Screening for colorectal cancer by full colonoscopy in first-degree relatives of colorectal cancer patients: a multicentric study by the Italian League for the Fight against Cancer

Background

Colorectal cancer currently presents the third-highest incidence of cancers worldwide, making secondary prevention through screening programs for colorectal cancer, usually by Fecal Occult Blood Testing, an essential preventive medicine intervention. First-degree relatives of colorectal cancer patients are a particularly at-risk group, with indications to consider direct screening by full colonoscopy. Colonoscopy is considered the gold standard for diagnosing colorectal cancer, as it has high sensitivity and specificity, and is both a diagnostic and therapeutic tool. However, it requires significant organizational and financial resources, and has a small but relatively higher risk of complications as opposed to fecal occult blood testing. The present study aimed to assess the appropriateness of a screening program without age restrictions of CRC by full colonoscopy in asymptomatic, first-degree adult relatives of patients with colorectal cancer, aiming both to actively increase screening coverage and to determine the detection rate of precancerous lesions and colorectal cancer in this population.

Study Design

Uncontrolled interventional study - colorectal cancer screening by full colonoscopy for at-risk population.

Methods

The Italian League for the Fight against Cancer started a colorectal cancer screening program by full colonoscopy for first-degree relatives of colorectal cancer patients in 1998 in the province of Latina, Lazio Region, Italy. The program was expanded to the provinces of Rieti, Lazio Region, and Sassari, Sardinia Region, in 2014 and 2016 respectively, and was concluded in 2018. Subjects were actively and voluntarily recruited by the study's working group. Subjects that had already been subjected to a full colonoscopy in the preceding 5 years were excluded from this study. Identified neoplastic lesions were treated either directly or referred to the Day Hospital setting, and histologically diagnosed following World Health Organization guidelines.

Results

In total, 2,288 subjects (age range 15-88, mean 52.3 yrs, M/F = 946/1,204) were screened by colonoscopy, of which 103 (4.5%) were incomplete and 2,173 (95.0%) complete, with data on colonoscopy performance missing for 12 participants. Out of 468 positive outcomes on colonoscopy, diagnosis for 422 (204M/173F), 19.4% of total subjects, was adenomatous polyps and 46 (20M/20F), 2.1% of total subjects, was colorectal cancer. Female sex was a protective factor against a positive test outcome, with a 35% reduction compared to male sex, with OR=0.64 95%CI (0.52-0.80). On the other hand, being over 50 years of age was found to be a risk factor, making a positive outcome more than twice as likely, with OR=2.3 95%CI (1.8-2.9). Subjects over 50 also had significantly more instances of multiple adenomas being found, however the size distribution of found adenomas was not significantly different between subjects under and over 50, despite size being a predictor of risk of neoplastic progression.

Conclusions

Given the high detection rate of precancerous lesions and colorectal cancer in the studied population, it is our opinion that guidelines should continue to recommend earlier and more frequent screening in first-degree relatives of patients with colorectal cancer, and, barring the introduction of more cost-effective and/or lower risk procedures with a similar efficacy profile, maintain the use of colonoscopy as the main screening option.

Ultrasonographic detection and assessment of the severity of Crohn's disease recurrence after ileal resection

BACKGROUND

Recurrence and severity of Crohn's disease mucosal lesions after "curative" ileal resection is assessed at endoscopy. Intramural lesions can be detected as increased wall thickness at Small Intestine Contrast Ultrasonography (SICUS).

AIMS

To assess after ileal resection whether: 1) SICUS detects recurrence of Crohn's disease lesions, 2) the intestinal wall thickness measured at the level of ileo-colonic anastomosis predicts the severity of endoscopic lesions, 3) the extension of intramural lesions of the neo-terminal ileum is useful for grading severity of the recurrence, 4) the combined measures of wall thickness of the ileo-colonic anastomosis and of the extension of intramural lesions at level of the neo-terminal ileum may predict the endoscopic Rutgeerts score

METHODS

Fifty eight Crohn's disease patients (M 37, age range 19-75 yrs) were prospectively submitted at 6-12 months intervals after surgery to endoscopy and SICUS for a total of 111 observations.

