Colorectal polyps in the elderly: what should be done?

Evaluation of histopathological findings in very old people (≥ 80 years old) in Turkish population

BACKGROUND

The lesions observed in very old populations exhibit a wide spectrum of characteristics. Histopathological evaluation may be necessary for accurate diagnosis in this demographic. There is limited amount of data on the histopathological evaluation of lesions in very old patients. Therefore, the aim of this study was to assess the histopathological features in this population.

METHODS

A total of 5376 pathological samples from very old patients (≥ 80 years old) were analyzed. Clinical and pathological data were retrospectively reviewed. Histopathological diagnoses were categorized into three groups: malignant (invasive) lesions (MLs), benign/inflammatory lesions (BLs), and dysplastic-dysmorphic/non-invasive malignant lesions (DLs). Statistical analyses were conducted on the histopathological data. Pearson's chi-square test and the Fisher exact test were used to analyze the data, and statistical significance was considered at a p-value of < 0.05.

RESULTS

The mean age of the patients was 83.6 ± 3.4 years (range: 80-107), with 53% being female. The upper gastrointestinal (GI) tract was the most common site among all materials (28%, n = 1524). Benign/inflammatory lesions (BLs) accounted for the highest proportion of cases (62%, n = 3322) compared to MLs and DLs. BLs were significantly more prevalent in female patients (p < 0.001). MLs were notably more common in biopsies from breast locations (p < 0.001). No patients were diagnosed with DLs in the cytological materials.

CONCLUSIONS

Despite the broad spectrum of lesions observed in very old patients, the majority tend to be benign. While the Coronavirus disease 2019 (COVID-19) pandemic has altered healthcare dynamics, the increased frequency of benign lesions among the very old population, as a result of more frequent healthcare facility visits, is noteworthy. However, dysplastic and malignant lesions remain significant in this population and can profoundly impact patients' quality of life. This study contributes to our understanding of histopathological diagnoses in the very old population, shedding light on the current approach to managing their pathological specimens.

Risks, indications and technical aspects of colonoscopy in elderly or frail patients. Position paper of the Societat Catalana de Digestologia, the Societat Catalana de Geriatria i Gerontologia and the Societat Catalana de Medicina de Familia i Comunitaria

Colonoscopy (CS) is an invasive diagnostic and therapeutic technique, allowing the study of the colon. It is a safe and well tolerated procedure. However, CS is associated with an increased risk of adverse events, insufficient preparation and incomplete examinations in the elderly or frail patient (PEA/F). The objective of this position paper was to develop a set of recommendations on risk assessment, indications and special care required for CS in the PEA/F. It was drafted by a group of experts appointed by the SCD, SCGiG and CAMFiC that agreed on eight statements and recommendations, between them to recommend against performing CS in patients with advanced frailty, to indicate CS only if the benefits clearly outweigh the risks in moderate frailty and to avoid repeating CS in patients with a previous normal procedure. We also recommended against performing screening CS in patients with moderate or advanced frailty.

Four-week short chain fructo-oligosaccharides ingestion leads to increasing fecal bifidobacteria and cholesterol excretion in healthy elderly volunteers

Background

Short-chain fructo-oligosaccharides (scFOS) are increasingly used in human diet for their prebiotic properties. We aimed at investigating the effects of scFOS ingestion on the colonic microflora and oro-fecal transit time in elderly healthy humans.

Methods

Stools composition, oro-fecal transit time, and clinical tolerance were evaluated in 12 healthy volunteers, aged 69 ± 2 yrs, in three consecutive periods: basal period (2 weeks), scFOS (Actilight^®) ingestion period (8 g/d for 4 weeks) and follow-up period (4 weeks). Two-way ANOVA, with time and treatment as factors, was used to compare the main outcome measures between the three periods.

