Surgical treatments for esophageal cancers.

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on the role of the nurse in preparation of esophageal resection (ER); the management of patients who develop high-grade dysplasia after having undergone Nissen fundoplication; the trajectory of care for the patient with esophageal cancer; the influence of the site of tumor in the choice of treatment; the best location for esophagogastrostomy; management of chylous leak after esophagectomy; the optimal approach to manage thoracic esophageal leak after esophagectomy; the choice for operational approach in surgery of cardioesophageal crossing; the advantages of robot esophagectomy; the place of open esophagectomy; the advantages of esophagectomy compared to definitive chemoradiotherapy; the pathologist report in the resected specimen; the best way to manage patients with unsuspected positive microscopic margin after ER; enhanced recovery after surgery for ER: expedited care protocols; and long-term quality of life in patients following esophagectomy.

Endoscopic diagnosis of dysplasia in Barrett's esophagus.

Barrett's esophagus, or columnar metaplasia with gastric cardiac cells or intestinal cells, develops in the squamous epithelium of the esophageal mucosa in relation to gastroesophageal reflux. An increased risk of neoplasia justifies surveillance at regular intervals. Conventional guidelines recommend detection of areas with intestinal metaplasia or dysplasia by taking random four-quadrant biopsies at every 1 or 2 cm. Alternatively, image processing with narrow band imaging (NBI), is proposed to improve detection. This international and randomized study in persons with Barrett's esophagus compares conventional endoscopy in white light with random four-quadrant biopsies and NBI imaging with focused biopsies only. Randomization enrolled 123 patients with Barrett's esophagus who successively underwent exploration with the two methods. The study confirmed that NBI had the same efficacy as white light in the detection of intestinal metaplasia, with a higher proportion of dysplasia detected (30 vs 21%) and a lower number of biopsies per patient (3.6 vs 7.6).

The incidence and survival rates of colorectal cancer in India remain low compared with rising rates in East Asia.

BACKGROUND: During the past 3 decades, the incidence of colorectal cancer was at a low level in urban and rural populations in India, in comparison with figures observed in developed countries of North America and Europe. OBJECTIVE: The aim of this study was to describe the time trends of incidence and mortality, and the survival rates of colorectal cancer, as well, in India. DESIGN: This is an ecological study. MAIN OUTCOME MEASURES: The primary outcome measured is the incidence data extracted from selected Indian cancer registries in the volumes on cancer incidence in 5 continents. RESULTS: Low and stable incidence and mortality rates from colon and rectum cancers were observed in India in both men and women. However, this low incidence rate was associated with a low 5-year relative survival rate. CONCLUSIONS: It is likely that the prevailing environmental factors and lifestyle, including a reduced consumption of sugars, calories and fat-rich food, an increased consumption of vegetables and fruits, and an adequate physical activity with avoidance of overweight and obesity, are responsible for the low risk of colorectal cancers. In contrast, the low survival, even for localized cases, suggests severe deficiencies in early diagnosis and effective treatment in India. A strategy to control the disease in India, based on improving awareness of the risk factors for colorectal cancer while keeping the traditional lifestyle, and on investments in early diagnosis and adequate treatment should be implemented. However, an organized, population-based screening of colorectal cancer may not prove cost-effective, given the low burden of colorectal cancer.

Laterally spreading tumors in the colon and rectum.

The large and relatively flat colorectal neoplastic lesions called laterally spreading tumors are classified as nonpolypoid despite some mixed patterns with protruding nodules. Large hyperplastic polyps and sessile serrated lesions are non-neoplastic lesions that also have this morphology and may potentially progress to neoplasia. All these large and relatively flat lesions are more frequent in the proximal colon and less conspicuous than polypoid lesions. Their underdiagnosis is a major factor in the failure of colonoscopy to prevent cancer in the proximal colon. The treatment of laterally spreading tumors by endoscopic resection (endoscopic mucosal resection, piecemeal endoscopic mucosal resection, endoscopic submucosal dissection), or by surgery is based on a careful morphologic analysis, taking into account the size and surface with nodules or depression. The technique of endoscopic submucosal dissection should be diffused because it reduces the number of surgical indications.

Survival from digestive cancer in emerging countries in Asia and Africa.

