Endoscopic ultrasound in the staging of gastrointestinal luminal malignancies

Endoscopic ultrasound (EUS) is an important tool in the staging of gastrointestinal cancers. This review highlights the use of EUS in the staging of gastrointestinal luminal malignancies and compares the performance of EUS with other imaging modalities (CT, MRI and PET-CT) in the staging of these malignancies. Management algorithms in the staging of these malignancies are also presented.peer-reviewe

Clinical management of endoscopically resected pT1 colorectal cancer

Background Implementation of colorectal cancer (CRC) screening programs increases endoscopic resection of polyps with early invasive CRC (pT1). Risk of lymph node metastasis often leads to additional surgery, but despite guidelines, correct management remains unclear. Our aim that are diagnosed and treated endoscopically and this number is expected to increase [1,2].Methods We retrospectively reviewed patients undergoing endoscopic resection of pT1 CRC from 2006 to 2016. Clinical, endoscopic, surgical treatment, and follow-up data were collected and analyzed. Lesions were categorized according to endoscopic/histological risk-factors into low and high risk groups. Comorbidities were classified according to the Charlson comorbidity index (CCI). Surgical referral for each group was computed, and dissociation from current European CRC screening guidelines recorded. Multivariate analysis for factors affecting the post-endoscopic surgery referral was performed.Results Seventy-two patients with endoscopically resected pT1-CRC were included. Overall, 20 (27.7%) and 52 (72.3%) were classified as low and high risk, respectively. In the low risk group, 11 (55%) were referred to surgery, representing over-treatment compared with current guidelines. In the high risk group, nonsurgical endoscopic surveillance was performed in 20 (38.5%) cases, representing potential under-treatment. After a median follow-up of 30 (6-130) months, no patients developed tumor recurrence. At multivariate analysis, age (OR 1.21, 95 %CI 1.02 -1.42; P = 0.02) and CCI (OR 1.67, 95 %CI 1.12 -3.14; P= 0.04) were independent predictors for subsequent surgery.Conclusions A substantial rate of inappropriate post-endoscopic treatment of pT1-CRC was observed when compared with current guidelines. This was apparently related to an overestimation of patient-related factors rather than endoscopically or histologically related factors

Safety and efficacy of endoscopic submucosal dissection for rectal neoplasia: a multicenter North American experience.

Background and aims  Rectal lesions traditionally represent the first lesions approached during endoscopic submucosal dissection (ESD) training in the West. We evaluated the safety and efficacy of rectal ESD in North America. Methods  This is a multicenter retrospective analysis of rectal ESD between January 2010 and September 2018 in 15 centers. End points included: rates of en bloc resection, R0 resection, adverse events, comparison of pre- and post-ESD histology, and factors associated with failed resection. Results  In total, 171 patients (median age 63 years; 56 % men) underwent rectal ESD (median size 43 mm). En bloc resection was achieved in 141 cases (82.5 %; 95 %CI 76.8-88.2), including 24 of 27 (88.9 %) with prior failed endoscopic mucosal resection (EMR). R0 resection rate was 74.9 % (95 %CI 68.4-81.4). Post-ESD bleeding and perforation occurred in 4 (2.3 %) and 7 (4.1 %), respectively. Covert submucosal invasive cancer (SMIC) was identified in 8.6 % of post-ESD specimens. There was one case (1/120; 0.8 %) of recurrence at a median follow-up of 31 weeks; IQR: 19-76 weeks). Older age and higher body mass index (BMI) were predictors of failed R0 resection, whereas submucosal fibrosis was associated with a higher likelihood of both failed en bloc and R0 resection. Conclusion  Rectal ESD in North America is safe and is associated with high en bloc and R0 resection rates. The presence of submucosal fibrosis was the main predictor of failed en bloc and R0 resection. ESD can be considered for select rectal lesions, and serves not only to establish a definitive tissue diagnosis but also to provide curative resection for lesions with covert advanced disease

An evidence-based treatment algorithm for colorectal polyp cancers:results from the Scottish Screen-detected Polyp Cancer Study (SSPoCS)

Objectives: Colorectal polyp cancers present clinicians with a treatment dilemma. Decisions regarding whether to offer segmental resection or endoscopic surveillance are often taken without reference to good quality evidence. The aim of this study was to develop a treatment algorithm for patients with screen-detected polyp cancers.Design: This national cohort study included all patients with a polyp cancer identified through the Scottish Bowel Screening Programme between 2000 and 2012. Multivariate regression analysis was used to assess the impact of clinical, endoscopic and pathological variables on the rate of adverse events (residual tumour in patients undergoing segmental resection or cancer-related death or disease recurrence in any patient). These data were used to develop a clinically relevant treatment algorithm.Results: 485 patients with polyp cancers were included. 186/485 (38%) underwent segmental resection and residual tumour was identified in 41/186 (22%). The only factor associated with an increased risk of residual tumour in the bowel wall was incomplete excision of the original polyp (OR 5.61, p=0.001), while only lymphovascular invasion was associated with an increased risk of lymph node metastases (OR 5.95, p=0.002). When patients undergoing segmental resection or endoscopic surveillance were considered together, the risk of adverse events was significantly higher in patients with incomplete excision (OR 10.23, p&lt;0.001) or lymphovascular invasion (OR 2.65, p=0.023).Conclusion: A policy of surveillance is adequate for the majority of patients with screen-detected colorectal polyp cancers. Consideration of segmental resection should be reserved for those with incomplete excision or evidence of lymphovascular invasion.</p

