Guía de práctica clínica. Diagnóstico y prevención del cáncer colorrectal. Actualización 2018

This document updates the recommendations made by the Spanish Society of Family and Community Medicine and the Spanish Association of Gastroenterology for the diagnosis and prevention of colorectal cancer (CRC). In order to evaluate the quality of the evidence and determine the recommendation levels of the interventions, we used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. This document establishes optimal delay intervals based on symptoms and the faecal immunochemical test (FIT) and recommends reducing the barriers for diagnostic confirmation in symptomatic subjects. With regard to CRC screening in the average-risk population, we propose strategies to achieve the universal implementation of organised CRC screening programmes based on biennial FIT and to increase the participation of the target population, including the involvement of Primary Healthcare. This Clinical Practice Guideline recommends universal screening for Lynch syndrome with mismatch repair proteins immunohistochemistry or microsatellite instability in incident CRCs and the use of gene panels in patients with adenomatous polyposis. It also updates the strategies to reduce the incidence and mortality of both CRC and other tumours associated with hereditary syndromes. Regarding non-hereditary familial CRC and surveillance after resection of adenomas, serrated lesions or CRC, we established the recommendations based on the attributable risk and the risk reduction of the proposed intervention. Finally, the document includes recommendations regarding surveillance intervals in inflammatory bowel disease and the attitude towards dysplasia.     

Nueva inmunoterapia y cáncer de pulmón

Recent research on the relationship between the immune system and cancer has revealed the molecular mechanisms by which cancer cells co-opt certain T cell receptors which block the cytotoxic response to defend themselves from the antitumor immune attack. These findings have helped identify specific targets (T cell receptors or their corresponding ligands) for the design of monoclonal antibodies that can unlock the immune response.These drugs, known as immune checkpoint inhibitors, have shown efficacy in metastatic melanoma and kidney cancer, and have been successfully tested in non-small cell lung cancer in recent trials. Immune checkpoint inhibitors were included in clinical practice as a second-line option after an initial chemotherapy (CT) regimen, and in the last year positive results have been reported from randomized trials in which they were compared in first line with standard CT. Responses have been surprising and durable, but less than 20%-25% in unselected patients, so it is essential that factors predicting efficacy be identified. One such biomarker is PD-L1, but the different methods used to detect it have produced mixed results.This non-systematic review discusses the results of the latest trials, the possibilities of incorporating these drugs in first-line regimens, the criteria for patient selection, adverse effects, and the prospects of combinations with conventional treatment modalities, such as CT, radiation therapy, and antiangiogenic agents.     

Factores de riesgo y tratamiento endoscópico para estenosis de anastomosis posterior a resección en pacientes con cáncer colorrectal

IntroductionBenign strictures are frequent complications following colorectal surgery, with an incidence of up to 20%. Endoscopic treatment is safe and effective but there is not enough evidence for establishing stricture management at that anatomic level.AimTo determine the risk factors associated with the development of stricture in patients with colorectal cancer and describe endoscopic treatment in those patients.Materials and methodsA retrospective study was conducted on patients with colorectal cancer that underwent surgery and anastomosis, evaluated through colonoscopy, within the time frame of 2014 to 2019.ResultsOf the 213 patients included in the study, 18.3% presented with stricture that was associated with the type of surgery. Intersphincteric resection was a risk factor (OR = 18.81, 95% CI: 3.31-189.40, p < .001). A total of 69.2% patients with stricture had a stoma, identifying it as a risk factor for stricture (OR = 7.07, 95% CI: 3.10-16.57, p < .001). Mechanical anastomotic stapling was performed in 87.4% of the patients that did not present with stricture, identifying it as a protective factor (OR = 0.41, 95% CI: 0.16-1.1, p = .04). Endoscopic treatment was required in 69.2% of the patients and provided favorable results in 83.3%. Only 2.6% of the patients had recurrence. No complications were reported.ConclusionIntersphincteric resection and the presence of a stoma were independent risk factors for stricture, and mechanical anastomosis was a protective factor against stricture development. Endoscopic treatment was safe and effective.     

