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"titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Abordaje laparoscópico por incisión única del hígado izquierdo: experiencia inicial" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 505 "Ancho" => 1290 "Tamanyo" => 144458 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Placement of GelPoint<span class="elsevierStyleSup">®</span> (left) and Endocone<span class="elsevierStyleSup">®</span> device (right) for single-port surgery.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Judith Camps Lasa, Esteban Cugat Andorrà, Eric 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Narrative Review" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "579" "paginaFinal" => "588" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "José Errasti Alustiza, Eloy Espín Basany, Ángel Reina Duarte" "autores" => array:3 [ 0 => array:4 [ "nombre" => "José" "apellidos" => "Errasti Alustiza" "email" => array:2 [ 0 => "jose.errastialustiza@osakidetza.net" 1 => "joseerrasti@yahoo.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Eloy" "apellidos" => "Espín Basany" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Ángel" "apellidos" => "Reina Duarte" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Unidad de Coloproctología, Servicio de Cirugía General, Hospital Universitario de Álava, Universidad del País Vasco, Vitoria-Gasteiz, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Coloproctología, Servicio de Cirugía General, Hospital Universitario Valle de Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Unidad de Cirugía Colorrectal, Complejo Hospitalario Torrecárdenas, Almería, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Neoplasias de recto poco frecuentes. Revisión de conjunto" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 743 "Ancho" => 990 "Tamanyo" => 216505 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Rectal sarcoma.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Rectal cancer is typically adenocarcinoma. Nonetheless, there are other types of tumors that are much less common, such as neuroendocrine neoplasms, lymphomas, sarcomas, and squamous-cell carcinomas, which can also be located in the rectum.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> The incidence of each of these tumors is difficult to calculate. According to the data from 2005 to 2009 from the National Cancer Institute's Surveillance Epidemiology and End Results (SEER),<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> out of 183<span class="elsevierStyleHsp" style=""></span>000 colorectal cancers (not including lymphomas), 94.3% were adenocarcinomas, 1.7% other carcinomas, 3.3% carcinoid tumors, 0.5% epidermoid carcinomas, 0.1% sarcomas, and 0.1% other types.</p><p id="par0010" class="elsevierStylePara elsevierViewall">All these tumors present very different characteristics from adenocarcinomas, which also makes their treatment and prognosis very different (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). In addition, there have been recent modifications in the diagnosis and treatment of some of the types. This all causes doubt and controversy in their clinical management, and it is recommended that they be treated by a multidisciplinary team including surgeons, oncologists, pathologists, and radiologists.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–8</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The objective of this article is to review the clinical and surgical management of these uncommon rectal neoplasms. We used PubMed to review the literature from 1997 to 2012 using the key words related to a colorectal location stated at the beginning of this article.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Neuroendocrine Neoplasms</span><p id="par0020" class="elsevierStylePara elsevierViewall">Neuroendocrine neoplasms are epithelial and present neuroendocrine differentiation.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> They can be located in different organs.</p><p id="par0025" class="elsevierStylePara elsevierViewall">They are classified<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a> by their degree of differentiation (well or poorly differentiated) and their histologic grade (G1, G2 and G3), based on the number of mitoses and the Ki67 index.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,12–14</span></a> Three different groups are defined: neuroendocrine tumors (NET), neuroendocrine carcinoma (NEC), and mixed adenoneuroendocrine carcinoma (MANEC).<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,12</span></a></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Neuroendocrine Tumors</span><p id="par0030" class="elsevierStylePara elsevierViewall">NET are well-differentiated neuroendocrine neoplasms made up of tumor cells that express neuroendocrine markers (chromogranin A, synaptophysin) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and hormones.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Cellular atypia and proliferative activity are low. By definition, they are grade G1 or G2 tumors. This category includes lesions that were previously called “carcinoid tumors”, a denomination that is now criticized and is no longer included in the gastrointestinal NET classifications, but is still widely used. The rectal location represents 18% of all NET and 27% of all digestive tract tumors.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,15</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The annual incidence of rectal NET, according to the SEER,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> is 0.86 per 100<span class="elsevierStyleHsp" style=""></span>000, which has experienced a large increase in recent decades.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The incidence is higher in Asians,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> and mean age is 56.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">NET usually present as small polypoid lesions or submucosal nodules.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> 45% measure 10<span class="elsevierStyleHsp" style=""></span>mm or less, while only 17% measure more than 20<span class="elsevierStyleHsp" style=""></span>mm.