The incidence of digestive cancer, including cancer of the esophagus, stomach, colon, and liver, is analyzed in developing and less developed countries in Africa, Asia, the Caribbean, and Latin America. The analysis is based on cancer registries for observed values, on a recent monograph published at International Agency for Research on Cancer and on the GLOBOCAN 2008 database for estimations. For all tumor sites analyzed, the incidence is lower in these countries than in developed countries of Europe, North America, and Japan. The 5-year relative survival from digestive cancer is also lower. In developing countries, there is room for prevention of cancer burden through lifestyle interventions and through improved early detection of cancer.

Endoscopy in screening for digestive cancer.

The aim of this study is to describe the role of endoscopy in detection and treatment of neoplastic lesions of the digestive mucosa in asymptomatic persons. Esophageal squamous cell cancer occurs in relation to nutritional deficiency and alcohol or tobacco consumption. Esophageal adenocarcinoma develops in Barrett's esophagus, and stomach cancer in chronic gastric atrophy with Helicobacter pylori infection. Colorectal cancer is favoured by a high intake in calories, excess weight, low physical activity. In opportunistic or individual screening endoscopy is the primary detection procedure offered to an asymptomatic individual. In organized or mass screening proposed by National Health Authorities to a population, endoscopy is performed only in persons found positive to a filter selection test. The indications of primary upper gastrointestinal endoscopy and colonoscopy in opportunistic screening are increasingly developing over the world. Organized screening trials are proposed in some regions of China at high risk for esophageal cancer; the selection test is cytology of a balloon or sponge scrapping; they are proposed in Japan for stomach cancer with photofluorography as a selection test; and in Europe, America and Japan; for colorectal cancer with the fecal occult blood test as a selection test. Organized screening trials in a country require an evaluation: the benefit of the intervention assessed by its impact on incidence and on the 5 year survival for the concerned tumor site; in addition a number of bias interfering with the evaluation have to be controlled. Drawbacks of screening are in the morbidity of the diagnostic and treatment procedures and in overdetection of none clinically relevant lesions. The strategy of endoscopic screening applies to early cancer and to benign adenomatous precursors of adenocarcinoma. Diagnostic endoscopy is conducted in 2 steps: at first detection of an abnormal area through changes in relief, in color or in the course of superficial capillaries; then characterization of the morphology of the lesion according to the Paris classification and prediction of the risk of malignancy and depth of invasion, with the help of chromoscopy, magnification and image processing with neutrophil bactericidal index or FICE. Then treatment decision offers 3 options according to histologic prediction: abstention, endoscopic resection, surgery. The rigorous quality control of endoscopy will reduce the miss rate of lesions and the occurrence of interval cancer.

Barrett's esophagus: natural history.

The following on the natural history of Barrett's esophagus (BE) includes commentary on histological sequences of the development of Barrett mucosa; the transformation of esophageal cells from squamous to columnar phenotype; the stages of natural history of dysplasia; the difficulties of predicting progression of dysplasia to adenocarcinoma; the preferable biopsy protocols; the role of Helicobacter pylori infection and gastric atrophy in the risk of BE; the value of decrease of proton pump inhibitor efficacy following eradication of H. pylori; the place of antireflux surgery in the natural history of BE; the newest procedures for the endoscopic detection of early neoplasia; and the essential importance of a good understanding of the natural history for the best management of high-grade dysplasia.

Proceedings of a preliminary workshop at Gastro 2009--narrow banding imaging in digestive endoscopy: clinical outcome of classification (Omed-Jges Educational Meeting held on 22 November, 2009).

This publication reports the proceedings of the preliminary meeting of the working party that met at Gastro 2009 during the World Congress in London. The purpose of the preliminary meeting was to consider the areas that require attention, to discuss some of the findings that have already been published and to agree on the way forward. Our reason for publishing these proceedings is to stimulate interest in this venture and to provide the opportunity for input from the endoscopy community worldwide. The next meeting of the working party will be at the JGES Society meeting in Aomori in April 2011 when we hope to prepare a preliminary classification. This will be presented for general discussion and debate at the International Congress of Endoscopy (ICE) in Los Angeles in September 2011.

Epidemiology of cancer from the oral cavity and oropharynx.

