The Impact of potential 'confounders' on the diagnostic sensitivity of circulating free DNA in management of FIT+ patients: a pilot study

Cell-free DNA (cfDNA) has long been established as a useful diagnostic and prognostic tool in a variety of clinical settings, ranging from infectious to cardiovascular and neoplastic diseases. However, non-neoplastic diseases can act as confounders impacting on the amount of cfDNA shed in bloodstream and on technical feasibility of tumour derived free circulating nucleic acids selecting patients with cancer. Here, we investigated the potential impact of other pathological processes in the clinical stratification of 637 FIT+ patients. A single and multiple logistic regression yielded similar results. Crude sensitivity was 75.9% versus adjusted sensitivity of 74.1%, relative risk 0.9761 (0.8516 to 1.1188), risk difference 0.0181 (-0.0835 to 0.1199) and OR 0.9079 (0.5264 to 1.5658). Potential confounding effect from other source of cfDNA plays a pivotal role in the clinical stratification of FIT+ patients.

The Association of Metabolic Risk Factors with Advanced Adenomas in Hispanic Patients

BACKGROUND

Obesity and metabolic syndrome (MetS) have been implicated as rising risk factors for the development of colorectal cancers. A rapid increase in the prevalence of obesity and severe obesity among Hispanic patients in the United States may present substantially increased risk for advanced colorectal neoplasia in this population. Currently, there is very little research in this area.

AIMS

We sought to identify metabolic risk factors for advanced adenomas (AA) in Hispanic Americans.

METHODS

We retrospectively reviewed data from the Los Angeles General (LAG) Medical Center of asymptomatic Hispanic patients above 45 years of age who underwent their first colonoscopies following a positive screening FBT. Patient demographics, metabolic characteristics, as well as colon polyp size and histology were recorded. Polyps were classified as adenomas or AA (including both high-risk adenomas and high-risk serrated polyps). Relative risk for AA was assessed by multivariate logistical regression analyses.

RESULTS

Of the 672 patients in our study, 41.4% were male, 67% had adenomas, and 16% had AA. The mean BMI was 31.2 kg/m2. The mean HDL-C was 49.5 mg/dL (1.28 mmol/L) and the mean triglyceride level was 151 mg/dL. 44.6% had diabetes and 64.1% had hypertension. When comparing patients with AA to patients with no adenoma, male sex, BMI > 34.9 kg/m2, and elevated fasting triglyceride levels were associated with an increased risk of AA. FIB-4 ≥1.45 was also associated with an increased risk of AA in males. There was no significant difference in the risk of AA with diabetes, hypertension, FIB-4 score, LDL-C level, and HDL-C level.

CONCLUSIONS

Hispanic patients with a positive FBT were observed to have a high incidence of AA. Class II obesity (BMI ≥ 35 kg/m2), elevated triglyceride levels were identified as risk factors among males in our study. Early interventions to address these modifiable risk factors in at-risk populations, such as multi-disciplinary weight management programs for the treatment of obesity and related co-morbidities, could potentially lead to risk reduction and CRC prevention.

Emerging and under-recognised patterns of colorectal carcinoma morphologies: a comprehensive review

While the overwhelming majority of colorectal carcinomas (CRC) are diagnosed as adenocarcinoma not otherwise specified, there are numerous under-recognised morphologic patterns of CRC. These patterns are recognised by the WHO, appear in reporting manuals for the American Joint Committee of Cancer, and/or are listed on synoptic reports, while many other variants have either fallen out of favour or are emerging as future bona fide patterns. Herein, we discuss 13 variants: serrated adenocarcinoma, micropapillary adenocarcinoma, medullary carcinoma, neuroendocrine carcinoma, mucinous adenocarcinoma, signet-ring cell carcinoma, adenosquamous carcinoma, adenoma-like adenocarcinoma, lymphoglandular complex-like CRC, carcinoma with sarcomatoid components, cribriform-comedo-type adenocarcinoma, undifferentiated carcinoma and low-grade tubuloglandular adenocarcinoma. The purpose of this review is to scrutinise these variants by assessing their clinical characteristics, morphologic cues, as well as pitfalls, and address their prognostic significance. Our analysis aims to bring clarity and updated understanding to these variants, offering valuable insights for pathologists. This contributes to more nuanced CRC diagnosis and treatment strategies, highlighting the importance of recognising a broad spectrum of morphologic patterns in CRC.

Uterine transposition for fertility preservation in pelvic cancers

OBJECTIVE

To review rates of uterine preservation and gonadal function, surgical outcomes, and pregnancy outcomes in patients undergoing surgical uterine transposition.

METHODS

A structured search and analysis of the published literature on uterine transposition was conducted. Information on study type, sample size, patient characteristics, clinical indications, details of the surgical technique, trans-operative and post-operative results, success rates in preserving reproductive organ function and fertility were extracted.

RESULTS

A total of 18 cases were reported to date. Patients' median age was 29 (range 3-38) years. Rectal cancers accounted for 9 (50%) cases of published cases of uterine transposition, followed by 6 (33%) cervical squamous cell carcinomas, 1 (6%) vaginal squamous cell carcinoma, 1 (6%) sacral yolk sac tumor, and 1 (6%) pelvic liposarcoma. The median time for uterine transposition to the upper abdomen was 150 (range 80-360) min, and 90 (range 80-310) min for organ reimplantation in the pelvis. Cervical ischemia occurred in 5 (27.8%) cases, being the most commonly reported complication. The median follow-up time was 25 months, and three patients achieved spontaneous pregnancies resulting in successful gestations, out of five patients who were reported as having tried. One patient experienced recurrence and succumbed to the tumor during treatment.

CONCLUSIONS

Uterine transposition is a feasible and safe surgical approach that offers patients undergoing pelvic radiotherapy an option to preserve gonadal and uterine function, with the potential for spontaneous pregnancy.

Incidental Ring-hyperenhancing Liver Micronodules at CT Hepatic Arteriography-guided Percutaneous Thermal Ablation of Colorectal Liver Metastases

CT during hepatic arteriography (CTHA) is a highly sensitive imaging method for detecting colorectal liver metastases (CLMs), which supports its use during percutaneous thermal liver ablation. In contrast to its high sensitivity, its specificity for incidental small CLMs not detected at preablation cross-sectional imaging is believed to be low given the absence of specific imaging signatures and the common presence of pseudolesions. In this retrospective study of 22 patients (mean age, 55 years ± 10.6 [SD]; 63.6% male, 36.4% female) with CLMs undergoing CTHA-guided microwave percutaneous thermal ablation between November 2017 and October 2022, the authors provided a definition of incidental ring-hyperenhancing liver micronodules (RHLMs) and investigated whether there is a correlation of RHLMs with histologic analysis or intrahepatic tumor progression at imaging follow-up after applying a biomechanical deformable image registration method. The analysis revealed 25 incidental RHLMs in 41.7% (10 of 24) of the CTHA images from the respective guided ablation sessions. Of those, four RHLMs were ablated. Among the remaining 21 RHLMs, 71.4% (15 of 21) were confirmed to be CLM with either histology (n = 3) or imaging follow-up (n = 12). The remaining 28.6% (six of 21) of RHLMs were not observed at follow-up imaging. This suggests that RHLMs at CTHA may be an early indicator of incidental small CLMs. Keywords: Colorectal Neoplasms, Liver, Angiography, CT, Incidental Findings, Ablation Supplemental material is available for this article. © RSNA, 2024.

Postoperative surveillance after surgery for colorectal liver metastasis: a cross-sectional study

INTRODUCTION

Colorectal liver metastases (CRLM) are associated with a high recurrence rate after surgery. There is paucity of high-quality evidence regarding the nature and overall benefit of surveillance after hepatectomy for CRLM. As part of a broader programme of research, this study aimed to assess current strategies for surveillance after liver resection for CRLM and outline surgeons' opinions regarding the benefit of postoperative surveillance.

METHODS

An online survey was sent to clinicians performing surgery for CRLM at tertiary hepatobiliary centres in the UK.

RESULTS

There were responses from a total of 23 centres (88% response rate); 15/23 centres used standardised surveillance protocols for all patients. Most centres followed patients up at six months, but there is variation in postoperative surveillance at 3, 9, 18 and beyond 60 months. Patient comorbidities, indeterminate findings on imaging, margin status and assessment of recurrence risk were identified as the major factors influencing personalised surveillance strategies. There was clear clinician equipoise regarding the costs and benefits of surveillance.

CONCLUSION

There is heterogeneity in postoperative follow-up for CRLM in the UK. High-quality prospective studies and randomised trials are necessary to elucidate the value of postoperative surveillance and identify optimal follow-up strategies.

