Local resection of ampullary tumors

There is no consensus on the appropriateness of local resection for ampullary tumors, because malignant recurrence of what were thought to be benign tumors has been reported. This study examined the role of local resection in the management of ampullary tumors. Thirty patients (mean age 66 years) had transduodenal local resections performed at UCSF-Moffitt Hospital or the San Francisco VA Medical Center (February, 1992 to March, 2004). Mean follow-up time was 5.8 years. Preoperative biopsies (obtained in all patients) showed 18 adenomas, four adenomas with dysplasia, five adenomas with atypia, one adenoma with dysplasia and focal adenocarcinoma, and two tumors seen on endoscopy, whose biopsies showed only duodenal mucosa. In comparison with the final pathology findings, the results of frozen section examinations for malignancy in 20 patients, during the operation, were false-negative in three cases. The final pathologic diagnosis was 23 villous adenomas, six adenocarcinomas, and one paraganglioma. On preoperative biopsies, all patients who had high-grade dysplasia and one of five patients with atypia turned out to have invasive adenocarcinoma when the entire specimen was examined postoperatively. Two (33%) adenocarcinomas recurred at a mean of 4 years; both had negative margins at the initial resection. Among the 23 adenomas, three (13%) recurred (all as adenomas) at a mean of 3.2 years; in only one of these cases was the margin positive at the time of resection. Tumor size did not influence recurrence rate. Ampullary tumors with high-grade dysplasia on preoperative biopsy should be treated by pancreaticoduodenectomy because they usually harbor malignancy. Recurrence is too common and unpredictable after local resection of malignant lesions for this to be considered an acceptable alternative to pancreaticoduodenectomy. Ampullary adenomas can be resected locally with good results, but the recurrence rate was 13%, so endoscopic surveillance is indicated postoperatively. Frozen sections were obtained during the operation, but they were less reliable than expected. No adenomas recurred as carcinomas, suggesting that local resection is appropriate for these tumors in the absence of dysplasia or atypia on preoperative biopsies. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (poster presentation).     

Primary tubulovillous adenoma of the urinary bladder: Case report and literature review

Primary tubulovillous adenomas are scarcely encountered in the urinary tract, and most of these tumors arise from the intestinal segments of urinary reconstruction. We report the extremely rare case of tubulovillous adenomas primarily occurring in the urinary bladder in this article. A 50-year-old female patient initially presented with painless gross hematuria for several times within 1 month. Image studies, including abdominal ultrasonography and computed tomography, demonstrated one urinary bladder tumor with suspicious perivesical invasion. The diagnosis was made by a transurethral resection and histopathology, and no involvement of muscularis propria was confirmed. Although the pathogenesis and clinical behavior are not well understood, tubulovillous adenomas may have a tendency to undergo malignant transformation into the form of invasive adenocarcinomas. Complete resection and rigorous follow-up are strongly recommended.     

Villous and tubulovillous adenomas of the colon and rectum. A retrospective review, 1964-1985

The records of 1,040 patients with 1,440 villous and tubulovillous adenomas of the colon and rectum treated at the Cleveland Clinic over a 21 year period were reviewed. The incidence of invasive adenocarcinoma was higher in patients with multiple adenomas at the time of presentation, in patients with a family history of colorectal cancer, and in those with adenomas greater than 4 cm in diameter. Eighty percent of the adenocarcinomas were Dukes' A or B, 15 percent were Dukes' C, and 5 percent presented with distant metastases. Clinical impression on examination was more accurate than biopsy in assessing the presence of malignancy in these tumors. Recurrence after local treatment of both benign and malignant tumors was high. Recurrence was significantly related to the size of the adenoma (more common when the tumor was more than 4 cm in diameter), location (more common when it was located in the rectum), and the type of treatment. Only 4 percent of the patients had died from colorectal cancer at the time of follow-up. The overall 5 year actuarial survival rate was 85 percent.     

Colorectal villous and tubulovillous adenomas equal to or greater than four centimeters.

