Fast-track barium enema: meeting the two-week wait rule for patients with suspected colorectal cancer

OBJECTIVES: To meet the introduction of the two-week wait (TWW) rule for patients with suspected colorectal cancer, a fast-track barium enema (FTBE) service was set up. This study was conducted to evaluate the success of this approach in preparation for meeting the forthcoming targets on waiting times to treatment from referral and diagnosis. METHODS: All patients were offered a double-contrast barium enema within two-weeks, except those with a palpable rectal mass. FTBE were double-reported by specialist gastrointestinal radiologists. Patients with a suspected malignancy were booked for an urgent staging CT and outpatient appointment, whilst the remaining patients were referred back to their general practitioner with a report. Prospective data were collected and two 16-month periods analysed. RESULTS: Three hundred and nine patients had a FTBE over the first 16-month period and 277 (89.6%) were seen within two-weeks. Mean times from initial referral to staging CT and first outpatient appointment were 30.7 and 36.0 days, respectively. Cancer was confirmed histologically in 32 (10.4%) patients. Of 267 patients without a malignancy, 46 (17.2%) were referred back to the colorectal outpatient or endoscopy service within 6-months. The number of referrals increased with time from a mean of 19.3 per month in the first period to 27.8 in the second, but the percentage with a suspected malignancy remained similar at 13.6% and 10.1%, respectively. CONCLUSION: FTBE diagnosed malignancy accurately and facilitated rapid staging. The TWW target was met in almost 90% of patients, whilst the impact on the colorectal outpatient and endoscopy service was minimized.     

Evaluation of a radiographer-provided barium enema service

Aim Radiographers performed and reported 5516 double contrast barium enemas (RDCBEs) over 4 years to October 2001. This study was undertaken to assess the accuracy of RDCBE and the sensitivity for diagnosing colorectal cancer (CRC). Method A total of 224 consecutive outpatient RDCBEs were reported; normal (C1), diverticulosis (C2), diverticulosis with filling defect (C3), diverticulosis & other pathology (C4) and abnormal (C5). RDCBEs were then reported by a radiologist (AL, NS) and the two reports compared. Of 450 CRCs, 153 had undergone DCBE; 152 RDCBEs. Reports were analysed to establish concurrence between radiographer and radiologist and final CRC diagnosis. Results By category: C1 – 37%, C2 – 31%, C3 – 21%, C4 – 11%, C5 – 0%. C4s included polyps (50%), cancer (12.5%), disrupted anastomosis (8%) and colitis (4%). There was no discrepancy between RDCBE and radiologist reports. Radiology and CRC diagnosis agreed in 145 of 152 DCBEs. There were three exclusions: DCBEs occurred outside the study period (2), one only with raised possibility of malignancy. Of eight remaining RDCBEs, seven were false negatives and one false positive. Sensitivity score for RDCBE was 94.5%. Double reporting by a radiologist did not improve sensitivity. Conclusion RDCBEs are as accurate as those performed by radiologists and have a very high sensitivity for CRC. In a time of ever increasing demands for complex staging investigations for CRC and interventional radiology, the ACPGBI needs to reconsider its guidelines on radiographers not only performing but also reporting DCBE.     

结肠气钡双重造影和结肠CT应用价值的对比分析

目的 探讨结肠气钡双重造影和结肠CT在结直肠疾病诊断中的应用价值,并对比分析两种检查方法的优缺点.方法 回顾性分析2005年6月至2013年8月我院213例结肠气钡双重造影和结肠CT检查结果,对比观察两种检查方法所检出的病种、结直肠肿瘤和息肉的大小、部位及并发症发生情况.结果 结肠气钡双重造影对溃疡性结肠炎、慢性阑尾炎、憩室等疾病和近端结肠及小病灶的诊断能力优于结肠CT;结肠CT对结直肠肿瘤及远端结肠的诊断能力则优于结肠气钡双重造影.结论 结肠气钡双重造影和结肠CT各具优势,在临床工作中应视具体情况加以选择或联合应用.     