[Sister Mary Joseph Nodule from Colorectal Cancern]

N/a.

Uterine transposition for fertility and ovarian function preservation after radiotherapy

OBJECTIVE

To evaluate the feasibility of uterine transposition as a method of preserving fertility and ovarian function after pelvic radiation.

METHODS

This prospective multicenter observational study included patients with non-gynecologic pelvic cancers who underwent pelvic radiation as part of their cancer treatment between June 2017 and June 2019. For inclusion in the study, patients were required to have normal menstrual cycles and hormone levels (follicle-stimulating hormone, luteinizing hormone, and estrogen) before treatment. Uterine transposition to the upper abdomen was performed prior to irradiation. Clinical examinations and Doppler ultrasonography were used to evaluate the gonadal vasculature post-surgery. The uterus was repositioned into the pelvis 2-4 weeks after radiation therapy or at the time of rectosigmoid resection in patients with rectal cancer who had undergone neoadjuvant treatment. Cancer treatment and follow-up were performed according to standard guidelines.

RESULTS

Eight patients (seven with rectal cancer and one with pelvic liposarcoma) underwent uterine transposition at a median age of 30.5 years (range 19-37). The uterus was successfully preserved in six patients, accompanied by normal menses, hormonal levels, and vaginal intercourse after treatment. One patient with rectal cancer died of carcinomatosis 4 months after uterine transposition. One patient presented with uterine necrosis 4 days after uterine transposition, and the uterus was removed; however, one ovary was preserved. Cervical ischemia was the most common post-surgical complication in three (37.5%) patients. Three patients attempted to conceive, and two (66%) were spontaneously successful and delivered healthy babies at 36 and 38 weeks by cesarean section without complications.

CONCLUSIONS

Uterine transposition is a feasible procedure for preserving gonadal and uterine function in patients requiring pelvic radiotherapy for non-gynecological cancer, with the potential for achieving spontaneous pregnancy and successful delivery.

Clinical Epidemiological Studies of Colorectal Cancer by Record Linkage of Cancer Registries and Biospecimen Data: A Systematic Review

BACKGROUND

The incidence and prognosis of colorectal cancer are associated with lifestyle, family history, and genetic predisposition. Record linkage between cancer registries and biospecimen data would enable us to conduct clinical epidemiological studies on incidence or prognosis including genome information. In this study, we conducted a systematic review of clinical epidemiological studies of colorectal cancer using record linkage between cancer registries and biospecimen data and examined the possibilities for future use of this linkage.

METHODS

We searched PubMed and Google Scholar for articles regarding cancer registries and biospecimen data use published before December 2021. Selected articles were summarized by cancer registry use, biospecimen use, exposure, outcome, informed consent, and participant numbers by study design and type of cancer registry.

RESULTS

Of the 2,793 identified articles, 81 studies were included in this review. The most frequently used cancer registries and study design were site specific cancer registries and cohort studies. Most use of cancer registries was for patient selection in cohort studies and case selection in case-control studies. Most use of biospecimen data was for prognostic factors in cohort studies and risk factors in case-control studies. In site specific cancer registries for the examination of familial colorectal cancer, most use of biospecimen data is to examine genome mutation, expression, or deficiency.

CONCLUSION

We suggest that record linkage between cancer registries and biospecimen data would enable the accurate capture of outcomes and detailed genome-environmental factors, and to conduct clinical epidemiological studies according to specific research questions and tailored study designs.

The association between pro-vegetarian dietary pattern and risk of colorectal cancer: a matched case-control study

BACKGROUND

Few studies assess the link between plant-based diets and colorectal cancer (CRC) incidence. To our knowledge, no study has examined the association between pro-vegetarian dietary pattern (PDP) and CRC globally or among Iranians. Therefore, the objective of our matched case-control study was to evaluate the association between PDP and CRC in the Iranian population.

METHODS

The present research was a hospital-based case (n = 71)-control (n = 142) study conducted in the same hospitals in Tehran, Iran. This study used a reliable and valid semi-quantitative food frequency questionnaire to evaluate the participants' dietary intake. According to the residual method, the selected plant and animal foods have been adjusted in the total energy intake to calculate the PDP index. Odds ratios (ORs) and 95% confidence intervals (CIs) adjusted for confounding variables were also expressed using logistic regression by SPSS software.

RESULTS

In the crude and adjusted models, we observed that the odds of CRC decreased significantly in the 3rd and last quartile of PDP compared to the 1st quartile (Q) (Crude model: Q3: OR = 0.36, 95% CI: 0.17 - 0.79, P-value = 0.011 and Q4: OR = 0.33, 95% CI: 0.14 - 0.79, P-value = 0.012 - Adjusted model: Q3: OR = 0.41, 95% CI: 0.18 - 0.94, P-value = 0.035 and Q4: OR = 0.35, 95% CI: 0.14 - 0.87, P-value = 0.025).

CONCLUSIONS

Based on the results of the present case-control study in the Iranian population, it was concluded that PDP, which involves consuming vegetables, fruits, cereals, dairy products, and low meat consumption, reduces the odds of CRC. In conclusion, adherence to PDP is associated with a decreased odds of CRC.

Mutation Analysis of KRAS and BRAF in Iranian Colorectal Cancer patients: A Novel Variant in Exon 15 of BRAF

BACKGROUND

Mitogen-Activated Protein Kinase (MAPK) pathway and its downstream signaling pathways, play an important role in intracellular signaling. Mutations in KRAS (activating mutation) and BRAF proto-oncogenes are identified as key finding of colorectal cancer. The aim of this study was to examine mutation analysis of KRAS and BRAF in Iranian Colorectal cancer patients.

METHODS

We used fifty archived formalin fixed paraffin-embedded (FFPE) blocks of Iranian colorectal cancer patients. DNA was extracted from FFPE blocks for PCR assay. The quality of PCR products was determined using horizontal electrophoresis. Then, sequencing and analysis of the sequencing results were performed to investigate variation status in the sequences.

RESULTS

KRAS exons and BRAF genes exon 15 in 50 CRC patients were analyzed, among the 19 mutant KRAS samples, 18 (36%) patients had a single base substitution (synonymous mutation) in exon 5, p. Arg161Arg (c.483G>A) and 1 (2%) patient in exon 2 (codon 12), p. Gly12Cys (c.34G>T). Also, we observed two mutations p. Val600Glu (c.1799 T>A) and p. Ser616Thr (c.1846T>A) in exon 15 of BRAF gene.

CONCLUSIONS

We found a novel variant in BRAF gene. The p. Ser616Thr (c.1846T>A) mutation was not previously reported and we conclude that other new mutations can be identified in KRAS and BRAF which may lead to colorectal cancer.

Highlighting functions of apoptosis and circular RNAs in colorectal cancer

Colorectal cancer (CRC) is known as one of the global problems that endangers the lives of thousands of people every year. Various treatments have been used to deal with this disease, but in some cases, they are not effective. Circular RNAs, as a novel class of noncoding RNAs, have different expression levels and various functions in cancer cells, such as gene regulation through microRNA sponging. They play an important role in various cellular processes, including differentiation, proliferation, invasion, and apoptosis. Changes in the process of apoptosis are closely related to the progression or inhibition of various malignancies. Induction of apoptosis in cancer cells is a promising target for tumor therapy. In this study, circRNAs were investigated as being central to the induction or inhibition of apoptosis in CRC. It is hoped that through targeted changes in the function of these biomolecules, better outcomes will be achieved in cancer treatment. Perhaps better outcomes for cancer treatment can be achieved by using new methods and modifying the expression of these nucleic acids. However, using this method may come with challenges and limitations.

Hospital surgical volume and colorectal cancer survival in Norway: A nationwide cohort study

BACKGROUND

Studies of hospital surgical volume and colorectal cancer survival are inconclusive. We investigated whether surgical volume was associated with survival of patients operated for colorectal cancer in Norway.

METHODS

Using Cancer Registry of Norway data, we compared excess mortality from colorectal cancer by hospital surgical volume among 26,989 colon and 9779 rectal cancer patients diagnosed 2009-2020 and followed-up to 31.12.2021. Hospitals were divided into terciles according to their three-year average annual surgical volume; colon: low (< 22), middle (22-73), high (> 73); rectal: low (< 17), middle (17-38), high (> 38). We estimated excess hazard ratios (EHR) with flexible parametric models adjusted for age, year, stage, surgical urgency and surgery location (within/outside patient's residential health trust).

