Abnormal patterns of colonic mucin secretion after ureterosigmoidostomy

Abnormal Patterns of Colonic Mucin Secretion after Ureterosigmoidostomy ADRIANA MARCHEGGIANO, BSc,* CARLO IANNONI, BSc,* FRANCESCO PALLONE, MD,* GUISEPPE FRIERI, MD,*, MICHELE GALLUCCI, MD, t AND RENZO CAPRILLI, MD* Colonic epithelial mucin was investigated histochemically in biopsy specimens from a group of patients who had undergone ureterosigmoidostomy. For comparison, colonic biopsy samp'-.es from uninvolved mucosa adjacent to carcinomas from another group of patients and from a group of patients undergoing sigmoidoscopy for hemorrhoids were also studied. The high-iron diamine-alcian blue ( H I D - A B ; pH 2.5) method was used, and the proportions of HID-positive and AB-positive cells were assessed semiquantitatively. In both ureterosigmoidostomy and cancer groups, highly significant increases in the proportions of AB-positive cells (sialomucins) were observed, particularly in the middle and lower segments of the crypts. Ureterosigmoidostomy introduces a high risk for the development of colonic carcinoma. Morphologic features that could account for such a high risk were investigated, and an abnormal pattern of colonic mucin secretion after ureteroslgmoldostomy was demonstrated. Although this abnormality cannot be related specifically to ureteroslgmoidostomy, data from the present investigation suggest that.histochemical studies of colonic specimens from patients who have undergone ureterosigmoidostomy may provide a useful tool for follow-up studies. HUM PATIIOL15:647--650, 1984.

Ureterosigmoidostom)' has long been nsed in tim treatment of patients with both malignant and nonmalignant diseases of the bladder. The development of colonic carcinoma at the site of reintplantation of the ureters has frequently been reported as a late complication of ureterosigmoidostomy. 1-7 These reports suggest that the risk of colonic carcinoma is actually increased after ureterosigmoidostomy by as much as 500 times. The risk factors involved are not known. It tins been postulated that urinary diversion may induce either chronic inflammation I or metabolic changes in the colonic mucosa, 3 thus inciting neoplastic changes. Regardless o f tim nmdtanism involved, it could be speculated tlmt ureterosigmoidostomy may alter the colonic epitheliuna, making tim mucosa more susceptible to the development of neoplasia. T h e present investigation was u n d e r t a k e n to study the possible morphologic features of such susceptibility. The histologic features and the bistochemical pattern of tim colonic mucosa adjacent to the site of tim stoma were therefore studied in a group of patients who had undergone nreterosigmoidostomy. Received May 5, 1983, from the Departments of *Gastroenterology and tUrology, University of Ro-me, Rome, haly. Accepted for publication August 4, 1983. Supported by grant CNR 75.00879.04/115.8474. Address correspondence and reprint requests to Dr. Pallone: Cattedra di Gastroenterologia, Olinica Medica II, Viale del Policlinico, 00161 Roma, Italy.

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MATERIALS AND METHODS

Patients and Control Subjects Nine male patients who had u n d e r g o n e nreterosigntoidostotny were included in tim study. The mean age of tile p,ttients was 59.2 _+ 7.5 years. Tim mean and median intervals elapsed after surgery were 29.5 __ 53 and six nmnths, respectively. The indication for ureterosiglnoidostomy had been carcinoma of the bladder in fill patients. Biopsy specimens were taken at the ureterosigmoidostomy site as well as 5 cm proximally and 5 cm distally. A total of 28 specimens were suitable for study. Twenty biopsy specimens obtained from ten patients (mean age, 58.3 • 16 )'ears; five men and five women), taken from uninvolved nmcosa ac!jacent to rectal carcinomas, were also included in the study. Twenty rectal biopsy specimens f r o m ten patients (mean age, 44.9 _ 17 )'ears; two men and eight women) undergoing sigmoidoscopy for hemorrlmids were used as control specimens.

Procedure All specimens were oriented, fixed in Bouin's solution, and processed .routinely. Two slides, with at least 30 serial sections (5 I.tm thick) each, were prepared front each block. One slide was stained with hematoxylin-eosin for routine histologic studies. A second slide was processed for the lfistochemical evaluation of mucosubstances by the high-iron diaminealcian blue ( H I D - A B ; pH 2.5) method. 8 Briefly, tim sections were stained for 18 tmurs in a mixture containing 120 nag of N,N-dimetlwl-m-ptmnylendiamine (HCl)_o, 20 mg of N,N-dimetiwl-p-phenylendiamine (HC1), and 1.4 ml of NF 10 percent FeCl a in 50 ml of distilled water, and for 30 minutes in alcian blue8GX 1 per cent in 3 per cent acetic acid. Tim H I D - A B - s t a i n e d slides were observed with a projecting microscope. Tim HID-positive and ABpositive cells were evaluated separately for tim upper, middle, and lower segments of tim crypt. For each specimen at least ten crypts per section were e;,'aluated in at least five sections 30 I.tm apart. T h e proportions of HID-positive and AB-positive cells were assessed in each crypt segment, and separate scores for HID-positive and AB-positive cells in each crypt segment were assigned according to the following semiquantitative evaluation: 0, absence of positive cells; 1, a third of cells p~3sitive; 2, half of cells positive; 3, two thirds of cells positive; and 4, all cells positive.

