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between PET results and final (pathological or clinical)
disease staging does not allow definitive conclusions
[15]. Even though reported sensitivity rates for complete
pathological response immediately or shortly after CRT
are poor, sensitivity and specificity rates for late recurrent rectal cancer reach 80%–90%. In fact, PET results
for recurrence after initial CRT are also associated with
sensitivity and specificity rates over 80% [16].
Interestingly, the positive predictive value and accuracy
seem to improve when PET is performed more than 12
months after CRT [16].
In our series, PET was performed in patients after a
considerably long interval after CRT completion.
Absence of FDG uptake was consistent with other
clinical, radiological, and endoscopic studies showing
no signs of disease persistence or recurrence. All
patients in the control group with disease persistence
had FDG uptake and therefore served as adequate positive controls.
In conclusion, PET may be a useful tool during late
assessment of local control after complete clinical
response and non-operative management for distal rectal
cancer following CRT. Also, this imaging study based on
altered cellular metabolism of cancer cells provides further evidence of adequate long-term local control after
this treatment.
A. Habr-Gama (쾷), J. Gama-Rodrigues
Habr-Gama Research Institute
São Paulo, Brazil
e-mail: [email protected]
R.O. Perez, I. Proscurshim, G.P. São Julião,
D. Kruglensky, D. Kiss, I. Ceconello
Department of Gastroenterology
Colorectal Surgery Division
University of São Paulo, School of Medicine
São Paulo, Brazil
C.A. Buchpiguel
Department of Radiology
University of São Paulo, School of Medicine
São Paulo, Brazil
References
1. Chessin DB, Kiran RP, Akhurst T, Guillem JG (2005) The emerging role of 18F-fluorodeoxyglucose positron emission tomography in the management of primary and recurrent rectal cancer.
J Am Coll Surg 201:948–956
2. Sauer R, Becker H, Hohenberger W et al (2004) Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J
Med 351:1731–1740
3. Habr-Gama A, de Souza PM, Ribeiro U Jr et al (1998) Low rectal cancer: impact of radiation and chemotherapy on surgical
treatment. Dis Colon Rectum 41:1087–1096
4. Habr-Gama A, Perez RO, Nadalin W et al (2005) Long-term
results of preoperative chemoradiation for distal rectal cancer
correlation between final stage and survival. J Gastrointest Surg
9:90–99; discussion, 99–101
5. Habr-Gama A, Perez RO, Nadalin W et al (2004) Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results. Ann Surg
240:711–717; discussion, 717–718
6. Hiotis SP, Weber SM, Cohen AM et al (2002) Assessing the predictive value of clinical complete response to neoadjuvant therapy for rectal cancer: an analysis of 488 patients. J Am Coll Surg
194:131–135; discussion, 135–136
7. Stipa F, Zernecke A, Moore HG et al (2004) Residual mesorectal
lymph node involvement following neoadjuvant combinedmodality therapy: rationale for radical resection? Ann Surg Oncol
11:187–191
8. Janjan NA, Khoo VS, Abbruzzese J et al (1999) Tumor downstaging and sphincter preservation with preoperative chemoradiation in locally advanced rectal cancer: the M.D. Anderson
Cancer Center experience. Int J Radiat Oncol Biol Phys
44:1027–1038
9. Habr-Gama A, Perez RO, Kiss DR et al (2004) Preoperative chemoradiation therapy for low rectal cancer. Impact on downstaging and
sphincter-saving operations. Hepatogastroenterology 51:1703–1707
10. Madbouly KM, Remzi FH, Erkek BA et al (2005) Recurrence
after transanal excision of T1 rectal cancer: should we be concerned? Dis Colon Rectum 48:711–719; discussion, 719–721
11. Ota DM, Nelson H (2007) Local excision of rectal cancer revisited: ACOSOG Protocol Z6041. Ann Surg Oncol 14:271
12. Guillem JG, Puig-La Calle J Jr, Akhurst T et al (2000)
Prospective assessment of primary rectal cancer response to
preoperative radiation and chemotherapy using 18-fluorodeoxyglucose positron emission tomography. Dis Colon Rectum
43:18–24
13. Guillem JG, Moore HG, Akhurst T et al (2004) Sequential preoperative fluorodeoxyglucose-positron emission tomography
assessment of response to preoperative chemoradiation: a means
for determining longterm outcomes of rectal cancer. J Am Coll
Surg 199:1–7
14. Moore HG, Gittleman AE, Minsky BD et al (2004) Rate of pathologic complete response with increased interval between preoperative combined modality therapy and rectal cancer resection. Dis
Colon Rectum 47:279–286
15. Capirci C, Rubello D, Chierichetti F et al (2004) Restaging after
neoadjuvant chemoradiotherapy for rectal adenocarcinoma: role
of F18–FDG PET. Biomed Pharmacother 58:451–457
16. Moore HG, Akhurst T, Larson SM, Minsky BD, Mazumdar M,
Guillem JG (2003) A case-controlled study of 18-fluorodeoxyglucose positron emission tomography in the detection of pelvic
recurrence in previously irradiated rectal cancer patients. J Am
Coll Surg 197:22–28
Brain abscess as a rare
complication of acute sigmoid diverticulitis
Received: 21 July 2007 / Accepted: 18 December 2007
Dear Sir,
Diverticulosis is an evolving pathology in the western
world probably related to diet and lifestyle [1]. It is usu-
Tech Coloproctol (2008) 12:73–78
Fig. 1 Cerebral CT scan showing a low density, well-defined lesion in
left temporal area, with peripheral oedema. The diagnosis was brain
abscess secondary to acute colonic diverticulitis
ally asymptomatic and therefore the exact prevalence is
unknown. However, it is estimated that 30% of persons
in the sixth decade of life has diverticulosis and that this
increases up to 50% in persons older than 85 years of age
[2]. Consequently, an increasing number of patients with
complicated diverticular disease is expected in the following years.
