Risk Factor Profiles Differ for Cancers of Different Regions of the Colorectum.

BACKGROUND & AIMS: The molecular features of colorectal tumors differ with their anatomic location. Colorectal tumors are usually classified as proximal or distal. We collected data from 3 cohorts to identify demographic, clinical, anthropometric, lifestyle, and dietary risk factors for colorectal cancer (CRC) at 7 anatomic subsites. We examined whether the associations differ among refined subsites and whether there are trends in associations from cecum to rectum. METHODS: We collected data from the Nurses' Health Study, Nurses' Health Study 2, and Health Professionals Follow-up Study (45,351 men and 178,016 women, followed for a median 23 years) on 24 risk factors in relation to risk of cancer in cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectosigmoid junction, and rectum. Hazard ratios were estimated using Cox proportional hazards regression. We tested for linear and nonlinear trends in associations with CRC among subsites and within proximal colon, distal colon, and rectum. RESULTS: We documented 3058 cases of CRC (474 in cecum, 633 in ascending colon, 250 in transverse colon, 221 in descending colon, 750 in sigmoid colon, 202 in rectosigmoid junction, and 528 in rectum). The positive associations with cancer risk decreased, from cecum to rectum, for age and family history of CRC. In contrast, the inverse associations with cancer risk increased, from cecum to rectum, for endoscopic screening and intake of whole grains, cereal fiber, and processed red meat. There was a significant nonlinear trend in the association between CRC and female sex, with hazard ratios ranging from 1.73 for ascending colon cancer to 0.54 for sigmoid colon cancer. For proximal colon cancers, the association with alcohol consumption and smoking before age 30 years increased from the cecum to transverse colon. For distal colon cancers, the positive association with waist circumference in men was greater for descending vs sigmoid colon cancer. CONCLUSIONS: In an analysis of 3058 cases of CRC, we found that risk factor profiles differed for cancers along the colorectum. Proximal vs distal classifications are not sufficient to encompass the regional variations in colorectal tumor features and risk factors.

Construction of a preoperative scoring system to predict the difficulty level of colorectal endoscopic submucosal dissection.

BACKGROUND: We attempted to examine the factors contributing to the difficulty in performance of colorectal ESD, with the aim of constructing a scoring system that could help in prediction of the difficulty level of the procedure. METHODS AND MATERIALS: The data were analyzed from two viewpoints: to determine the factors contributing to 1) non-en bloc resection and the factors contributing to 2) a slow resection speed. Factors falling under these two categories contributing to difficulty in performance of ESD were extracted and used to construct a scoring system. The validity of this scoring system was evaluated by calculating the correlation between the score and the resection speed in a different dataset. RESULTS: Based on the results of our analysis, we assigned scores for various factors as follows: 4 points for EMR of a scarred lesion, 1 point for tumors with a diameter of ≥ 30 mm, 2 points for lesions located in the liver/splenic flexure, 1 point for lesions located in the transverse colon, 3 points for LST-NG-PD/depressed lesions, 1 point for protruded lesions and LST-NG-F lesions (range 0-10). In the validation study, the rank correlation coefficient between the score according to the scoring system and the resection speed was -0.130, representing a weak and negative correlation (P = 0.03). We defined the difficulty level depending on the sum of the scores: 0-2, low difficulty level; 3-5, intermediate difficulty level; ≥ 6, high difficulty level. The average resection speed was 12.6 mm2/min in the group with scores of 0-2, 8.1 mm2/min in the group with scores of 3-5, and 5.5 mm2/min in the group with scores of ≥ 6 (11.2 mm2/min in all lesions). CONCLUSION: Our colorectal ESD scoring system would be useful for selection of operators with the appropriate skill level in the procedure for colorectal ESD cases.

Insurance Status, Not Race, is Associated With Use of Minimally Invasive Surgical Approach for Rectal Cancer.