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> These tumors are frequently asymptomatic<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,18</span></a> or accompanied by mild symptoms such as bleeding, tenesmus or discomfort.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17,18</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">49% of the NET only affect the mucosa and submucosa, 24% infiltrate the muscularis propria, and 15% extend to the perirectal fat.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> 75%–85% are located in the rectal wall.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Tumor size and lymphovascular invasions are risk factors for lymph node involvement.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,17,19,20</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Liver metastases become more frequent as tumor size increases.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> These are present in 1.7% of the NET≤1<span class="elsevierStyleHsp" style=""></span>cm, in 15% of those between 1 and 2<span class="elsevierStyleHsp" style=""></span>cm and in 50% of those >2<span class="elsevierStyleHsp" style=""></span>cm.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The majority of NET are diagnosed endoscopically.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Endorectal ultrasound seems to be the best method for assessing the size and invasion depth of these tumors.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,18,20,21</span></a> In NET measuring less than 1<span class="elsevierStyleHsp" style=""></span>cm and without risk factors, no further studies are necessary. MRI and CT are indicated in larger tumors in order to study the pelvis and to rule out liver metastasis.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> OctreoScan seems to have high sensitivity, but it is not often used<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>; it is mainly used in cases with suspected metastatic disease.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,18</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Less than 1% of the colorectal NET produce serotonin or other hormones; therefore, the routine analysis of serotonin and 5-HIAA is not recommended.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Chromogranin A may be elevated and is useful as a tumor marker in the follow-up of surgically treated patients in stages <span class="elsevierStyleSmallCaps">II</span>and <span class="elsevierStyleSmallCaps">III</span> or in metastatic disease.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,12,18</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Tumor size predicts its behavior and the type of treatment necessary.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,16,17</span></a> Other factors must also be taken into account, such as invasion of the muscularis propria, lymphovascular invasion, atypia, and mitotic rate.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,20,22</span></a> The treatment of a localized NET is complete resection.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12–14</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">NET measuring less than 1<span class="elsevierStyleHsp" style=""></span>cm can be treated with local resection<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,18,19,21</span></a> as they present a risk of less than 3% for lymph node metastasis.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Previously, infiltration of the muscularis propria needs to be ruled out with ultrasound.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Resection can be performed with standard (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) or dual-channel endoscopic ultrasound,<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22–27</span></a> through transanal surgery,<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17,21</span></a> or even with band ligation.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The treatment of NET from 1 to 2<span class="elsevierStyleHsp" style=""></span>cm in diameter is not clear because between 10% and 15% will have lymph node metastasis.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,18</span></a> Local resection is indicated in cases where no involvement of the muscularis propria and lymph nodes has been detected by ultrasound<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18,21</span></a> and the mitotic rate is low.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> If atypia and high mitotic rate are identified, radical surgery should be considered.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Tumors that are more than 2<span class="elsevierStyleHsp" style=""></span>cm in size have a risk of between 60% and 80% for lymph node metastasis.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,18</span></a> NET larger than 2<span class="elsevierStyleHsp" style=""></span>cm, with invasion of the muscularis propria or lymph node involvement should be treated with either anterior resection of the rectum or abdominoperineal resection, depending on the distance to the anal margin.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,18</span></a> There is no evidence for adjuvant treatment after surgery.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Curative surgery should be proposed in patients with operable liver metastasis, since 5-year survival reaches 60%–80%.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> Subsequent adjuvant treatment is not recommended.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> Liver transplantation can be carried out in selected cases in which surgical removal is not possible.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">In metastatic disease, long-acting release (LAR) octreotide and interferon-α have been used.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,18,21,29</span></a> Recently, radiotherapy has been applied with peptide receptor radionuclide therapy using somatostatin analogs, providing responses of 30% in patients with tumors that express somatostatin receptors.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,18</span></a> On rare occasions, chemotherapy is indicated in NET G1 or G2. When used due to disease progression, streptozotocin is most often administered in combination with 5-fluorouracil±doxorubicin, but the response is less than 25%.