The records of 237 patients treated for benign and malignant villous and tubulovillous adenomas at Roswell Park Memorial Institute from 1963 to 1987 were reviewed. Sixty-five adenomas were greater than or equal to 4 cm and form the basis of this report. Fifteen (23%) were in the cecum, 3 (5%) in the right colon, 1 (1%) in the splenic flexure, 10 (15%) in the sigmoid colon, and 36 (55%) in the rectum. The most common symptoms were rectal bleeding (70%), mucus diarrhea (44%), constipation (22%), and tenesmus (19%). Fifty-five (85%) of these large adenomas contained invasive adenocarcinoma and one in situ carcinoma. Two thirds of invasive carcinomas arose from predominantly villous adenomas and one third from tubulovillous adenomas. Half of all malignant adenomas demonstrated metastases to regional lymph nodes or distant metastases. Seven malignant adenomas (12%) were associated with synchronous adenocarcinomas of the colon, and 29% of malignant adenomas were associated with synchronous adenomatous polyps, principally tubular type. Four of nine benign, large adenomas were associated with synchronous adenomas but with no adenocarcinomas. No relationship was found between the size of the adenoma, location, or Dukes' stage. Though the incidence of in situ and invasive carcinomas is clearly related to the size of the adenoma, a linear relationship could not be demonstrated.     

Villous tumors of the rectum. 50 cases treated surgically

The authors report a study of 50 patients who underwent surgery for a villous adenoma between 1978 and 1988 (29 men and 21 women). Mean age was 70 years old. 84% of the lesions were sessile. They ranged from 1 to 15 centimeters in size. They were associated 12 times with colon adenomas and 3 times with adenocarcinomas. All these lesions were biopsied preoperatively. Removal was performed: in 38% of cases vie a transanal approach in 38% of cases by colorectal resection vie an abdominal approach in 12% of cases by rectal amputation vie both an abdominal and perineal approach, in 12% of cases by Kraske's procedure. 22 adenocarcinomas and 28 benign lesions were discovered. 2 patients died in the early post-operative course after colorectal resection performed vie an abdominal approach. At long term (minimum of 2 years) there were 5 complications and 9 recurrences, the later occurring after tumorectomies. It is essential to know the lesions histologic characteristics in order to administer appropriate therapy, but this is not only possible to determine precisely before excision. Even biopsy specimens may miss the malignant portion of a lesion. Only complete pathological examination of the tumor can establish the diagnosis of a malignancy. Surgery remains the principal method of treatment of these lesions because it permits complete histologie examination and properly adapted management: simple removal for benign tumors or those with malignant degeneration in situ, wide excision for invasive tumors.     

Increased endocrine cells in treated rectal adenocarcinomas: a possible reflection of endocrine differentiation in tumor cells induced by chemotherapy and radiotherapy

The presence of focal endocrine cells in colorectal adenocarcinoma is a relatively common phenomenon. However, endocrine differentiation in treated adenocarcinomas of the gastrointestinal tract has received little attention. We noted striking numbers of cells with endocrine morphology and phenotype in the residual tumor of six randomly encountered cases of rectal adenocarcinoma that were subjected to neoadjuvant therapy. All six cases had a substantial treatment response (> or =50%). To validate our initial observation and to explore its clinicopathologic significance, further morphologic and immunohistochemical studies were performed on 53 cases of rectal adenocarcinomas treated with preoperative radiation with (33 cases) or without (20 cases) chemotherapy. Pretreatment biopsies from 20 of the 53 cases and 79 resection specimens of rectal adenocarcinoma that received no neoadjuvant therapy were used as controls. Chromogranin positivity was identified in the posttreatment resection specimens in 36 of the 53 study cases (67.9%). Twenty of the 36 showed positive staining in > or =20% of the residual tumor cells. The chromogranin-positive cells in these cases often formed cords or nests. On hematoxylin and eosin sections these cells had markedly eosinophilic cytoplasm and round and uniform or sometimes pleomorphic nuclei with an often dense chromatin pattern. The proportion of chromogranin-positive cells was significantly associated with the extent of treatment response (p = 0.0005). Tumors treated with both chemotherapy and radiotherapy were more likely to have abundant chromogranin-positive cells compared with tumors treated with radiotherapy alone (p = 0.0004). In contrast, only 30% of the pretreatment biopsies and 17.7% of the control resection specimens of untreated rectal carcinomas showed chromogranin-positive cells, predominantly arranged as scattered individual positive cells, constituting <10% of the tumor. No significant correlation was observed between pretreatment and posttreatment specimens with regard to chromogranin positivity (p = 1.0). Ten of 15 patients (66.7%) whose resection specimens showed positive chromogranin staining failed to demonstrate any chromogranin positivity in their pretreatment biopsy specimens. In addition, groups or nests of chromogranin-positive cells noted in posttreatment specimens showed a very low Ki67 labeling index (<5%) but showed a frequency of abnormal p53 protein expression comparable with that observed in tumor foci resembling conventional adenocarcinoma (66.7% vs 62.5%). Our findings demonstrate that there is an increased frequency and density of cells with an endocrine phenotype in rectal adenocarcinomas that were subjected to neoadjuvant therapy and that the extent of endocrine cells appears proportional to the degree of treatment response. The possible mechanism for the increased endocrine cells in treated rectal adenocarcinomas may be related to induction of endocrine differentiation in tumor cells by cytotoxic insult.     

