[Incidence of colorectal carcinoma and patient survival in the Grand-Duchy of Luxembourg]

As in many other Western countries, colorectal cancer is one of the most common malignant tumours in Luxembourg. It is thus an important target for prevention measures. In light of the discussions on the introduction of organized screening programmes in Luxembourg a description of the current cancer incidence and relative survival rates, as well as a comparison with neighbouring countries are important. The tumour incidence is comparable to that in other countries with similar socio-economic development. The standardized incidence rate (world population) in 2010 was 26.4 and 44.4 per 100,000 for women and men, respectively. In some, but not all, Western European countries, a decreasing trend of the standardized incidence is emerging. No such trend is currently observed in Luxembourg. The mortality and relative survival rates are comparable to those in other European countries. The proportion of colorectal carcinomas of stages T1 + T2, 18.7% in the years 2000 to 2011, is markedly lower in Luxembourg than for example in Rhineland -Palatinate (29.4%), while the proportion of carcinomas of stage T4 is higher (17.4% versus 13.9%). This suggests that further successes in prevention are possible and illustrates the benefits of an organized screening colonoscopy program compared with opportunistic screening.

Evolution of colorectal cancer epidemiology in a setting of opportunistic screening. A 20 year national survey in Luxembourg

Invasive colorectal cancer (CRC) is the second leading cause of cancer death in Luxembourg. There is no organized screening programme in Luxembourg. This study aims to obtain a precise epidemiological description of the evolution of invasive CRC and high grade intraepithelial neoplasia (HGIEN) from 1990 to 2009, extracted from the database of the Morphologic Tumor Registry. Tumor stages and observed survival rates were also recorded. They were compared to the change in use of colonoscopic procedures. During the 20-year period, 4810 invasive CRC cases and 1180 HGIEN were recorded. Incidence rose from 1990 to 2005 and declined thereafter, especially in women. A sharp rise in HGIEN was noted from 2004 onwards, paralleling the rates of colonoscopies. 76% of CRC cases were found in advanced stages pT3 and pT4. The pT stage distribution did not change over the observation period. Observed survival rates improved during the study period.

CONCLUSION

Under opportunistic screening conditions, mainly through colonoscopy, the incidence of CRC was declinig in recent years, whereas HGIEN incidence is rising in Luxembourg. Tumor pT staging remained unchanged whereas survival rates improved. We conclude that opportunistic screening is of little benefit for CRC prevention. A national organized screening programme is warranted.

[Prostate cancer in Luxembourg from 1982 to 2006. Incidence and mortality. Survival of a hospital cohort]

Prostate cancer incidence has tripled in Luxembourg as in many other western countries. From 1982 to 2006, new cases increased from 80 to 309 per year, while the incidence (world stand.pop.) rose from 29.5 to 85 per 100 000 men. Since 1991 prostate cancer is the most frequent male cancer in Luxembourg, exceeding colo-rectal, lung and stomach cancer. Prostate cancer deaths have diminished from 64 in 1982 to 45 in 2006. This represents less than 10% of male cancer related deaths; it represents the third most frequent cancer death, behind lung and colo-rectal cancers. Annual mortality rate has decreased from 29 to 10 per 100 000 men during the same period, this difference between incidence and mortality is explained on the one hand by the widespread use of PSA since the 1990's and on the other hand by a better local control as well as a multidisciplinary approach of advanced disease. The increase of the incidence is particularly important in the 60 to 70 age group, while for men older than 70, the peak incidence was reached in 2002. A lowering of the age at diagnosis is confirmed by the 5-year age group analysis. The hospital cohort consists of 628 patients from the urological department of the Centre Hospitalier de Luxembourg diagnosed with prostate cancer between 1st January 1982 and 31st December 2006; follow-up ended 31st December 2011. During this period, age at diagnosis decreased from 71.5 to 68.9 years whereas the proportion of localized clinical stages increased from 44 to 70%. Median PSA dropped from 14.5 to 9 ng/ml. Furthermore the analysis of cancer specific mortality confirms the negative effects of an advanced clinical stage (10-year survival: 90% for localized disease, 60% for advanced disease) or a high PSA level at diagnosis (10-year survival: 97% if PSA < 4 ng/nl, 94% if 4 < PSA < 10, and 72% if PSA > 10 ng/ml), as well as a poor differentiation (60% 10-year survival compared to 90% for differentiated tumors). Kaplan-Meier curves show that long term surveillance is necessary as even tumors with a good initial prognosis may relapse after 10-12 years.