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,12</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Five-year survival is 91% in localized disease, 49% in regional disease and 32% in metastatic disease.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Follow-up is not necessary in NET<1<span class="elsevierStyleHsp" style=""></span>cm that present with no other data for poor prognosis.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> In the remainder, follow-up includes endorectal ultrasound, rectoscopy, MRI or CT, and chromogranin A<span class="elsevierStyleSup">13</span> for 10 years.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Neuroendocrine Carcinomas and Mixed Adenoneuroendocrine Carcinomas</span><p id="par0105" class="elsevierStylePara elsevierViewall">NEC are poorly differentiated high-grade malignant neoplasms of tumor cells that express neuroendocrine markers (chromogranin A, synaptophysin) and have marked cellular atypia, frequent necrosis and high proliferative activity.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,30</span></a> NEC and MANEC are G3 tumors by definition. There are 2 categories of NEC: small-cell and large-cell. Due to their histologic characteristics, they behave much more aggressively than NET.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31,32</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The annual incidence of these colorectal carcinomas is 2 cases per 1<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>000 inhabitants.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Symptoms are similar to those of rectal adenocarcinomas, but they differ because many have already metastasized at diagnosis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>a and b) and have a poorer prognosis.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> Mean survival is 11 months.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31,33</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">In NEC, chromogranin A is usually negative, but neuron-specific enolase can be used as a marker.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">There is no standardized treatment.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> The usual treatment is surgical: amputation or anterior resection depending on the location, with total mesorectal excision.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Nonetheless, it seems that surgery alone is curative on few occasions, so adjuvant chemotherapy is recommended in most cases.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> The same chemotherapy is used as in neuroendocrine lung cancer, which is a combination of cisplatin or carboplatin and ectoposide.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,29,30</span></a> Radiotherapy can be indicated in cases at risk for local recurrence.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> There have been cases described with good evolution after chemotherapy alone, without surgery.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Sarcomas</span><p id="par0125" class="elsevierStylePara elsevierViewall">Up until the 1990s, most intestinal mesenchymal tumors were leiomyomas or leiomyosarcomas, but with the development of immunohistochemistry techniques it was seen that the majority of these tumors belonged to a different group: gastrointestinal stromal tumor (GIST).<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35,36</span></a></p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Gastrointestinal Stromal Tumors</span><p id="par0130" class="elsevierStylePara elsevierViewall">GIST originate in the interstitial cells of Cajal, which are intestinal pacemakers. They are characterized by having specific markers, such as CD117 (c-KIT) in more than 95% and CD34 in 70%, which differentiate them from leiomyomas and leiomyosarcomas.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> The annual incidence is estimated at 1.5 per 100<span class="elsevierStyleHsp" style=""></span>000.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The most common locations are the stomach and small bowel; however, 10% of GIST are situated in the rectum.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">GIST are submucosal tumors, most of which measure between 4 and 15<span class="elsevierStyleHsp" style=""></span>cm. They can present central necrosis and ulcerate to the rectal lumen. The most frequent symptoms are tenesmus and rectal bleeding.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Diagnosis is reached with CT, MRI, and endorectal ultrasound. Rectal GIST are visualized as eccentric masses with well-defined tumor margins (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), which can have areas of hemorrhage or necrosis.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39,40</span></a> MRI seems to be the preferred test for rectal localization.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> Ultrasound is able to confirm that the tumor originates in the muscle wall and not in the mucosa.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> The histologic diagnosis can be difficult with unaffected mucosa.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> In cases of extensive or risky surgeries, or in cases of doubtful diagnoses with processes that require other treatments, endoscopic ultrasound biopsy is recommended, which has a success rate of 80%–90%.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">Standard treatment of localized GIST is surgical resection with free margins,<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,36,43,44</span></a> and, as lymph node metastases are infrequent,<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,37</span></a> lymph node dissection is not required if the nodes are clinically negative. These tumors have a pseudocapsule and are friable, so they should be manipulated with care to avoid rupture,<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">37,42,43</span></a> which would worsen the prognosis.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">In the rectum, the size and location of the GIST determine the type of surgery. Small tumors can be treated with local resection, involving either the abdominal or transanal approaches.