Small rectosigmoid polyps as markers of proximal neoplasms

PURPOSE

The aim of this study was to determine the spatial distribution and histotype of small colorectal polyps and to determine the validity of distal-small colorectal polyps as markers of proximal neoplasms.

METHODS

In 366 patients who underwent total colonoscopy and removal of all polyps, the presence and features of polyps were recorded. The relationship between proximal neoplasms and distal polyps was investigated in 216 of 366 subjects who had no personal or familial history of colorectal neoplasia.

RESULTS

Of 366 patients, 96 were free from polyps. A total of 733 small colorectal neoplasms was removed from the remainder: 79.9 percent neoplastic and 20.1 percent hyperplastic, inflammatory, or hamartomatous. High-grade dysplasia was noted in 2.7 percent of the neoplastic polyps. One adenoma containing invasive carcinoma was observed. In the subset of 216 patients, proximal neoplasms were found in 11.4 percent of those with no distal polyps, 33.8 percent of those with distal-small colorectal polyps only (P < 0.01), and 58.8 percent of those with at least one polyp > 5 mm in diameter (P = 0.001). The proximal neoplasm percentage was the same in patients with at least one adenomatous-small polyp and those with only hyperplastic-small polyps.

CONCLUSIONS

A distal-small colorectal polyp, whether adenomatous or hyperplastic, may be a proximal neoplasm marker. Total colonoscopy is thus justified in all patients with distal polyps, regardless of their size and histotype.

Bromodeoxyuridine uptake and proliferating cell nuclear antigen expression throughout the colorectal tumor sequence

In vitro uptake of bromodeoxyuridine and expression of proliferating cell nuclear antigen (PCNA) were evaluated histochemically in rectal mucosa of control subjects and subjects with colorectal neoplasia in large intestine adenomas and adenocarcinomas. Both labeling indices progressively increased along the path of tumor progression, as did the difference between them (PCNA labeling indices were always greater than those of bromodeoxyuridine). The correlation between them was fairly close in the controls and in adenomas with low-grade dysplasia, whereas no significant linear relations were noted in adenomas with high-grade dysplasia or in adenocarcinomas. The progressive increase in PCNA would thus seem to be related to both hyperproliferation and neoplastic deregulation of PCNA synthesis. In the mucosa of subjects with colorectal neoplasia, PCNA labeling revealed hyperproliferation but not the surface-wards shift of the proliferative compartment detected by bromodeoxyuridine. PCNA expression, therefore, is not a sufficiently sensitive marker of the risk of tumor transformation in the intestinal mucosa.

Cell proliferation in colorectal adenomas containing invasive carcinoma

Immunohistochemical detection of the nuclear antigen recognised by the monoclonal antibody Ki67, DNA polymerase alpha, and the proliferating cell nuclear antigen (PCNA), and histochemical staining for the argyrophilic proteins associated with the nucleolar organizer regions (AgNOR) were carried out on histological sections from 107 colorectal adenomas containing invasive carcinoma (ACIC), including 7 with regional lymph node metastases. Separate evaluations were made for fields corresponding to adenoma with low-grade dysplasia, adenoma with high-grade dysplasia and early cancer. The same techniques were also employed in 20 cases of normal mucosa and 20 advanced carcinomas. The mean percentages of Ki67, DNA polymerase alpha, and PCNA-positive nuclei and the number of AgNOR per nucleus progressively increased along the sequence from normal mucosa via low-grade and high-grade dysplasia adenoma to advanced cancer, whereas the early cancer values were not significantly different from those in the low-grade dysplasia areas. No significant difference in PCNA positivity and number of AgNOR were noted in ACIC with and without lymph node metastases. It is suggested that the decrease in proliferative activity thus revealed in early cancer may be due to changes in the submucosa microenvironment caused by invasion, and that the metastatic potential of an early colorectal cancer cannot be correlated to such activity.

