European guidelines for quality assurance in colorectal cancer screening and diagnosis: overview and introduction to the full supplement publication

Population-based screening for early detection and treatment of colorectal cancer (CRC) and precursor lesions, using evidence-based methods, can be effective in populations with a significant burden of the disease provided the services are of high quality. Multidisciplinary, evidence-based guidelines for quality assurance in CRC screening and diagnosis have been developed by experts in a project co-financed by the European Union. The 450-page guidelines were published in book format by the European Commission in 2010.  They include 10 chapters and over 250 recommendations, individually graded according to the strength of the recommendation and the supporting evidence. Adoption of the recommendations can improve and maintain the quality and effectiveness of an entire screening process, including identification and invitation of the target population, diagnosis and management of the disease and appropriate surveillance in people with detected lesions. To make the principles, recommendations and standards in the guidelines known to a wider professional and scientific community and to facilitate their use in the scientific literature, the original content is presented in journal format in an open-access Supplement of Endoscopy. The editors have prepared the present overview to inform readers of the comprehensive scope and content of the guidelines.

Socioeconomic position and participation in colorectal cancer screening

BACKGROUND

Colorectal cancer (CRC) screening with faecal occult blood test (FOBT) has the potential to reduce the incidence and mortality of CRC. Screening uptake is known to be inferior in people with low socioeconomic position (SEP) when compared with those with high position; however, the results of most previous studies have limited value because they are based on recall or area-based measures of socioeconomic position, and might thus be subject to selective participation and misclassification. In this study we investigated differences in CRC screening participation using register-based individual information on education, employment, and income to encompass different but related aspects of socioeconomic stratification. Also, the impact of ethnicity and cohabiting status was analysed.

METHODS

A feasibility study on CRC screening was conducted in two Danish counties in 2005 and 2006. Screening consisted of a self-administered FOBT kit mailed to 177 114 inhabitants aged 50-74 years. Information on individual socioeconomic status was obtained from Statistics Denmark.

RESULTS

A total of 85 374 (48%) of the invited returned the FOBT kits. Participation was significantly higher in women than in men (OR=1.58 (1.55-1.61)), when all socioeconomic and demographic variables were included in the statistical model. Participation also increased with increasing level of education, with OR=1.38 (1.33-1.43) in those with a higher education compared with short education. Also, participation increased with increasing income levels, with OR=1.94 (1.87-2.01) in the highest vs lowest quintile. Individuals with a disability pension, the unemployed and self-employed people were significantly less likely to participate (OR=0.77 (0.74-0.80), OR=0.83 (0.80-0.87), and OR=0.85 (0.81-0.89), respectively). Non-western immigrants were less likely to participate (OR=0.62 (0.59-0.66)) in a model controlling for age, sex, and county; however, this difference might be attributed to low SEP in these ethnic groups ((OR=0.93 (0.87-0.99), when adjusting for SEP indicators).

CONCLUSION

This study based on individual information on several socioeconomic dimensions in a large, unselected population allowed for identification of several specific subgroups within the population with low CRC screening participation. Improved understanding is needed on the effect of targeted information and other strategies in order to reduce socioeconomic inequalities in screening.

Evidence for immune system involvement in reflex sympathetic dystrophy

Skin biopsies from patients with reflex sympathetic dystrophy were immunostained using a variety of antisera. An incidental finding with S100 staining was the presence of numerous Langerhans cells in the epidermis. All patients had significant pain at the time of biopsy, and all had symptoms refractory to treatment. The potential implications of this finding are discussed.

The ultrasonic diagnosis of urachal anomalies

Seven cases of urachal anomalies are presented. The spectrum of the disorder and the criteria for ultrasound diagnosis are described. Six of seven cases were correctly diagnosed pre-operatively with diagnostic ultrasound, but one case with no cystic component was missed. The appearance of a fixed, midline, cystic, extraperitoneal swelling between the umbilicus and the bladder should suggest the diagnosis.

Digital nerve compression by hyperplastic Pacinian corpuscles. A case report and immunohistochemical study

A 68-year-old lady developed digital pain within days of the excision of a palmar ganglion. This was found to be due to a mass of hyperplastic Pacinian corpuscles compressing the digital nerve. Immunohistochemistry was carried out on the resected corpuscles using antisera to a range of neuropeptides. Possible mechanisms of hyperplasia are discussed.

Dieulafoy's ulcer: a palpable entity?

Two cases of Dieulafoy's ulcer are reported. Diagnosis was delayed but successful surgical treatment was achieved once the lesion was located by palpation.

Parathyroid cyst: report of case in the mediastinum

Though a rare lesion a parathyroid cyst is of clinical significance because it usually mimics a thyroid cyst and can be associated with hyperparathyroidism. The cyst can be ectopic with location in the lateral neck or in the mediastinum and therefore constitutes a differential diagnosis to a branchial or thymic cyst. A case report of a mediastinal parathyroid cyst without hyperparathyroidism is presented. Fine needle aspiration with parathyroid hormone assay on the cyst fluid will reveal the correct diagnosis. Surgical removal of the cyst is recommended, and hyperparathyroidism should be considered.

Malignant fibrous histiocytoma of the kidney

Malignant fibrous histiocytoma is a primitive mesenchymal tumor which seldom occurs in the genitourinary organs. Despite radical operation, prognosis is generally poor and seems not to be improved by chemotherapy or radiotherapy. We present a case of a malignant fibrous histiocytoma of the renal capsule. The tumor could be removed totally and no signs of metastases were found. Eight months later the patient was readmitted with recurrence of tumor and widespread metastases.