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> There should be no tumor cells in the resection margins.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> It is not clear whether asymptomatic tumors <1<span class="elsevierStyleHsp" style=""></span>cm should be removed or have strict follow-up and only be resected if they increase in size.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,42</span></a> Large tumors, which are generally larger than 5<span class="elsevierStyleHsp" style=""></span>cm, are usually treated with anterior resection and without the need for mesorectal excision, or by means of abdominoperineal resection.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38,44,47,48</span></a> There have also been reports of large tumors removed using the transacral<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49,50</span></a> or transvaginal<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> approaches.</p><p id="par0155" class="elsevierStylePara elsevierViewall">The most important prognostic factors are tumor size, number of mitoses, and their location.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,36,43,52,53</span></a> Rectal tumors have a poorer prognosis than gastric lesions.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,45</span></a> Furthermore, tumor rupture is another adverse factor.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">GIST are resistant to chemotherapy but sensitive to imatinib, a tyrosine-kinase inhibitor that has demonstrated important clinical benefits in patients with advanced disease or recurrence.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> It is also effective for increasing survival in patients at risk in an adjuvant treatment.<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">54–56</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Disease-free survival after 5, 10, and 15 years is 70%, 63%, and 60%, respectively.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> Adjuvant therapy is indicated in patients at risk for recurrence.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,43</span></a> In rectal GIST>5<span class="elsevierStyleHsp" style=""></span>cm with any number of mitoses/50 fields, in those of any size with >5<span class="elsevierStyleHsp" style=""></span>mitoses/50 fields or in those with rupture,<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45,57</span></a> the recommended dose is 400<span class="elsevierStyleHsp" style=""></span>mg/day for 3 years.<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">54,58</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Given the good response of GIST to imatinib, it is being used as neoadjuvant treatment to be able to resect initially unresectable tumors and to avoid abdominoperineal resection in large distal tumors.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">37,42,59–62</span></a> After neoadjuvant therapy decreases tumor size and increases resectability,<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">60,62–64</span></a> there may even be a complete response.<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">62,63,65</span></a> These indications are not supported by randomized studies and are based on short series or isolated cases. A recent multicenter study<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> confirmed that neoadjuvant treatment reduces tumor size and increases resectability, but it does not avoid mutilating surgery; it also concluded that surgery continues to be the treatment of choice in primary resectable GIST. Before neoadjuvant therapy, there should be histologic confirmation.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a> The optimal duration of preoperative treatment is unknown.<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">63,66,67</span></a> For some, maximum tumor response is achieved after 3–6 months of treatment,<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40,68</span></a> while others consider 6–12 months reasonable.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a> Treatment should be maintained until the maximum response is reached, defined by non-improvement between 2 CT or MRI studies.<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">63,66,67</span></a> The use of PET can predict the response to treatment 2 weeks after initiation since functional results become evident before morphological results.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">For patients with inoperable metastatic tumors, the standard treatment is imatinib.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40,41,68</span></a> Treatment should be continued indefinitely because its interruption is generally accompanied by rapid tumor progression.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,68</span></a> In cases of progression during treatment with imatinib, other substances can be used such as second-line sunitinib or third-line regorafenib.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">There are no data to recommend a follow-up protocol in patients operated on due to localized GIST, but it seems logical for the follow-up to be done in line with patient risk.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Most recurrences arise within the first 5 years and rarely do so after 10 years.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Other Sarcomas</span><p id="par0185" class="elsevierStylePara elsevierViewall">Soft tissue sarcomas and sarcomas of other organs (excluding GIST) have an estimated annual incidence of 4–5 per 100<span class="elsevierStyleHsp" style=""></span>000.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Rectal sarcomas are very rare since gastrointestinal sarcomas represent 2.6% of all sarcomas and, amongst these, only 15% are colorectal.<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a> There are numerous histologic subtypes as they are classified according to the cells of origin of the tissue. In the rectum, the most frequent type is leiomyosarcoma.<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a> The histologic grade of malignancy (G1, G2 or G3) is determined by 3 parameters: differentiation, tumor necrosis, and the number of mitoses.