Oesophageal intraepithelial and invasive neoplasia of squamous cell type: epidemiology and outcome in Luxembourg, 1980-2001

BACKGROUND AND STUDY AIMS

Oesophageal intraepithelial neoplasia of squamous cell type (INSC) and invasive oesophageal squamous cell carcinoma (IOSCC) are infrequent diseases in Western Europe. The aim of the present study was to collect population-based data of both entities over a 20 year-period and to look for concomitant neoplastic affections in order to define an adequate diagnostic strategy.

PATIENTS AND METHODS

The National Morphologic Tumour Registry allowed to review the data of all patients with INSC and IOSCC diagnosed between 1980 and 2001 and to record the time trends in incidence, the oncologic co-morbidity and the outcome of the patients.

RESULTS

29 patients with INSC and 363 cases of IOSCC were identified. The overall age-standardized (world) incidence rate of intraepithelial neoplasia and invasive squamous cell carcinoma were 0.2 and 4.2 per 10(5), respectively, the M/F-ratio for both 3:1. During the study period, the incidence rate of invasive cancer remained stable in males but showed a 3-fold increase in females. There was a 2-fold increase of the intraepithelial neoplasia incidence in the last decade. The precancerous/cancerous-ratio increased slightly over the last 5 years. 31% of the patients with an INSC and 17.6% of those with IOSCC had concomitant precancerous and cancerous lesions especially of head and neck (laryngopharyngeal) or pulmonary origin. The observed 5-year survival rate was 8.8 +/- 3% (95% confidence interval) for IOSCC and 27.6% +/- 17% for INSC.

CONCLUSIONS

The incidence of invasive oesophageal squamous cell carcinomas remains stable whereas that of detected intraepithelial squamous cell neoplasias is remarkably low, indicating potential underdiagnosis. Considering the overall low incidence rates, mass screening for oesophageal cancer does not seem reasonable in Luxembourg. Nevertheless, patients at high-risk for oesophageal or head and neck or broncho-pulmonary cancer should be identified and surveilled by endoscopy, possibly with vital staining.

Cervical screening in Luxembourg: 1990-1999

For quality assurance purposes, the results of the 1990's obtained by the National Cervical Cancer Screening Programme (NCCSP) launched in 1962 were reviewed. The positive cytodiagnosis, the histologically verified in situ and invasive cervical cancers and the mortality rates were reported.

Atypical squamous cells of undetermined significance: audit and the impact of potential litigation. Retrospective review of 682 cases

For quality assurance purposes, the frequency of 'abnormal' cytological diagnoses of the non-systematic National Cervical Cancer Screening Programme (NCCSP) was evaluated. In 1999, an unexpected high number of Class (Cl) III cases (i.e. atypical squamous cells of undetermined significance) was reported. The cytological and histological results were reviewed in order to detect a possible cause for this threefold increase. The abnormal Papanicolaou (PAP) smears examined by conventional methods from 1 January 1990 to 31 December 2002 were analysed. The smears of 682 cases diagnosed in 1999 with a Cl III category were reviewed in 2000 and correlated with the available histological diagnoses provided by the Central Department of Pathology. Of the 682 Cl III cases, 176 cases (26.1%) had no follow-up, 314 cases (46.0%) had repeat cytology and 192 cases (28.2%) an histological correlate corresponding to 90 (46.9%) benign lesions, 78 (40.6%) squamous intraepithelial lesions, two (1%) invasive cervical cancers (one squamous and one glandular). Twenty-two Cl III cases (11.5%) were histologically within normal limits. Retrospective smear review confirmed 330 Cl III diagnoses (48.3%), 127 cases (18.6%) were recategorized as Cl IIIG (i.e. atypical glandular cells of undetermined significance), 22 cases (3.2%) as Cl IIID (i.e. mild to moderate dysplasia) and six cases (0.9%) as Cl IVa (i.e. severe dysplasia and/or carcinoma in situ). A total of 197 original Cl III cases had to be reclassified in the Cl II category (28.9%), only two cases showing mild and moderate dysplasia on histology. Thus, 195 cases (28.6%) comprised cytological overdiagnoses. The Cl III category being, by definition, a delicate and often subjective diagnosis, all external influences such as pressure of litigation should be avoided to reduce cytological overdiagnoses as a result of an unnecessary 'fear-factor'.

