Colonic cancer: an enemy in retreat?

Argentina and Uruguay are countries with high mortality rates for colorectal cancer. In the Province of Santa Fe, colorectal cancer ranks as third when considering cancer as the cause of death. The aim in this study was to compare the mortality rates for colorectal cancer in the Province for a 10 year period. The mortality rates for 1985-1987 and 1995-1997 were 17.2% an 19.1% respectively. There was no significant difference with the mortality rates during that decade our study encompasses.     

Small Esophageal Varices in Patients with Cirrhosis—Should We Treat Them?

Purpose of Review

The natural history and classification systems of small varices (≤?5 mm in diameter) in cirrhotic patients with portal hypertension are summarized. Studies that assessed the course of and therapeutic intervention for small varices are discussed.

Recent Findings

Current non-invasive methods show suboptimal sensitivity to detect small varices in patients with cirrhosis. Next to etiological therapy, hepatic venous pressure gradient (HVPG)-guided non-selective betablocker or carvedilol treatment has shown to impact on natural history of small varices.

Summary

The main therapeutic focus in cirrhotic patients with small varices is the cure of the underlying etiology. The optimal management of small varices should include measurement of HVPG. A pharmacological decrease in HVPG by non-selective betablocker therapy of ≥?10% reduces the risk of progression to large varices, first variceal bleeding, and hepatic decompensation. If HVPG is not available, we would recommend carvedilol 12.5 mg q.d. for treatment of small varices in compensated patients without severe ascites. Only if small esophageal varices (EV) are not treated or in hemodynamic non-responders, follow-up endoscopies should be performed in 1–2 years of intervals considering the activity of liver disease or if hepatic decompensation occurs.

     

Does positron emission tomography change management in primary rectal cancer? A prospective assessment

PURPOSE The influence of positron emission tomography in the management of recurrent rectal cancer is well established but its role in primary rectal cancer remains uncertain. This study therefore prospectively assesses the impact of position emission tomography scanning on the management of primary rectal cancer.METHODS Forty-six patients with advanced primary rectal cancer referred for consideration of adjuvant preoperative therapy underwent position emission tomography scanning. The referring physicians prospectively recorded each patients stage following conventional imaging and the proposed treatment plan prior to position emission tomography scanning. This was then compared with subsequent stage and actual management implemented, and the appropriateness of position emission tomography-induced changes was noted by subsequent clinical follow-up.RESULTS The surgical management of 36 of 46 patients (78 percent) was unchanged as a result of position emission tomography, even though position emission tomography upstaged disease in 3 of 36 cases (8 percent) and downstaged disease in 5 of 36 cases (14 percent). In 8 of 46 cases (17 percent), management was altered because of the position emission tomography scan findings, including 6 cases (13 percent) in which surgery was cancelled and 2 other cases (4 percent) in which the radiotherapy field was changed. Where available, follow-up confirmed the appropriateness of position emission tomography-induced management change in each case. Two patients had a change in therapy independent of the position emission tomography scan due to clinical circumstances. Overall tumor stage was changed following position emission tomography in 18 of 46 patients (39 percent).CONCLUSION Position emission tomography scanning appears to accurately change the stage or appropriately alter the therapy of almost a third of patients with advanced primary rectal cancer. In view of this, we suggest that position emission tomography scanning be considered part of standard workup for such patients, particularly if neoadjuvant chemoradiation is being considered as part of primary management.Presented at the meeting of The American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003.     

Esophageal motility disorders—Symptomatic and manometric spectrum in Punjab,northern India

Background

Data on the spectrum of esophageal motility disorders in Indian population are scarce. We aimed to study the symptomatic and manometric profile of patients with suspected esophageal motility disorders.

Methods

Consecutive patients with esophageal symptoms who underwent esophageal high-resolution manometry (HRM) from January 2010 to December 2014 were included in this retrospective analysis of prospectively acquired data. HRM was performed with 22-channel water-perfusion system and patients classified using Chicago classification v3.0.