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,70</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">There is no clear etiology for these tumors, but an increased risk for the appearance of sarcomas after ionizing radiation has already been identified. They generally appear 7–10 years after radiotherapy.<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">71</span></a> Leiomyosarcomas and angiosarcomas have been detected after pelvic radiotherapy.<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">72–75</span></a> Furthermore, Kaposi's sarcoma has been associated with AIDS.<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">76</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">Leiomyosarcomas have a different origin than GIST: they derive from the cells of the muscularis mucosae or the muscular propria.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36,47</span></a> Immunohistochemistry studies show their positivity to smooth-muscle actin and desmin and negativity to CD117 and CD34, which differentiates them from GIST.<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">47,70</span></a> They frequently present as polypoid lesions measuring between 2 and 5<span class="elsevierStyleHsp" style=""></span>cm<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). They are usually well-differentiated tumors with high mitotic activity, but it seems that their prognosis can be better than GIST with a similar number of mitosis.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0200" class="elsevierStylePara elsevierViewall">The histologic grade, size, and invasion of neighboring organs determine the prognosis.<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">69,70</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Surgical resection with free margins is the treatment of choice.<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a> Lymph node metastases are uncommon.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> It is not clear whether local resection is sufficient for small low-grade tumors.<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a> The indication for anterior resection or abdominoperineal resection is done according to the size and location of the tumor. Radiotherapy can have results similar to those of the treatment of sarcomas of the extremities and it is recommended in high-grade tumors and those larger than 5<span class="elsevierStyleHsp" style=""></span>cm.<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Recurrences can present as liver, lung or local pelvic metastases. Depending on their characteristics, treatment may include surgical resection, ablation, radiotherapy or chemotherapy.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> As there is no specific marker, follow-up should be done with imaging tests.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Lymphomas</span><p id="par0215" class="elsevierStylePara elsevierViewall">Gastrointestinal lymphomas are rare, but the digestive tract is the most frequent non-lymph node location of non-Hodgkin lymphomas (NHL). Colorectal involvement is rarer than gastric or small bowel locations. This lymphoma is considered primary when there is no systemic involvement, meaning that there are no peripheral lymphadenopathies, no mediastinal lymph node involvement, normal peripheral blood and bone marrow biopsy studies, lymphadenopathies located only in the proximity of the lesion, and no involvement of the liver or spleen.<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">78,79</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">Secondary rectal lymphoma is a generalized process with rectal involvement due to lymph node metastasis. The differentiation between primary and secondary lymphoma is important because treatment and prognosis are different for each. The treatment of secondary lymphoma is chemotherapy and five-year survival is 15%.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">In the rectum, all histological lymphoma subtypes may be present, but the majority of primary lymphomas are B-cell NHL,<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">79–81</span></a> with their different variations: large B-cell, mantle-cell, follicular, Burkitt, and mucosa-associated lymphoid tissue (MALT).<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">78,82,83</span></a> The proportion of these different subtypes varies according to geographical region.<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">79</span></a> T-cell NHL are more frequent in Asia than in Western countries.<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">79,80</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">Different factors have been involved in the genesis of gastrointestinal lymphomas; these are generally associated with immunosuppression, such as HIV infection, inflammatory bowel disease, organ transplantation or treatment with corticosteroids.<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">79,80</span></a> They have also been related with infectious agents, such as <span class="elsevierStyleItalic">Helicobacter pylori</span> and others.<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">80</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">Mean age at diagnosis is 55.<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">78,79</span></a> The most frequent symptoms are abdominal pain, weight loss, change in bowel habits, and rectal bleeding.<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">79,81</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">Although in the colon it presents as a polypoid lesion (possibly ulcerated), stenosing mass, segmental polyposis, or nodularity of the mucosa,<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">79,80,83</span></a> the most typical rectal presentation is a homogenous mass (due to the concentric wall thickening) with luminal stenosis.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39,84</span></a> Suspicion of lymphoma is due the existence of large, numerous lymphadenopathies.<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">79</span></a> Ultrasound biopsy with immunohistochemistry provides the diagnosis, although in many cases precise preoperative diagnosis can be difficult.