RESULTS

Low-volume hospitals had the highest proportion of late-stage or acutely operated colon cancer patients. Colon cancer patients operated at low- versus high-volume hospitals had significantly increased crude excess mortality (EHR = 1.30; 95 % CI = 1.14-1.48) but no difference after adjustment for age, year, and stage (EHR = 0.97; 0.85-1.11). High-volume hospitals had the highest proportion of late-stage rectal cancer patients and patients operated outside their residential area. Rectal cancer patients operated at low- versus high-volume hospitals did not have significantly different excess mortality before (EHR = 0.84; 0.64-1.10) or after (EHR = 1.03; 0.79-1.35) adjustment for age, year, stage, surgical urgency and surgery location. After accounting for case-mix, hospital surgical volume was not associated with excess mortality from colon (P = 0.40) or rectal cancer (P = 0.22).

CONCLUSION

Low hospital surgical volume was not associated with poorer colorectal cancer survival.

The first case report of metastatic rectal adenocarcinoma to the oral vestibule in a young woman

BACKGROUND

The available literature regarding metastasis to the oral cavity from colorectal cancer, especially rectal cancer, is currently limited. With this in mind, we aimed to report the first case of rectal adenocarcinoma metastasis to the oral vestibule.

CASE REPORT

A 36-year-old Caucasian female with a 17-months history of rectal adenocarcinoma and several metastases was referred to the Dental Oncology Service due to a nodular swelling in the oral cavity. Intraoral examination showed a large, painless nodule with superficial necrosis on the right side of the mandibular vestibule. An incisional biopsy was performed, and the microscopic analysis demonstrated an infiltrative tumor characterized by islands of malignant epithelial cells with a columnar appearance and tubular pattern. The epithelial component presented pseudoductal structures resemble intestinal mucosa, which exhibited intraluminal secretion. The neoplastic cells were immunoreactive for CDX2 and Cytokeratin 20, and negative for Cytokeratin 7. Therefore, the final diagnosis of metastatic rectal adenocarcinoma was established. Unfortunately, the patient died 23 months after the diagnosis of the primary tumor.

CONCLUSION

The study highlights that metastases to the oral cavity should be considered in the differential diagnosis of large reactive lesions affecting young patients, especially in the setting of a patient history of cancer.

Comparing Time to Diagnosis and Treatment Between Younger and Older Adults With Colorectal Cancer: A Population-Based Study

BACKGROUND & AIMS

Younger adults (aged <50 years) with colorectal cancer (CRC) may have prolonged delays to diagnosis and treatment that are associated with adverse outcomes. We compared delay intervals by age for patients with CRC in a large population.

METHODS

This was a population-based study of adults diagnosed with CRC in Ontario, Canada, from 2003 to 2018. We measured the time between presentation and diagnosis (diagnostic interval), diagnosis and treatment start (treatment interval), and the time from presentation to treatment (overall interval). We compared interval lengths between adults aged <50 years, 50 to 74 years, and 75 to 89 years using multivariable quantile regression.

RESULTS

Included were 90,225 patients with CRC. Of these, 6853 patients (7.6%) were aged <50 years. Younger patients were more likely to be women, present emergently, have stage IV disease, and have rectal cancer compared with middle-aged patients. Factors associated with significantly longer overall intervals included female sex (8.7 days; 95% confidence interval [CI], 6.6-10.9 days) and rectal cancer compared with proximal colon cancer (9.8 days; 95% CI, 7.4-2.2 days). After adjustment, adults aged <50 years had significantly longer diagnostic intervals (4.3 days; 95% CI. 1.3-7.3 days) and significantly shorter treatment intervals (-4.5 days; 95% CI, -5.3 to -3.7 days) compared with middle-aged patients. However, there was no significant difference in the overall interval (-0.6 days; 95% CI, -4.3 to 3.2 days). In stratified models, younger adults with stage IV disease who presented emergently and patients aged >75 years had longer overall intervals.

CONCLUSIONS

Younger adults present more often with stage IV CRC but have overall similar times from presentation to treatment as screening-eligible older adults.

Spatio-Temporal Distribution of Colorectal Cancer Incidence in Córdoba, Argentina

OBJECTIVE

To study the trend of colorectal cancer (CRC) incidence, considering its spatiotemporal distribution and its association with the level of urbanisation in Córdoba, Argentina (2004-2014).

METHODS

An ecological and longitudinal study was conducted in the province of Córdoba (the second most populated of the country) using annual data for the period 2004-2014. Age-standardised incidence rates (ASIR) (standard national and world population) by sex were calculated for Córdoba and its 26 departments for CRC using the provincial tumour registry database. Joinpoint regression models were adjusted to provincial ASIRs. Departments ASIRs were mapped in quintiles. The departments were grouped into three strata according to urbanisation: High (n1=6, >107,000 people); Intermediate (n2=13, 33,000-107,000 people); and Low (n3=7, <33,000 people). The spatio-temporal correlation analysis of the departments' rates was fulfilled using the multilevel modelling strategy.

RESULTS

ASIRs of CRC in Córdoba province were 30.9 ±1.5 and 24.3 ±1.5 cases/100,000 for men and women, respectively. During 2004-2014, ASIRs tended to decrease (annual per cent change: -0.6; CI95% -1.8, 0.6). Maps reflected different geospatial patterns by sex. CRC incidence in males was higher than in females in all strata (high urbanisation, incidence rate ratios (IRR): 1.66; intermediate, IRR: 1.59; and low, IRR: 1.40). There was a significant downward temporary variation in the most populous departments (3% per year).

CONCLUSIONS

CRC presents a non-random spatial pattern across the territory with a decreasing temporal variation in the most populous departments. Differential incidence and temporospatial tendency burden in Córdoba involve sex and urbanisation. Men continue to be the population at the greatest risk; this pattern is more noticeable in most urban settings.

Clinical, pathological, genetics and intratumoural immune milieu of micropapillary carcinoma of the colon

AIM

Micropapillary carcinoma (MPC) is a recognised WHO variant of colonic carcinoma (CC), although little is known about its prognosis, immune microenvironment and molecular alterations. We investigated its clinical, pathological and immunological characteristics.

METHODS

We assessed 903 consecutive CCs and used the WHO definition to identify MPC. We recorded serrated and mucinous differentiation and mismatch repair (MMR) status. We performed immunohistochemistry and quantification on tissue microarrays for HLA class I/II proteins, beta-2-microglobulin (B2MG), CD8, CD163, LAG3, PD-L1, FoxP3, PD-L1and BRAF V600E.

RESULTS

We classified 8.6% (N=78) of CC as MPC. Relative to non-MPC, MPC was more often high grade (p=0.03) and showed serrated morphology (p<0.01); however, we found no association with extramural venous invasion (p=0.41) and American Joint Committee on Cancer stage (p=0.95). MPCs showed lower numbers of CD8 positive lymphocytes (p<0.01), lower tumour cell B2MG expression (p=0.04) and lower tumour cell PD-L1 expression (p<0.01). There was no difference in HLA class I/II, LAG3, FOXP3, CD163 and PD-L1 positive histiocytes. There was no association with MMR status or BRAF V600E relative to non-MPC. MPC was not associated with decreased disease-specific survival (p=0.36).

CONCLUSION

MPCs are associated with high-grade differentiation and a less active immune microenvironment than non-MPC. MPC is not associated with inferior disease-specific survival.

Non-coding RNAs in Precursor Lesions of Colorectal Cancer: Their Role in Cancer Initiation and Formation

Colorectal cancer (CRC) is one of the world's most common types of malignancy. The proliferation of precancerous lesions causes this type of cancer. Two distinct pathways for CRC carcinogenesis have been identified: the conventional adenoma-carcinoma pathway and the serrated neoplasia pathway. Recently, evidence has demonstrated the regulatory roles of noncoding RNAs (ncRNAs) in the initiation and progression of precancerous lesions, especially in the adenoma-carcinoma pathway and serrated neoplasia pathway. By expanding the science of molecular genetics and bioinformatics, several studies have identified dysregulated ncRNAs that function as oncogenes or tumor suppressors in cancer initiation and formation by diverse mechanisms via intracellular signaling pathways known to act on tumor cells. However, many of their roles are still unclear. This review summarizes the functions and mechanisms of ncRNAs (such as long non-coding RNAs, microRNAs, long intergenic non-coding RNAs, small interfering RNAs, and circRNAs) in the initiation and formation of precancerous lesions.

Fluoroscopic Stent Placement as a Bridge to Surgery for Malignant Colorectal Obstruction: Short- and Long-Term Outcomes

Purpose

To assess the outcomes of single-stage surgery following fluoroscopic stent placement for malignant colorectal obstruction.