Histology, histochemistry, tumor and serum markers in gastrointestinal tract cancer

Integration of morphologic and molecular information is being pursued as a result of more extensive use of in situ hybridization techniques. Oncogenes, gene products, and viral genomes involved in the genesis and progression of gastrointestinal tumors have been located in specific histotypes or tumor sectors. The main advances in this area relate to cell-matrix interactions and the biologic mechanisms of tumor invasion. Some aspects of the morphogenetic sequences of gastric and colorectal adenocarcinomas and hepatocellular carcinoma have been elucidated. Studies of DNA ploidy have furnished results consonant with carcinogenesis models envisaging sequential genome alterations due to genetic instability of the transformed cell. The prognostic role of DNA content in gastrointestinal tumors, however, has not been unequivocally established. Research on tumor markers has been directed toward the tissue expression and distribution of apomucins with different molecular structures. Evaluation of tumor markers in body fluids has proved inadequate for the early detection and screening of gastrointestinal neoplasia. Some interesting results have been reported with regard to the monitoring of gastric and colorectal carcinomas by means of serum tumor markers.

Endoscopy to detect oral and oesophageal candidiasis in acquired immune deficiency syndrome

Cytologic evidence of candidiasis was sought on endoscopic oesophageal brushings from 116 patients with acquired immune deficiency syndrome (AIDS) to determine the reliability of oesophagoscopy and the possibility of predicting Candida spp. oesophagitis from concomitant oral candidiasis or oesophageal symptoms. Oesophageal candidiasis was present in 42 patients and constituted the first opportunistic infection in 19 patients. Sensitivity and specificity were, respectively, 98% and 96% for oesophagoscopy, 69% and 42% for oral candidiasis, 52% and 74% for oesophageal symptoms, and 83% and 35% for the presence of at least one of these last two parameters. Endoscopy also proved to be the examination of choice for diagnosis, and cytology was needed only when it was negative. Oral candidiasis and oesophageal symptoms were not sufficient to predict oesophageal candidiasis. Endoscopy would seem to be indispensable to the diagnosis of oesophageal candidiasis and its differentiation from other forms, thus preventing any empirical resort to unwarranted forms of treatment. It is also indicated for staging purposes in asymptomatic patients, since oesophageal candidiasis is one indicator of the transition to full-blown AIDS.

Cell proliferation in colorectal tumor progression: an immunohistochemical approach to intermediate biomarkers

Cell renewal in the large intestine mucosa is normally tied to a rigidly compartmentalized model. Immunohistochemical identification of cells in S phase through uptake of bromodeoxyuridine is the method of choice for detailed compartmental mapping of proliferation, while immunohistochemical detection of proliferation-associated antigens (Ki-67, PCNA, DNA polymerase alpha) provides information in advanced tumor cases. Mucosal hyperproliferation due to inflammation may be transient (self-limited colitis, Crohn's disease, acute radiation damage) or lasting (ulcerative colitis). Progressive shifting of the proliferation zone to the crypt surface (Stage II abnormality) is a late feature of irradiated rectal mucosa and subgroups of ulcerative colitis patients at high risk for cancer. Hyperproliferation and Stage II abnormality coexist in the mucosa of patients with colorectal neoplasia, but are mutually independent and correlated to different clinical and pathological features of the disease. These cytokinetic abnormalities are highly predictive markers of the adenoma-carcinoma sequence, but are not associated with de novo adenocarcinoma. Proliferation increases progressively in the subsequent steps of this sequence, except in early cancer.

Correlations between rectal mucosa cell proliferation and the clinical and pathological features of nonfamilial neoplasia of the large intestine

An in vitro study of proliferative activity as shown by immunohistochemical detection of the uptake of bromodeoxyuridine was run on rectal biopsies from 400 patients with nonfamilial large bowel neoplasia: 200 adenoma; 150 adenocarcinoma; 50 adenoma plus adenocarcinoma. The controls were 400 subjects with negative personal and family histories of colorectal neoplasia. The number and height distribution of bromodeoxyuridine positive cells were determined by dividing the crypt into five longitudinal compartments. The total labeling index and the labeling index of each compartment were higher in all three groups compared with the controls. In subjects with adenoma, total labeling index and labeling index values were correlated with tumor size and decreased in function of the duration of the polyp-free colon state. The major zone of DNA synthesis had shifted to the intermediate and surface crypt compartments in all three groups. This stage II abnormality was more marked in adenoma patients with a high degree of dysplasia and in those with adenoma plus adenocarcinoma. Hyperproliferation and the proliferative compartment shift are cytokinetic abnormalities that coexist in the flat rectal mucosa of patients with colorectal neoplasia. Nonetheless, they are independent, controlled by different factors, and are expressions of different biological aspects of large bowel carcinogenesis.