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FIGURE 1 (top left. Biopsy specimen from ureterosigmoidostomysite showing normal appearance of the colonic mucosa. [Hematoxylineosin stain, xl00.) FIGURE 2 [top right]. Biopsy specimen from a normal control patient. High-iron diamine[HID)-positive cells [black) are predominant as Compared with alcian blue(AB)-positive cells [grey). [HID-AB stain, x 250.) FIGURE 3 (bottom left). Biopsy specimen from ureterosigmoidostomy site. All but three goblet cells ~ one crypt are AB-positive [grey). (High-iron diamine-alcian blue stain, x 250.] FIGURE 4 [boflom rightJ. - Biopsy specimen from transitional mucosa adjacent to rectal carcinoma. The vast majority of goblet cells are alcian blue-positive (grey]. (High-iron diamine~alcian blue stain, x 100.) 9

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COLONIC MUCIN SECRETIONAFTERURETEROSIGMOIDOSTOMY[Marcheggiano et al.) TABLE 1. Scores [mean _ SD] for HID-positive and AB-positive Cells

Middle Segment

Upper Segment Group Normal Cancer (transitional mucosa adjacent to rectal carcinoma) Ureterosigmoidostomy

Lower Segment

1liD-positive

AB-positive

IIID-positive

AB-posidve

111D-positive

AB-positive

1.8 -- 0.4

3.0 • 0.3

2.7 ~ 0.5

1.5 • 0.4

3.7 -+- 0.4

0.45 ~ 0.5

1.4 • 0.6 1.5 • 0.7

3.3 -- 0.5 3.1 -- 0.5

0.9 • 0.9* 1.2 • 0.8*

3.3 --- 0.6* 3.1 • 0.5*

1.25 - 1.1" 1.3 • 0.9*

3.25 • 0.7* 3.1 • 0.8*

* P < 0.001.

Results were e x p r e s s e d as the m e a n --- SD o f the scores f o r HID-positive a n d AB-positive cells. For statistical analysis the S t u d e n t ' s / - t e s t was used.

RESULTS C o n v e n t i o n a l staining with h e m a t o x y l i n - e o s i n did n o t reveal any significant a b n o r m a l i t i e s in the s p e c i m e n s f r o m the u r e t e r o s i g m o i d o s t o m y g r o u p (fig. 1). Specifically, no e v i d e n c e o f i n f l a m m a t i o n , atrophy, or dysplasia o f the crypts was f o u n d . N o r m a l n u m b e r s o f mucin-containing epithelial cells were observed in all specimens f r o m tile three groups. Resuits o f the semiquantitative histochemical evaluation are s u m m a r i z e d in table 1. In the u p p e r s e g m e n t o f the crypts o f all specim e n s , s i a l o m u c i n - c o n t a i n i n g AB-positive cells w e r e predominant, and no differences were observed a m o n g the t h r e e groups. In the control g r o u p , the middle segments showed h i g h e r p r o p o r t i o n s o f sulfomucin-containing HID-positive cells, while cells in the l o w e r s e g m e n t s w e r e virtually all H I D - p o s i t i v e (fig. 2). In both the u r e t e r o s i g m o i d o s t o m y a n d cancer groups, statistically significant increases (p < 0.001) in the p r o p o r t i o n s o f AB-positive cells in the middle a n d lower segments o f the crypt were observed (figs. 3 and 4).

DISCUSSION Retrospective studies suggest that patients who u n d e r g o u r e t e r o s i g m o i d o s t o m y are at high risk for colonic carcinoma. T h e risk factors are u n k n o w n . A direct carcinogenic effect o f the urine has b e e n considered,l, 6 b u t t h e r e is no convincing evidence for such a mechanism. Particularly, e x p e r i m e n t a l studies suggest that u r i n a r y carcinogens have no effect on the colonic e p i t h e l i u m . 9 T h e o b s e r v a t i o n that virtually all o f the carcinomas arise close to the stoma suggests that a carcinogenic factor may be g e n e r a t e d at the site o f the anastomosis. Such a factor could either have an inciting effect o n previously susceptible m u c o s a o r i n d u c e p r e m a l i g n a n t c h a n g e s in " n o r m a l " colonic epithelium. Some histologic alterations, e.g., a t r o p h y o r c h r o n i c i n f l a m m a t i o n , have been cited as factors that could incite the carcinogenesis (or predispose to cancer).3,1~ We f o t m d no significant abnormalities in histologic sections o f colonic m u c o s a a d j a c e n t to the u l ? e t e r o s i g m o i d o s t o m y site. Particularly, n o e v i d e n c e o f e i t h e r c h r o n i c inflam-