High-grade prostatic intraepithelial neoplasialike ductal adenocarcinoma of the prostate: a clinicopathologic study of 28 cases

Most of the prostatic ductal adenocarcinomas of the prostate are characterized by cribriform and/or papillary architecture lined by columnar pseudostratified malignant epithelium. We report 28 cases of ductal adenocarcinomas on needle biopsy and transurethral resection of prostate closely resembling high-grade prostatic intraepithelial neoplasia (HGPIN) composed of simple glands with flat, tufting, or micropapillary architecture. The mean age of the patients was 68 years (range, 50 to 91 y). Prostate specific antigen serum level at diagnosis ranged from 1.2 to 12.1 ng/mL. Treatment included radical prostatectomy (n=9), hormone therapy (n=7), radiotherapy (n=5), and cryotherapy (n=1). Three patients had recent biopsies without information on treatment and 3 patients were lost to follow-up after diagnosis. The number of cores involved by tumor in each case ranged from 1 to 18, with more than 1 core involved in 13 cases. Flat was the most common pattern (42%), followed by tufted (41%), and micropapillary (17%) (some with more than 1 pattern). Fourteen cases revealed segments of dilated gland on the edge of the biopsies, suggesting a large gland component. In radical prostatectomies, tumor was primarily composed of small (25%), medium (17%), or cystically dilated (58%) cancer glands, with all cases demonstrating a mixture of different gland sizes. Cytologically, tumors were characterized by tall columnar atypical cells, basally located nuclei, and amphophilic cytoplasm. The tumors lacked marked pleomorphism, necrosis, solid areas, cribriform formation, or true papillary fronds. Immunohistochemically, alpha-methyl acyl coenzyme-A racemase staining was seen in 93% of cases, with the majority showing strong and diffuse staining. No basal cells were present on p63 and/or high molecular weight cytokeratin staining. In the radical prostatectomy specimens, tumor volumes ranged from a small focus (less than 0.01 cm3) to 1.2 cm3. Concurrent conventional acinar Gleason score 6 adenocarcinomas were seen in 6 of the 9 radical prostatectomy cases, in all cases as separate nodules from the PIN-like ductal adenocarcinomas. Only one of the PIN-like ductal adenocarcinomas at radical prostatectomy had extraprostatic extension, which was focal. PIN-like ductal adenocarcinoma differs from HGPIN by the presence of cystically dilated glands, a greater predominance of flat architecture, and less frequently prominent nucleoli. Verification often requires the immunohistochemical documentation of the absence of basal cells in numerous atypical glands. Although usual ductal adenocarcinoma is considered comparable to Gleason score 8, PIN-like ductal adenocarcinoma was accompanied by Gleason score 6 acinar carcinoma and behaved similar to Gleason score 6 acinar cancer. Recognition of this entity is critical to differentiate it from both HGPIN and conventional ductal adenocarcinoma.     

In situ adenocarcinoma of the bladder.