Consequences of a National Mammography Screening Program on diagnostic procedures and tumor sizes in breast cancer. A retrospective study of 1540 cases diagnosed and histologically confirmed between 1995 and 1997

In 1992, a national screening mammography program, including female patients between 50 and 64 years of age, was launched in Luxembourg. The effects of this campaign on the different diagnostic procedures, especially fine needle aspirations (FNA), large core needle biopsies (LCNB), and surgical specimens, were analyzed. From 1983 to 1997, the National Cancer Registry recorded 3167 new cases of invasive female breast cancer, all histologically diagnosed in one central pathology department. In 1996, the population consisted of 418,300 inhabitants (212,900 females). The number of breast cancer, tumor size, the nature of the diagnostic procedures, their diagnostic value as well as the number of physicians, "aspirators", and "biopsists" were evaluated. Between 1992 and 1994, the incidence of invasive breast cancers increased, concomitant with the launching of a National Screening Mammography Program. The diagnosis of in situ cancers tripled, and the mean size of invasive breast cancer decreased from 2.1-2.4 cm to 1.1-1.4 cm. Since 1994, the number of FNA had remained stable, LCNB had increased by 417.5%, and surgical biopsies had decreased by 18.95%. Between 1995 and 1997, 28.37% of 1075 FNA, and only 9.6% of 465 LCNB yielded inadequate samples. FNA were done by 77 different doctors (53.25% being gynecologists) and LCNB by 34 (52.94% being radiologists). The first diagnoses of all invasive cancers (n = 790) were made by using frozen sections from surgical specimens in 58.35% (n = 461), LCNB in 18.23% (n = 144), mastectomy in 10.13% (n = 80), formalin-fixed biopsies in 9.49% (n = 75), and FNA in 3.17% (n = 25). There are beneficial effects (increase in the number of diagnoses of in situ cancer; decrease in tumor sizes) not only for the "target" age group (50-64 years), but also for all female age groups (> 15 years). For quality assurance purposes, it is absolutely recommended to carry out pathological, radiological, and diagnostic work in specialized centers.

Accuracy of frozen section diagnoses of breast lesions after introduction of a national programme in mammographic screening

AIMS

By introducing mammography screening programmes, the size of the detected breast lesions became smaller and the histopathological interpretation problems greater. The study's aim was to analyse the risks and possible limitations of the frozen section method.

METHODS AND RESULTS

Frozen section consultations of breast lesions (n=559) 2 years before and 6 years after launching a national mammographic screening programme in 1992 were evaluated in regard of the benign/malignant ratio, tumour size, preoperative frozen section results and final permanent section diagnoses. The breast frozen section examinations of 1990 compared with those from 1998 declined from 70.7% (299/423) to 62.2% (260/418) (P < 0.01), the benign/malignant ratio from 1.09 to 0.54 (P < 0.0001), the rate of the conclusive, correct frozen section diagnoses from 96.3% to 91.9% (P < 0.03). The sensitivity dropped from 92.3% to 87.6%, the negative predictive value from 95.7% to 88.3%, whereas the negative likelihood ratio rose from 0.08 to 0.12. The 'small' (< or = 10 mm) invasive breast carcinomas increased from 14.2% to 22.3% (P < 0.01) and the 'in situ' carcinomas from 2.1% to 6.6% (P < 0.05).

CONCLUSIONS

The declining sizes of breast tumours (< or = 10 mm), especially from radiologically detected lesions and sometimes without a macroscopic correlate, create new limitations and changing indications in the histopathological interpretation. Considering the performance of new diagnostic methods (i.e. large core needle biopsies), frozen sections of surgical specimens should not be the primary diagnostic procedure for breast lesions and should be performed only after other preoperative methods have failed.