m a t o r y changes o r epithelial dyplasia has been observed. O u r results show ttmt the histochemical pattern o f the colonic epithelium adjacent to tile ureterosigm o i d o s t o m y site is significantly abnormal. Both qualitative and semiquantitative estimations indicate that such an abnormality is similar to that observed in tile rectal mucosa adjacent to carcinomas. This observation c o u l d s u g g e s t t h a t p r e m a l i g n a n t c h a n g e s d o occur in the colonic epithelium adjacent to tile uret e r o s i g m o i d o s t o m y site. I n d e e d , increases in sialomucins and decreases in sulfomucins have been rep o r t e d as "specific" findings in the so-called transitional mucosa (i.e., the mucosa s u r r o u n d i n g colonic carcinomas). II E x p e r i m e n t a l studies suggest that such histochemical abnormalities can be r e g a r d e d as a feature o f early colonic carcinogenesis) 2 O n the o t h e r hand, the specificity o f the histochemical changes in the mucin in tile transitional mucosa has not been c o n f i r m e d , 13 suggesting that the changes may be secondary phenomena. Moreover, a disproportionate increase in sialomucins has been r e p o r t e d after bowel resection in e x p e r i m e n t a l animals as an adaptative r e s p o n s e . o f the intestinal mucosa. 14 It seems, therefore, that the a b n o r m a l histochemical pattern that we have o b s e r v e d c a n n o t be r e g a r d e d as d e f i n i t e evidence that p r e m a l i g n a n t changes occur in the colonic mucosa a f t e r u r e t e r o s i g m o i d o s t o m y . H o w e v e r , d a t a f r o m the p r e s e n t investigation suggest that histochemical studies o f colonic biopsy specimens f r o m patients who have u n d e r g o n e ureterosigmoidostomy may provide a usefid tool for prospective follow-up studies, particularly in y o u n g patients. M o r e o v e r , as u r e t e r o s i g m o i d o s t o m y can be reg a r d e d as a h u m a n e x p e r i m e n t a l model for colonic carcinogenesis, such studies may d e t e r m i n e the significance o f mucin histochemistry in detecting premalignant changes in the colonic epithelium.

Acknowledgments. The authors are indebted to Prof. U. Bracci and Prof. A. Torsoli for helpful criticism and advice. REFERENCES 1. KozakJA, Watkins WE, Jewell WR: Neoplastic stonml obstruction: a complication of ureterosigmoidostomy. J Urol 96:691, 1966 2. Mueller CE, Thornbury JR: Adenocarcinoma of the colon complicating ureterosigmoidostomy: a case report and review of the literature. J Urol 109:225, 1973 3. RivardJY, Bedard A, Dionne L: Colonic neoplasms following ureterosigmoidostomy. J Urol 113:781, 1975

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Volume '15, No. 7 [July '1984] 10. Sommo G, Traverso GB: Modificazioni istochimiche della mucosa rettale in soggetti operati di u~eterosigmoidostomia. Pathologica 59:447, 1967 . .. 11. Filipe MI, Branfoot AC: Mucin lustochemlstry of the colon. In Morson BC (ed): Current Topics in Pathology. Pathology o f tile Gastrointestinal Tract. Berlin, Springer-Verlag, 63:143, 1976 12. Filipe MI: Mucous secretion in rat colonic mucosa during carcinogesis induced by dimethylhydrazine. A morphological and histochemical study. B r J Cancer 32:60, 1975 13. Isaacson P, Attwood PRA: Failure to demonstrate specificity of morphological and histochemical changes in mucosa'adjacent to colonic carcinoma (transitional mucosa). J Clin Pathol 32:214, 1979 14. Olobuyide IO, Williamson RC, Bristol JB, et ah Adaptation of tile shortened gut: increased numbers of sialomncin-containing goblet ceils. Gut 23:A881, 1982

4. Harguinday SS, Kolbeck RC, Bransome ED: Ureterosigmoidostom)" and cancer: new obser.vations. Ann Intern Med 83:833, 1975 5. Parsons CD, Thomas MH, Garrett RA: Colonic adenocarcinoma: a delayed complication of ureterosigmoidostomy. J Urol 118:31, 1977 6. Recht KA, BelisJA, Kandzari SJ, et al: Ureterosigmoidostomy followed by carcinoma of the colon. Cancer 44:1538, 1979 7. Macrae FA, Stewart M, Williams CB: Colonic tumours and ureterosigmoldostomy: an endoscopic study. Gut 23:A453, 1982 8. Spicer SS: Diamine methods (or differentiating mucosubstances histochemically. J Histochem Cytochem 13:211, 1965 9. Scott WW, Bo)'d HL: A stud)' of tile carcinogenic effect of betanaphthylamine on the normal and substituted isolated sigmoid loop bladder of dogs. J Urol 70:914, 1953

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