Pathology reporting of resected colorectal cancers in New South Wales in 2000

BACKGROUND: The aim of this study was to determine the extent to which pathology reporting of colorectal cancers notified to the New South Wales Central Cancer Registry during 2000 conformed to guidelines promulgated by the National Health and Medical Research Council. METHODS: De-identified reports for 2233 resected specimens of primary invasive colorectal carcinoma were coded according to a standardized system to compile information on 28 clinical and pathology features. An overall score for each report was calculated by computing the number out of 13 essential features specified in the guidelines for which data had been recorded explicitly and unambiguously in the report. RESULTS: The overall score ranged from 3 to 13 features with a mean of 9. No more than 7 features were reported explicitly in just less than one quarter of the reports and no more than 10 in three quarters. There were only 110 reports (4.9%) that included all features. Information on direct spread and nodal metastasis was well reported; resection margins less so. Many reports lacked information on metastases beyond the operative field, the involvement of deep or circumferential resection margins and tumour stage. CONCLUSION: In some respects pathology reports of resected colorectal cancer specimens displayed a high level of completeness. Some important features, however, were poorly described. Reporting could be improved if surgeons were to use a standardized form to convey clinical information to the pathologist and if pathologists were to report in a structured or synoptic format, explicitly recording the presence or absence of each feature in a standard list.     

微卫星不稳定性检测在遗传性非息肉病性结直肠癌家系遴选中的作用

目的 探讨微卫星不稳定性(MSI)检测在遗传性非息肉病性结直肠癌(HNPCC)家系遴选中敏感性、特异性及临床应用的价值。方法 对12例符合Amsterdam标准的HNPCC患和16例散发性结直肠癌患的肿瘤标本进行微卫星不稳定性检测。结果 若将高微卫星不稳定性(MSI-H)及低微卫星不稳定性(MSI-L)的结直肠癌患作为HNPCC家系的诊断标准,其敏感性为100％,特异性为75％,正确率为81％;若仅将MSI-H的结直肠癌患作为HNPCC家系的诊断标准,其敏感性为100％,特异性为94％,正确率为95％。结论 微卫星不稳定性检测遴选HNPCC家系敏感性和特异性较高,而且两简单、经济,适合在临床广泛应用。     

The appearance of a normal appendix on barium enema examination does not rule out a diagnosis of chronic appendicitis: Report of a case and review of the literature

We report herein the rare case of a 15-year-old girl with chronic appendicitis in whom the appendix was clearly depicted by a barium enema (BE) examination. The patient presented with a 4-month history of diffuse abdominal pain and tenderness in the lower abdomen. Neither computed tomography nor ultrasonography showed any abnormal findings in the lower abdomen or pelvic cavity. Furthermore, BE examination depicted an appendix filled with the contrast medium. However, at elective surgery, she was found to have chronic appendicitis which was later confirmed histologically. Following this case report, a discussion on the value and limitations of BE examination for the diagnosis of acute and chronic appendicitis is presented.     

The clinicopathologic features of serum CA 19-9-positive colorectal cancers

The preoperative serum levels of carbohydrate antigen 19-9 (CA 19-9) were determined in 206 patients with colorectal cancer, 52 (25.2%) of whom were found to be positive. All of these patients had advanced cancers and significantly higher incidences of tumor invasion through the muscularis propria (91.3%) and lymph node involvement (54.5%). The incidences of liver metastasis and Dukes' stage D in the CA 19-9-positive group were 38.5% and 42.9%, respectively, significantly higher than those in the CA 19-9-negative group of 6.5% and 14.8%, respectively. Moreover, the incidence of liver metastasis in the CA 19-9-positive group patients with Dukes' stage D cancer was 95.2% (20/21); CA 19-9 showing higher specificity (81.7%) and a more positive predictive value (38.5%) for liver metastasis than the carcinoembryonic antigen (CEA). When a cutoff value of 160 U/ml was used, the specificity and positive predictive value reached 97.7% and 81.0%, respectively. An analysis of response operating characteristic (ROC) curves for liver metastasis revealed that CA 19-9 was more useful than CEA. The long-term survival of the CA 19-9-positive group patients was significantly worse than that of the CA 19-9-negative group patients (P < 0.0001), with no 1.25-year survivors in the former group when the cutoff value of 160U/ml was used. These results suggest that serum CA 19-9 as a useful preoperative indicator of liver metastasis and prognosis in colorectal cancer.     