In situ adenocarcinoma of the bladder has not been well studied. Only one other case not associated with infiltrating adenocarcinoma has been reported in the literature. We identified 19 biopsies of in situ adenocarcinoma of the bladder without concurrent infiltrating adenocarcinoma or villous adenoma from the surgical pathology files of the Johns Hopkins Hospital between May 1984 and July 2000. The majority of patients (89%) were seen in consultation. The mean age at diagnosis was 70.4 years (range 48-88 years) and 79% were male. None of the patients developed a pure infiltrating adenocarcinoma; however, two patients had invasive urothelial carcinoma with focal glandular differentiation on prior or subsequent specimens. Two cases were pure in situ adenocarcinoma and 10 were seen with carcinoma in situ and/or papillary transitional cell cancer without invasion. Most patients (74%) had invasive carcinoma on either concurrent or subsequent specimens (five small cell and nine transitional cell [four micropapillary]). The majority (84%) of in situ adenocarcinomas were papillary, often seen in combination with either cribriform or flat architecture. In most cases the in situ adenocarcinoma was the predominant component when it was present with another in situ urothelial carcinoma. Seventy-nine percent of in situ adenocarcinomas showed >5 mitoses/10 HPF and 42% showed >10 mitoses/10 HPF. Moderate to severe nuclear pleomorphism was seen in 84% of cases. All cases showed apoptosis, and only one case showed focal necrosis. Seven patients were treated with cystectomy within 2-12 months. Of the other 12 patients, 10 were followed for a mean of 19.3 months (range 1-62 months). Ten (52%) patients were treated with bacille Calmette-Guérin, of whom four had no residual tumor on subsequent biopsy or cystectomy specimens. Three patients developed metastatic disease. In situ adenocarcinoma is a rare lesion that has a high incidence of association with small cell and micropapillary transitional cell carcinomas. When identified, in situ adenocarcinoma may indicate subsequent development of specific types of prognostically poor invasive carcinomas.     

细胞增殖标记物微型染色体维持蛋白2在结肠腺瘤和腺癌中的表达差异及意义

目的 探讨细胞增殖标记物MCM2在结肠癌、结肠腺瘤及正常结肠黏膜中的表达差异及在不同临床病理特征的结肠腺瘤巾的表达差异.方法 应用免疫组织化学(免疫组化)SP法检测MCM2在正常结肠黏膜、结肠腺瘤及结肠癌中的表达部位;应用实时荧光定量聚合酶链反应法检测MCM2 mRNA在12例结肠癌、33例结肠腺瘤及5例正常黏膜中表达量的差异并分析其意义,同时用REST-XL(C)软件分析不同临床病理特征的腺瘤之间MCM2的表达差异及其意义.结果 MCM2在正常黏膜中仅表达在腺凹底部,而在结肠腺瘤及腺癌组织中均呈全层上皮表达,但两者在MCM2 mRNA水平上的表达量差异有统计学意义(P=0.001).结肠腺瘤与正常黏膜相比较,MCM2表达上调,但差异无统计学意义(P＞0.05).不同临床病理特征的结肠腺瘤之间MCM2表达差异无统计学意义(P＞0.05).结论 MCM2在正常黏膜和结肠肿瘤中表达部位不同,且在结肠腺瘤及结肠癌中的表达量差异显著,可能作为早期筛查诊断结肠癌及评估腺瘤突变的指标之一.     

Poorly differentiated colorectal carcinoma with invasion restricted to lamina propria (intramucosal carcinoma): a follow-up study of 15 cases