The classification of sites in tumors of the oral cavity, oropharynx, pharynx, and hypopharynx varies in the literature. More than 90% of these tumors of the mucosal lining are classified as squamous cell carcinoma developed from premalignant lesions such as leukoplakia and erythroleukoplakia. These carcinomas are associated to environmental and lifestyle risk factors, among which tobacco and alcohol play a major role. In addition to tobacco smoking, tobacco chewing is another risk factor as well as chewing betel quid and areca nut in Asia. Certain strains of virus, such as the sexually transmitted human papilloma virus, also play a carcinogenetic role. The temporal trends in incidence of these tumors relate to environmental factors; there is an increase in tendency in countries without prevention and a decrease in countries having an active policy of prevention of alcohol and tobacco consumption. In contrast, an increased incidence occurs in the world at tumor sites related to human papilloma virus infection in relation to changes in sexual habits.

Cascade colorectal cancer screening guidelines: a global conceptual model.

BACKGROUND: Guidelines should be a catalyst toward achieving, as a universal standard, the most effective possible care. However, guidelines mainly use evidence of effectiveness as the basis for recommendations. This approach may not be the most appropriate for all healthcare settings because of differing levels of available medical and financial resources. This report from the Guidelines Committee of the World Gastroenterology Organization presents a new conceptual model of cascade colorectal cancer screening guidelines that is also evidence based but resource driven. The emphasis in this variation of the model is on colonoscopy resources at the top of the cascade for a screening goal of prevention by finding and removing the colorectal cancer precursor lesions, the adenoma, as well as early detection. This is a concept study for consideration in the development of future guidelines. Various tests can be reordered within the framework of this model. The cascade concept says, "do what you can with what you have," rather than, "do it this way or no way." METHODS: A systematic review of colorectal cancer screening was performed and an evidence-based cascade (hierarchical recommendations) developed that could apply to healthcare settings having different levels of medical (primarily colonoscopy in this version of the model) resources. A review team representing both developed and developing countries examined published data and provided expert opinion. Cascade guidelines were prepared and reviewed by the team. RESULTS: A set of 4 resource levels were delineated based on available data: colonoscopy, sigmoidoscopy, different sensitivity fecal occult blood tests, and recommendations for colorectal cancer screening were made based on each level, from high to low resources for average risk men and women. The major resource considered was endoscopic in this version of the model. CONCLUSIONS: Each country, region, or healthcare setting needs to determine whether colorectal cancer screening is a legitimate consideration based on other healthcare priorities. Where there is a major burden of colorectal cancer and sufficient resources to mount a screening program, the cascade colorectal cancer screening guidelines model can assist in decisions regarding screening methods. This version is based mainly on available endoscopic resources. These guidelines are evidence based but resource driven. Each healthcare setting needs to determine its resource level as a basis for selecting the screening approach that is most applicable and therefore most likely to succeed. This concept study provides a model that can be adapted to a variety of evidence-based options with consideration of available resources. Its goal is to enhance colorectal cancer screening worldwide, especially in developing countries where the colorectal cancer incidence and mortality is rising rapidly.

Annex to Quirke et al. Quality assurance in pathology in colorectal cancer screening and diagnosis: annotations of colorectal lesions.

Multidisciplinary, evidence-based European Guidelines for quality assurance in colorectal cancer screening and diagnosis have recently been developed by experts in a pan-European project coordinated by the International Agency for Research on Cancer. The full guideline document includes a chapter on pathology with pan-European recommendations which take into account the diversity and heterogeneity of health care systems across the EU. The present paper is based on the annex to the pathology chapter which attempts to describe in greater depth some of the issues raised in the chapter in greater depth, particularly details of special interest to pathologists. It is presented here to make the relevant discussion known to a wider scientific audience.

Quality assurance in pathology in colorectal cancer screening and diagnosis­European recommendations.

In Europe, colorectal cancer is the most common newly diagnosed cancer and the second most common cause of cancer deaths, accounting for approximately 436,000 incident cases and 212,000 deaths in 2008. The potential of high-quality screening to improve control of the disease has been recognized by the Council of the European Union who issued a recommendation on cancer screening in 2003. Multidisciplinary, evidence-based European Guidelines for quality assurance in colorectal cancer screening and diagnosis have recently been developed by experts in a pan-European project coordinated by the International Agency for Research on Cancer. The full guideline document consists of ten chapters and an extensive evidence base. The content of the chapter dealing with pathology in colorectal cancer screening and diagnosis is presented here in order to promote international discussion and collaboration leading to improvements in colorectal cancer screening and diagnosis by making the principles and standards recommended in the new EU Guidelines known to a wider scientific community.