Host response to colorectal cancer

It has long been established that inflammation and immunity play critical roles in the pathogenesis, control and eventual metastasis of cancers. With the advent of more sophisticated animal models and immunohistochemical techniques a greater understanding of the immune system and its interactions has occurred. Individual immune cells are dynamic structures that have variable behaviour controlled by complex interactions in the tumour microenvironment. In the setting of colorectal cancer it was first observed that peritumoral inflammatory infiltrates were associated with improved prognosis. Immunohistochemistry has shown the individual cells types within these infiltrates. It now appears that an adaptive immune response, differentiated along the T-helper 1 pathway controls tumour invasion and metastasis. Furthermore, the immune system exerts selection pressure leading to the evolution of tumour cell variants that can induce tolerance and disable adaptive immunity. These tumour cells then use the mechanisms of innate immunity to facilitate further growth, angiogenesis, invasion and eventual metastasis. These issues are investigated with particular relevance to colorectal cancer. Using the immune response to defeat CRC has been under intense investigation but has so far been unsuccessful. Nevertheless, researchers remain optimistic that immunotherapy will play an important role in the treatment of this common disease.     

术前结直肠炎症对于结直肠癌局部进展的预测意义

目的研究术前结直肠非特异性炎症对结直肠肿瘤局部进展及预后的影响。方法本研究为回顾性队列研究,通过回顾中山大学附属第六医院2007年至2010年的结直肠癌患者。所有具备该中心术前肠镜资料或手术病理证实肠炎的患者纳入研究,分为炎症组(肠镜下肠炎及手术病理肠炎)及对照组;比较肿瘤分期、淋巴结转移、癌结节转移、其他手术病理资料及生存预后等指标;比较总体生存及肿瘤复发等随访情况,随访时间3年。结果回顾病例907例,纳入研究346例;其中炎症组患者共70例,包括镜下远处肠炎39例(20.2%)、镜下肿瘤原位肠炎16例(22.9%)手术病理肠炎15例(21.4%),对照组276例(78.8%)。炎症组进展期肿瘤发生率74.3%(P0.001),淋巴结转移率62.3%(P0.001),癌结节转移率40.2%(P=0.001)均高于对照组。经logistic回归分析,手术病理肠炎是进展期肿瘤(P=0.016)、淋巴结转移(P=0.017)及癌结节转移(P=0.017)的独立危险预后因素;镜下远处肠炎是进展期肿瘤(P=0.003)、淋巴结转移(P=0.017)的独立危险预后因素。结论手术前结直肠非特异性炎症与肿瘤的分期存在明确的相关性,此类病例可用于结直肠炎症与恶性肿瘤关系研究。     

Screen‐detected colorectal cancers show improved cancer‐specific survival when compared with cancers diagnosed via the 2‐week suspected colorectal cancer referral guidelines

Aim Biennial screening for colorectal cancer using faecal occult blood testing has been shown to reduce the relative risk of mortality from colorectal cancer. The Norwich screening centre commenced screening in July 2006 and so far has diagnosed over 350 patients with colorectal cancer. We compared the stage at diagnosis and cancer‐specific mortality and survival in patients diagnosed through screening with a cohort of symptomatic patients with colorectal cancer within the same age range. Method A comparative analysis was undertaken of all screen‐detected colorectal cancer patients diagnosed between July 2006 and December 2010, with an age‐matched group of patients diagnosed in the Norfolk and Norwich Hospital through the 2‐week suspected colorectal cancer guidelines. Results Three hundred and fifty‐six cases of colorectal cancer were diagnosed through the screening programme, in patients with an age range of 60–79 years. In the same time period, 292 patients in the same age range were diagnosed with colorectal cancer through the 2‐week suspected colorectal cancer pathway. Sixteen patients in the screening group had evidence of metastatic disease at presentation compared with 62 in the symptomatic group (χ², P < 0.001). The proportion of T1/T2 and Dukes A cancers was significantly greater in the screening group (χ², P < 0.001). There were 21 colorectal cancer‐related deaths in the screening group compared with 66 in the symptomatic group. Survival analysis curves showed significantly better survival in the screening group (log‐rank analysis P < 0.001). Conclusion Screening for colorectal cancer identifies cancers at a significantly earlier stage than in symptomatic patients, with subsequent improvement in cancer‐specific survival.     