Cervical cancer screening in Luxembourg

In 1962, a programme for early detection of cervical cancer was established at the national level. The programme is based on the collaboration of different groups of doctors and not on a system of sending out invitations to every woman. This programme was re-adapted twice according to the needs for assuring quality in a system of mainly liberal medicine. At present the programme is 'institutionalised' and is carried out according to the criteria defined in 1990. This includes a centralisation of the smear readings and handing out the material needed to take the smears. The contribution of the doctors is regulated by a system of bonuses given by the government and a reimbursement by the Health Fund. The annual cervical smear is free of charge for every woman. The participation of the women targeted by the programme (>15 years old) has increased by approximately 50% every decade from the early 1970s increasing from 10950 in 1972 to 70441 in 1999. Between 1980 and 1999, the number of women at risk taking part in the programme increased from 10.80 to 38.92%. The number of all the doctors taking smear samples increased from 68 to 105 and the number of gynaecologists increased from 19 (ratio Gyn/GP (gynaecologists/General Practitioners) of 28%) to 52 (ratio Gyn/GP of 50%). The mortality rate has decreased continuously from 6. 1/100000 in 1990 to 0.9/100000 in 1997. In conclusion, to be successful, a cervical cancer screening programme should be flexible enough to allow short-term adaptations to unexpected local situations and needs a highly motivated team of the different participants involved in the regional and national health policy.

Breast cancer screening pathology: an assessment of the practise and needs in Belgium and Luxembourg

Education and quality assurance (QA) in breast screening pathology have been encouraged by the Europe Against Cancer programme. As a prerequisite for the set-up of a QA programme in Belgium and in the Grand Duchy of Luxembourg, an inquiry was initiated to evaluate the daily practise in breast pathology, the modalities in handling and analysing breast specimens and the willingness of the pathologists to participate in a QA scheme. Of the 278 mailed questionnaires, 109 confidential and valid questionnaires were returned, meaning a participation rate of 40%. All 109 respondents indicated their willingness to voluntarily participate in the further QA programme. Segmental resections for conservative surgery and excision biopsies ranked first and second, respectively, in examination requests. Of the respondents, 50% complained about the lack of clinical information on the pathology request form. A multidisciplinary team approach for the diagnosis of screen-detected lesions was deemed desirable by 87% of the respondents, but only 16% of them actually participate in such pre-operative meetings. Even more puzzling is that 75% of the respondents report regular unavailability of the control radiogram of the surgical specimen removed for non-palpable lesions. One-quarter to one-third of the pathologists still regularly perform frozen sections on microcalcifications or tumours smaller than 1 cm. However, 81% of the respondents estimate that pre-operative diagnosis is not appropriate for this type of lesion. The results of this inquiry show that the guidelines for the diagnosis of screen-detected breast lesions are not yet fully applied in daily practise. The development of local comprehensive breast teams involving a pathologist should improve the co-ordination between the medical disciplines, represent an important way of disseminating the guidelines on breast screening pathology and stimulate the relay unit to conduct QA programmes.

Colorectal high-grade adenomas: incidence, localization and adenoma-adenocarcinoma ratio in a retrospective and comparative population-based study of 225 consecutive cases between 1988 and 1996

Colorectal high-grade adenomas can be regarded as precancerous lesions. This study collected epidemiological data from a defined region (Luxembourg) that can serve as reference data for designing a national screening program for early colorectal cancer detection. Nine pathologists diagnosed and reviewed slides retrospectively from 288 new colorectal and anal in situ carcinomas from the period 1988-1996 (63 were excluded for various reasons). In all, 225 new colorectal high-grade adenomas were considered. There were 129 men (57%) and 96 women (42%), and 78% of patients were aged over 60 years. Over this period we found an increase in incidence of high-grade colorectal adenomas (11 cases in 1988, 40 cases in 1996) for both sexes. The overall incidence rate was 2.9 x 100,000 in 1988 and 9.6 x 100,000 in 1996. The average annual age-standardized incidence rate for this period was 3.7+/-0.5 (95% confidence interval); the cumulative rate (0-74 years) was 0.4%. Three-fourths of the adenomas were situated in the rectum (n=78, 35%) or sigmoid colon (n=92, 41%). Histological diagnosis was provided by 160 total polypectomy specimens (71%), 30 surgical resections (13.3%), and 35 biopsy specimens (16%). Over the study period there was an increased incidence of new colorectal adenocarcinomas. There were eight times as many adenocarcinomas (n=1782) as adenomas (n=225); the distribution of anatomical sites was comparable. These epidemiological data on 225 new colorectal high-grade adenomas can be the basis for quality assurance in clinical and histological diagnostic procedures, especially in regard to the 1:8 ratio between high-grade adenomas and invasive adenocarcinomas and may provide additional data for the design of a regional or national colorectal cancer screening program.