Results

Of the 401 patients studied [median age 43 (18–85) years; 61% males], 217 presented with dysphagia, 157 with predominant retrosternal discomfort and 27 with predominant regurgitation. Among patients with dysphagia, 43.8% had ineffective esophageal motility [IEM], 26.3% had achalasia cardia [AC], 6.9% had distal esophageal spasm [DES] and 19.4% had normal manometry [NM]. Among patients with retrosternal discomfort, 42.7% had IEM, 5.7% had AC, 4.5% had DES and 42% had NM. AC was significantly more common among patients presenting with dysphagia compared to those with retrosternal discomfort [p< 0.001] or regurgitation [p< 0.001]. NM was significantly more common among patients presenting with retrosternal symptoms compared to those with dysphagia [p< 0.001]. AC patients had longer duration of dysphagia, more frequent bolus obstruction and more weight loss compared to those with IEM or NM [p< 0.05].

Conclusion

Dysphagia was the commonest presenting symptom followed by retrosternal discomfort. Ineffective esophageal motility (not achalasia cardia) was the commonest manometric finding both among patients with dysphagia and retrosternal discomfort. This study highlights the high prevalence of IEM among patients with esophageal symptoms, which can present with dysphagia or retrosternal discomfort due to poor bolus transit.

     

γ-Catenin is an independent prognostic marker in early stage colorectal cancer

Purpose  

Expression and role of γ-catenin in colorectal carcinogenesis is not well understood. We aimed at characterizing γ-catenin’s expression pattern during colorectal carcinogenesis.     

Secondhand Smoking and the Risk of Esophageal Squamous Cell Carcinoma in a High Incidence Region,Kashmir, India: A Case-control–observational Study

Studies have associated secondhand smoking (SHS) with cancers of the lung, larynx, and pharynx. Only a few studies have examined the association between SHS and esophageal squamous cell carcinoma (ESCC) and the findings are inconclusive. We aimed to investigate the association between SHS and risk of ESCC in a case-control study in Kashmir, where the incidence of ESCC is high.We recruited 703 histopathologically confirmed ESCC cases and 1664 hospital-based controls individually matched to the cases for age, sex, and district of residence. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated using conditional logistic regression models.Among never-tobacco users, the ORs for the association between SHS and ESCC risk were above unity with ever exposure to SHS (OR = 1.32; 95% CI, 0.43–4.02) and exposure to SHS for >14 h/wk (median value) (OR = 2.69; 95% CI, 0.75–20.65). In the analysis of data from all participants, the OR (95% CI) for the association between SHS and ESCC was (OR = 1.02; 95% CI, 0.53–1.93) for SHS ≤14 h/wk and (OR = 1.91; 95% CI, 0.75–4.89) for SHS >14 h/wk in the models adjusted for tobacco use and several other potential confounding factors.We found an indication of increased risk of ESCC associated with exposure to SHS. Studies with larger numbers of SHS-exposed never tobacco users are required to further examine this association.     

Genetic susceptibility and environmental factors of esophageal cancer in Xi＇an

AIM: To analyse the role of genetic susceptibility and environmental factors in the process of esophageal cancer (EC) formation in Xi‘an, China. METHODS: A hospital based case-control study, combined with molecular epidemiological method, was carded out. A total of 127 EC cases and 101 controls were interviewed with questionnaires containing demographic items, habit of tobacco smoking, alcohol drinking, and family history of EC. Polymorphism of CYPIA1 and GSTM1 of 127 EC cases and 101 controls were detected by PCR method. The interactions between genetic susceptibility and environmental factors were also discussed. RESULTS: Tobacco smoking, alcohol drinking and a family history of EC were risk factors for EC with an OR of 2.04 (95% CI 1.15-3.60), 3.45(95% CI 1.74-6.91), 3.14 (95% CI 1.28-7.94), respectively. Individuals carrying CYP1A1 Val/Val genotype compared to those with CYP1A1 Ile/Ile genotype had an increased risk for EC (OR 3.35, 95% CI 1.49-7.61). GSTM1 deletion genotype was a risk factor for EC (OR1.81, 95% CI 1.03-3.18). Gene-environment interaction analysis showed that CYPIA1 Val/Val genotype, GSTM1 deletion genotype had synergetic interactions with tobacco smoking, alcohol drinking and family history of EC. CONCLUSION: Tobacco smoking, alcohol drinking and a family history of EC are risk factors for EC. CYP1A1 Val/Val and GSTM1 deletion genotypes are genetic susceptibility biomarkers for EC. There are synergic interactions between genetic susceptibility and environmental factors.     