Needle biopsy of submucosal lesions of the gastrointestinal tract

Needle biopsy of submucosal lesions is an important addition to the diagnostic capabilities of gastrointestinal endoscopy. A series of 22 cases is described employing a guillotine needle to diagnose submucosal lesions, 4 of which were infiltrating adjacent carcinomas. The specimens obtained were sufficient for firm histological diagnosis in 20 cases. There were no complications apart from minor bleeding in 1 case.

Late cytokinetic abnormalities in irradiated rectal mucosa

Late cytokinetic changes of the colonic crypt epithelium after radiation therapy were investigated. A monoclonal antibody to bromodeoxyuridine (anti-BrdU MAb) was used in tissue specimens previously incubated with BrdU to show S-phase cells by immunohistochemical technique. Endoscopic rectal biopsies were taken from 30 patients previously treated with radiotherapy for gynaecological cancer and from 50 patients with comparable but untreated neoplasms, as controls. Number and height distribution of S-phase cells were evaluated by dividing each crypt column into 5 equal longitudinal compartments. No statistically significant differences were found in total Labelling Index (LI) between controls and irradiated mucosa, whereas LI per crypt compartment, percentage of labelled compartments and percentage of BrdU-positive cells in the middle and superficial portions of the crypt were significantly higher in patients submitted to radiation therapy. This kinetic abnormality corresponds to a progressive shift of the major zone of DNA synthesis to the upper third of the crypt as a late reaction to radiation and represents an early step in the histogenesis of colorectal cancer. These results lend support to the view that there is a higher risk of colorectal carcinoma after pelvic irradiation.

[Lipoma of the small intestine. A clinical case]

The paper reports a case of a 45-year-old female with long-standing anemia, recurrent abdominal pain and subocclusive crises. Following a negative endoscopy of the upper tract of the large intestine, barium enema and angiography, the patient underwent total colonoscopy. Massive bleeding from the ileal valve suggested an ileal pathology: a small intestine enema confirmed a polypoid proliferation 60 cm above the Bahuino valve with related ileal invagination 25 cm long. The patient underwent surgery and pathological findings revealed a 7 cm-wide ileal lipoma near a small angiodysplasia. The latter seemed to be the cause of bleeding. The diagnosis of small intestine tumours is made difficult by the fact that the only important signs are abdominal pain, intestinal bleeding and subocclusive crises, which are common symptoms in many pathologies. The authors stress the importance of a thorough endoscopic examination and selective angiography.

Colorectal adenomas containing invasive carcinoma. Pathologic assessment of lymph node metastatic potential

Adenomas that contain early invasive carcinoma (ACIC) represent the earliest form of clinically relevant cancer of the colorectum in most patients. In order to assess the incidence of nodal metastases of ACIC, we studied 31 patients in whom the colon was resected after endoscopic polypectomy (EP) done from 1975 to 1987. We also reviewed the pathologic features reported in individual cases and in literature series of ACIC with lymph node metastases published from 1958 to 1986. The lymph node metastatic potential of ACIC is relatively high, ranging from an average value of 8.5% in the literature of to 16.1% in our own study, and is equivalent to the range of 10%-17% that occurs in colorectal carcinomas that invade the submucosa. When an ACIC is seen in an EP specimen in which the polypectomy margin is normal, the decision as to whether the patient should enter a follow-up protocol or have radical surgical resection is determined by the assessment of the probability of the occurrence of nodal metastases. According to several authors, certain histopathologic features make it possible to distinguish between an ACIC with a high-risk of nodal metastases versus those with a low-risk. The most relevant pathologic parameters include the state of the resection margins, the grade of the invasive carcinoma, and the presence or absence of vascular invasion. Of 351 cases of ACIC that were operated on, derived from 16 literature series, 45.6% were high-risk cases and 8.5% had lymph node metastases. In our group of high-risk ACIC that had surgical resection subsequently, the lymph node metastatic rate was 35.7%. Our results help to estimate the nodal metastatic potential of early colorectal carcinomas and stress the importance of adequate pathologic evaluation in order to assess metastatic risk in these patients accurately.