It is well known that acute inflammation, stenosis and
fistula are the most common complications of this disorder
[1]. However, there are few reports about extra-abdominal
infectious complications of this common disorder.
A 75-year-old man presented to the emergency room
with fever and reduced consciousness. His family reported a 3-month history of intermittent episodes of fever and
weight loss, and some episodes of abdominal discomfort.
His medical history was remarkable for arterial hypertension and diabetes mellitus. Physical examination on
admission showed only disorientation and fever (38° C).
Although the abdomen was slightly distended, the physical examination was defined as unspecific. Cranial computed tomography (CT) revealed a well-defined low density lesion in the left temporal region, with peripheral
oedema (Fig. 1). The differential diagnosis included
brain abscess vs. metastasis of unknown origin.
The patient was admitted to the intensive care unit,
and antibiotic therapy (cefotaxime, metronidazole and
ampicillin) and dexamethasone plus mannitol bolus were
commenced. As the evolution was favourable, the patient
was transferred 2 days later to the neurosurgery service.
On day 4 after admission, the patient referred acute lower
77
abdominal pain. Physical examination showed diffuse
abdominal pain and tenderness. Abdominal CT revealed
complicated acute diverticulitis in the sigmoid colon,
free peritoneal fluid, pneumoperitoneum and a 6-cm pericolonic abdominal abscess.
With the diagnosis of colonic perforation due to complicated colonic diverticulitis, surgery was indicated.
Surgery confirmed the diagnosis of perforated acute
diverticulitis with faecal peritonitis. Hartmann’s procedure was performed. Ten days after operation, the brain
abscess was drained by aspiration using stereotactic
guidance. Neurologic symptoms disappeared and a control cerebral CT scan in the follow-up period revealed
that the abscess was completely drained.
Examination of brain abscess aspiration and abdominal fluid revealed gram-positive cocci, and from
abdominal fluid culture Enterococcus faecalis sp. was
finally isolated. The final pathological report indicated
that the patient had acute sigmoid diverticulitis with
pericolonic abscess.
This rare presentation of complicated diverticular disease lets us take into account the very uncommon, remote
complications of this evolving pathology. There are some
factors associated with diverticular complications, like
age less than 50 years, number of acute diverticulitis
attacks, male gender, and stenosis in the barium enema
study [1]. However, there are few reports on the long-term
complications of this western disease. An extraperitoneal
complication, a rare presentation as arthritis and finally
two cases of brain abscess have been reported [2–4].
As we considered the diagnosis of cerebral metastasis, CT appearance and the acute diverticulitis episode
were of paramount importance for the final diagnosis of
brain abscess. Even in consideration that preoperatively
colonic cancer can mimic an acute diverticulitis, cerebral
metastasis from colonic neoplasm is uncommon. Thus,
the incidence of brain metastasis varies from 1% to 3.5%
[5]. Otherwise, definitive diagnosis was done by the
histopathologic analysis that confirmed infectious origin.
It is very interesting to claim that colonic complication is, as far we know, a rare cause of brain abscess. The
most rational hypothesis of the vehiculation of sepsis
from the abdominal cavity to brain abscess is by transient
bacteremia from acute diverticulitis. The unknown origin
of bacteremia is one of the well recognised first manifestations of colonic tumour [4]. However, it is interesting
that in this rare presentation, the liver was not affected,
considering that haematogenous bacterial spread via the
portal vein with formation of liver abscess has seldom
been described [2]. Brain abscess, moreover, usually
originates in otic or traumatic infections [6].
The first-line treatment of the brain lesion with
antibiotics was enough to stabilise the patient and there-
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fore definitive stereotactic aspiration is not always necessary. Despite the fact that Enteroccocus faecalis sp. is
responsible for brain abscess in only around 2% of cases,
it is interesting to note that this pathogen was also
described in a previous report [2].
In conclusion, brain abscess is an atypical presentation of complicated diverticular disease in which combined treatment is necessary.
M. Valero, D. Parés (쾷), M. Pera, L. Grande
Colorectal Surgery Unit
Department of Surgery
Hospital del Mar
Barcelona, Spain
e-mail: [email protected]
References
1. Stollman N, Raskin B (2004 ) Diverticular disease of the colon.
Lancet 363:631–639
2. Helfritzsch H, Seifert S, Solch O, Pfister W, Scheele J (2001)
Brain abscess in retroperitoneal perforated colonic diverticulitis.
Chirurg 72:1427–1430
3. Dixon AR, Holmes JT, Waters A (1989) Intracranial abscess complicating diverticulitis with CT scan mimicking primary glioma.
Postgrad Med J 65:565–567
4. Alba S, Nascimbeni R, Di Betta E, Villanacci V, Salerni B (2001)
Artritis as a rare extra-intestinal manifestation of acute sigmoid
diverticulitis. Dig Surg 18:233–234
5. Ko FC, Liu JM, Chen WS, Chiang JK, Lin TC, Lin JK (1999)
Risk and patterns of brain metastases in colorectal cancer: 27year experience. Dis Colon Rectum 42:1467–1471
6. Hakan T, Ceran N, Erdem I, Berkman MZ, Goktas P (2006) Bacterial brain abscesses: an evaluation of 96 cases. J Infect 52:359–366