Results

Fecal bifidobacteria counts were significantly increased during the scFOS period (9.17 ± 0.17 log cfu/g vs 8.52 ± 0.26 log cfu/g during the basal period) and returned to their initial values at the end of follow-up (8.37 ± 0.21 log cfu/g; P < 0.05). Fecal cholesterol concentration increased during the scFOS period (8.18 ± 2.37 mg/g dry matter vs 2.81 ± 0.94 mg/g dry matter during the basal period) and returned to the baseline value at the end of follow-up (2.87 ± 0.44 mg/g dry matter; P < 0.05). Fecal pH tended to decrease during scFOS ingestion and follow-up periods compared to the basal period (P = 0.06). Fecal bile acids, stool weight, water percentage, and oro-fecal transit time did not change throughout the study. Excess flatus and bloating were significantly more frequent during scFOS ingestion when compared to the basal period (P < 0.05), but the intensity of these symptoms was very mild.

Conclusion

Four-week 8 g/d scFOS ingestion is well tolerated and leads to a significant increase in fecal bifidobacteria in healthy elderly subjects. Whether the change in cholesterol metabolism found in our study could exert a beneficial action warrants further studies.

Survival of elderly persons undergoing colonoscopy: implications for colorectal cancer screening and surveillance

BACKGROUND

In the elderly, the increased prevalence of colorectal neoplasia and the protective effect of colonoscopy may be offset by advancing age and comorbidity.

OBJECTIVE

To describe and quantify the endoscopic findings, survival, and predictors of mortality of elderly persons after colonoscopy.

DESIGN, SETTING, AND PATIENTS

Retrospective cohort study of persons aged>or=75 years who underwent colonoscopy in 1999 and 2000 at a U.S. Veterans Affairs facility and urban county hospital.

MAIN OUTCOME MEASURES

Advanced neoplasms were defined as colorectal cancer (CRC), polyp with high-grade dysplasia, villous histologic features, or tubular adenoma>or=1 cm. Comorbidity was measured with the Charlson comorbidity index. Subjects were followed until death or study closure.

RESULTS

Of 469 eligible subjects, 65 were excluded and 404 were included in the study. Fifty-nine of 404 (15%) had an advanced neoplasm, including 8 (2%) with CRC. There were 167 deaths (41%); the mean overall survival was 4.1+/-0.1 years (median 5.95 years). A symptomatic indication for colonoscopy was not predictive of death. Mortality was predicted by age (hazard ratio 1.16 for each year increase beyond age 75 years, 95% CI 1.07-1.3, P=.0003) and Charlson score (hazard ratio 8.3 for each point increase, 95% CI 1.4-48.5, P=.02). The median survival of patients aged 75 to 79 years was >5 years if the Charlson score was <or=4. Among patients aged>or=80 years, the median survival was <5 years regardless of Charlson score.

LIMITATIONS

Retrospective design.

CONCLUSIONS

In this cohort of elders, age and comorbidity were predictors of death. The protective effect of younger age lessens as comorbidity increases. These findings may have important implications for CRC screening and surveillance in elders.

New Dosage Formulations for Targeted Delivery of Cyclo-Oxygenase-2 Inhibitors

NSAIDs are a widely used class of analgesic and anti-inflammatory drugs that act by inhibiting the cyclo-oxygenase (COX) enzyme. However, because of their nonspecificity of action, use of these agents as long-term therapy for chronic pain in diseases such as rheumatoid arthritis (RA) and osteoarthritis (OA) is often discouraged. Among NSAIDs, COX-2 inhibitors are promising candidates for long-term therapy of chronic diseases, particularly in the elderly, because of their reduced incidence of gastrointestinal adverse effects. However, in recent times these agents have also been shown to cause adverse effects such as cardiovascular effects (myocardial infarction, stroke and hypertension) and renal effects (decreased renal blood flow/glomerular filtration rate), which in 2004 led to the withdrawal of rofecoxib and in 2005 the withdrawal of valdecoxib from the US market. Importantly, these adverse effects can be effectively reduced by achieving site specific/targeted delivery through new formulation approaches. These formulations not only restrict the drug supply to specific organs but also reduce the dose required. As a result, use of new delivery systems such as nanoparticles, microparticles, microemulsions and nanogels has gained widespread applicability in the management of chronic disease, especially in the elderly, and particularly when there is a need to decrease dose-dependent adverse effects (as is the case with COX-2 inhibitors). This article reviews various new approaches to the delivery of COX-2 inhibitors and highlights issues related to the development of delivery systems for these agents for RA, OA, cancer (familial adenomatous polyposis, prostate, breast and non-small cell lung cancer), ocular diseases (such as diabetic retinopathy) and inflammatory diseases of the skin, with emphasis on their potential for use in the elderly. Emphasis is also placed on the preparation of these particulate systems, their release profile and behaviour in biological systems.