Early onset colorectal cancer in Canterbury,New Zealand

Background

The overall incidence of colorectal cancer is decreasing in much of the world, yet the incidence in those under 50 years of age is increasing (early onset colorectal cancer (EOCRC)). The reasons for this are unclear. This study was undertaken to describe the clinical, pathological and familial characteristics of patients with EOCRC and their oncological outcomes and compare this with previously published data on late onset colorectal cancer (LOCRC).

Methods

A retrospective review of all patients diagnosed with EOCRC in Canterbury between 2010 and 2017 was conducted. Data was collected on demographics, family history, treatment, and oncologic outcomes. Kaplan–Meier survival curves were calculated to assess overall survival based on disease stage.

Results

During the study period (2010–2017) there were 3340 colorectal cancers diagnosed in Canterbury, of which 201 (6%) were in patients under 50 years (range: 17–49). Of these, 87 (43.3%) were female and 125 (62.2%) were aged between 40 and 49 years. 28 (13.9%) were associated with hereditary conditions. Of the 201 patients, 139 (69.2%) had rectal or left-sided cancers. 142 (70.6%) patients presented with either stage 3 or 4 disease and the 5-year overall survival by stage was 79.1% and 14.4%, respectively.

Conclusion

EOCRC is increasing and usually presents as distal left sided cancers, and often at an advanced stage. They do not appear to have the common risk factors of family history or inherited pre-disposition for colorectal cancer. Planning by healthcare providers for this epidemiological change is imperative in investigating symptomatic patients under 50 and optimizing early detection and prevention.     

Chemotherapy and radiotherapy for colorectal cancers

Surgery remains the cornerstone of the curative treatment of localized colorectal cancer (CRC), but both radiotherapy and chemotherapy play an important role in the management of these patients to help improve survival. Treatment of locally advanced and metastatic disease often requires multimodality therapy. Advances in both surgical techniques and non-surgical oncology have led to a reduction in the mortality rate over the last 40 years.     

Carcinoembryonic antigen to detect hepatic metastases of colorectal cancers

Purpose. The spread of colorectal carcinoma (CRC) affects both staging and treatment. In this prospective study we examined the relationship between carcinoembryonic antigen (CEA) levels in bile, mesenteric venous blood, and peripheral venous blood, and the presence of occult hepatic metastases in patients with CRC.Methods. Sixty patients who underwent elective surgery at Ankara Oncology Hospital were voluntarily assigned to one of the three groups of 20 patients each. The control group consisted of patients operated on for benign biliary disorders, the second group consisted of patients with CRC without metastases, and the third group consisted of patients with CRC and isolated liver metastases. Bile, mesenteric venous blood, and peripheral venous blood was collected perioperatively for the measurement of CEA levels.Results. The bile CEA levels were significantly higher in the CRC patients with metastases than in those without metastases and the controls. The CEA levels in the mesenteric venous blood and peripheral venous blood were significantly higher in the two groups of CRC patients than in the control group. Overt hepatic metastases later developed in seven patients from the CRC without metastases group who had relatively high CEA levels, but the difference was not significant.Conclusion. The CEA levels in bile, mesenteric venous blood, and peripheral venous blood were increased in patients with CRC and liver metastases. The detection of elevated CEA levels in bile taken at surgery did not herald metachronous hepatic metastases in CRC patients without liver metastases.     