Colorectal adenomas containing invasive carcinoma. Pathologic assessment of lymph node metastatic potential

Adenomas that contain early invasive carcinoma (ACIC) represent the earliest form of clinically relevant cancer of the colorectum in most patients. In order to assess the incidence of nodal metastases of ACIC, we studied 31 patients in whom the colon was resected after endoscopic polypectomy (EP) done from 1975 to 1987. We also reviewed the pathologic features reported in individual cases and in literature series of ACIC with lymph node metastases published from 1958 to 1986. The lymph node metastatic potential of ACIC is relatively high, ranging from an average value of 8.5% in the literature of to 16.1% in our own study, and is equivalent to the range of 10%-17% that occurs in colorectal carcinomas that invade the submucosa. When an ACIC is seen in an EP specimen in which the polypectomy margin is normal, the decision as to whether the patient should enter a follow-up protocol or have radical surgical resection is determined by the assessment of the probability of the occurrence of nodal metastases. According to several authors, certain histopathologic features make it possible to distinguish between an ACIC with a high-risk of nodal metastases versus those with a low-risk. The most relevant pathologic parameters include the state of the resection margins, the grade of the invasive carcinoma, and the presence or absence of vascular invasion. Of 351 cases of ACIC that were operated on, derived from 16 literature series, 45.6% were high-risk cases and 8.5% had lymph node metastases. In our group of high-risk ACIC that had surgical resection subsequently, the lymph node metastatic rate was 35.7%. Our results help to estimate the nodal metastatic potential of early colorectal carcinomas and stress the importance of adequate pathologic evaluation in order to assess metastatic risk in these patients accurately.

Histological aspects and healing rates of gastric ulcers treated with omeprazole 20 mg once daily or ranitidine 150 mg B.I.D

The aim of this double blind trial was to compare omeprazole 20 mg once daily with ranitidine 150 mg b.i.d. in treatment of benign gastric ulcer, evaluating both rates and histological aspects of the ulcer healing process. Eighteen patients were randomized, 9 to each treatment; one patient (ranitidine group) was excluded from the analysis because of malignant ulcer. Omeprazole appeared to be more effective than ranitidine in healing gastric ulcer. A more rapid relief of symptoms was observed in the omeprazole group than in the ranitidine group. Both drugs reduced chronic atrophic gastritis (with a trend in favour of omeprazole), while omeprazole showed a prompter activity on the components of acute inflammation.

Immunohistochemical study of epithelial cell proliferation in hyperplastic polyps, adenomas, and adenocarcinomas of the large bowel

A monoclonal antibody to bromodeoxyuridine was used in tissue specimens previously incubated with bromodeoxyuridine to show S-phase cells by immunohistochemical technique. Biopsy specimens of normal mucosa (n = 10), hyperplastic polyps (n = 10), adenomas with low-grade dysplasia (n = 20), adenomas with high-grade dysplasia (n = 10), and invasive adenocarcinomas (n = 10) of the large bowel were studied. Labeling index and cell proliferative patterns were analyzed. No statistically significant difference was found in labeling index between normal mucosa and hyperplastic polyps or between adenomas with high-grade dysplasia and adenocarcinomas. The labeling index was significantly lower in normal mucosa and in hyperplastic polyps than in adenomas and adenocarcinomas (p less than 0.001). The difference in labeling index between adenomas with high-grade dysplasia and low-grade dysplasia was also statistically significant (0.01 less than p less than 0.05). In normal mucosa and in hyperplastic polyps the proliferative zone was confined to the lower two-thirds of the crypt; no kinetic activity was found in the upper portions of the crypt or in surface epithelium. In adenomas the labeled cells were either present in the upper third or scattered along the whole axis of the crypt and in the surface epithelium. Labeling patterns in invasive carcinomas were similar to those observed in adenomas with high-grade dysplasia. The difference in proliferative patterns between hyperplastic polyps and adenomas supports a different significance of the two polypoid lesions in the histogenesis of large bowel cancer; our results confirm the subsequent steps of the adenoma-carcinoma sequence. Immunohistochemical labeling patterns observed with monoclonal antibody to bromodeoxyuridine in polypoid and cancer lesions of the large bowel are similar to those described by autoradiographic studies.

