodynamically unstable. Digital rectal examination showed a penny-sized anterior rectal wall defect 6 cm from the anal verge. Computed tomography (CT) revealed a hematoma (12 × 10 × 15 cm) with bleeding in the pelvic cavity and an adjacent pseudoaneurysm in the rectum. A large amount of blood and massive hematoma were evacuated by surgery. The Hartmann procedure was performed, but the pseudoaneurysm was not resected. On the 11th postoperative day, hemoglobin decreased (11.6 g/dL–7.9 g/dL), and CT revealed a recurrent hematoma (6.0 × 4.2 cm) in the pelvic cavity, with a residual pseudoaneurysm. Angiography failed to localize the pseudoaneurysm. Consequently, prophylactic embolization at the anterior branch of both the internal iliac arteries was performed. The subsequent hospitalization course was uneventful.DiscussionRectal impalement injury may result in pseudoaneurysm of the rectal arteries. However, pseudoaneurysm rupture of the mid rectal artery, followed by massive hemoperitoneum, has not been reported in the English literature. From our experience, preoperative diagnosis of a pseudoaneurysm is crucial for definite surgical management. When surgical resection is indicated, it should include the underlying pseudoaneurysm.ConclusionAlthough pseudoaneurysm rupture causing hemoperitoneum after a rectal impalement injury is extremely rare, meticulous preoperative evaluation is necessary for correct management.     

Comparison between the ICRU rectal point and modern volumetric parameters in brachytherapy for locally advanced cervical cancer

PurposeThe implementation of image-guided brachytherapy in cervical cancer raises the problem of adapting the experience acquired with 2D brachytherapy to this technique. The GEC-ESTRO (Groupe européen de curiethérapie – European Society for Radiotherapy and Oncology) has recommended reporting the dose delivered to the rectum in the maximally exposed 2 cm³ volume, but so far, the recommended dose constraints still rely on 2D data. The aim of this study was to evaluate the relationship between the doses evaluated at the ICRU rectal point and modern dosimetric parameters.Material and methodsFor each patient, dosimetric parameters were generated prospectively at the time of dosimetry and were reported. For analysis, they were converted in 2 Gy equivalent doses using an α/β ratio of 3 with a half-time of repair of 1.5 hours.ResultsThe dosimetric data from 229 consecutive patients treated for locally advanced cervical cancer was analyzed. The mean dose calculated at ICRU point (DICRU) was 55.75 Gy ± 4.15, while it was 59.27 Gy ± 6.16 in the maximally exposed 2 cm³ of the rectum (P = 0.0003). The D2 cm³ was higher than the DICRU in 78% of the cases. The mean difference between D2 cm³ and DICRU was 3.53 Gy ± 4.91. This difference represented 5.41% ± 7.40 of the total dose delivered to the rectum (EBRT and BT), and 15.49% ± 24.30 of the dose delivered when considering brachytherapy alone. The two parameters were significantly correlated (P = 0.000001), and related by the equation: D2 cm³ = 0.902 × DICRU + 0.984. The r² coefficient was 0.369.ConclusionIn this large cohort of patients, the DICRU significantly underestimates the D2 cm³. This difference probably results from the optimization process itself, which consists in increasing dwell times above the ICRU point in the cervix. Considering these findings, caution must be taken while implementing image-guided brachytherapy and dose escalation.     

Usefulness of a state-legislated,comparative database to evaluate quality in colorectal surgery

PURPOSE: Colorectal surgery, a high-volume procedure, has been targeted for performance improvement to reduce length of stay. Specific postoperative quality indicators and readmission rates should be analyzed concomitantly to assure that adverse events are not associated with earlier discharge. METHODS: From July 1, 1990, to June 30, 1997, 1,218 consecutive patients who underwent transabdominal colorectal surgery were analyzed for length of stay, mortality, morbidity, and discharge disposition. Each patient was assigned an Admission Severity Group rating 0 to 4 using a hospital-based state-legislated software system (Atlas) to validate comparative performance internally and externally. Readmission data within 120 days of discharge were available for the last 678 consecutive patients from July 1, 1993, to June 30, 1997, using Lastword (computerized medical records). RESULTS: The annual frequencies of the 1,218 procedures were 173, 183, 175, 146, 167, 189, and 185, respectively, from July 1990 through June 1997. Severity distribution was 32 for Admission Severity Group 0, 517 for Admission Severity Group 1, 540 for Admission Severity Group 2, 128 for Admission Severity Group 3, and 1 for Admission Severity Group 4, with no annual difference (P=0.012). There was a significant reduction in total length of stay of 3.1 (12.9–9.8) days during the seven years (P=0.001). The overall operative mortality rate was 1.4 percent, and the morbidity was 2.6 percent, with no annual differences (P=0.655 andP=0.033, respectively). The disposition to home did not change (P=0.21). Of the 678 patients followed up for readmission, 100 (14.7 percent) were readmitted within 120 days, with no annual difference (P=0.302). CONCLUSION: Mortality, morbidity, disposition, and readmission rates were not affected by a decreased length of stay after colorectal surgery.Presented at the Research Forum at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio, Texas, May 2 to 7, 1998.     

Fever Evaluations after Colorectal Surgery: Identification of Risk Factors that Increase Yield and Decrease Cost

Purpose This study was designed to evaluate the yield and cost of fever evaluations in average-risk inpatients after elective colorectal surgery. Methods A 12-month, retrospective study was performed on patients who developed a postoperative fever ≥ 38°C after elective colorectal surgery. A positive fever evaluation was defined as a blood culture, urine culture, chest x-ray, or abdominal CT result that led to a change in patient management. Logistic regression, Fisher’s exact test, and chi-squared test were used; odds ratios were calculated. Results Of 133 patients, 26 percent had a positive evaluation. Blood culture, urine culture, chest x-ray, and CT were positive in 3, 8, 7, and 46 percent, respectively. Risk factors for a positive fever evaluation were temperature ≥ 38.5°C, fever evaluation after postoperative Day 6, and a clinical manifestation of systemic inflammatory response syndrome other than fever (all, P < 0.01). The cost per positive fever evaluation for the entire group, patients with 2 risk factors, or patients with 3 risk factors was $5,600, $4,200, and $2,140, respectively. Conclusions The current approach to fever evaluation after elective colorectal surgery is low yield and costly. High fever, late postoperative fever, and systemic inflammatory response syndrome are risk factors for a positive fever evaluation after colorectal surgery. Read at meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 7, 2007.