Materials and Methods

This retrospective study included 46 patients (28 male and 18 female; mean age, 67.2 years) who had undergone fluoroscopic stent placement followed by laparoscopic resection (n = 31) or open surgery (n = 15) for malignant colorectal obstruction. The surgical outcomes were analyzed and compared. After a mean follow-up of 38.9 months, the recurrence-free and overall survival were estimated, and prognostic factors were evaluated.

Results

The mean interval between stent placement and surgery was 10.2 days. Primary anastomosis was possible in all patients. The mean postoperative length of hospitalization was 11.0 days. Bowel perforation was detected in six patients (13.0%). During the follow-up, ten patients (21.7%) developed recurrence; these included five of the six patients with bowel perforation. Bowel perforation had a significant effect on recurrence-free survival (p = 0.010).

Conclusion

Single-stage surgery following fluoroscopic stent placement may be effective for treating malignant colorectal obstruction. Stent-related bowel perforation is a significant predictive factor for tumor recurrence.

Faecal immunochemical testing (FIT) in primary care: a follow-up service evaluation

AIM

Colorectal cancer (CRC) is the fourth most common cancer in the UK. Following National Institute for Health and Care Excellence guidance for faecal immunochemical testing (FIT), we introduced a service for the measurement of faecal haemoglobin (f-Hb) in symptomatic patients. Previously, we evaluated the first 6 months of the service in three local boroughs, here we re-examine the use of FIT, over a similar 6 months in the two successive years.

METHODS

Patients who had FIT requested in April-September 2020 and 2021 were studied. Results were obtained from the laboratory information systems and matched with the clinical outcomes of those referred via the urgent lower gastrointestinal cancer pathway. Patient demographics, reason for referral, clinical outcome and diagnostic test performance are reported.

RESULTS

In 2020, 4042 samples were analysed and 57 CRC detected. In 2021, 10 508 samples were analysed and 65 CRC detected. Six (4.9%) patients with CRC had f-Hb <10 µg/g, of whom three were anaemic. In 2020, 27.7% of samples were from patients under 50 years; and in 2021, 32.8%. Sensitivity, specificity, positive predictive value and negative predictive value of f-Hb at ≥10 µg/g for CRC were 92.9%, 46.6%, 6.4% and 99.4% in 2020 and 96.9%, 29.9%, 3.2% and 99.8% in 2021.

CONCLUSIONS

As currently used in primary care in North East London, specificity of FIT at a cut-off of 10 µg/g is much lower than in published studies and the impact of this on colorectal services needs to be considered.

Stemness targeting of colorectal cell lines mediated by BAMLET and 5-Flourouracil

PURPOSE

Stemness is the potential for self-renewal and repopulation causing the relapse, progression, and drug resistance of colorectal cancer. We investigated the effects of bovine alpha-lactalbumin made lethal to tumor cells and 5-Flourouracil consisting of bovine α-lactalbumin protein and oleic acid, on colorectal cancer cells on stemness.

METHODS

The quantitative real-time polymerase chain reaction assessed the expression levels of stemness-related genes (c-myc, Lgr5, OCT4). Expression of stemness-related surface markers (CD44 and CD24) was also measured by the flow cytometry technique following the treatments.

RESULTS

Our results indicated decreased expression levels of C-Myc, Lgr5, oct4 as the stemness-related genes (P < 0.0001), and reduced population of CD44⁺ as the stemness-related cell surface marker upon treatment with BAMLET and 5-Flourouracil. BAMLET inhibited the stemness more effectively than 5-Flourouracil (P < 0.0001).

CONCLUSION

Based on the result, inhibition of the Stemness related-genes (C-Myc, Lgr5, Oct4) and the surface markers (CD 24+ and CD44⁺) is a promising therapeutic approach using BAMLET.

CD8+ CD226high T cells in liver metastases dictate the prognosis of colorectal cancer patients treated with chemotherapy and radical surgery

CD226 has been reported to participate in the rescue of CD8+ T cell dysfunction. In this study, we aimed to assess the prognostic value of CD226 in tumor-infiltrating lymphocytes (TILs) derived from colorectal cancer (CRC) liver metastases treated with chemotherapy and radical surgery. TILs from 43 metastases were isolated and analyzed ex vivo using flow cytometry. CD155 and CD3 levels in the tumor microenvironment were assessed by immunohistochemistry. Exploration and validation of biological processes highlighted in this study were performed by bioinformatics analysis of bulk RNA-seq results for 28 CRC liver metastases pretreated with chemotherapy as well as public gene expression datasets. CD226 expression contributes to the definition of the immune context in CRC liver metastases and primary tumors. CD226 on CD8+ T cells was not specifically coexpressed with other immune checkpoints, such as PD1, TIGIT, and TIM3, in liver metastases. Multivariate Cox regression analysis revealed CD226 expression on CD8+ T cells to be an independent prognostic factor (p = 0.003), along with CD3 density at invasion margins (p = 0.003) and TIGIT expression on CD4+ T cells (p = 0.019). CD155 was not associated with the prognostic value of CD226. Gene expression analysis in a validation dataset confirmed the prognostic value of CD226 in CRC liver metastases but not in primary tumors. Downregulation of CD226 on CD8+ TILs in the liver microenvironment was restored by IL15 treatment. Overall, CD226 expression on liver metastasis-infiltrating CD8+ T cells selectively contributes to immune surveillance of CRC liver metastases and has prognostic value for patients undergoing radical surgery.

Metastasis-Directed Local Therapy of Hepatic Oligometastasis from Colorectal Cancer and Future Perspective in Radiation Therapy

Introduction of the concept for oligometastasis (OM) led to wide application of metastasis-directed local ablative therapies for metastatic colorectal cancer (CRC). By application of the metastasis-directed local ablative therapies including surgical resection, radiofrequency ablation (RFA), and stereotactic ablative body radiotherapy (SABR), the survival outcomes of patients with metastatic CRC have improved. The liver is the most common distant metastatic site in CRC patients, and recently various metastasis-directed local therapies for hepatic oligometastasis from CRC (HOCRC) are widely used. Surgical resection is the first line of metastatic-directed local therapy for HOCRC, but its eligibility is very limited. Alternatively, RFA can be applied to patients who are ineligible for surgical resection of liver metastasis. However, there are some limitations such as inferior local control (LC) compared with surgical resection and technical feasibility based on location, size, and visibility on ultrasonography of the liver metastasis. Recent advances in radiation therapy (RT) technology have led to an increase in the use of SABR for liver tumors. SABR is considered complementary to RFA for patients with HOCRC who are ineligible for RFA. Furthermore, SABR can potentially result in better LC for liver metastases >2~3 cm compared with RFA. In this article, the previous studies regarding curative metastasis-directed local therapies for HOCRC based on the radiation oncologist's and surgeon's perspective are reviewed and discussed. In addition, future perspectives regarding SABR in the treatment of HOCRC are suggested.

Microvesicular hyperplastic polyp and sessile serrated lesion of the large intestine: a biological continuum or separate entities?

The range of lesions with a serrated appearance within the large intestine has expanded and become more complex over the last 30 years. The majority of these were previously known as metaplastic polyps but are today called hyperplastic polyps (HPs). HPs show two main growth patterns: microvesicular and goblet cell-rich. The former type shows morphological and molecular similarities (eg, BRAF mutations) to the more recently described sessile serrated lesion (SSL). In this review, we debate whether these lesions represent a biological spectrum or separate entities. Whichever view is held, microvesicular HPs and SSLs are distinct from the goblet cell-rich HP and the traditional serrated adenoma (TSA), which may themselves share molecular changes (eg, KRAS mutations), with the goblet cell-rich HP representing a precursor to the TSA. Both SSLs and the goblet cell-rich HP-TSA pathway are routes to colorectal cancer within the serrated pathway and overlaps between them can occur, for example, a (BRAF-mutated) TSA may arise from an SSL.

Anticancer Effect of Fluorouracil and Gum-Based Cerium Oxide Nanoparticles on Human Malignant Colon Carcinoma Cell Line (Caco2)

OBJECTIVE

We investigated whether co-incubation of 5-FU and gum-based cerium oxide nanoparticles (CeO₂ NPs) would improve half-maximal inhibitory concentration (IC₅₀) and apoptosis in the Caco-2 cancer cell line Materials and Methods: In this experimental study, we synthesized Ceo-2-XG by the nano perception method. X-ray diffraction (XRD), field emission scanning electron microscopy (FESEM), transmission electron microscopy (TEM), dynamic light scattering (DLS) and vibrating sample magnetometer (VSM) techniques were employed to characterize the synthesized nanoparticles. The Caco-2 cancer cells were cultured and treated with Ceo-2- XG and 5-FU. Cytotoxicity analysis was carried out using MTT assay on Caco-2 cancer cells. CXCR1, CXCR2, CXCL8, BAX, BCL-2, P53, CASPASE-3, CASPASE-8 and CASPASE-9 gene expression changes were assessed by quantitative reverse-transcriptase polymerase chain reaction (qRT-PCR). The Caco-2 cancer cell mortality mechanism was analyzed using Annexin V-FITC/PI flow cytometry. Using the inverted microscope morphology changes of the Caco-2 cancer cells was observed.