Cancer risk in endoscopically unresectable colon polyps

BACKGROUND

The purpose of the current study was to define the rate of underlying malignancy in endoscopically unresectable polyps.

METHODS

An institutional review board-approved review identified all patients undergoing colectomy for radiologically identified or endoscopically unresectable polyps between 1997 and 2006. Patients were included if the endoscopic impression and biopsy findings suggested an adenomatous polyp without invasive cancer. Patient information was abstracted.

RESULTS

Eighty procedures in 79 patients were identified. Median patient age was 66 (range 38 to 85) years, and patients were predominately male (98%) and Caucasian (73%). The median endoscopic size of polyps was 3.0 cm (range 0.8 to 10 cm). Polyps were most frequently proximal to the splenic flexure (72%). Biopsy histology included 36 (51%) tubulovillous and villous adenomas. Invasive cancer was identified in 13 of 80 (16%) subsequent surgical specimens, but only 3 of 71 (4%) were lymph node-positive. Surgical morbidity was 37% and in-hospital mortality 3%. Size of polyp (P = .81) and histologic type (P = .34) were not significantly associated with invasive cancer. Compared with polyps proximal to the splenic flexure, polyps located distally were more likely to harbor malignancy (rate; P < .02), by both univariate and multivariate analysis (odds ratio [OR] 1.38 [95% confidence interval 1.07 to 1.8]).

CONCLUSION

The cancer risk in polyps deemed inappropriate for endoscopic resection was lower than previously reported. Neither polyp size nor histologic type appeared to be significantly associated with invasive cancer. Location of an endoscopically unresectable polyp distal to the splenic flexure confers an increased risk for occult malignancy.

Colonoscopy in the elderly: low risk, low yield in asymptomatic patients

PURPOSE

Current colonoscopy guidelines do not address the issue of when to stop performing screening and surveillance colonoscopy in the elderly. We reviewed our experience and results of colonoscopy in patients aged 80 years and older to assess the risks and diagnostic yield in this population.

METHODS

We reviewed retrospectively the endoscopic and pathologic reports from consecutive colonoscopies performed on patients aged 80 years and older at a single, high-volume endoscopy center between August 1999 and May 2003. Patient characteristics, indications for examination, findings at colonoscopy, and complications were recorded and analyzed.

RESULTS

A total of1,199 colonoscopic examinations were performed on 1,112 patients. Average age was 83.1 (range, 80-100) years. Male:female distribution was 1:1.7. Leading exclusive indications for colonoscopy included: polyp surveillance, 227 (19 percent); altered bowel habits, 168 (14 percent); iron-deficiency anemia, 132 (11 percent); and cancer follow-up, 108 (9 percent). Eighty-six examinations (7 percent) were performed solely for an indication of colorectal cancer screening. Twenty-two percent of patients had more than one indication for colonoscopy. Forty-five malignancies were found (3.7 percent). No cancers were found in the screening group, and two malignancies (0.7 percent) were detected in patients undergoing colonoscopy for polyp surveillance. There were eight (0.6 percent) reported major complications.

CONCLUSIONS

Colonoscopy can be performed safely in patients aged 80 years and older. However, the diagnostic yield is low, particularly in patients undergoing routine screening or surveillance examinations. Colonoscopy should for the most part be limited to elderly patients with symptoms or specific clinical findings.