Morbimortalidad de la resección pulmonar en pacientes octogenarios con cáncer de pulmón

ObjectiveEvaluate the restrictiveness of selection criteria for lung resection in lung cancer patients over 80 years of age compared to those applied in younger patients. Compare and analyze 30-day mortality and postoperative complications in both groups of patients.MethodsCase-controlled retrospective analysis. Study population: Consecutive patients undergoing elective anatomical lung resection. Population was divided into octogenarians (cases) and younger patients (controls). Variables determining surgical risk (BMI, FEV1%, postoperative FEV1%, FEV1/FVC, DLCO and pneumonectomy rate) were compared using either Wilcoxon or Chi-squared tests. Thirty-day mortality and morbidity odds ratio were calculated. A logistic regression model with bootstrap resampling was constructed, including postoperative complications as dependent variable and age and post-operative FEV1% as independent variables. Data were retrieved from a prospective database.ResultsNo statistically significant differences were found in BMI (P=.40), FEV1% (P=.41), postoperative FEV1% (P=.23), FEV1/FVC (P=.23), DLCO (P=.76) and pneumonectomy rate (P=.90). Case mortality was 1.85% and control mortality was 1.26% (OR: 1.48). Cardiorespiratory complications occurred in 12.80% of younger subjects and in 13.21% of patients aged 80 years or older. (OR: 1.03). In the logistic regression, only FEV1% was related to postoperative complications (P<.005).ConclusionSelection criteria for octogenarians are similar to those applied in the rest of the population. Advanced age is not a factor for increased 30-day mortality or postoperative morbidity.     

Impacto de una intervención de Atención Primaria en el programa de detección precoz de cáncer colorrectal

AimTo assess the effectiveness of a telephonic interview performed by primary care professionals among non-participants in the first round of the colorectal cancer early detection programme in the basic urban health area Guineueta in Barcelona, Spain.Patients and methodsThe Primary Healthcare Team of La Guineueta contacted people who did not respond to the invitation to the first round of the colorectal cancer early detection programme using a standardised telephone call protocol. We analysed the impact of the intervention based on participation and diagnosed disease.ResultsWe made 3,327 phone calls to 2,343 people. After the intervention the participation rate was 54.9%, which meant an increase of 5.7% with respect to the participation in the usual protocol for the programme (49.2%). The intervention allowed 5 cancers, 2 high-risk neoplasms and 8 low- and intermediate-risk lesions to be diagnosed. An average of 9 phone calls was necessary to achieve the participation of one additional person.DiscussionThe telephonic intervention performed by primary care professionals has significantly increased the population participation rate and the detection of neoplasms with respect to the usual colorectal cancer early detection programme protocol.     

La asociación entre Fusobacterium nucleatum y el cáncer colorrectal: una revisión sistemática y metaanálisis

IntroductionThe etiological factors of colorectal cancer (CRC) are not precisely known, although genetic and environmental factors have been implicated. A possible association with Fusobacterium nucleatum may provide opportunities for an early diagnosis.ObjectiveTo review studies that address the association between F. nucleatum and CRC.MethodsThe MEDLINE PubMed database was searched using the terms «colorectal cancer» and «Fusobacterium nucleatum», retrieving publications published up to January 1 2020. Stata software was used for a meta-analysis.ResultsThe systematic review included 57 articles. Meta-analysis results indicated a more frequent presence of F. nucleatum in CRC tumor tissue samples in comparison to control samples of healthy tissue, with an odds ratio of 4.558 (95% CI: 3.312-6.272), and in comparison, to control samples of colorectal adenomas, with an odds ratio of 3.244 (95% CI: 2.359-4.462).ConclusionThere is a more frequent presence of F. nucleatum in the CRC. However, further studies are needed to verify this relationship.     

Asociación entre infección por Fusobacterium nucleatum y cáncer colorrectal: un estudio mexicano

Introduction and aimsColorectal cancer (CRC) is the third most prevalent cancer worldwide. Many risk factors are involved, and current evidence links the gut microbiota and colorectal carcinogenesis. Fusobacterium nucleatum is proposed as one of the risk factors at the onset and during the progression of CRC, due to immune system and inflammatory modulation.Materials and methodsNinety samples from three different regions of the colon were collected through colonoscopy in patients with CRC, and qPCR TagMan® was conducted to detect F. nucleatum and cytokines (IL-17, IL-23, and IL-10) in tumor, peritumor, and normal samples. The differences between them were analyzed and correlated.ResultsThe abundance of F. nucleatum determined through the 2^-ΔΔCt method in CRC (7.750 [5.790-10.469]) was significantly higher than in the normal control (0.409 [0.251-0.817]) (p < 0.05). There was no significant association between F. nucleatum and the cytokines (p > 0.05).ConclusionsCRC is a heterogeneous disease that presents and progresses in a complex microenvironment, partially due to gut microbiome imbalance. F. nucleatum was enriched in CRC tissue, but whether that is a cause of the pathology or a consequence, has not yet been clearly defined.     