OBJECTIVE: To determine the impact of race and insurance on use of minimally invasive (MIS) compared with open techniques for rectal cancer in the United States. BACKGROUND: Race and socioeconomic status have been implicated in disparities of rectal cancer treatment. METHODS: Adults undergoing MIS (laparoscopic or robotic) or open rectal resections for stage I to III rectal adenocarcinoma were included from the National Cancer Database (2010-2012). Multivariate analyses were employed to examine the adjusted association of race and insurance with use of MIS versus open surgery. RESULTS: Among 23,274 patients, 39% underwent MIS and 61% open surgery. Overall, 86% were white, 8% black, and 3% Asian. Factors associated with use of open versus MIS were black race, Medicare/Medicaid insurance, and lack of insurance. However, after adjustment for patient demographic, clinical, and treatment characteristics, black race was not associated with use of MIS versus open surgery [odds ratio [OR] 0.90, P = 0.07). Compared with privately insured patients, uninsured patients (OR 0.52, P < 0.01) and those with Medicare/Medicaid (OR 0.79, P < 0.01) were less likely to receive minimally invasive resections. Lack of insurance was significantly associated with less use of MIS in black (OR 0.59, P = 0.02) or white patients (OR 0.51, P < 0.01). However, among uninsured patients, black race was not associated with lower use of MIS (OR 0.96, P = 0.59). CONCLUSIONS: Insurance status, not race, is associated with utilization of minimally invasive techniques for oncologic rectal resections. Due to the short-term benefits and cost-effectiveness of minimally invasive techniques, hospitals may need to improve access to these techniques, especially for uninsured patients.

[Diagnostics of the primary multiple forms of the colorectal cancer].

The issue analyses the diagnostics of the repeated malignant lesions of the colorectal region. The study covers the two decades period (1992-2011 yy). Of the observed patients with primary colorectal tumors, 238 showed the repeated lesions of the region. The article focuses on the on-time diagnostics and differential approach to the repeated malignancies of the colorectal region.

Transanal endoscopic microsurgery for residual rectal cancer (ypT0-2) following neoadjuvant chemoradiation therapy: another word of caution.

BACKGROUND: Significant tumor downstaging among patients with rectal cancer following neoadjuvant chemoradiation has raised the issue of offering patients with small residual cancers restricted to the bowel wall an alternative treatment strategy to total mesorectal excision. Transanal endoscopic microsurgery may allow proper primary tumor resection with promising oncological outcomes, less postoperative morbidity, and minimal long-term sexual, urinary, and fecal continence disorders in comparison with radical resection. OBJECTIVE: The aim of this study was to determine the oncological outcomes of patients with residual rectal cancers restricted to the rectal wall (ypT0-2) following neoadjuvant chemoradiation and transanal endoscopic microsurgery. DESIGN: This study considered a prospective cohort of patients with residual rectal cancers following neoadjuvant chemoradiation treated by transanal endoscopic microsurgery and no additional systemic therapy. SETTINGS: This study was a single-institution experience. PATIENTS: Patients with adenocarcinoma of the rectum located no more than 7 cm from the anal verge and endorectal ultrasound- or magnetic resonance-staged cT2-4N0-2M0 treated by neoadjuvant chemoradiation (50.4-54 Gy and 5-fluorouracil-based chemotherapy) were eligible for the study. Patients with small residual tumors (≤3 cm) radiologically staged ycT0-2N0 were treated by transanal endoscopic microsurgery. INTERVENTIONS: Transanal endoscopic microsurgery was performed. MAIN OUTCOME MEASURES: The primary outcome measured was local recurrence. RESULTS: Of the 27 patients treated by transanal endoscopic microsurgery, 3 had ypT0, 6 had ypT1, and 18 had ypT2 cancers. All patients underwent R0 transanal endoscopic microsurgery excision. Local recurrence was observed in 4 (15%) patients after a median follow-up of 15 months. Only lymphovascular invasion was an independent predictive factor for local failure (p = 0.04). Tumor size, ypT status, T-status downstaging, lateral/radial margins, and tumor regression grade were not predictors of local failure. LIMITATIONS: This study was limited by the small sample size and limited follow-up. CONCLUSIONS: A local failure rate of 15% after transanal endoscopic microsurgery for patients with residual rectal cancers restricted to the bowel wall (ypT0-2) may limit the indication of this procedure to highly selected patients as an alternative to standard radical total mesorectal excision.

Risk factors for residual cancer and lymph node metastasis after noncurative endoscopic resection of early colorectal cancer.