Invasive colorectal carcinomas (CRCs) with invasion confined to the lamina propria (LP) [intramucosal carcinoma (IMC)] lack access to lymphatics and therefore have no potential for metastases and local intervention (usually polypectomy) should be adequate treatment. For this reason, they are classified as "Tis" in the TNM system. It is believed that carcinomas invading the submucosa with unfavorable histology (tumors at/near the margin, and/or vascular invasion, and/or poor differentiation) require additional intervention after polypectomy, whereas those with favorable histology can be safely treated endoscopically. However, there are few data on poorly differentiated (PD) carcinomas showing invasion confined to the LP. Polypectomy is theoretically curative but in practice this has not been well demonstrated. Thus, the clinicopathologic features of 15 cases of PD CRCs with invasion limited to the LP on initial biopsies were studied to determine the best course of management for this rare subset of carcinomas. A computer search and histologic review of cases seen at Johns Hopkins Hospital was performed. Fifteen cases of PD CRC with invasion limited to the LP were identified. The clinicopathologic features of these tumors were reviewed. All 15 cases showed PD IMC with single cells infiltrating only the LP. Patients were 38 to 79 years (median, 62) of age with a male predominance (M:F=4:1). Three cases had signet ring cell differentiation, 1 had focal small cell features, and another had focal squamous differentiation. Fourteen of the cases were associated with background adenomas or adenomalike lesions including: 7 involving tubulovillous or villous adenomas, 6 involving tubular adenomas, 1 involving dysplasia associated with chronic inflammatory bowel disease. Nine of the lesions had surrounding high-grade dysplasia. One case showed no background dysplasia or adenoma. One patient was lost to follow-up and the remaining 14 were followed for 1 to 96 months (mean, 21.3 mo; median, 13 mo). Seven patients had no residual disease on follow-up colonoscopy, and no resection was performed. The remaining 7 patients were treated with partial colectomy (6) or low anterior resection (1), and of these, 5 had no infiltrating carcinoma and negative lymph nodes. One patient had a separate large colorectal (T3) carcinoma with 8/10 positive regional lymph nodes; the IMC seen on biopsy was presumably a metastasis as it was unassociated with an in situ component. Finally, the resected rectum from which an IMC had been previously detected had no residual invasive carcinoma, but the anal skin was involved by Paget disease. Thus, of the 15 cases of PD CRCs limited to the LP, 1 was a metastasis from a separate CRC and another had associated Paget disease of the anal skin. As such, even in the setting of PD carcinomas, no metastatic disease was seen arising from any of the cases that were confirmed as early primary lesions. These preliminary findings suggest that patients with isolated intramucosal PD CRCs may be managed endoscopically.     

Prognostic significance of high‐grade dysplasia in colorectal adenomas

Aim Colonoscopy to detect and remove polyps has contributed to a reduction in colorectal carcinoma. Three‐year follow up is recommended for patients considered to be at high risk (at least three adenomas, adenoma ≥ 1 cm, villous or high‐grade features). Our study focused on patients diagnosed with high‐grade dysplasia with regard to initial management and follow up. Method A search of patients who had had endoscopic removal of a high‐grade adenoma was carried out. Patients with the following were excluded: follow up of < 1 year, polyposis syndromes, prior colon cancer and a diagnosis of adenocarcinoma within 6 months following initial diagnosis. Results Eighty‐three patients treated between 1999 and 2007 for high‐grade dysplasia (HGD) in a colorectal adenoma were identified. Over a median follow‐up period of 4 years, 53 (64%) developed further adenomatous polyps. Among these, 7% had an adenoma with HGD or an adenocarcinoma. In all these patients, the initial high‐grade adenoma was > 1 cm in diameter. Initial follow‐up colonoscopy was performed on average 7 months following the initial diagnosis. Ten per cent of patients underwent prophylactic segmental resection, and 6% received argon laser therapy. Conclusion The study demonstrates that patients who have a colorectal adenoma > 1 cm with HGD may be at high risk of developing further adenomas with HGD or carcinoma. Close follow up is warranted.     

Intraductal papillary mucinous tumors of the pancreas: imaging studies and treatment strategies.