Early changes in parathyroid function after high-dose irradiation of the neck

Hyperparathyroidism (HPT) will develop years later in a number of patients irradiated to the neck for benign diseases. Twenty-nine patients with malignant diseases were studied for 3 years after irradiation with cancer therapeutic doses to the neck. The serum concentration of parathyroid hormone (iPTH) showed an increasing trend suggesting that HPT also might develop in these patients.

Interleukin-1 affects the function of cultured human thyroid cells

Cytokines are peptide hormones essential for cellular communication in the immune response. The purpose of this study was to investigate the influence of cytokines, especially recombinant interleukin 1 beta (rIL-1 beta), on human thyroid cells. Thyroglobulin (Tg) was measured by a double antibody radioimmunoassay, and cyclic AMP (cAMP) by a competitive protein binding assay. Supernatants from unstimulated and phytohaemagglutinin-stimulated blood mononuclear cells were added to human thyroid cells cultured in monolayers. A dose-dependent inhibition of the secretion of Tg and cAMP was demonstrated. Both subcultured and primary cultured cells incubated with rIL-1 beta at pharmacological levels (10(-1)-10(2) U/ml) exhibited an inhibition of Tg and cAMP secretion, while at physiological levels (10(-5)-10(-3) U/ml), the secretion of Tg was enhanced. The similar stimulation of cAMP was demonstrated in subcultures. These in vitro studies suggest that IL-1 beta may play a role in the pathogenesis of autoimmune thyroid diseases. Further, the stimulations at low concentrations indicate that IL-1 beta may regulate the function of the thyroid gland under physiological conditions.

Comparison of 99Tcm lymphoscintigraphy and lymphangiography in patients with malignant lymphomas

Comparison of abdominal lymphoscintigraphy with 99Tcm microcolloid and conventional lymphangiography in 38 patients with malignant lymphomas showed 62 per cent agreement when the results were classified as normal, doubtful and abnormal. The present scintigraphic method seems to be sufficiently safe and accurate as a screening test, without significant side effects and associated with little patient discomfort.

Unchanged parathyroid function following irradiation for malignancies of the head and neck

Irradiation to the neck increases the prevalence of hyperparathyroidism and may cause parathyroid insufficiency. In this study, 35 patients who received therapeutic irradiation to the neck and a control group comprising 19 patients who received radiation to the bladder were studied before, during, and until 2 months after irradiation in order to see whether there were any measurable changes in the parathyroid function. In both groups the serum concentrations of calcium, phosphate and parathyroid hormone were unchanged. Serum protein and albumin decreased in the bladder cancer group. The results support the concept that the parathyroid gland has a low radiation sensitivity, and radiation induced changes may not manifest itself before years after irradiation, due to the low mitotic activity.

Influence of thyroid substitution therapy and thyroid autoantibodies on the value of serum thyroglobulin in recurring thyroid cancer

The study was performed to evaluate the influence of thyroxine substitution therapy and the presence of thyroglobulin antibodies (TgAb) on the usefulness of serum thyroglobulin (Tg) measurements in the follow-up of patients treated for well differentiated thyroid carcinoma. Seventy-two consecutive patients with differentiated thyroid cancer and eight with medullary carcinoma as well as controls were studied on one or more occasions and blood was drawn for measurement of serum Tg, TgAb, TSH and thyroid hormones. In 23 patients the hormonal substitution was withdrawn and 3-4 weeks later new blood samples and a 131I scintigraphy was performed. Eighteen patients were shown to have recurrence or metastases. Four of these had TgAb, two had normal Tg values, and the remaining 12 had extremely elevated levels. Those with TgAb and normal Tg values all had high Tg levels off thyroxine substitution. The 54 patients without evidence of recurrence had low levels of serum Tg except for one with highly elevated values. Based on the results from this and other studies is concluded that serum Tg is an important adjunct in the follow-up of patients with well differentiated thyroid carcinoma, but certain limiting factors have to be taken into account, i.e., the radicality of surgery, the sufficiency of the substitution, the presence of TgAb and the method for measurement of Tg.

Nuclear imaging of pulmonary metastases in thyroid carcinoma

Pulmonary metastases were diagnosed in 14 of 52 patients with well differentiated thyroid carcinoma by 131I whole body scintigraphy or radiography. Three patients had metastases only demonstrable on scintigraphy, whereas chest radiography was diagnostic in 4 patients with normal scintigraphic findings. Thus, in this type of thyroid carcinoma, neither 131I scintigraphy nor routine chest films alone will reveal all cases of pulmonary metastases.

Kidney scintigraphy with 99mTc-DMSA and 131I-hippurate

43 patients underwent an extended scintigraphic procedure with 99mTc-dimercaptosuccinylic acid in order to investigate its proper use for diagnosing morphological and functional kidney abnormalities. The group was comprised of patients without renal disease, and patients with diffuse parenchymal disease, obstructive uropathy, renal cysts and renal tumors. The study was followed by 131I-hippurate renography. We propose a simplified routine procedure with scintiphotos taken 10-15 min after injection for topographic information and 120 min after injection for renal morphology. This procedure allows excellent case finding of diffuse parenchymal disease of a special value in cases of radiological non-visualization. The technique is indicated, when iodine contrast media cannot be used for radiological examinations. DMSA studies, however, do not allow safe functional evaluation in all categories of patients. Neither can obstructive nephropathy be diagnosed unless the renal pelvis is dilated. Renal perfusion studies are contaminated by the perfusion of liver and spleen. Nevertheless, a tentative differentiation between cysts and tumours is possible, the former being hypoperfused the latter hyperperfused. When supplemented with gamma camera 131I-hippurate renography, the total scintigraphic procedure will also include split function determination and run-off evaluation.