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

Improving assessment and management of large non-pedunculated colorectal lesions in a Western center over 10 years. lessons learned and clinical impact

Background and study aims Outcomes of endoscopic assessment and management of large colorectal (CR) non-pedunculated lesions (LNPLs) are still under evaluation, especially in Western settings. We analyzed the clinical impact of changes in LNPL management over the last decade in a European center.Patients and methods All consecutive LNPLs >= 20mm endoscopically assessed (2008-2019) were retrospectively included. Lesion, patient, and resection characteristics were compared among clinically relevant subgroups. Multivariate logistic regression (for predictors of submucosal invasion [SMI] and recurrence), Kaplan-Meier curves and ROC curves (for temporal cut-offs in trends analyses) were used.Results A total of 395 LNPLs were included (30mm [range 20-40]; SMI=9.6%; primary endoscopic resection [ER]=88.4%). Pseudo-depression and JNET classification independently predicted SMI beyond single morphologies/location. After complete ER, involvement of ileocecal valve/dentate line, piece-meal resection and high-grade dysplasia independently predicted recurrence. Rates of 5-year recurrence-free, surgery-free and cancer-free survival were 77.5%, 98.6% and 100%, respectively, with 93.8% recurrences endoscopically managed and no death attributable to ER or CR cancer (versus 3.4% primary surgery mortality). ROC curves identified the period >= 2015 (following Endoscopic Submucosal Dissection [ESD] introduction and education on pre-resective lesion assessment) as associated with improved lesions' characterization, increased en-bloc resection of SMI lesions (87.5% vs 37.5%; p=0.0455), reduced primary surgery (7.5% vs 16.7%; p=0.0072), surgical referral of benign lesions (5.1% vs 14.8%; p=0.0019), and recurrences.Conclusions ESD introduction and educational interventions allowed ER of more complex lesions, offset by increased complementary surgery for complications or intrinsic histological risk. Nevertheless, overall, they have reduced surgery demand and increased appropriateness and safety of LNPL management in our center

Gestione e miglioramento di pascoli italiani

Experimental results of trials on pastures management and improvement, conducted by 10 University Institutes within the study team «Characterization of italian pastures» are reported. The trials carried out in different soil and climate conditions, ranging from the Alps to the southern Appennines and to the Islands, in different years, provide some conclusive and generaI considerations. With periodical cuts, the forage availability period becomes longer, while using one cut at flowering yield results are higher. As far as management techniques are concerned, fertilization with the three main nutrients affects positively quanti-qualitative yield, although in real situations the application of one or two elements may be sufficient and more economically convenient, and in relation to the botanical composition. Undersowing determines positive effects both on botanical composition and on pasture utilization. Positive results, furthermore, are obtained by mechanical scrub clearing. Vengono riferiti i risultati sperimentali delle prove sulla gestione e sul miglioramento dei pascoli condotte da dieci Istituti Universitari costituenti il gruppo di studio «Caratterizzazione di pascoli italiani», Dalle prove condotte in ambienti pedoclimatici diversi, dalle alpi all'appennino meridionale ed alle isole, e in annate differenti, sono emerse come generalizzabili alcune considerazioni conclusive. Con sfalci periodici si allunga il periodo di disponibilità di foraggio verde, mentre con quello unico alla fioritura la produzione risulta più elevata. Per gli interventi tecnici, la concimazione con i tre macroelementi influisce favorevolmente sull'entità e sulla qualità della produzione, anche se, nelle situazioni concrete, può essere sufficiente, e più vantaggioso dal lato economico, la somministrazione di uno o due elementi, anche in relazione alla facies floristica. La trasemina determina effetti favorevoli sia sulla composizione floristica sia nella migliore utilizzazione del pascolo. Risultati positivi, infine, si conseguono con il decespugliamento meccanico