BACKGROUND: Endoscopic resection could be a curative treatment for early colorectal cancer without the possibility of lymph node metastasis. However, if the resection margin is positive, and there is a risk of lymph node metastasis, additional surgery should be performed. OBJECTIVE: The aim of this study was to investigate the characteristics of patients who underwent additional surgery to determine risk factors associated with residual tumor and lymph node metastasis. DESIGN: This study is a retrospective analysis. SETTINGS: This study was conducted at a tertiary academic hospital. PATIENTS: We evaluated 85 patients who underwent additional surgery with curative intent after endoscopic resection for early colorectal cancer at the Samsung Medical Center, Seoul, South Korea, between January 2001 and April 2010. MAIN OUTCOME MEASURES: We identified risk factors associated with residual tumor or lymph node metastasis in surgical specimens after noncurative endoscopic resection for early colorectal cancer. RESULTS: Among 85 patients who underwent additional surgery after noncurative endoscopic resection, 76 (89.4%) had submucosal invasion greater than 1000 µm. Twenty-one (24.7%) and 25 patients (29.4%) had a positive lateral or vertical resection margin, and 11 patients (12.9%) had inadequate lifting sign. After additional surgery, patients were divided into 2 groups according to the presence or absence of residual tumor and/or lymph node metastasis. There was no significant difference between the groups in positive lateral margin, but there was a significant difference in positive vertical margin (p = 0.015 with an OR of 15.02). In patients with inadequate lifting sign, the OR was 13.68 (p = 0.013). LIMITATIONS: This study was limited by its retrospective nature. CONCLUSION: There is a greater need for additional surgery in cases with positive vertical resection margin or inadequate lifting sign, because the risk of residual tumor and lymph node metastasis is higher than in other cases.

Role of positron emission tomography-computed tomography in the management of anal cancer.

PURPOSE: Pre- and post-treatment staging of anal cancer are often inaccurate. The role of positron emission tomograpy-computed tomography (PET-CT) in anal cancer is yet to be defined. The aim of the study was to compare PET-CT with CT scan, sentinel node biopsy results of inguinal lymph nodes, and anal biopsy results in staging and in follow-up of anal cancer. METHODS AND MATERIALS: Fifty-three consecutive patients diagnosed with anal cancer underwent PET-CT. Results were compared with computed tomography (CT), performed in 40 patients, and with sentinel node biopsy (SNB) (41 patients) at pretreatment workup. Early follow-up consisted of a digital rectal examination, an anoscopy, a PET-CT scan, and anal biopsies performed at 1 and 3 months after the end of treatment. Data sets were then compared. RESULTS: At pretreatment assessment, anal cancer was identified by PET-CT in 47 patients (88.7%) and by CT in 30 patients (75%). The detection rates rose to 97.9% with PET-CT and to 82.9% with CT (P=.042) when the 5 patients who had undergone surgery prior to this assessment and whose margins were positive at histological examination were censored. Perirectal and/or pelvic nodes were considered metastatic by PET-CT in 14 of 53 patients (26.4%) and by CT in 7 of 40 patients (17.5%). SNB was superior to both PET-CT and CT in detecting inguinal lymph nodes. PET-CT upstaged 37.5% of patients and downstaged 25% of patients. Radiation fields were changed in 12.6% of patients. PET-CT at 3 months was more accurate than PET-CT at 1 month in evaluating outcomes after chemoradiation therapy treatment: sensitivity was 100% vs 66.6%, and specificity was 97.4% vs 92.5%, respectively. Median follow-up was 20.3 months. CONCLUSIONS: In this series, PET-CT detected the primary tumor more often than CT. Staging of perirectal/pelvic or inguinal lymph nodes was better with PET-CT. SNB was more accurate in staging inguinal lymph nodes.

Treatment strategy for recurrent or residual colorectal tumors after endoscopic resection.

