Performing a colonoscopy 12 months after surgery for colorectal neoplasia

BACKGROUND: There appears to be acceptance that following up patients after surgery for colorectal neoplasia is of value. However, specific issues relating to which investigations to perform and how often remain unresolved. The aim of this project was to evaluate the clinical utility of performing a colonoscopy 12 months after curative surgery for colorectal neoplasia. METHODS: Patients were selected if they had undergone a curative resection for colorectal neoplasia, and if they had had a completed colonoscopy prior to surgery. Study endpoints included: (i) compliance with follow up; (ii) the prevalence, total number, size, and histology of polyps; and (iii) identification of recurrent or metachronous cancer. RESULTS: The study group included 253 patients of mean age 69.7 years (SD 11.6) and a male : female ratio of 1.4:1.0. Colonoscopies were completed on 90% of patients at a mean of 1.1 years following surgery. A total of 149 polyps were identified in 30% of patients. On histology, 42% were tubular adenomas, 6% tubulo-villous adenomas, 7% were villous adenomas, and 37% were hyperplastic. Advanced adenomas were identified in 7.9% of patients (95% CI 4.8-12.1%). No recurrent or metachronous cancers were identified. CONCLUSION: We have observed a high prevalence of advanced adenomas in patients undergoing a 12-month, follow-up colonoscopy after curative surgery for colorectal neoplasia. The significance of these observations requires further evaluation.     

Pathology of colorectal neoplasia

Colorectal adenomas and cancers are common. Diagnosis and management of these lesions requires close clinicopathological correlation. This article emphasizes clinically important issues in management of adenomas, including serrated lesions, and early stage cancers removed by local excision. Pathological interpretation and staging of formal resection specimens is also discussed. The biology of colorectal cancer is emphasized, particularly reflecting the need for molecular analysis to guide adjuvant oncological treatment.     

Risk of colorectal neoplasia in patients with solid organ transplantation

The incidence of colorectal adenomas and advanced neoplasia in the transplant population has not been well characterized. The aim of this study was to determine whether or not there was an increased incidence of colorectal adenomas and advanced neoplasia in solid organ transplantation (SOT) recipients compared with an average-risk population. We reviewed 360 patients with solid organ transplants who underwent colonoscopy between February 1995 and July 2008, and 360 age- and gender-matched patients in an average-risk population. The mean duration from transplantation to colonoscopy in the SOT group was 40.4 ± 34.0 months. Ninety-three (25.8%) adenomas were detected in the SOT group, while 98 (27.2%) adenomas were detected in the control group (p = 0.763). There was a statistically significant difference (p < 0.0001) in the number of patients with advanced neoplasia in the SOT group (24 patients [6.7%]) compared with the control group (3 patients [0.8%]). The independent risk factors of advanced neoplasia were old age (odds ratio [OR], 1.067; 95% CI, 1.019-1.118) and transplantation (OR, 6.069; 95% CI, 1.455-25.314). In summary, there was a significant increase in the incidence of advanced colorectal neoplasia in SOT recipients. The reason for this finding is unclear, and studies with a larger number of patients are needed to further evaluate this group.     

Risk of colorectal advanced neoplasia in patients with acute diverticulitis with and without previous colonoscopy

Background and Aim

Guidelines recommend a colonoscopy after an episode of complicated diverticulitis and after a first episode of uncomplicated diverticulitis. The influence of a previous colonoscopy on postdiverticulitis colonoscopic findings has not been studied. The aim of this work was to examine the incidence of adenoma detection rate (ADR), advanced adenoma (AA) and colorectal cancer (CRC) in patients with diverticulitis with and without previous colonoscopy.

Method

This was a retrospective case–control study of subjects with acute diverticulitis. Subsequent and previous colonoscopies were abstracted for ADR, AA and CRC diagnoses. The incidence of neoplasia was compared between patients with and without previous colonoscopy and also with that of a screening population.

Results

Compared with a healthy control group (n = 975), diverticulitis patients without prior colonoscopy (n = 325) had a significantly higher ADR (26.8% vs. 20.5%, p = 0.019) and invasive CRC rate (0.9% vs. 0%, p = 0.016). Risk factors for advanced neoplasia included age ≥ 70 years and complicated diverticulitis. Among subjects with diverticulitis and previous colonoscopy (n = 124), only one patient developed AA and there were no cancer cases.

Conclusions

A previous normal colonoscopy within 5 years before diverticulitis probably overshadows other risk factors for findings of advanced neoplasia and should be considered in the decision to repeat a colonoscopy.     

Screening colonoscopy and detection of neoplasia in asymptomatic,average‐risk,solid organ transplant recipients: case–control study

The aim of this study was to evaluate the detection of colonic neoplasia in an average‐risk population of SOT recipients. Studies regarding colonic neoplasia in solid organ transplantation (SOT) recipients have demonstrated mixed results due to the inclusion of above average‐risk patients. We performed a case–control study of 102 average‐risk SOT recipients who underwent screening colonoscopy, compared with an average‐risk, age and sex‐matched control group (n = 287). Cancer rates were compared with an age‐matched cohort from the National Cancer Institute’s Survival, Epidemiology, and End Results (SEER) database. There was no difference in number of patients with adenomas (P = 1.00). There was no difference in polyps per patient (P = 0.31). Although the number of advanced lesions (excluding adenocarcinoma) between groups did not differ (P = 0.25), there were two adenocarcinomas identified in the SOT group and none in the control group (P = 0.068). Detection of colorectal cancer was an unexpected finding in the SOT cohort and was more likely when compared to age‐matched cancer incidence generated by the SEER database. These results suggest no increased adenoma detection in SOT recipients, but with more cases of colorectal cancer than anticipated. Given previous, larger, transplant database studies demonstrating increased colorectal cancer rates, more frequent screening may be justified.     