<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">81,85–87</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">Due to the small number of patients and the various histological subtypes, there is no standardized treatment for colorectal lymphomas.<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">79,88</span></a> A combination of surgery and chemotherapy can be used, reserving radiotherapy for certain cases.<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">82,83</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">Oncologic surgical resection is the most common treatment for localized lymphomas<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">78,79,81–83</span></a> as it offers the possibility of a cure without adjuvant treatment and prevents complications such as bleeding, obstruction or perforation.<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">82,85</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">Chemotherapy as an initial treatment is usually reserved for patients with locally advanced tumors<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">81</span></a> or disseminated disease.<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">83</span></a> Adjuvant chemotherapy after surgery is recommended in aggressive lymphomas or advanced stages.<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">79,85</span></a> The most widely used chemotherapy regime is CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone).<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">78,82,83,85,89</span></a> Results improve when an anti-CD 20 monoclonal antibody, rituximab, is added to this classic protocol (R-CHOP).<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">79</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">Adjuvant radiotherapy could play a role in locoregional control after incomplete resection<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">82,83</span></a> or in cases of chemo-resistant tumors.<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">79</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">Rare rectal MALT lymphomas have been treated in many different ways. In some <span class="elsevierStyleItalic">H. pylori</span>-positive MALT, antibiotic therapy has been used successfully alone<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">90,91</span></a>; in other cases, radiotherapy, chemotherapy or surgery has been used.<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">92</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">Five-year survival of colorectal lymphomas is between 25% and 57%, which is worse than gastric and small intestine lymphomas.<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">82</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Squamous-Cell Carcinoma</span><p id="par0275" class="elsevierStylePara elsevierViewall">Squamous-cell carcinoma is an uncommon tumor that is usually found in the esophagus and anus. Rectal involvement is very rare. In many cases, supposed rectal squamous-cell carcinomas are, in reality, an extension of an anal carcinoma.<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">93</span></a> Occasionally, they have a mixed histologic pattern and are called adenosquamous carcinoma.<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">94</span></a></p><p id="par0280" class="elsevierStylePara elsevierViewall">Mean age is 57 years and this pathology is somewhat more frequent in women than in men.<a class="elsevierStyleCrossRefs" href="#bib0465"><span class="elsevierStyleSup">93,95</span></a> There are no clear risk factors, but there has been an association with inflammatory diseases of the rectum, human papilloma virus (HPV), and colorectal adenocarcinoma.<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">95</span></a></p><p id="par0285" class="elsevierStylePara elsevierViewall">Symptoms are similar to those of rectal adenocarcinoma, and the most frequent is rectal bleeding.<a class="elsevierStyleCrossRefs" href="#bib0465"><span class="elsevierStyleSup">93,95</span></a> Endoscopic findings can be varied, from a polypoid formation up to an ulcerative and stenosing tumor<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">95</span></a>; biopsy provides the diagnosis. Occasionally, there can be difficulties in distinguishing it from a poorly differentiated tumor, but immunohistochemistry can define the lesion.<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">95</span></a> The most useful cytokeratins are CAM 5.2, AE1/AE3, and 34B12.<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">95</span></a></p><p id="par0290" class="elsevierStylePara elsevierViewall">For staging, MRI (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>), CT and endorectal ultrasound are used. Squamous-cell carcinoma antigen is a tumor marker that is high in some patients. It is not used for diagnosis but can be used for monitoring response or progression.<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">95,96</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0295" class="elsevierStylePara elsevierViewall">Traditionally, the usual treatment has been surgery, followed by adjuvant radiotherapy or chemotherapy in some cases.<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">97,98</span></a> In the last decade, given the good results of chemoradiotherapy in squamous-cell carcinoma of the anus, this traditional approach has been questioned<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">99</span></a> and, even though a standard treatment has not been established,<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">93</span></a> there has been a tendency to modify this approach, making chemotherapy the initial treatment for squamous-cell carcinoma of the rectum, and reserving surgery for persistent tumors after treatment.<a class="elsevierStyleCrossRefs" href="#bib0465"><span class="elsevierStyleSup">93,96,100,101</span></a> The regimes used are the same that have been shown to be effective in squamous carcinoma of the anus.<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">95</span></a> Treatment entails a combination of mitomycin-C with 5-fluorouracil and radiotherapy at a minimum dose of 45–50<span class="elsevierStyleHsp" style=""></span>Gy.