Large bowel adenomas containing carcinoma--a diagnostic and therapeutic approach

Adenomas containing invasive carcinoma of the large bowel form the majority of early colorectal cancers. Conclusive histological diagnosis of early colorectal cancer depends on two conditions; first, the whole lesion must be examined and second the resection margin must border on healthy tissue. The presence of certain histopathological features makes it possible to distinguish between cases with high and low risk of having lymph node metastases. Sixty-six adenomas containing invasive carcinoma are reported. They comprised 3.15% of 2,095 adenomas removed by colonoscopic polypectomy during the same period. Five cases were lost to follow-up. Forty-nine patients considered to be at low risk of having lymph node metastases have been treated by endoscopic polypectomy only with a rigorous follow-up regime including CEA estimation, ultrasonography and total colonoscopy at regular intervals. In none have distant metastases been found on follow-up examinations at a mean duration of 3 years. Two of these cases have developed a metachronous colorectal carcinoma and 15 (30.5%) have metachronous adenomas. Two low risk patients with no tumour found in the operative specimen have undergone major surgical resection. Ten high risk cases have been referred for major surgery and lymph node metastases have been found in four (40%). The need for careful histological examination for lymphatic and veinous invasion is stressed by the presence of this finding in all four high risk patients with involved lymph nodes.

Inverted urothelial papilloma: a lesion with malignant potential

Two cases of inverted urothelial papilloma are presented. In the first case the inverted papilloma was in the ureter and varying degrees of cellular atypia were demonstrated on histology: 7 years later, a single bladder lesion consisting of papillary transitional cell carcinoma and inverted papilloma developed in the same patient. In the second case a bladder tumor consisting of inverted papilloma mixed with papillary infiltrating transitional cell carcinoma was detected. The peculiar morphological findings, histogenesis and biological behavior of inverted urothelial lesions are discussed.

Bone marrow evaluation in small cell carcinoma of the lung

Bone marrow examination is commonly included in the staging of small cell lung carcinoma (SCLC). We reviewed marrow samples of 103 patients. Marrow examination was mainly performed by unilateral or bilateral biopsy of iliac crests, using a Jamshidi needle. Only 6 of 97 evaluable cases (6.2 per cent) were positive for marrow metastases at staging, and in 3 cases (3 per cent) bone marrow was the only metastatic site. No focal metastases were found in additional sections made from the blocks of negative samples. In our experience bone marrow biopsy was of little value in staging SCLC. Bilateral biopsy plus aspirate, with the addition of more sophisticated staining techniques might, however, provide a higher yield of positive marrow involvement.

Clinico-pathological features of collagenous colitis: case report and literature review

Collagenous colitis is a newly identified condition, with clinical features of chronic watery diarrhea and abdominal pain. Histologically the main characteristic is the presence of a thick collagen band below the surface epithelium. Collagenous colitis occurs in adults, especially women. Endoscopy reveals no particular changes in the intestinal mucosa. Symptoms may persist for years with periods of remission and recurring acute attacks. The cause of this condition is still unknown, and because of no real knowledge only symptoms can be treated, usually with little success.

Sacrococcigeal and vertebral chordomas. Report of three cases and review of the literature

Three cases of sacrococcygeal and vertebral chordoma are described. Histogenetic and anatomopathological aspects with particular reference to differential diagnosis from similarly distributed neoplasias are discussed. Anti-cytoskeleton monoclonal antibodies were used to this purpose. The clinical profile of sacrococcygeal and vertebral chordomas is characterized by a pronounced metastatic potential; radiation treatment can only partially counter their biological behaviour, while chemotherapy has proved little or no effectiveness. Where possible, radical surgery is currently the only treatment to guarantee long-term survival or complete cure. Palliative surgery, associate with efficient painkilling, offers a better quality of life and slows down the progress of the disease.

[Intestinal adaptive response of the rat after bilio-pancreatic and food diversion from the duodenum]

The object of the research was to evalute, in the rat, the effects brought about on the intestinal trophism by the selective and combined exclusion of the bile, the pancreatic secretion and the food exsert, certainly, a trophic activity on the intestinal mucous membrane where they pass trough, as it has been observed by other authors; but the modifications, observed on last segments of the ileum, do not explain a direct action of these factors to modulate the adaptative intestinal reaction. In the following essay we propose the hypothesis that the privation of biliary and pancreatic secretions and the food from the duodenum may stimulate a hormonal and duodenal reaction which is able to produced observed phenomena.