RESULTS

With a sample size of roughly 11 nm, TEM analysis revealed spherical structures. Interestingly, after 72 hours, 400 μg/ml nanoparticles significantly lowered the ₅₀ of 5-FU from 101 to 71 μg/ml (P<000.1). Furthermore, qRT-PCR analysis showed that BCL-2, CXCR1, CXCR2 and CXCR8 expressions were significantly decreased in the 5-FU and Ceo-2-XG nanoparticles co-incubated group, compared to the 5-FU alone (P<0.001). Notably, gene expressions of BAX, P53, CASPASE-3, CASPASE-8 and CASPASE-9 were significantly higher in the 5-FU and Ceo- 2-XG nanoparticles co-incubated group, compared to the 5-FU alone (P<0.001). The findings revealed that dead cells owing to apoptosis were more than two times higher in 5-FU and Ceo-2-XG nanoparticles cancer cells than in 5-FU alone treated cancer cells.

CONCLUSION

Co-incubation of 5-FU and Ceo-2-XG nanoparticles significantly increased apoptosis in the Caco-2 cancer cells. The antiproliferative activity of co-incubated 5-FU and Ceo-2-XG nanoparticles on Caco-2 cancer cells was substantially higher than that of 5-FU alone.

Risk Factors for Metachronous Colorectal Cancer or Advanced Adenomas After Endoscopic Resection of High-risk Adenomas

BACKGROUND & AIMS

Among the characteristics of high-risk adenomas (HRAs), some may predict a higher risk of metachronous advanced lesions. Our aim was to assess which HRA characteristics are associated with high risk of metachronous colorectal cancer (CRC) or advanced adenomas (AAs).

METHODS

We systematically searched Pubmed, EMBASE, and Cochrane for cohort studies and clinical trials of CRC or AA incidence at surveillance stratified by baseline lesion size, histology, and multiplicity. We calculated pooled relative risks (RRs) using a random-effects model. Heterogeneity was assessed with the I² statistic.

RESULTS

Fifty-five studies were included, with 936,540 patients with mean follow-up 5.4 ± 2.9 years. CRC incidence per 1000 person-years was 2.6 (2.1-3.0) for adenomas ≥20 mm, 2.7 (2.2-3.2) for high-grade dysplasia (HGD), 2.0 (1.8-2.3) for villous component, 0.8 (0.1-1.4) for ≥5 adenomas, 1.0 (0.7-1.2) for ≥3 adenomas. Metachronous CRC risk was higher in adenomas ≥20 mm vs 10 to 19 mm (RR, 2.08; 95% confidence interval [CI], 1.20-3.61), HGD vs low-grade dysplasia (RR, 2.89; 95% CI, 1.88-4.44), villous vs tubular (RR, 1.75; 95% CI, 1.33-2.31). No significant differences in CRC risk were found in ≥3 adenomas vs 1 to 2 (RR, 1.24; 95% CI, 0.84-1.83), nor in ≥5 adenomas vs 3 to 4 (RR, 0.79; 95% CI, 0.30-2.11). Compared with normal colonoscopy, RR for CRC risk was 2.61 (95% CI, 2.06-3.32) for ≥10mm, 6.62 (95% CI, 4.60-9.52) for HGD, 3.58 (95% CI, 2.24-5.73) for villous component, and 2.03 (95% CI, 1.40-2.94) for ≥3 adenomas. Similar trends were seen for metachronous AAs.

CONCLUSION

Metachronous CRC risk is highest in patients with baseline adenomas with ≥20 mm or HGD. Multiplicity does not seem to be associated with substantially higher CRC risk in the near term.

Current status and quality of radiomic studies for predicting KRAS mutations in colorectal cancer patients: A systematic review and meta‑analysis

PURPOSE

The purpose of this study was to evaluate the methodological quality of radiomics-based studies for noninvasive, preoperative prediction of Kirsten rat sarcoma (KRAS) mutations in patients with colorectal cancer; furthermore, we systematically evaluate the diagnostic accuracy of predicting models.

METHODS

We systematically searched PubMed, Embase, Cochrane Library and Web of Science databases up to 20 April 2022 for eligible studies. The methodological quality of included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) and Radiomics Quality Score (RQS) tools. A meta-analysis of studies on the prediction of KRAS status in colorectal cancer patients was performed.

RESULT

Twenty-nine studies were identified in the systematic review, including three studies on the prediction of KRAS status in colorectal cancer liver metastases. All studies had an average RQS score of 9.55 (26.5% of the total score), ranging from 3 to 17. Most studies demonstrated a low or unclear risk of bias in the domains of QUADAS-2. Nineteen studies were included in the meta-analysis, mostly imaged with magnetic resonance imaging (MRI), followed by computed tomography (CT), positron emission tomography-CT (PET/CT). With pooled sensitivity, specificity and area under the curve (AUC) of the training cohorts were 0.80(95% confidence interval(CI), 0.75-0.84), 0.80(95% CI, 0.74-0.85) and 0.87(95% CI, 0.84-0.90),respectively. The pooled sensitivity, specificity, and AUC for the validation cohorts (13 studies) were 0.78(95% CI, 0.71-0.84), 0.84(95% CI, 0.74-0.90), and 0.86(95% CI, 0.83-0.89), respectively.

CONCLUSION

Radiomics is a potential noninvasive technology that has a moderate preoperative diagnosis and prediction effect on KRAS mutations. However, it has not been implemented as a clinical decision-making tool. Future researchers should pay more attention to the methodological quality of the study and further externally validate the model using multicenter datasets.

Consequences of aberrated DNA methylation in Colon Adenocarcinoma: a bioinformatic-based multi-approach

INTRODUCTION

The biology of colorectal cancer (CRC) is remained to be elucidated. Numerous genetic and epigenetic modifications are in concert to create and progress CRC. DNA methylation as a principal epigenetic factor has gained increased attention and could be utilized for biological studies. This study aims to find novel methylated and downregulated genes with a focus on HAND2 in CRC and decipher the biological consequences.

MATERIAL AND METHOD

Data on DNA methylation from GEO and SMART databases and the expression GEPIA2 database were downloaded. Afterward, a set of hypermethylated and downregulated genes in CRC was chosen by overlapping genes. Consequently, HAND2 was selected as a key gene for further investigation and confirmed with cell lines methylation and expression data. The functions of HAND2 were further analyzed using gene ontology analyses and the protein-protein interaction network.

RESULTS

The methylation (p < 0.01) and expression (p < 0.01) of HAND2 are significantly varied in CRC compared to normal control. The correlation analysis (Pearson's correlation coefficient = -0.44, p = 6.6e-14) conveys that HAND2 significantly downregulated and has a reverse correlation with the methylation status of CpG islands. The biological process analysis of HAND2 target genes conveyed that disruption in HAND2 expression could dysregulate ERK1 and ERK2 signaling pathways.

CONCLUSION

Together, the findings showed that DNA hypermethylation of HAND2 was critical evidence in CRC. Further validation and prospective studies are needed to utilize HAND2 methylation as a promising biomarker.

Tissue Content and Pattern of Expression of Claudin-3 and Occludin in Normal and Neoplastic Tissues in Patients with Colorectal Cancer

BACKGROUND

Metastasis is the worst prognostic variable of patients with colorectal cancer (CRC). For the development of metastases, it is necessary that cancer cells detach from the primary tumor, migrate into the angiolymphatic system, and invade the tissue where they will develop. The breakdown of the tight junctions (TJs) plays an important role in colorectal metastatic tumors. Claudin-3 and occludin are the main component proteins of TJs.

AIM

To analyze the expression and tissue content of claudin-3 and occludin in normal and neoplastic tissues of patients with metastatic CRC.

METHODS

Fifty-seven consecutive patients with stage III and IV CRC were included. Fragments of neoplastic tissue were collected from the tumor margins, and samples of the normal tissue were collected from the same patient in a standardized distance of 10 cm from the cranial margin of the tumor. Immunohistochemistry technique was used to identify the tissue staining of claudin-3 and occludin. To measure the content of both proteins in cellular membranes of normal and cancer cells, a validated immunoscore was used.