<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">102–104</span></a> The response to chemoradiotherapy is assessed 6–8 weeks after the end of treatment using rectoscopy with biopsy, MRI or PET.<a class="elsevierStyleCrossRefs" href="#bib0465"><span class="elsevierStyleSup">93,99–101</span></a> If there is complete clinical and radiological response, periodical follow-up is performed; cases of tumor persistence should be re-evaluated after 4–6 weeks, as recommended in anal cancer.<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">104</span></a> Rescue surgery may be necessary, which entails anterior resection or amputation, depending on the tumor and patient characteristics.<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">97</span></a></p><p id="par0300" class="elsevierStylePara elsevierViewall">There are few published series in which the initial treatment was chemoradiotherapy and they include few cases, but between 66% and 100% showed complete response and did not require later surgery.<a class="elsevierStyleCrossRefs" href="#bib0465"><span class="elsevierStyleSup">93,96,99–101</span></a> After complete response, clinical follow-up should include rectal biopsies and radiological studies, which become progressively spaced out over time.<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">99</span></a></p><p id="par0305" class="elsevierStylePara elsevierViewall">Five-year survival is 50% in stage <span class="elsevierStyleSmallCaps">II</span> and drops to 33% when there is lymph node involvement.<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">95</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusions</span><p id="par0310" class="elsevierStylePara elsevierViewall">The rarity of these tumors and their heterogenous origin, treatment, and prognosis mean that physicians may have difficulties in the management of these patients. A multidisciplinary approach including pathologists, radiologists, oncologists, radiotherapists, and surgeons is recommended.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflict of Interest</span><p id="par0315" class="elsevierStylePara elsevierViewall">The authors declare having no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:2 [ "identificador" => "xres376563" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec355684" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres376562" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec355685" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Neuroendocrine Neoplasms" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Neuroendocrine Tumors" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Neuroendocrine Carcinomas and Mixed Adenoneuroendocrine Carcinomas" ] ] ] 6 => array:3 [ "identificador" => "sec0025" "titulo" => "Sarcomas" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Gastrointestinal Stromal Tumors" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Other Sarcomas" ] ] ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Lymphomas" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Squamous-Cell Carcinoma" ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflict of Interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-03-05" "fechaAceptado" => "2013-06-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec355684" "palabras" => array:8 [ 0 => "Rectal neoplasms" 1 => "Lymphoma" 2 => "Gastrointestinal stromal tumors" 3 => "Sarcoma" 4 => "Neuroendocrine tumors" 5 => "Carcinoid tumor" 6 => "Squamous cell carcinoma" 7 => "Review literature" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec355685" "palabras" => array:8 [ 0 => "Cáncer de recto" 1 => "Linfoma" 2 => "Tumor del estroma gastrointestinal" 3 => "Sarcoma" 4 => "Tumores neuroendocrinos" 5 => "Tumor carcinoide" 6 => "Carcinoma de células escamosas" 7 => "Revisión de la literatura" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Most rectal neoplasms are adenocarcinomas, but there is a small percentage of tumors which are of other histological cell lines such as neuroendocrine tumors, sarcomas, lymphomas, and squamous cell carcinomas, which have special characteristics and different treatments. We have reviewed these rare tumors of the rectum from a clinical and surgical point of view.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La mayoría de los cánceres de recto son adenocarcinomas, pero existe un pequeño porcentaje de tumores de otras estirpes histológicas, como neoplasias neuroendocrinas, sarcomas, linfomas y carcinomas de células escamosas, que tienen unas características y tratamientos diferentes. Hemos efectuado una revisión de estos raros tumores del recto desde un punto de vista clínico y quirúrgico.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Errasti Alustiza J, Espín Basany E, Reina Duarte Á. Neoplasias de recto poco frecuentes. Revisión de conjunto. Cir Esp. 2014;92:579–588.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 694 "Ancho" => 990 "Tamanyo" => 152386 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Rectal neuroendocrine tumor treated with endoscopic polypectomy with disease-free resection margins (macro–micro photo); immunohistochemistry for synaptophysin.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1327 "Ancho" => 900 "Tamanyo" => 191214 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(a, b) Locally advanced rectal neuroendocrine carcinoma with liver metastases.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1000 "Ancho" => 750 "Tamanyo" => 154384 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Rectal GIST.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 743 "Ancho" => 990 "Tamanyo" => 216505 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Rectal sarcoma.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 622 "Ancho" => 900 "Tamanyo" => 80502 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Squamous carcinoma of the rectum.</p>" ] ] 5 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">IBD: inflammatory bowel disease; GIST: gastrointestinal stromal tumor; HIV: human immunodeficiency virus; HPV: human papilloma virus; MANEC: mixed adenoneuroendocrine carcinoma; NEC: neuroendocrine carcinoma; NET: neuroendocrine tumor; CRT: chemoradiotherapy; CTx: chemotherapy; RT: radiotherapy.