Caratterizzazione della dinamica produttiva di pascoli naturali italiani

This work studies herbage production and its seasonal distribution in indigenous pastures, and analyses the relationship between the environmental factors (soil, clima, vegetation) and the productivity of these resources. The investigations have been carried on during the period 1983-90 by the joint activity of 10 different University Istitutions in 23 different environments distributed along the Italian peninsula and the main islands. For each environment, pasture production has been measured with the Corrall and Fenlon method, analysing the more important vegetational and ecological conditions; altogether the total yearly production and the seasonal pattern of herbage production have been detected on 104 pastures. The total herbage yield is not significantly influenced by the latitudinal gradient, and the overall regional (alps, central Appenine, south Apennine and islands) production is about 2.3 t ha-1 year-1 The wide range (0.5-6.3 t ha-1 year-1) of herbage production, on small or medium scale, seems to be due to evident changeof environmental or management factors. Five types of seasonal distribution of herbage growth are evidenced with multivariate analysis methods, based on the growing season and the amplitude of the growth. With mean temperature above 12°C and total rainfall below 800 mm, herbage distribution shows a standstill during summer period and an evident regrowth in autumn. On the contrary, for the 4 other distribution types, the winter standstill become important, and the types are distinct by summer growth amplitude and by the growing season lenght. With cluster analysis method, for each type of herbage distribution, have been pointed out under-types characterized by interannual herbage production variation. Among the environmental factors, vegetation characheristics, expressed as Pasture Value following Daget and Poissonet seems to be strictly correlated with total production. The comparative poor role played by the soil and climatic factor, may be due to the strong past and present antropic influence, related with management and utilization techniques. Il presente lavoro ha come scopo l'approfondimento delle conoscenze sulla produzione e sulla distribuzione stagionale della crescita dell'erba dei pascoli naturali, nonché l'analisi delle interazioni tra i fattori ambientali, pedo-climatici e vegetazionali, e la risposta produttiva di queste risorse. La ricerca è stata condotta nel periodo 1983-90 da 10 diverse Istituzioni Universitarie, in 23 ambienti differenti, distribuiti lungo tutta la penisola e le isole maggiori. Per ogni ambiente, con il metodo di rilievo di Corrall e Fenlon, è stata saggiata la risposta produttiva di pascoli rappresentativi delle principali situazioni vegetazionali e di giacitura; complessivamente sono state rilevate la produzione totale annua e la curva di produttività media pluriennale di 104 pascoli. Riguardo la produzione annua complessiva si è osservato che essa non presenta variazioni significative lungo il gradiente latitudinale, collocandosi tra le diverse regioni (alpina, centro appenninica, suq, appenninica e insulare) attorno a 2.3 t ha-1 anno-1. La fitomassa raccolta è soggetta invece a variazioni sensibili (0.5-6.3 t ha-1 anno-1) riconducibili a fattori ambientali e gestionali che si esprimono su piccola e media scala. Con metodi di analisi multivariata si sono individuate 5 tipologie distributive della crescita dell'erba, in rapporto alla stagione vegetativa e alle variazioni dell'intensità di crescita nel corso della stagione stessa. Con temperature medie e precipitazioni annue rispettivamente maggiori di 12°C e minori di 800 mm, risulta evidente la stasi vegetativa nel trimestre estivo e la ripresa vegetativa autunnale. Nel caso opposto la stasi è invernale e le 4 tipologie afferenti a questo modello, sono distinguibili dall'entità della crescita nei mesi estivi e dalla durata della stagione vegetativa. Per ogni tipologia produttiva, sono state evidenziate, tramite l'analisi cluster, sotto-tipologie distinte per la variabilità produttiva interannuale. Tra i fattori ambientali, la vegetazione, espressa attraverso l'indice del valore pastorale di Daget e Poissonet, presenta una buona capacità predittiva nei confronti del livello produttivo dei pascoli. Il contributo comparativamente modesto offerto dai fattori pedoclimatici sembra attribuibile alla forte influenza antropica, pregressa e attuale, attraverso le cure colturali e l'utilizzazione