RESULTS

Claudin-3 and occludin in normal tissues are in the apical and lateral membranes of cells, while in the neoplastic, in cytoplasm. The mean of the tissue content of claudin-3 in the normal tissue was 2.57 ± 0.16, while in the neoplastic tissue was 1.03 ± 0.13. The contents of occludin were 2.77 ± 0.1 in normal tissue, while in the neoplastic were 1.08 ± 0.14.

CONCLUSION

There is a reduction in the content of the claudin-3 and occludin in the cell membranes of the neoplastic tissue in patients with CRC.

No evidence of delay in colorectal cancer diagnosis during the COVID-19 pandemic in Gwangju and Jeonnam, Korea

Objectives

We evaluated whether the coronavirus disease 2019 (COVID-19) pandemic caused delays in the diagnosis and treatment of colorectal cancer (CRC) in Korea, where there have been no regional or hospital lockdowns during the pandemic period.

Methods

Data on CRC patients (n=1,445) diagnosed in Gwangju Metropolitan City and Jeonnam Province between January 2019 and December 2021 were assessed. The stage at the time of CRC diagnosis, route to diagnosis, time to initial cancer treatment, and length of hospital admission were compared before and during the COVID-19 pandemic. Logistic regression was also performed to identify factors associated with the risk for diagnosis in an advanced stage.

Results

No negative effects indicating a higher CRC stage at diagnosis or delayed treatment during the pandemic were observed. Instead, the risk for an advanced stage at diagnosis (TNM stage III/IV) decreased in CRC patients diagnosed during the pandemic (odds ratio, 0.768; 95% confidence interval, 0.647 to 0.911). No significant differences in the interval from diagnosis to operation or chemotherapy were observed.

Conclusion

No negative effects on CRC diagnosis and treatment were found until the end of 2021, which may be related to the small magnitude of the COVID-19 epidemic, the absence of a lockdown policy in Korea, and the rebound in the number of diagnostic colonoscopy procedures in 2021.

Modifiable lifestyle factors have a larger contribution to colorectal neoplasms than family history

BACKGROUND

 Screening recommendations for colorectal cancer (CRC) are mainly based on family history rather than lifestyle risk factors. We aimed to assess and compare risk factors for colorectal neoplasm (CRN) and evaluate trends in neoplasm detection rates during the three rounds of screening from 2012 to 2020 in Tianjin, China.

METHODS

This study was based on 89,535 first-recorded colonoscopies in Tianjin CRC screening program, 2012-2020. Of these, 45,380 individuals with complete family history and lifestyle factors were included for population attributable fraction (PAF) estimation.

RESULTS

 The overall detection rate of nonadvanced adenomas, advanced adenomas and CRC was 39.3%, 5.9% and 1.5%, respectively. The PAFs of current smoking, alcohol consumption, physical activity, higher BMI and family history of CRC, respectively, were 8.9%, 2.6%, 1.9%, 5.8%, and 1.1% for males with nonadvanced CRN; 12.3%, 7.3%, 4.9%, 7.2%, and 0.8% for males with advanced CRN; 3.4%, 0.4%, 2.1%, 7.8%, and 0.7% for females with nonadvanced CRN; and 4.3%, 0.2%, 8.2%, 8.5%, and -0.6% for females with advanced CRN. The PAFs of selected lifestyle factors were 19.9% for males with nonadvanced CRN, 29.0% for males with advanced CRN, 9.7% for females with nonadvanced CRN and 13.8% for females with advanced CRN.

CONCLUSIONS

 Modifiable lifestyle factors, including smoking, alcohol consumption, physical activity and BMI, have a larger contribution to CRN than family history of CRC. Our findings will provide references for developing guidelines of CRC prevention and control in China.

Role of EFNA1 SNP (rs12904) in Tumorigenesis and Metastasis of Colorectal Cancer: A Bioinformatic Analysis and HRM SNP Genotyping Verification

OBJECTIVE

Colorectal cancer is a prevalent disease with a poor prognosis and is known as a heterogeneous disease with many differences in clinical Symptoms and molecular profiles. The present study aimed to systematically evaluate the association of SNPs in miRNA binding sites of target genes that are involved in CRC angiogenesis, epithelial to mesenchymal transition, and cytoskeleton organization with tumorigenesis and metastasis of CRC.

METHODS

A case-control study was performed on 146 samples of CRC patients and 132 healthy samples. After that, the DNA of all samples was isolated by the salting-out method. Finally, the genotypes for EFNA1 SNP (rs12904) were identified by HRM (High-resolution melting analysis) method. In order to evaluate the results of genotyping, two samples from each genotype were sequenced using the sanger sequencing method.

RESULT

The frequency of AA genotype and the frequency of GG for rs12904 in satge4 and other stages are different from each other (P-value <0.0001) (P-value = 0.008). Also, the frequency of AA genotype in patients with different grades is different from each other (P-value = 0.035), while the frequency of AG   genotype and the frequency of GG   genotype is not significantly different in patients with different grades (P-value = 0.377) (P-value = 0.284).

CONCLUSION

Results of this study indicated that patients carrying the GA and GG genotypes reduced the risk of disease progression compared to the AA genotype. As a result, this polymorphism plays a key role in CRC pathogenesis and metastasis and could be used as a biomarker in molecular diagnosis and metastatic state prediction in the near future after further study of its signaling pathways and molecular mechanism.

The tumor/normal tissue ratio of Keap1 protein is a predictor for lymphovascular invasion in colorectal cancer: A correlation study between the Nrf2 and KRas pathways

PURPOSE: Oxidative stress has impacts on the KRas and Nrf2/Keap1 pathways, which have multiple interactions with each other and play important roles in colorectal cancer (CRC). This study investigated the expressions of proteins in the KRas and Nrf2/Keap1 pathways and their associations with clinicopathological features in CRC.METHODS: The protein levels of Nrf2, Keap1, Bach1, p62, HO1, KRas, Erk, Raf1 and PI3K in both the tumor and normal tissues of 60 CRC subjects were determined by Western blot and their T/N (tumor/normal tissue) ratios were correlated with clinicopathological features.RESULTS: The T/N ratios of proteins in the KRas and Nrf2/Keap1 pathways had correlation patterns and proximity profiles in cluster dendrograms different in CRC with different status of lymphovascular invasion (LVI) or lymph node/distant metastases. The Keap1 protein T/N ratio was a significant predictor (odd ratio: 2.24; 95% confidence interval: 1.26 - 4.38) of LVI, which in turn predicted metastases (11.0; 3.49 - 39.8).CONCLUSION: The interactions between the KRas and Nrf2/Keap1 pathways may be affected differently by LVI and metastases, and the protein T/N ratio of Keap1 may be helpful for predicting LVI in CRC.

Colonoscopy screening and surveillance disparities during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has increased barriers to accessing preventive healthcare. This study identifies populations disproportionately underrepresented in screening and surveillance colonoscopies during the COVID-19 pandemic.

METHODS

In this single-center cohort study, colonoscopy procedures were reviewed during 6-month intervals before the pandemic (July 1, 2019 - December 31, 2019) and during the pandemic (July 1, 2020 - December 31, 2020 and January 1, 2021 - June 30, 2021). 7095 patients were categorized based on procedure indication, demographics, Charlson Comorbidity Index and Social Vulnerability Index (SVI). Statistics performed using VassarStats.

RESULTS

2387 (2019) colonoscopies pre-pandemic and 2585 (2020) and 2123 (2021) during the pandemic were identified. There was a decrease in colonoscopies performed during months when COVID-19 cases peaked. The total number of average CRC risk patients presenting for first colonoscopy declined during the pandemic: 232 (10 %) pre-pandemic to 190 (7 %) in 2020, 145 (7 %) in 2021 (p < 0.001). Fewer of these patients presented from highly vulnerable communities, SVI > 0.8, during the pandemic, 39 in 2019 vs 16 in 2020 and 22 in 2021. Of all screening and surveillance patients, fewer presented from communities with SVI > 0.8 during the pandemic, 106 in 2019 versus 67 in 2020 and 77 in 2021.

CONCLUSION

It is important to address the decline in CRC preventive care during this pandemic among average CRC risk first-time screeners and vulnerable community patients. An emphasis on addressing social determinants of health and establishing patients in gastroenterology clinics is imperative to promote future health in these populations.

Cancer Risk Score Prediction Based on a Single-Nucleotide Polymorphism Network

Objectives

Genome-wide association studies (GWAS) are performed to study the associations between genetic variants with respect to certain phenotypic traits such as cancer. However, the method that is commonly used in GWAS assumes that certain traits are solely affected by a single mutation. We propose a network analysis method, in which we generate association networks of single-nucleotide polymorphisms (SNPs) that can differentiate case and control groups. We hypothesize that certain phenotypic traits are attributable to mutations in groups of associated SNPs.