Prevention of gastrointestinal cancer by surveillance endoscopy.

The classification of the endoscopic appearance of superficial neoplastic lesions of the digestive mucosa aims to evaluate the risk of progression to advanced neoplasia in 3° (low, intermediate, high) and to predict appropriate treatment and corresponding surveillance. The privileged position of endoscopy results from its double impact on prevention of digestive cancer through reduction in incidence after early detection and eradication of precursors; and through reduction of mortality after detection and treatment of cancer at an early and curable stage. However the efficacy of diagnostic endoscopy still requires improvement and quality control on the following points: (1) technology, with a generalized use of the recently introduced high-resolution endoscopes. (2) diagnosis of poorly visible nonpolypoid precursors: this applies to small depressed lesions and large slightly elevated or sessile serrated and non-serrated precursors, particularly in the proximal colon. (3) treatment and training in therapeutic endoscopy, including the most recent techniques of mucosal resection of nonpolypoid lesions.

Evaluation of the clinical outcomes associated with EXERA II and LUCERA endoscopes.

AIM: Regarding the assessment of colonic lesions, important differences between Japan and the Western world have emerged during the last decade. The aim of this study was to compare the clinical outcomes of the same equipment when used in Japan or in France. METHOD: Chromoscopy has not been extensively accepted in the West, in contrast to the wide acceptance in Japan which is probably due to the national screening programme for early gastric cancer. With the development of narrow-band imaging (NBI) we might expect a more generalized approach to the clinical use of various classifications. Narrow band imaging might be an important step towards virtual chromoscopy. A total of 48 patients were examined with back-to-back colonoscopy, using a non-sequential (EXERA II, Olympus Medical Systems Corp., Tokyo, Japan) endoscope, and a sequential endoscope (LUCERA, Olympus Medical Systems Corp.). RESULTS: Education differences also play a role in the evaluation of the clinical outcome of the endoscopy. In Japan, detailed classification of the morphology of the detected lesion is done as a preliminary characterization step before the treatment decision. In the West a treatment decision immediately leads to the therapeutic outcome (non-neoplastic or neoplastic; removed or not). This study showed clearly that, with the same equipment, we obtained identical results for image quality of image in Japan and France. Non-Japanese endoscopists could achieve the same results as Japanese colleagues if knowledge of the minute classification is more widely accepted. CONCLUSION: While the differences in the evaluation of the clinical outcome are mostly cultural, the analysis of endoscopic imaging indicates that the LUCERA and EXERA series provide the same clinical benefit.

Second look colonoscopy: indication and requirements.

BACKGROUND: There are circumstances when a colonoscopy should be repeated after a short interval following the first endoscopic procedure which has not completely fulfilled its objective. REVIEW OF THE LITERATURE: A second look colonoscopy is proposed when there remains a doubt about missed neoplastic lesions, either because the intestinal preparation was poor or because the video-endoscope did not achieved a complete course in the colon. The second look colonoscopy is also proposed at a short interval when it is suspected that the endoscopic removal of a single or of multiple neoplastic lesions was incomplete and that a complement of treatment is required. When the initial endoscopic procedure has completely fulfilled its objective, a second look colonoscopy can be proposed at longer intervals in surveillance programs. The intervals in surveillance after polypectomy are now adapted to the initial findings according to established guidelines. This also applies to the surveillance of incident focal cancer in patients suffering from a chronic inflammatory bowel disease. CONCLUSION: Finally, in most developed countries, a priority is attributed to screening of colorectal cancer and focus is given on quality assurance of colonoscopy which is considered as the gold standard procedure in the secondary prevention of colorectal cancer.

Mass screening for colorectal cancer is not justified in most developing countries.

Most developed countries insist on the prevention of colorectal cancer (CRC) and offer screening to the population. Mass screening is proposed to both sexes in the population aged 50 years or more. Colonoscopy is then offered to persons having a positive faecal occult blood test. This recommendation should not be diffused over the world without considering the distinct dimensions of the risk and resources in developed and developing countries. A national screening policy is legitimate in developed countries like Japan, South Korea, and in North America and Europe. On the other hand, a mass screening policy for CRC is not recommended in most developing countries. The limited amount of resources attributed to health care for cancer should concern other indications in the control of common cancers, particularly in the cervix or liver. Indeed the risk of CRC is very low in most regions of Africa, and in some countries of South America and Asia.