Early rectal cancer and screening for colorectal cancer

Colorectal cancer (CRC) is the second most common form of cancer in Europe, and population based screening for colorectal cancer is recommended by the European Union. Screening enables detection of precursor lesions, i.e. adenomas, and cancer at an early stage, and randomised trials have demonstrated that screening reduces mortality in colorectal cancer. In rectal cancer, oncological results after abdominal resection surgery have improved over many years, but the morbidity, mortality and negative functional side effects following surgery and oncological treatment are considerable. Local excision techniques, on the other hand, demonstrate excellent functional results and a low morbidity and mortality but have high local recurrence rates, mainly since the technique does not allow for excision of mesorectal lymph nodes, which could be exposed to metastatic disease not detectable in the preoperative radiological staging. Since further expansion of population based screening programs for CRC will increase the detection of early cancer, local excision techniques are of great interest, provided that an adequate oncological out-come can be ensured. In paper I all patients in Sweden undergoing surgery for stage I rectal cancer 1995-2006 were assessed regarding survival, local recurrence rates and risk factors for death. Patients undergoing local excision had a higher local recurrence rate and a poor survival, especially in the age group ≥ 80 years, compared to patients undergoing abdominal resection surgery. Paper II analysed risk factors for lymph node metastases in patients with rectal cancer. All patients in Sweden 2007-2010 with histopathologically confirmed radical resections of pT1-2 rectal cancer follow-ing abdominal resection surgery without (neo)adjuvant treatment were included. T2 stage, poor differen-tiation and vascular infiltration were identified as risk factors for lymph node metastases. A model calcu-lating the total risk depending on the number of risk factors included, displayed a risk range of 6-65 % and 11-78 % in T1 and T2 tumours respectively. In paper III all Swedish patients aged 60-69 years with screening detected colorectal cancer were com-pared to those with non-screening detected cancer diagnosed 2008-2012. Pre- and postoperative staging, MDT-assessment, surgical and oncological treatment were compared between the groups. Patients with screening detected cancer were staged and MDT-assessed to a higher extent compared to those with non-screening detected cancer and tumours were found at an earlier stage in the screening group. Surgical and oncological treatment did not differ between the groups. Patients with endoscopically resected can-cer did not undergo staging and MDT-assessment to the same extent as did patients with surgically re-sected cancer. Paper IV included all individuals with a positive FOBT in the Stockholm screening programme, January 2008 - June 2012. Complications and mortality within 30 days after interventions, i.e. colonoscopies or surgery for adenomas or cancer, subsequent to a positive screening test were assessed. Total complica-tion rates were acceptable and mortality was low, but the rate of anastomotic leakage, which was 13 % and 12 % in the adenoma and cancer surgery groups respectively, was higher than expected

Patterns of injury and violence in Yaoundé Cameroon: an analysis of hospital data.

BackgroundInjuries are quickly becoming a leading cause of death globally, disproportionately affecting sub-Saharan Africa, where reports on the epidemiology of injuries are extremely limited. Reports on the patterns and frequency of injuries are available from Cameroon are also scarce. This study explores the patterns of trauma seen at the emergency ward of the busiest trauma center in Cameroon's capital city.Materials and methodsAdministrative records from January 1, 2007, through December 31, 2007, were retrospectively reviewed; information on age, gender, mechanism of injury, and outcome was abstracted for all trauma patients presenting to the emergency ward. Univariate analysis was performed to assess patterns of injuries in terms of mechanism, date, age, and gender. Bivariate analysis was used to explore potential relationships between demographic variables and mechanism of injury.ResultsA total of 6,234 injured people were seen at the Central Hospital of Yaoundé's emergency ward during the year 2007. Males comprised 71% of those injured, and the mean age of injured patients was 29 years (SD = 14.9). Nearly 60% of the injuries were due to road traffic accidents, 46% of which involved a pedestrian. Intentional injuries were the second most common mechanism of injury (22.5%), 55% of which involved unarmed assault. Patients injured in falls were more likely to be admitted to the hospital (p &lt; 0.001), whereas patients suffering intentional injuries and bites were less likely to be hospitalized (p &lt; 0.001). Males were significantly more likely to be admitted than females (p &lt; 0.001)DiscussionPatterns in terms of age, gender, and mechanism of injury are similar to reports from other countries from the same geographic region, but the magnitude of cases reported is high for a single institution in an African city the size of Yaoundé. As the burden of disease is predicted to increase dramatically in sub-Saharan Africa, immediate efforts in prevention and treatment in Cameroon are strongly warranted

Integrative analysis of the colorectal cancer proteome : potential clinical impact

Peer reviewedPostprin

Prevention of gastrointestinal cancer by surveillance endoscopy

The classification of the endoscopic appearance of superficial neoplastic lesions of the digestive mucosa aims to evaluate the risk of progression to advanced neoplasia in 3° (low, intermediate, high) and to predict appropriate treatment and corresponding surveillance. The privileged position of endoscopy results from its double impact on prevention of digestive cancer through reduction in incidence after early detection and eradication of precursors; and through reduction of mortality after detection and treatment of cancer at an early and curable stage. However the efficacy of diagnostic endoscopy still requires improvement and quality control on the following points: (1) technology, with a generalized use of the recently introduced high-resolution endoscopes. (2) diagnosis of poorly visible nonpolypoid precursors: this applies to small depressed lesions and large slightly elevated or sessile serrated and non-serrated precursors, particularly in the proximal colon. (3) treatment and training in therapeutic endoscopy, including the most recent techniques of mucosal resection of nonpolypoid lesions