Impacto de la colonoscopia intraoperatoria en la detección y prevención de la fuga de la anastomosis colorrectal por cáncer de recto

Introduction and aimThe value of leakage testing during colorectal resections to identify anastomotic leaks or bleeding has not been established. Our aim was to compare the impact of intraoperative colonoscopy (IOC) versus insufflation with a syringe, as leakage testing in lower anterior resection for rectal cancer, with respect to the incidence of postoperative leakage (PL).Materials and methodsA retrospective study utilizing a prospective database of 426 patients with rectal cancer that underwent elective lower anterior resection, within the time frame of January 2015 and December 2019, was conducted. The anastomotic leak test was chosen by the surgeon. The incidence of PL was compared between patients that underwent IOC and those that had the syringe leak test, utilizing the logistic regression analysis. Propensity score matching was included.ResultsThere were no significant differences in the clinical characteristics or morbidity and mortality rates between the 2 groups. Four patients were excluded, leaving a patient total of 422. Seventy patients with IOC were compared with 352 that had the syringe leak test. The incidence of PL was 5.7% in the IOC group and 12.2% in the control group (P = .001). After propensity score matching (n = 221), balancing the characteristics between the groups, the incidence of PL was 5.7% in the IOC group and 13.9% in the syringe leak test group (P = .001).ConclusionIOC was shown to be a safe method for evaluating the integrity of colorectal anastomosis and was associated with a higher percentage of protective stoma use, appearing to reduce the risk for PL.     

Avances en la etiopatogenia,identificación y manejo clínico de las formas hereditarias y familiares de cáncer colorrectal

Hereditary and familial forms of colorectal cancer (CRC) represent approximately 30–35% of CRC cases. Identification of these forms and appropriate management of affected families are essential, as they constitute a group at high risk of CRC that benefits from specific preventive measures. Moreover, in some of these forms of CRC, mainly familial CRC, the alterations causing genetic susceptibility are not well characterized and thus identification of these alterations is a priority for correct diagnosis and management. The present review discusses the most important advances presented at the American Gastroenterological Association's congress on the etiopathogenesis, identification and clinical management of hereditary and familial CRC.     

Técnicas de imagen avanzada en la detección y caracterización de las lesiones precursoras del cáncer gástrico y del cáncer gástrico precoz

Diagnosis of early gastric cancer and its precancerous lesions remains a challenge for great part of western endoscopists. Changes seen in the mucosal pattern are generally subtle and hence difficult to identify. In this article, we will review the usefulness of conventional and virtual chromoendoscopy and magnification endoscopy in the recognition and classification of these lesions.     

Supervivencia de cáncer colorrectal en un centro oncológico de Colombia. Estudio de cohorte histórica

Introduction and aimsIn Colombia, cancer of the colon is the third most frequent cancer in relation to incidence and mortality. Five-year survival depends on stage at diagnosis, albeit that rate is not known for the country. The aim of the present study was to characterize the overall survival and disease-free survival rates in an adult population with colorectal cancer treated at an oncology center in Medellín, Colombia.Materials and methodsA retrospective cohort study was conducted. The case records of patients with a histologic diagnosis of colorectal cancer, seen within the time frame of 2011 and 2015, were reviewed. The overall survival and disease-free survival curves were calculated using the Kaplan-Meier method.ResultsA total of 824 (54.9%) patients with cancer of the colon and 676 (45.1%) with cancer of the rectum were treated. Mean patient age was 63.3 years, female sex predominated (56.3%), and 98.1% of the tumors were adenocarcinomas. The majority of the lesions were stage iii (31.9% in the colon and 35.5% in the rectum) at the time of diagnosis. Surgery was the most frequent treatment in the colon (85.2%) and radiotherapy was the most frequent in the rectum (75.4%). Overall survival at the median follow-up (27.3 months) was 66.7% for cancer of the colon and 63.9% for cancer of the rectum. Disease-free survival at the median follow-up (18.6 months in colon and 14.9 in rectum) was 72.5 and 68.9%, respectively.ConclusionsThe clinical characteristics and treatment of patients were similar to those found in other studies. Two-year survival was higher than in other Colombian reports and 5-year survival was lower than that observed in developed countries.