Sulphasalazine in arthritis — an old drug rediscovered

Summary Sulphasalazine (salicyl-azo-sulphapyridine) has been in clinical use for over 40 years. Although the drug was originally introduced for the treatment of rheumatic polyarthritis and ulcerative colitis, it is only in the past 10 years that its value in rheumatology has been appreciated. Controlled studies indicate that the drug is an effective remittive agent in both rheumatoid arthritis and ankylosing spondylitis. This is an area of great research interest since the drug is proving to be a useful tool for investigating the aeteology and pathogenesis of these diseases.     

Microscopic spread of low rectal cancer in regions of mesorectum：Pathologic assessment with whole-mount sections

AIM: To assess the microscopic spread of low rectal cancer in mesorectum regions to provide pathological evidence for the necessity of total mesorectal excision (TME). METHODS: A total of 62 patients with low rectal cancer underwent low anterior resection and TME, surgical specimens were sliced transversely on the serial embedded blocks at 2.5 mm interval, and stained with hematoxylin and eosin (HE). The mesorectum on whole-mount sections was divided into three regions: outer region of mesorectum (ORM), middle region of mesorectum (MRM) and inner region of mesorectum (IRM). Microscopic metastatic foci were investigated microscopically on the sections for the metastatic mesorectal regions, frequency, types, involvement of lymphatic vessels and correlation with the original rectal cancer. RESULTS: Microscopic spread of the tumor in mesorectum and ORM was observed in 38.7% (24/62) and 25.8% (16/62) of the patients, respectively. Circumferential resection margin (CRM) with involvement of microscopic metastatic foci occurred in 6.5% (4/62) of the patients, and distal mesorectum (DMR) involved was 6.5% (4/62) with the spread extent within 3 cm of low board of the main lesions. Most (20/24) of the patients with microscopic metastasis in mesorectum were in Dukes C stage. CONCLUSION: Results of the present study support that complete excision of the mesorectum without destruction of the ORM is essential for surgical management of low rectal cancer, an optimal DMR clearance resection margin should be no less than 4 cm, further pathologic assessment of the regions in extramesorectum in the pelvis is needed.     

Microscopic spread of low rectal cancer in regions of mesorectum:Pathologic assessment with whole-mount sections

AIM:To assess the microscopic spread of low rectal cancerin mesorectum regions to provide pathological evidencefor the necessity of total mesorectal excision(TME).METHODS:A total of 62 patients with low rectal cancerunderwent low anterior resection and TME,surgical specimenswere sliced transversely on the serial embedded blocks at2.5 mm interval,and stained with hematoxylin and eosin(HE).The mesorectum on whole-mount sections was divided intothree regions:outer region of mesorectum(ORM),middleregion of mesorectum(MRM)and inner region of mesorectum(IRM).Microscopic metastatic foci were investigatedmicroscopically on the sections for the metastatic mesorectalregions,frequency,types,involvement of lymphatic vesselsand correlation with the original rectal cancer.RESULTS:Microscopic spread of the tumor in mesorectumand ORM was observed in 38.7%(24/62)and 25.8%(16/62)of the patients,respectively.Circumferential resectionmargin(CRM)with involvement of microscopic metastaticfoci occurred in 6.5%(4/62)of the patients,and distalmesorectum(DMR)involved was 6.5%(4/62)with thespread extent within 3 cm of low board of the main lesions.Most(20/24)of the patients with microscopic metastasisin mesorectum were in Dukes C stage.CONCLUSION:Results of the present study support thatcomplete excision of the mesorectum without destructionof the ORM is essential for surgical management of lowrectal cancer,an optimal DMR clearance resection marginshould be no less than 4 cm,further pathologic assessmentof the regions in extramesorectum in the pelvis is needed.