Methods

We propose a method based on a network analysis framework to study SNP-SNP interactions related to cancer incidence. We employed logistic regression to measure the significance of all SNP pairs from GWAS for the incidence of colorectal cancer and computed a cancer risk score based on the generated SNP networks.

Results

We demonstrated our method in a dataset from a case-control study of colorectal cancer in the South Sulawesi population. From the GWAS results, 20,094 pairs of 200 SNPs were created. We obtained one cluster containing four pairs of five SNPs that passed the filtering threshold based on their p-values. A locus on chromosome 12 (12:54410007) was found to be strongly connected to the four variants on chromosome 1. A polygenic risk score was computed from the five SNPs, and a significant difference in colorectal cancer risk was obtained between the case and control groups.

Conclusions

Our results demonstrate the applicability of our method to understand SNP-SNP interactions and compute risk scores for various types of cancer.

[Effects of the Advanced Practice Nurse-Led Psychoeducational Program for Colorectal Cancer Survivors]

PURPOSE

This study aimed to investigate the effects of an advanced practice nurse-led psychoeducational program on distress, anxiety, depression, coping with cancer (CWC), health promotion behavior (HPB), and quality of life (QOL) among colorectal cancer survivors.

METHODS

This study was designed as a quasi-experimental study with a non-equivalent control group pretest-posttest. The participants were survivors of colorectal cancer who underwent follow-up care. There were 39 survivors: 19 in the experimental group and 20 in the control group. The experimental group performed a psychoeducational program for 120 minutes per session, once a week for a total of six weeks, while the control group received routine education and counseling. Distress, anxiety, depression, CWC, HPB, and QOL were investigated before, immediately after, and 4 weeks after the intervention. The data were analyzed with SPSS/WIN ver. 24.0, using repeated measures ANOVA.

RESULTS

There were significant interactions between time and group for distress and anxiety. In addition, CWC interacted with the total of CWC and interpersonal coping, and QOL interacted with the total of QOL and functional status. However, there were no significant differences in the depression or HPB scores.

CONCLUSION

Based on the results of this study, we expect that this program can be used as an effective intervention for colorectal cancer survivors.

Prevalence and Predictors of Young-Onset Colorectal Neoplasia: Insights From a Nationally Representative Colonoscopy Registry

BACKGROUND & AIMS

A disturbing increase in early-onset colorectal cancer (EOCRC) has prompted recent guidelines to recommend lowering the colorectal cancer (CRC) screening starting age from 50 to 45 years old for average-risk individuals. Little is known about the prevalence of colorectal neoplasia in individuals between 45 and 49 years old, or even younger, in the United States. We analyzed a large, nationally representative data set of almost 3 million outpatient colonoscopies to determine the prevalence of, and risk factors for, colorectal neoplasia among patients aged 18 to 54.

METHODS

Findings from high-quality colonoscopies were analyzed from AMSURG ambulatory endoscopy centers (ASCs) that report their results in the GI Quality Improvement Consortium (GIQuIC) Registry. Logistic regression was used to identify risk factors for EOCRC.

RESULTS

Increasing age, male sex, White race, family history of CRC, and examinations for bleeding or screening were all associated with higher odds of advanced premalignant lesions (APLs) and CRC. Among patients aged 45 to 49, 32% had any neoplasia, 7.5% had APLs, and 0.58% had CRC. Rates were almost as high in those aged 40 to 44. Family history of CRC portended neoplasia rates 5 years earlier. Rates of APLs were higher in American Indian/Alaskan Natives, but lower among Blacks, Asians, and Hispanics, compared with White counterparts. The prevalence of any neoplasia and APL gradually increased between 2014 and 2019, in all age groups.

CONCLUSIONS

These data provide support for lowering the screening age to 45 for all average-risk individuals. Early messaging to patients and providers in the years leading up to age 45 is warranted, especially in those with a family history of CRC.

Colorectal Screening Program in Northern Portugal: First Findings

INTRODUCTION

In Portugal, a colorectal cancer screening program based on faecal immunochemical test followed by colonoscopy was shown to be cost-effective for individuals between 50 and 74 years old. We report the first findings of the implementation of a population-based program In Northern Portugal.

MATERIAL AND METHODS

In the pilot phase, eligible subjects were allocated either to a direct mailing invitation or to primary care centers. In the first year of program implementation, we assessed the uptake rate, the faecal immunochemical test -positivity rate, the diagnostic yield of advanced neoplasia, and the quality parameters for post-faecal immunochemical test + colonoscopy.

RESULTS

We invited 100 501 eligible subjects (49% male with a median age of 55 years). Of these, 5228 participated in the pilot phase and 95 273 participated in the first year of the program. In the first year of the program, the adherence was 29%, with a positivity rate of 5% and a 60% compliance to colonoscopy. The faecal immunochemical test-detection rate of advanced neoplasia was 0.35/1000 subjects, and the positive predictive value at post- faecal immunochemical test + colonoscopy was 44% and 2% for advanced adenoma and invasive cancer, respectively. No major adverse events were reported after colonoscopy.

DISCUSSION

The suboptimal adherence to faecal immunochemical test and post-faecal immunochemical test + colonoscopy remains the most urgent step to be addressed.

CONCLUSION

A centralized invitation system based on direct mailing was feasible and both colonoscopy quality and diagnostic yield were adequate antecipating the success of the programme.

Quality of Colonoscopy Is Associated With Adenoma Detection and Postcolonoscopy Colorectal Cancer Prevention in Lynch Syndrome

BACKGROUND & AIMS

Colonoscopy reduces colorectal cancer (CRC) incidence and mortality in Lynch syndrome (LS) carriers. However, a high incidence of postcolonoscopy CRC (PCCRC) has been reported. Colonoscopy is highly dependent on endoscopist skill and is subject to quality variability. We aimed to evaluate the impact of key colonoscopy quality indicators on adenoma detection and prevention of PCCRC in LS.

METHODS

We conducted a multicenter study focused on LS carriers without previous CRC undergoing colonoscopy surveillance (n = 893). Incident colorectal neoplasia during surveillance and quality indicators of all colonoscopies were analyzed. We performed an emulated target trial comparing the results from the first and second surveillance colonoscopies to assess the effect of colonoscopy quality indicators on adenoma detection and PCCRC incidence. Risk analyses were conducted using a multivariable logistic regression model.

RESULTS

The 10-year cumulative incidence of adenoma and PCCRC was 60.6% (95% CI, 55.5%-65.2%) and 7.9% (95% CI, 5.2%-10.6%), respectively. Adequate bowel preparation (odds ratio [OR], 2.07; 95% CI, 1.06-4.3), complete colonoscopies (20% vs 0%; P = .01), and pan-chromoendoscopy use (OR, 2.14; 95% CI, 1.15-3.95) were associated with significant improvement in adenoma detection. PCCRC risk was significantly lower when colonoscopies were performed during a time interval of less than every 3 years (OR, 0.35; 95% CI, 0.14-0.97). We observed a consistent but not significant reduction in PCCRC risk for a previous complete examination (OR, 0.16; 95% CI, 0.03-1.28), adequate bowel preparation (OR, 0.64; 95% CI, 0.17-3.24), or previous use of high-definition colonoscopy (OR, 0.37; 95% CI, 0.02-2.33).

CONCLUSIONS

Complete colonoscopies with adequate bowel preparation and chromoendoscopy use are associated with improved adenoma detection, while surveillance intervals of less than 3 years are associated with a reduction of PCCRC incidence. In LS, high-quality colonoscopy surveillance is of utmost importance for CRC prevention.

Mediators of screening uptake in a colorectal cancer screening intervention among Hispanics

Background

Colorectal cancer (CRC) is the second leading cause of cancer deaths in the USA. Although a number of CRC screening tests have been established as being effective for CRC prevention and early detection, rates of CRC screening test completion in the US population remain suboptimal, especially among the uninsured, recent immigrants and Hispanics. In this study, we used a structural equation modelling approach to identify factors influencing screening test completion in a successful CRC screening program that was implemented in an uninsured Hispanic population. This information will enhance our understanding of influences on CRC screening among historically underscreened populations.

Methods

We used generalized structural equation models (SEM) utilizing participant reported information collected through a series of surveys. We identified direct and indirect pathways through which cofactors, CRC knowledge and individual Health Belief Model constructs (perceived benefits, barriers, susceptibility, fatalism and self-efficacy) and a latent psychosocial health construct mediated screening in an effective prospective randomized CRC screening intervention that was tailored for uninsured Hispanic Americans.