RESULTS

Six months or more after surgery wall thickness of ileo-colonic anastomosis > 3.5 mm identified 100% of patients with endoscopic lesions (p < 0.0001). ROC curve analysis, combining wall thickness of ileo-colonic anastomosis and the extension of intramural lesions of neo-terminal ileum, discriminated (0.95) patients with, from those without, endoscopic lesions. Performing two multiple logistic regression analyses only wall thickness of ileo-colonic anastomosis and extension of neo-terminal ileum intramural lesions were significantly associated with absence or presence of endoscopic lesions. An ordinal polychotomus logistic model, considering all investigated variables, confirmed that only SICUS variables were associated with endoscopic grading of severity.

CONCLUSIONS

In patients submitted to ileal resection for Crohn's disease non-invasive Small Intestine Contrast Ultrasonography 1) by assessing thickness of ileo-colonic anastomosis accurately detects initial, minimal Crohn's disease recurrence, and 2) by assessing both thickness of ileo-colonic anastomosis and extension of intramural lesions of neo-terminal ileum grades the severity of the post-surgical recurrence.

Prevalence of intestinal metaplasia in the distal esophagus in patients endoscopically suspected for short Barrett's esophagus

The clinical importance of Barrett's esophagus is related to its correlation to adenocarcinoma. The diagnosis is based on histologic demonstration of specialized intestinal metaplasia in the distal esophagus. The aim of this study was to assess the prevalence of intestinal metaplasia of the distal esophagus in a population submitted to gastroscopy not selected for reflux disease, and with columnar lined distal esophagus between 0.5 and 2 cm. Four biopsies in the distal esophagus were done in 224 patients undergoing routine gastroscopy. Patients were not selected for gastroesophageal reflux. Other clinical parameters were recorded to assess any possible association. In four Centers 224 patients received endoscopy with biopsies demonstrating specialized intestinal metaplasia in 21% of cases. No association was present among the patients with esophagitis or hiatal hernia, as well as with reflux symptoms. A significant association was present in over 70 (females), as well as with the presence of antral intestinal metaplasia demonstrated in 45 patients by gastric biopsies. No other significant associations were present. Biopsy samplings can diagnose the presence of intestinal metaplasia during endoscopy in patients endoscopically suspected for Barrett's esophagus: at present there is not clear evidence to promote this screening to achieve mortality reduction of esophageal adenocarcinoma.

Hydropneumatic anal dilation in conservative treatment of chronic anal fissure: clinical outcomes and randomized comparison with topical nitroglycerin

BACKGROUND

The surgical approach in chronic anal fissures (CAF) may, occasionally result in anal incontinence. The aim of this investigation was to study feasibility, effectiveness, and safety of hydropneumatic anal dilation (HAD) in conservative treatment of CAF and to compare it with local nitroglycerin (GTN) treatment.

METHODS

Efficacy of HAD was evaluated in 109 patients (65 male, 44 female; mean age, 53.3 years), following anal dilation using Microvasive Rigiflex instrument (Otw 40 mm). Thereafter, 36 patients were randomly divided into two groups to undergo treatment with 0.25% GTN or HAD.

RESULTS

Recovery rate with HAD was 79.8% after 10 days and 94.5% after 30 days. An immediate (within 24 hours) drop was observed in the level of pain; no significant complications or recurrence were reported within 2 years. Healing rate was 94.5% following HAD vs. 38.9% after GTN.

CONCLUSION

HAD should be considered a new safe option in CAF treatment.

Prevalence and incidence of hepatitis B virus, hepatitis C virus and human immunodeficiency virus among personnel and patients of a psychiatric hospital

In 1989 and 1992, HIV, HBV and HCV serosurveys were carried out among personnel and patients of an Italian Psychiatric Hospital. No HIV cases were found. Mean annual HBV seroconversion rate was 0.99% in patients and 4.4% in personnel; HCV rate was 0.42% among patients. Although the nosocomial risk of bloodborne infection was low, efforts should be made to minimize it.