OBJECTIVE: We analyzed clinicopathologic and imaging features and the prognosis of intraductal papillary mucinous tumor (IPMT) of the pancreas to identify imaging findings indicative of malignancy and to establish the optimal treatment strategy. SUMMARY BACKGROUND DATA: In IPMT, preoperative differentiation between adenoma and adenocarcinoma is often difficult. Appropriate treatment based on pathologic study and surgical outcome has not been adequately documented. METHODS: Forty-one patients with IPMT underwent surgery; 15 with adenoma and 26 with adenocarcinoma; main duct type in 13, combined type in 12, and branch duct type in 16. RESULTS: In malignant IPMT, deep invasion was found in 62% and lymph node metastasis in 23% (peripancreatic nodes in 19% and distant nodes in 4%). Tumors with mural nodules (86%) had a significantly higher incidence of carcinoma than tumors without nodules (37%). IPMT with a main pancreatic duct > or =15 mm or tumor diameter > or =30 mm (branch duct type) showed a high prevalence of adenocarcinoma. Main duct (54%) and combined (58%) type tumor, and tumors with mural nodules (64%) often showed invasion. All five branch duct tumors less than 30 mm without nodules were adenomas. However, imaging studies could not definitely distinguish adenocarcinomas from adenomas. Complete resection was possible for all adenomas and 88% of adenocarcinomas. Five-year survival rates for patients with adenomas and adenocarcinomas were 100% and 82%, respectively. CONCLUSIONS: IPMT has a favorable prognosis, regardless of deep invasion or node metastasis. IPMT requires peripancreatic node dissection in addition to complete tumor excision. Node dissection may be omitted for branch duct tumors less than 30 mm without mural nodules.     

Follow-up after transanal endoscopic microsurgery or transanal excision of large benign rectal polyps

Methods: Between January 1986 and December 1995, 238 patients with benign rectal polyps under-went either transanal endoscopic microsurgery (n = 226) or transanal excision (n = 12) at the Clinic of General and Abdominal Surgery, Johannes Gutenberg-University, Mainz. Results: Mean polyp size was 4.2 cm; 89.1% of polyps measured more than 2 cm in diameter. In 89.1% of cases, histological analysis revealed polyps containing tubulovillous or villous adenomas. Synchronous colonic polyps were detected in 12.5% of patients. Follow-up data are available on 222 patients (94%). At follow-up examination, 169 of the 193 surviving patients (87.6%) were recurrence free. Seven of 193 patients (3.6%) had developed neoplastic colonic polyps and, in 17 patients (8.8%), metachronous polyps were detected. Conclusions: Transanal endoscopic microsurgical polypectomy was furthermore demonstrated to be a low-risk procedure with a low recurrence rate for the complete resection of large rectal polyps. At a follow-up rate of 61.1%, the incidence of metachronous carcinoma ranged at 3.1%, which is markedly below the rate of 8–18% for tubulovillous or villous adenomas larger than 1 cm in diameter cited in the literature. Received: 24 October 1997 / Accepted: 13 July 1998     

Colonoscopy and the management of polyps containing invasive carcinoma.

Experiences with 565 colonoscopic polypectomies and 91 colonic and rectal resections containing infiltrating carcinoma in polyps are reviewed. A plan of management based on pathologic study of resected polyps is formulated to avoid further unnecessary surgery. It was concluded that: (1) Tubular adenomas containing invasive carcinomas have a low incidence of metastatic node involvement. This incidence is related to the depth of carcinomatous involvement. Resection of these polyps with a margin free of carcinoma constitutes definitive and adequate treatment and that (2) Villous adenomas containing invasive carcinoma have a high incidence of metastatic nodal involvement, and operative resection of the involved area of the colon is recommended, and that (3) Pedunculated tubulovillous adenomas containing invasive carcinoma behave like tubular adenomas, and the recommendations for further surgery in the patient with tubular adenomas with carcinoma apply equally well for these lesions. Sessile tubulovillous polyps tend to behave like villous adenomas, and if invasive carcinoma is demonstrated, further operation is recommended.     

Duodenal villous tumors

The treatment of 36 patients with duodenal villous tumors was reviewed to determine the long-term outcome of various surgical treatment options for specific adenoma histopathology. Duodenal villous tumors were typically solitary and periampullary in location. Villous adenomas contained epithelial atypia in 30% of patients, in situ carcinoma in 14%, and invasive carcinoma in 33%. Treatment consisted of transduodenal submucosal excision in 19 patients and radical pancreaticoduodenectomy in 15. There was no perioperative mortality. Perioperative morbidity for transduodenal excision and pancreaticoduodenectomy was 16% and 47%, respectively. Benign adenomas recurred more than 5 years postoperatively in 17% of patients undergoing transduodenal excision. Five-year survival following radical resection for invasive cancers was 45%. Overall median follow-up was 5.8 years. We conclude that duodenal villous tumors without invasive cancer can be managed successfully by local submucosal excision, but invasive carcinoma requires radical resection.     