BACKGROUND: Piecemeal resection of colorectal neoplasms is associated with a higher risk of recurrent or residual tumors, but nearly all such cases can be cured by additional endoscopic resection (ER). Although the adoption of endoscopic submucosal dissection (ESD) for colorectal neoplasm is continuing, the safety of this treatment for recurrent or residual tumors has not been fully assessed. We evaluated salvage therapy for the treatment of recurrent or residual tumors, and propose an endoscopic treatment strategy for these tumors. METHODS: This retrospective study was conducted for 60 consecutive patients who had with locally recurrent or residual tumor after ER between January 2004 and October 2005. Endoscopic treatment strategy, treatment results, complications and clinical outcomes were recorded. RESULTS: Among 69 lesions in 60 patients, 67 were treated endoscopically, whereas 2 required surgical treatment. Of these 67, 87% (58/67) were resected by endoscopic mucosal resection (EMR) and 13% (9/67) by ESD. En bloc resection rate was 39% (23/58) in the EMR group and 56% (5/9) in the ESD group. One limitation of this study is that it was a single-center retrospective analysis. CONCLUSIONS: ESD is safe and effective for the treatment of recurrent or residual colorectal tumors. However, because of its technical difficulty, the en bloc resection rate is lower than that for the treatment of nonrecurrent lesions.

Transanal endoscopic microsurgery: a necessary requirement?

INTRODUCTION: There has been a gradual introduction of transanal endoscopic microsurgery (TEM) into UK practice although the uptake remains variable. This study aimed to assess the availability, application and referral pattern of TEM amongst colorectal surgeons. METHODS: A questionnaire was sent to all consultant members of the Association of Coloproctology. This considered their practice, the availability, application and referral pattern for TEM, and their views on application regarding a selection of rectal tumour scenarios. RESULTS: There were 142 replies representing 116 hospitals and 297 colorectal surgeons. The median catchment area was 280,000 (range 70,000-1,000,000). TEM was available in 18% of hospitals and 72% either performed or referred patents for TEM. Of 21 units performing TEM, 15 received referrals. From 305 TEM procedures performed over the previous year, 206 were referred cases. Eighty-five per cent of consultants considered TEM a necessary technique for optimum management of rectal lesions. Although 61% of consultants considered endoanal excision optimal for low benign rectal tumours, 58% said TEM was optimal for midrectal lesions and between 30% and 55% for high rectal lesions depending if the tumour position was anterior or posterior, respectively. One-third of consultants would perform TEM for a low T1 rectal carcinoma although half would proceed to anterior resection. DISCUSSION: TEM is considered to have a significant role in the optimal management of rectal lesions. The presence of the technique in a limited number of hospitals does appear to provide adequate resources although audit should continue to be centralized.

Accuracy and reliability of the endoscopic classification of chronic radiation-induced proctopathy using a novel grading method.

GOALS: To assess a novel grading method of radiation proctitis for intraobserver and interobserver agreement among endoscopists. BACKGROUND: There are no established criteria for the endoscopic classification of chronic radiation-induced proctopathy. We introduce a classification system based on telangiectasia density and vascular coalescence. Accuracy and reproducibility of this system were examined. STUDY: A total of 131 endoscopic images of the rectum in 74 consecutive patients undergoing lower endoscopy who had received pelvic radiation therapy were analyzed. Each image was duplicated, reversed, and rotated 90 degrees for a total of 262 images. These were shown in random order to 13 endoscopist evaluators (6 attending physicians, 7 gastroenterology fellows) using an online computer testing program. Each image was scored from grade 0 to 3 using criteria from the rectal telangiectasia density (RTD) classification we developed. Kappa (kappa) statistics and percent agreement were used to quantify the reproducibility and level of agreement. RESULTS: Intraobserver agreement: The mean (SD) for kappa among the 13 raters was 0.58 (0.09); 95% confidence interval [CI] = 0.527-0.636. Interobserver agreement: The estimated kappa across all 13 raters was 0.518 (95% CI = 0.506-0.530). For the 7 trainees, kappa was 0.547 (95% CI = 0.523-0.571). For the 6 attending physicians, the kappa was 0.481 (95% CI = 0.453-0.509). As another indicator of agreement, all 13 evaluators agreed on 30 (22.9%) of images, differed by no more than 1 grade on 60 (45.8%) images, no more than 2 grades on 33 (25.2%) of images, and no more than 3 grades on 8 of the images (6.1%); 73% of patients referred for bleeding control were RTD grade 2 or 3. CONCLUSIONS: The RTD grading scale for radiation proctopathy is reproducible among endoscopists. Hematochezia is associated with high RTD grade.