[Prostatic cancer in the Grand Duchy of Luxembourg. Role of PSA]

We reviewed the trends in prostate cancer incidence and mortality in Luxembourg between 1983 and 1995 to discuss the importance of total and free PSA in early detection. The study was performed on all the new cases recorded by the National Cancer Registry (Registre Morphologique des Tumeurs). Total and free PSA were measured with the automated Immulite System (DPC, Los Angeles) using a chemoluminescent immunometric assay. The performance of free-to-total serum PSA was analysed by a hospital based study of 113 patients (55 PC, 58 BPH). The age standardized incidence rate increased from 29.3/100,000 in 1983 to 71.5/100,000 in 1995. Mortality rates only changed slightly. The widespread use of PSA testing from 1988 on is probably the main cause of this incidental increase; however no major changes in the age-specific-incidence have been found suggesting the absence of a systematic screening policy by the PSA. The superiority of free-to-total serum PSA ratio in discriminating between cancer and benign condition was confirmed. Early health-conscious man over 50 should be proposed prostate cancer screening by digital rectal examination and PSA. However a systematic screening policy cannot been recommended since a benefit in survival after early treatment has not yet been proven.

[Tubular differentiated stomach carcinoma of the (Ming) infiltrating type]

Gastric carcinoma of the infiltrative type (according to Ming) occasionally shows adenomatous differentiation only. Over the past 18 years, we have observed 23 cases of this tumour type, accounting for 3.6% of all surgically treated gastric carcinomas. Macroscopically they were classified as Borrmann IV or III, while histologically most of them were well differentiated. Histologically, these tumours retained the pre-existing structures of the stomach, most readily observable at the tunica muscularis propria; a pronounced desmoplasia was also characteristic, particularly in the submucosal and subserosal layers. In all cases the tumour tissue spread inside lymphatic vessels. All but 2 cases with metastatically involved lymph nodes, often small, showed infiltration of the lymph node sinus; in three quarters of cases the serosa was infiltrated by the tumour. Significant findings among the patients under observation for extended periods included bilateral ovarian metastases in 4 of 5 women examined and tumour recurrence at the anastomosis in 6 of 9 patients in whom Billroth II operation had been performed. The mean survival time of 16 patients was 14.9 months. Owing to the diffuse type of tumour growth, extensive surgery is recommended as in cases of signet ring cell cancer. The high incidence of small lymph node metastases from this type of tumour should also be taken in account preoperative staging. Preoperative diagnosis of this tumour subtype is difficult, because histological criteria alone do not allow clear identification. Close cooperation with clinical investigators is necessary, and intraoperative assessment of the tumour--including frozen section of necessary--in particular is of the utmost importance.

[Inflammatory granulation tissue polyp of the submandibular gland]

Case report on a pedunculated granulation tissue formation in a duct of the salivary gland with consecutive obstructive sialadenitis, clinically imposing as submandibular tumour. The morphologically particular and rare form of such a repair process in a salivary gland can be explained by the continuous chronic irritation of a foreign body. The significance of such a benign lesion is primarily given by clinical differential diagnosis to a tumorous process, where the histological verification permits the exclusion of a tumour.

Radiation induced osteosarcoma of the sacrum following radiation of an undiagnosed bone lesion

Years ago a 20-year-old patient presented with low back pain. Radiologically a cystic lesion of the sacrum was found and interpreted as malignant tumor. Without biopsy and histological diagnosis the patient was given radiation therapy with 21 000 rad. One year later a similar lesion was radiated in the left femoral neck. A pathological fracture ensued recessitating several operations. Twenty years after initial radiation therapy the patient developed a rapidly growing tumor of the sacrum, metastasizing to the lungs. One year later he died.