Intrarectal ultrasonography in the staging and management of rectal tumors

Intrarectal ultrasonography (IRUS) was used in the preoperative staging of 17 patients with rectal neoplasms. Fourteen patients had biopsy proven adenocarcinoma, and three others had large villous adenomas. Comparisons were made between clinical examination, IRUS staging and subsequent histopathologic staging. IRUS was performed with a Bruel and Kjaer radial scanner, type 1849, equipped with a 7.0 MHz transducer. IRUS accurately staged 3/3 rectal villous adenomas, and 11/13 rectal adenocarcinomas compared with histopathology. Clinical exam correctly staged all three villous tumors, and 6/9 carcinomas (24% of lesions were not palpable). IRUS correctly diagnosed the status of regional nodes in 88% of patients. IRUS is a highly accurate preoperative staging tool for rectal cancers both in delineating depth of bowel wall invasion and in assessing regional lymph nodes. It is easy to perform, safe, and well tolerated by the patients. IRUS has definitely arrived as the state of the art in evaluating rectal neoplasms and may impact heavily on surgical decision making for these neoplasms.     

Proliferation patterns and aneuploidy in adenomatous polyps of the colon

The frequency of aneuploidy and the proliferative activity of 57 colorectal adenomatous polyps was investigated by static cytophotometry and compared with 43 adenocarcinomas and 60 samples of normal mucosa. Twenty per cent of the adenomas contained aneuploid cells compared with 63 per cent of the adenocarcinomas. Except in the case of villous adenomas, there was a general increase in the proliferative activity of the diploid adenomas with increasing degrees of dysplasia. All of the adenomas showed an increase in proliferation compared with normal mucosa. There was a positive correlation between the size of the diploid adenomas and proliferative activity (P less than 0.001).     

Villous adenomas of the duodenum and an unusual variant

We report two cases of villous adenoma of the duodenum, one arising from the main papilla and the other from the accessory papilla. Both were managed by local resection. In one case endoscopic biopsies and intraoperative frozen sections were negative for carcinoma but histology of the locally resected specimen revealed a focus of invasive adenocarcinoma. Villous adenomas of the duodenum have a high risk of malignant change and foci of carcinoma can be missed on endoscopic biopsy. The literature is reviewed and the clinical, diagnostic, pathological and therapeutic aspects of villous adenomas of the duodenum are discussed.     

Endoscopic mucosal resection for advanced non-polypoid colorectal adenoma and early stage carcinoma

Purpose: Endoscopic mucosal resection (EMR) techniques were evaluated in the treatment of flat and sessile colorectal neoplasm. Patients and methods: Fifty-seven patients (32 female, 25 male) with non-polypoid colorectal lesions (n = 71, size ? 10 mm) were included in the study. Tumor location, shape, size, and depth (in malignant lesions) were determined by endoscopy and endoscopic ultrasound. EMR was performed using snare resection, endoscopic aspiration mucosectomy, or EMR using a cap-fitted endoscope. Results: Lesion size ranged from 10 to 50 mm. Complete resection was achieved in 59 of 61 benign and 6 of 8 malignant tumors. Thirty-five tumors were excised in one segment and 34 tumors in piecemeal technique. Pathological examination of neoplasm treated by EMR showed adenoma in 61 and early-stage carcinoma in 8 cases. Because of the non-lifting sign, 2 of 71 tumors were not treated endoscopically and referred to surgical resection revealing a T2 adenocarcinoma in both cases. Resection was incomplete in 2 of 61 adenomas with histological positive resection margin. Complications occurred in 2 patients, with 1 bleeding treated endoscopically and 1 perforation treated by surgery. Local recurrence was observed in 2 of 59 completely resected adenomas and in none of 6 early-stage carcinomas during a mean follow-up of 18 months (range 6 to 30 months). Conclusion: Advanced non-polypoid colorectal adenomas and early-stage carcinomas can be safely and effectively resected by endoscopic mucosal resection.