Symptoms and signs in patients with colorectal cancer

The symptoms and signs of colorectal cancer vary from the general population to primary care and in the referred population to secondary care. This review aims to address the diverse symptoms, signs and combinations with relevance to colorectal cancer at various points in the diagnostic pathway and tries to shed light on this complex and confusing area. A move towards a lower threshold for referral and increased use of diagnostics might be a more reliable option for early diagnosis.     

The yield of flexible fiberoptic sigmoidoscopy in the detection of asymptomatic colorectal neoplasia

Recent evidence of a reduction in mortality rates from distal colorectal cancers in populations screened by rigid sigmoidoscopy suggests that further benefits may be achieved by the use of fiberoptic sigmoidoscopy as the screening modality. However, there is limited evidence as to the expected yield of neoplasia using the standard 60-cm instrument. The aim of this study was to determine the yield of neoplasia in an asymptomatic population in the at-risk age group undergoing fiberoptic sigmoidoscopy.Recruitment into the screening program was among State Department personnel. In total, 4,216 asymptomatic subjects (50–65 years) were offered flexible sigmoidoscopic screening performed following a simple enema bowel preparation. Those in whom a neoplastic condition was identified underwent further investigation (colonoscopy or barium enema).Of those offered screening 4,005 (95%) underwent the examination. Eleven carcinomas were detected at flexible sigmoidoscopy and two carcinomas were detected at further investigation in subjects with rectosigmoid polyps. The overall detection rate of carcinomas was 3.2 per 1,000 subjects screened.Histologically proven adenomas were detected in 217 subjects, 5.4% of the population screened.In this cohort of individuals flexible sigmoidoscopy appears to have been an acceptable form of screening.The detection rate of neoplasia, particularly colorectal adenomas, is higher than that reported from studies of fecal occult blood screening.     

Pathology of colorectal polyps and cancer

Colorectal adenomas and cancers are common. Diagnosis and management of these lesions requires close clinical-pathological correlation. This article emphasizes clinically important issues in management of adenomas, including serrated lesions, and early stage cancers removed by local excision. Pathological interpretation and staging of formal resection specimens is also discussed. The biology of colorectal cancer is emphasized, particularly reflecting the need for molecular analysis to guide adjuvant oncological treatment.     

Changing trends in polypoid colorectal cancer diagnosed by colonoscopy

Aim This study analysed trends in polypoid colorectal cancer (PCRC) diagnosed by colonoscopy during the period 1995–2008 and compared the patterns observed in the years 2005–2008 with 1995–1998. Method In the period 1995–2008, 24 245 colonoscopies were performed and 1041 patients with PCRC were diagnosed: pediculated (n = 220) or sessile (n = 821). Results The mean age at diagnosis was 68.3 ± 11.6 years. Males were more likely to have PCRC (males 62.6%vs females 37.4%; P < 0.0001). Significantly more pediculated PCRCs were located in the distal colon (P < 0.001). In the 2005–2008 period the prevalence of PCRC among patients undegoing colonoscopy decreased, the number of polypectomies increased significantly (P < 0.0001) and the pediculated PCRC location changed, with a significant increase in right‐sided lesions. Conclusion The prevalence of PCRC in patients undergoing colonoscopy decreased, with a significant increase in the number of polypectomies in the last decade. Pediculated PCRCs were more often located in the left colon and sessile PCRCs in the right colon. From the period 1995–1998 to 2005–2008 the location of pediculated PCRCs changed, with an increase in right‐sided lesions.     

结直肠无蒂锯齿状病变的特征和临床问题

无蒂锯齿状息肉/腺瘤（SSL）曾经被认为是良性病变,而现有研究表明,通过锯齿状瘤变途径,约15%～30%的SSL最终发展为结直肠癌。锯齿状息肉分为增生性息肉、无蒂锯齿状病变、伴发育不良的无蒂锯齿性病变、传统锯齿状腺瘤和未分类锯齿状腺瘤,每一种都具有不同的形态学和分子特征。尽管对SSL的理解有所提高,但由于频繁的病理错误分类、结肠内镜检测不足和不完全切除率高,SSL仍然是内镜和病理医生面临的诸多临床挑战。本文总结了目前对锯齿状息肉的新认识和诊断问题。     

Surgery for colorectal cancer in elderly patients —A comparison with younger adult patients—

Between 1972 and 1986, 668 patients without familial polyposis coli underwent surgery for colorectal cancer at the National Kyushu Cancer Center. Among these, there were 85 patients aged 75 years and older, and 39 patients aged 39 years and younger. The older patients tended to have a higher frequency of less advanced disease (stage I–III) and the progression of cancer in the older patients appeared to be relatively mild. The operative mortality rate of the older patients was as low as 1.2 per cent, which was almost identical to that of the younger adults (0 per cent), being 16.7 per cent for emergency operations, whereas it was 0 per cent for elective operations. The five-year survival curve of the older patients with curative resections was significantly better than that of those with noncurative resections. There was no significant difference in the cancer-related five-year survival curves between the older and younger patients with curative resections. Surgery for colorectal cancer in elderly patients should therefore not be restricted on the basis of chronological age alone.