Perendoscopic manometry of the distal ileum and ileocecal junction: technique, normal patterns, and comparison with transileostomy manometry

The technique of perendoscopic manometry was used to study the motor patterns of the ileocecal junction and distal ileum. An expert endoscopist cannulated the distal ileum of 20 unsedated subjects in 260 +/- 252 (mean +/- SD) seconds, causing no discomfort beyond that of an ordinary colonoscopic examination. No sphincter-like motor activity was detected at the ileocecal junction, and four distinct motility patterns were identified in the distal ileum: (1) tone variations, (2) slow phasic contractions, (3) regular rapid phasic contractions, and (4) prolonged rapid phasic contractions. Previous appendectomy and insertion of the colonoscope into the distal ileum to position the manometric catheter did not affect the manometric recordings. Perendoscopic manometry of the distal ileum was compared with transileostomy manometry in 9 subjects. Perendoscopic and transileostomy manometric recordings showed the same motor patterns except for a longer occurrence of tone variations with perendoscopic manometry. In conclusion, this study shows that perendoscopic manometry of the distal ileum and ileocecal junction is feasible; recorded motor patterns are not affected.

Perendoscopic manometry of the distal ileum and ileocecal junction in humans

Previous manometric studies of the ileocolonic junction were performed without assessing the precise spatial relationship between recording sensors and ileocolonic junction. In the present study, the motor activity of the ileocolonic junction was recorded using manometric sensors localized under direct colonoscopic control in 11 patients (4 men, 7 women; mean age, 55 years) referred for hematochezia with normal stool frequency. No medications were administered before and during endoscopy. A perfused catheter (OD 1.7 mm, with three side holes 4 mm apart and marked by evenly spaced black rings in the distal 6 cm) was passed through the biopsy channel of the endoscope and advanced through the ileocolonic junction and 6 cm into the ileum. The catheter was then withdrawn into the cecum by 1-cm steps, and motor activity was recorded for 4-6 minutes at each station. A single catheter taped to the endoscope continuously recorded cecal pressure. An ileocecal pressure gradient could not be identified in the majority of subjects; individual values ranged from -8 to +4 mm Hg, and gradients were maintained over the entire length of the ileum. In the distal ileum, tonic and phasic pressure waves were detected. Tonic variations were present for 70.1% of the recording time, either alone (44%) or together with phasic waves (56%). Phasic waves were present for 10.3% of the recording time and, according to their duration, were subdivided into those compatible with the rate of ileal slow waves and prolonged waves not compatible with the rate of ileal slow waves. Regular phasic waves could be either isolated or in clusters; prolonged waves were always isolated. A similar proportion of regular (27.9%) and prolonged (31.2%) phasic waves propagated aborally along the ileum or from ileum to cecum. Clusters presented an average of 8.7 +/- 0.6 peaks/min, and 44% of them propagated aborally. The manometric characteristics did not vary between the segments 5-3 cm and 2-0 cm proximal to the ileocecal junction. In conclusion, a powerful ileocecal sphincter was not detected at the human ileocecal junction, and motor activity of the distal ileum was characterized by tonic changes and rapid phasic contractions.

Liver enzyme abnormalities in subacute thyroiditis

In a retrospective study of liver function tests in subacute thyroiditis, 13 out of 22 patients with the disease demonstrated an elevation of alkaline phosphatase level. Less prevalent abnormalities were elevations in gamma-glutamyl transpeptidase (5 pts), alanine (4 pts) and aspartate (3 pts) aminotransferase activities. These enzyme alterations were not correlated with thyroid hormone levels, concomitant diseases, drugs or alcoholic intake, and normalized in six patients followed until recovery. A benign, short-lived and subclinical hepatic involvement is common in subacute thyroiditis.

[Treatment of hypophyseal prolactin-secreting macroadenomas]

We investigated a group of 26 patients with prolactin-secreting pituitary macroadenomas. Seventeen underwent neurosurgical operation alone, nine were also submitted to medical therapy with bromocriptine 7.5 mg/day, immediately after the operation. Patients presented similar clinical and biological characteristics. Fourteen patients without medical therapy showed a persistent hyperprolactinemia and the tumor recurred in 8 of these 17 patients. Of the 9 patients receiving medical and surgical therapy, only 1 presented persistent hyperlactinemia and none relapsed. Our results suggest that combined sequential surgical and medical therapy may be useful in the management of patients with prolactin-secreting pituitary macroadenomas.