Review of biomarkers in colorectal cancer

Aim Advances in molecular technology have resulted in the discovery of many putative biomarkers relevant to colorectal cancer (CRC). Method Literature searches were performed on PubMed and EMBASE using the words ‘colorectal cancer’, AND ‘biomarkers OR markers’. Biomarkers that are either currently in clinical use or have potential clinical use were identified. Results Most potential markers are in the discovery phase waiting to undergo clinical validation. Hypermethylation of the plasma septin‐9 gene shows promise as a nonstool‐based screening tool. Hypermethylation of the DYPD gene (encodes the enzyme dihydropyrimidine dehydrogenase) and variation of the uridine diphosphate‐glucuronosyltransferase 1A (UGT1A1) gene have predictive value for side effects and the efficacy of 5‐fluoruracil and irinotecan, respectively. Mismatch repair protein immunohistochemistry is able to predict response to 5‐fluorouracil, and the KRAS (Kirsten rat sarcoma viral oncogene) and B‐RAF (v‐RAF murine sarcoma viral oncogene homolog B1) somatic gene mutation status can predict the response to anti‐epidermal growth factor receptor therapy. Conclusion Recent advances indicate that the widespread use of biomarkers may herald the next major advance in the diagnosis and management of CRC.     

Immunohistochemistry in screening for heritable colorectal cancer: what to do with an abnormal result

Recent developments in our understanding of molecular genetics have transformed screening and diagnostic practices for Lynch syndrome. The current standard involves universal tumour analysis of resected colorectal cancer (and ideally polypectomy) specimens using immunohistochemistry and molecular techniques. Patients with abnormal immunohistochemical findings are subsequently referred for definitive mutational testing. This review relates the molecular pathogenesis of Lynch syndrome to current immunohistochemistry‐based screening strategies and discusses the interpretation and clinical implications of screening results.     

Audit of definitive colorectal surgery in patients with early and advanced colorectal cancer

Background : The role of surgery in patients with advanced colorectal cancer may be questioned in the era of specialized intensive palliative care. Should patients with advanced disease be advised against surgery because of the risks of the surgery itself? In this study, the perioperative outcomes in patients undergoing definitive surgery for early (Dukes’ stages A, B and C) and advanced colorectal cancer (stage D) were examined. Methods : All patients undergoing definitive surgery for colorectal cancer during a 15‐year period were identified. Details of tumour site and stage, surgery performed, perioperative complications and postoperative mortality were compared. Results : A total of 374 patients underwent definitive surgery. There were 193 men, a male : female ratio of 1:0.9. Seventy‐one patients had advanced disease. There were no differences between the early and advanced groups in perioperative requirements for either blood or total parenteral nutrition. In the advanced group, more operations were performed as emergencies than in the early group (32.4 vs 17.5%; P < 0.01) and more patients presented with bowel obstruction in the advanced group (23.9 vs 10.2%; P < 0.01). There were no site differences between the early and advanced groups and no differences between the operations performed except that endo‐anal destruction was not performed in advanced patients. There were no differences in perioperative morbidity or mortality in the groups studied. Conclusion : Resection rates, operation type and postoperative morbidity and mortality were similar in patients with both early and advanced colorectal cancers. In terms of perioperative outcome, the presence of advanced cancer, per se, should not, therefore, be a justification to decline surgery.     

Deficiencies in pathological reporting of colorectal cancer in Victoria

Background: Colorectal cancer (CRC) pathological reporting deficiencies have been shown to be common, with deviations from the suggested minimum dataset. Information from both surgeon and pathologist is necessary for a complete report. These deficiencies have been shown to be correctable with the use of synoptic reporting. We carried out an audit on a random sample of CRC pathological reports from the first 6 months of 2004 in Victoria, Australia, with the aim of documenting current CRC pathological reporting deficiencies. Methods: A random sample of pathological reports for CRC was obtained from the Cancer Council of Victoria. One hundred and sixteen of these reports were reviewed by a team of surgical and pathology trainees. Presence or absence of the various fields of the 1999 National Health and Medical Research Council minimum dataset for CRC reporting was recorded. Results: There were deviations from the minimal dataset. Most notable was the absence of the information on the apical node, the presence of distant metastasis and perineural invasion. Conclusions: The opportunity exists for improvement in the pathological reporting of CRC in Victoria through the uniform introduction of synoptic reporting.