Could laparoscopic colon and rectal surgery become the standard of care? A review and experience with 750 procedures.

INTRODUCTION: The benefits of the laparoscopic approach to colon and rectal surgery do not seem as great as for other laparoscopic procedures. To study this further we decided to review the current literature and the 10-year experience of a surgical group from university teaching hospitals in Montréal, Québec and Toronto in performing laparoscopic colon and rectal surgery. METHODS: The prospectively designed case series comprised all patients having laparoscopic colon and rectal surgery. The procedures were carried out by a group of 4 surgeons between April 1991 and November 2001. We noted intraoperative complications, any conversions to open surgery, operating time, postoperative complications and postoperative length of hospital stay. RESULTS: The group attempted 750 laparoscopic colon and rectal procedures of which 669 were completed laparoscopically. Malignant disease was the indication for surgery in 49.6% of cases. Right hemicolectomy and sigmoid colectomy accounted for 54.5% of procedures performed. Intraoperative complications occurred in 8.3%, with 29.0% of these resulting in conversion to open surgery. The overall rate of conversion to open surgery was 10.8%, most commonly for oncologic concerns. Median operating time was 175 minutes for all procedures. Postoperative complications occurred in 27.5% of procedures completed laparoscopically but were mostly minor wound complications. Pulmonary complications occurred in only 1.0%. The anastomotic leak rate was 2.5%. The early reoperation rate was 2.4%. Postoperative mortality was 2.2%. No port site metastases have yet been detected. The median postoperative length of stay was 5 days. CONCLUSIONS: The clinical outcomes of laparoscopic colon and rectal surgery in this 10-year experience are consistent with numerous cohort studies and randomized clinical trials. Laparoscopic colon and rectal surgery in the hands of well-trained surgeons can be performed safely with short hospital stay, low analgesic requirements and acceptable complication rates compared with historical controls and other reports in the literature. Evidence from published randomized clinical trials is emerging that under these conditions laparoscopic resection represents the better treatment option for most benign conditions, but concerns regarding its appropriateness for malignant disease are still to be resolved.

Experience with a one-stop colorectal clinic.

BACKGROUND AND OBJECTIVE: Colorectal services have traditionally been arranged for the convenience of hospitals rather than patients. This model is not ideal, particularly for minor interventions and diagnostic procedures. In order to address this a one-stop colorectal clinic was set up. PATIENTS AND METHODS: Weekly clinics ran from 6.00 to 9.30 p.m. on Wednesdays for a period of 6 months. Patients with rectal bleeding, altered bowel habit, anorectal symptoms and those requesting screening advice were seen by a consultant or specialist registrar. Patients were asked to fill in a questionnaire at the end of their clinic attendance. RESULTS: 197 patients were seen in 17 clinics; 134 underwent proctoscopy, 72 had a rigid sigmoidoscopy and 85 had a flexible sigmoidoscopy carried out. Twenty-four patients subsequently had a barium enema and 3 were listed for colonoscopy. The main diagnosis was haemorrhoids (n = 104); 14 colorectal neoplasms were discovered (5 cancers and 9 polyps). During the study period the number of patients waiting for lower gastrointestinal endoscopy fell from 119 to 63; 2 months after ending the pilot scheme, the number had risen to 108. CONCLUSION: The clinic was found to have significantly improved patient care. The majority of patients were satisfied with an evening clinic. Flexible sigmoidoscopy without sedation was well tolerated and the ability to perform this at initial assessment had a marked effect on the number of patients awaiting lower gastrointestinal endoscopy.

Colorectal cancer screening in North Carolina: associations with diabetes mellitus and demographic and health characteristics.