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Tumor type \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Cells of origin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Risk factors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Prognostic factors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Usual treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Adjuvant treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">5-year survival % \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NET \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Kultschitzky cells \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– No. of mitoses– Ki67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><1<span class="elsevierStyleHsp" style=""></span>cm: local resection>2<span class="elsevierStyleHsp" style=""></span>cm: oncologic resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NEC, MANEC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oncologic resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CTx \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">GIST \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Interstitial cells of Cajal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– Size– No. of mitoses– Tumor rupture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Resection with free margins \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Imatinib \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other sarcomas \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rectal connective tissue \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– Previous RT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– Differentiation– Tumor necrosis– No. of mitoses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Resection with free margins \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lymphomas \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rectal lymphoid tissue \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– HIV– IBD– Immunosuppression \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– Histologic type– Histologic grade \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oncologic resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CTx \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30–60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Squamous carcinoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rectal epithelium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– HPV– Chronic rectal inflammatory processes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CRTOncologic resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n 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Year/Month | Html | Total | |
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2024 October | 45 | 5 | 50 |
2024 September | 57 | 19 | 76 |
2024 August | 37 | 14 | 51 |
2024 July | 41 | 7 | 48 |
2024 June | 54 | 4 | 58 |
2024 May | 55 | 7 | 62 |
2024 April | 46 | 9 | 55 |
2024 March | 50 | 4 | 54 |
2024 February | 54 | 3 | 57 |
2024 January | 55 | 5 | 60 |
2023 December | 60 | 5 | 65 |
2023 November | 75 | 5 | 80 |
2023 October | 57 | 15 | 72 |
2023 September | 27 | 5 | 32 |
2023 August | 46 | 11 | 57 |
2023 July | 62 | 5 | 67 |
2023 June | 55 | 7 | 62 |
2023 May | 90 | 2 | 92 |
2023 April | 98 | 4 | 102 |
2023 March | 73 | 3 | 76 |
2023 February | 52 | 1 | 53 |
2023 January | 53 | 7 | 60 |
2022 December | 57 | 4 | 61 |
2022 November | 39 | 8 | 47 |
2022 October | 35 | 7 | 42 |
2022 September | 42 | 30 | 72 |
2022 August | 37 | 15 | 52 |
2022 July | 36 | 10 | 46 |
2022 June | 33 | 8 | 41 |
2022 May | 19 | 12 | 31 |
2022 April | 21 | 8 | 29 |
2022 March | 38 | 13 | 51 |
2022 February | 37 | 8 | 45 |
2022 January | 55 | 6 | 61 |
2021 December | 45 | 25 | 70 |
2021 November | 59 | 12 | 71 |
2021 October | 68 | 9 | 77 |
2021 September | 60 | 14 | 74 |
2021 August | 40 | 10 | 50 |
2021 July | 35 | 5 | 40 |
2021 June | 34 | 15 | 49 |
2021 May | 47 | 10 | 57 |
2021 April | 122 | 15 | 137 |
2021 March | 55 | 11 | 66 |
2021 February | 56 | 8 | 64 |
2021 January | 58 | 22 | 80 |
2020 December | 45 | 4 | 49 |
2020 November | 63 | 5 | 68 |
2020 October | 42 | 7 | 49 |
2020 September | 53 | 14 | 67 |
2020 August | 65 | 5 | 70 |
2020 July | 49 | 9 | 58 |
2020 June | 36 | 6 | 42 |
2020 May | 36 | 12 | 48 |
2020 April | 25 | 5 | 30 |
2020 March | 43 | 7 | 50 |
2020 February | 36 | 14 | 50 |
2020 January | 36 | 13 | 49 |
2019 December | 37 | 16 | 53 |
2019 November | 27 | 12 | 39 |
2019 October | 43 | 6 | 49 |
2019 September | 49 | 7 | 56 |
2019 August | 25 | 10 | 35 |
2019 July | 28 | 14 | 42 |
2019 June | 60 | 11 | 71 |
2019 May | 135 | 18 | 153 |
2019 April | 71 | 17 | 88 |
2019 March | 32 | 6 | 38 |
2019 February | 34 | 7 | 41 |
2019 January | 19 | 7 | 26 |
2018 December | 16 | 1 | 17 |
2018 November | 32 | 11 | 43 |
2018 October | 48 | 6 | 54 |
2018 September | 19 | 10 | 29 |
2018 August | 16 | 3 | 19 |
2018 July | 15 | 5 | 20 |
2018 June | 16 | 3 | 19 |
2018 May | 12 | 8 | 20 |
2018 April | 24 | 0 | 24 |
2018 March | 26 | 2 | 28 |
2018 February | 10 | 1 | 11 |
2018 January | 15 | 0 | 15 |
2017 December | 11 | 2 | 13 |
2017 November | 20 | 1 | 21 |
2017 October | 23 | 2 | 25 |
2017 September | 29 | 2 | 31 |
2017 August | 23 | 3 | 26 |
2017 July | 31 | 3 | 34 |
2017 June | 44 | 15 | 59 |
2017 May | 39 | 1 | 40 |
2017 April | 28 | 2 | 30 |
2017 March | 31 | 37 | 68 |
2017 February | 55 | 2 | 57 |
2017 January | 18 | 3 | 21 |
2016 December | 45 | 7 | 52 |
2016 November | 63 | 5 | 68 |
2016 October | 96 | 4 | 100 |
2016 September | 170 | 10 | 180 |
2016 August | 94 | 3 | 97 |
2016 July | 65 | 3 | 68 |
2016 June | 46 | 13 | 59 |
2016 May | 49 | 21 | 70 |
2016 April | 54 | 40 | 94 |
2016 March | 54 | 36 | 90 |
2016 February | 52 | 26 | 78 |
2016 January | 44 | 41 | 85 |
2015 December | 55 | 32 | 87 |
2015 November | 46 | 20 | 66 |
2015 October | 40 | 30 | 70 |
2015 September | 49 | 12 | 61 |
2015 August | 55 | 29 | 84 |
2015 July | 50 | 23 | 73 |
2015 June | 23 | 17 | 40 |
2015 May | 41 | 25 | 66 |
2015 April | 38 | 26 | 64 |
2015 March | 41 | 27 | 68 |
2015 February | 24 | 8 | 32 |
2014 December | 0 | 2 | 2 |
2014 November | 0 | 4 | 4 |