BACKGROUND: Diabetes mellitus (DM) may increase the risk of colorectal cancer, a leading cause of cancer death in the United States. This report examines factors associated with colorectal cancer screening, including DM status. METHODS: Data from the 1993/1995/1997 North Carolina (NC) Behavioral Risk Factor Surveillance System were analyzed to assess self-reported screening rates within guidelines for sigmoidoscopy/proctoscopy (sig/proct) and fecal occult blood test (FOBT). RESULTS: Overall, 28.6, 27.2, and 19.7% received a sig/proct, FOBT, or either test within guidelines, respectively. Screening rates varied according to some demographic variables, but not by DM status. However, DM status changed some relationships between screening and some demographic/health characteristics. CONCLUSIONS: Colorectal cancer screening in NC is similar to national rates, but certain subgroups are less likely to get screened. Persons with DM are as likely to get colorectal cancer screening, but some groups with DM (ethnic minorities, persons of low socioeconomic status) may be at high risk for not getting screened. Educational efforts to increase screening should target these groups.

Type of health care coverage and the likelihood of being screened for cancer.

OBJECTIVES: This study explored whether type of outpatient health coverage affected the likelihood of men and women aged 20 to 64 years receiving recommended cancer screening procedures. METHODS: Data from the 1989 and 1990 California Behavioral Risk Factor Surveillance Surveys were used to compare Pap smear, mammogram, fecal occult blood test, and proctoscopic examination rates for adults with three different types of private health care coverage (Group/staff model health maintenance organization, Independent Practice Association Model health maintenance organization, indemnity plan) and no outpatient health insurance. Logistic regression models were used to control for sociodemographic and health characteristics and whether individuals had a usual health care provider. RESULTS: Individuals with Group Model health maintenance organization coverage were significantly more likely than those with indemnity plans to have had recent cervical, breast, and colorectal cancer screening, whereas screening likelihood for those with Independent Practice Association model health maintenance organization coverage did not differ substantially from those with indemnity plans. Individuals with no outpatient coverage were less likely to be screened than those with outpatient coverage. The most consistently significant predictor across cancer screening procedures for both men and women was having a usual doctor who knew their medical history. CONCLUSIONS: Adults who had private outpatient insurance were more likely to undergo recommended cancer detection procedures than those who did not. Adults who belonged to a health maintenance organization, which emphasizes and pays for a broader spectrum preventive care, were more likely to receive Pap smears, mammograms, and fecal occult blood tests than those covered by indemnity plans. Receiving care primarily from one doctor significantly increased the likelihood of having screening procedures, irrespective of type of health plan.

Tratamiento del cáncer rectal / Treatment of rectal cancer

Se analiza la morbimortalidad, recidiva y sobrevida quinquenal de 99 pacientes tratados con intención curativa entre los años 1983 a 1992. Se trata de 51 mujeres y 48 hombres con una edad promedio de 59,4 años (17-90). Cincuenta y cuatro pacientes recibieron sólo cirugía y 46 además radioterapia coadyuvante. Veintidós Tu se localizaron en recto superior siendo tratados con RANT y HART, 28 en recto medio donde se agregaron tratamientos locales y AAP y 49 en recto inferior donde predominaron las AAP. El 50,5 por ciento de los pacientes presentaron alguna morbilidad siendo mayor en el grupo irradiado. La mortalidad global fue del 3 por ciento. Hubo diferencia significativa en la recidiva local la que se presentó más en el grupo no irradiado (40,3 por ciento vs 20,4 por ciento). La radioquimioterapia aumentó la resecabilidad de los Tu avanzados locales, disminuyendo en forma notable su recidiva local. La sobrevida global quinquenal fue del 44,8 por ciento siendo mejor en los pacientes con Tu localizados

Has the use of cervical, breast, and colorectal cancer screening increased in the United States?

This report describes trends in reported breast, cervical, and colorectal cancer screening within the US population from 1987 to 1992. Data from the 1987 and 1992 Cancer Control Supplements of the National Health Interview Survey were analyzed to determine use of Pap smears by women aged 18+; of mammography and clinical breast examination by women aged 50+; and of proctoscopy, digital rectal examination, and fecal occult blood testing among men and women aged 50+. Use of mammography doubled between 1987 and 1992 while Pap smear use changed very little. Use of the three colorectal cancer screening modalities increased but levels remained low. Usage trends were also assessed in relation to several sociodemographic factors. Disparities in screening reported in 1987 according to income and education persisted in 1992.