Results

Seven hundred twenty-three participants were eligible for inclusion; mean age was 56 years, 79.7% were female, and 98.9% were Hispanic. The total intervention effect was comparable in both models, with both having a direct and indirect effect on screening completion (n = 715, Model 1: RC = 2.46 [95% CI: 2.20, 2.71, p < 0.001]; n = 699, Model 2 RC =2.45, [95% CI: 2.18, 2.72, p < 0.001]. In Model 1, 32% of the overall effect was mediated by the latent psychosocial health construct (RC = 0.79, p < 0.001) that was in turn mainly influenced by self-efficacy, perceived benefits and fatalism. In Model 2, the most important individual mediators were self-efficacy (RC = 0.24, p = 0.013), and fatalism (RC = 0.07, p = 0.033).

Conclusion

This study contributes to our understanding of mediators of CRC screening and suggests that targeting self-efficacy, perceived benefits and fatalism could maximize the effectiveness of CRC screening interventions particularly in Hispanic populations.

Prognostic Factors of Recurrence and Survival in Operated Patients with Colorectal Cancer

BACKGROUND: The recurrence of colorectal cancers is considered to be one of the greatest post-surgical complications that is affected by various factors. This study was designed to investigate the prognostic factors that affect the recurrence and survival of patients with colon and rectal cancers. METHODS: A retrospective study was performed on 380 patients with colorectal cancers who underwent surgery were enrolled in the study (152 patients with colon cancer and 228 patients with rectal cancer). Preoperative serum albumin level, type of surgery, tumor size, differentiation grade, proximal, distal and radial, and marginal involvement, the total number of excised lymph nodes, the number of involved lymph nodes, and tumor stage were recorded. Also, the incidences of recurrence and metastasis were recorded during the study. RESULTS: 380 patients with a mean age of 57.11 years were enrolled in the study. 152 patients with an average age of 57.57 years were diagnosed as having colon cancer. Recurrence and metastasis occurred in two patients (1.3%) and five patients (3.3%), respectively. 18 patients (11.8%) died because of colon cancer. 228 patients with a mean age of 56.81 had rectal cancer. Recurrence was seen in 19 patients (8.3%) and metastasis in 33 patients (14.5%). 38 patients (16.7%) died because of rectal cancer. Tumor size and involved lymph nodes were independent prognostic factors for the recurrence and metastases of colon cancer. Only involved lymph nodes were associated with death due to colon cancer. Independent prognostic factors for rectal cancer metastasis include serum albumin level and age. The total number of excised lymph nodes was the only predictor of tumor recurrence and death in rectal cancer. The median survival times of colon and rectal cancers were 90 and 110 months, respectively. CONCLUSION: The size of the tumor and the number of involved lymph nodes were independent prognostic factors for recurrence and metastasis of colon cancer. Also, the number of involved lymph nodes was associated with colon cancer-related deaths. In the case of rectal cancer, serum albumin levels and age predicted metastases. Only the total number of excised lymph nodes had a reverse relationship with recurrence and rectal cancer-related death.

DNA Methylation Profiling of MYC, SMAD2/3 and DNMT3A in Colorectal Cancer

Epigenetic modifications, particularly DNA methylation, is commonplace and a remarkable factor in carcinogenesis transformation. Conspicuously, previous findings have presented a cluster of irregular promoter methylation alterations related with silencing of tumor suppressor genes, little is accepted regarding their sequential DNA methylation (hypo and hyper) modifications during the cancer progression. In this way, fluctuations of DNA methylation of many genes, especially MYC, SMAD2/3, and DNMT3A, have an impressive central key role in many different cancers, including colorectal cancer (CRC). CRC is distinguished by DNA methylation, which is related to tumorigenesis and also genomic instability. Importantly, molecular heterogeneity between multiple adenomas in different patients with CRC may show diverse developmental phenotypes for these kinds of tumors. Conclusively, studying factors that are involved in CRC carcinogenesis, especially the alterations in epigenetic elements, such as DNA methylation besides RNA remodeling, and histone modification, acetylation and phosphorylation, can be influential to find new therapeutic and diagnostic biomarkers in this type of malignancy. In this account, we discuss and address the potential significant methylated modifications of these genes and their importance during the development of CRC carcinogenesis.

Radiation Proctitis and Management Strategies

Radiotherapy (RT) is a treatment modality that uses high-energy rays or radioactive agents to generate ionizing radiation against rapidly dividing cells. The main objective of using radiation in cancer therapy is to impair or halt the division of the tumor cells. Over the past few decades, advancements in technology, the introduction of newer methods of RT, and a better understanding of the pathophysiology of cancers have enabled physicians to deliver doses of radiation that match the exact dimensions of the tumor for greater efficacy, with minimal exposure of the surrounding tissues. However, RT has numerous complications, the most common being radiation proctitis (RP). It is characterized by damage to the rectal epithelium by secondary ionizing radiation. Based on the onset of signs and symptoms, post-radiotherapy RP can be classified as acute or chronic, each with varying levels of severity and complication rates. The treatment options available for RP are limited, with most of the data on treatment available from case reports or small studies. Here, we describe the types of RT used in modern-day medicine and radiation-mediated tissue injury. We have primarily focused on the classification, epidemiology, pathogenesis, clinical features, treatment strategies, complications, and prognosis of RP.

Low-volume reduced bowel preparation regimen for CT colonography: a randomized noninferiority trial

PURPOSE

To determine whether the quality of a low-volume reduced bowel preparation (LV-RBP) for CT Colonography (CTC) is noninferior to full-volume reduced bowel preparation (FV-RBP) regimen.

METHODS

In this randomized controlled trial, consecutive participants referred for CTC were randomly assigned to receive LV-RBP (52.5 g of PMF104 in 500 mL of water) or FV-RBP (105 g of PMF104 in 1000 mL of water). Images were independently reviewed by five blinded readers who rated the quality of bowel preparation from 0 (best score) to 3 (worst score). The primary outcome was the noninferiority of LV-RBP to FV-RBP in the proportion of colonic segments scored 0 for cleansing quality, with noninferiority margin of 10%. Volume of residual fluids, colonic distension, lesions and polyps detection rates and patient tolerability were secondary outcomes.

RESULTS

From March 2019 to January 2020, 110 participants (mean age 65 years ± 14 [standard deviation]; 74 women) were allocated to LV-RBP (n = 55) or FV-RBP (n = 55) arms. There were 92% segment scored 0 in colon cleansing quality in LV-RBP and 94% in FV-RBP for prone scans, and 94% vs 92% for supine scans. Risk difference was - 2.1 (95% CI -5.9 to 1.7) and 1.5 (95% CI -2.4 to 5.4) for prone and supine positions, respectively. Residual fluids and colonic distension were also noninferior in LV-RBP. LV-RBP was associated with a lower number of evacuations during preparation (7 ± 5 vs 10 ± 6, p = 0.002).

CONCLUSION

The LV-RBP for CTC demonstrated noninferior quality of colon cleansing with improved gastrointestinal tolerability compared to FV-RBP regimen.

Mobile health interventions for improving colorectal cancer screening rates: A systematic review and meta-analysis

Objective:

The aim of this systematic review and meta-analysis was to determine the efficacy of different mHealth interventions in increasing colorectal cancer (CRC) screening rates.

Methods:

A literature search for eligible studies was done in ClinicalTrials.gov, PubMed, and Scopus in October 2020. Included studies were randomized controlled trials done on adults due for CRC screening, who received either an mHealth intervention to promote screening or usual care. The primary outcome from these studies was completion of CRC screening. Two reviewers independently worked on selecting studies, collecting data, and determining risk of bias. Adjusted odds ratios (AOR) for CRC screening rates were summarized into a Forest plot.

Results:

A total of ten trials from three continents were included in the qualitative analysis. Risk of bias is low in terms of randomization, but high in terms of participant blinding, due to the nature of the interventions. Meta-analysis of four trials showed low clinical and statistical heterogeneity (I²=0%). Overall, the use of mHealth interventions is associated with higher CRC screening uptake when compared to usual care (AOR 1.33; 95% CI, 1.20-1.46). This effect was seen across different types of mHealth interventions, which included automated and non-automated telephone education and text-message reminders.

Conclusion:

This study showed that mHealth is associated with increased CRC screening participation regardless of the type of intervention used.

BRAF V600E and Mismatch Repair Proteins Expression in Sporadic Young-onset Colorectal Cancer in Kelantan, Malaysia

Objectives

We sought to determine the immunohistochemistry expression of mismatch repair (MMR) and BRAF V600E proteins in sporadic young-onset colorectal cancer (CRC) and their association with clinicopathological features in the Kelantan population.

Methods

This was a cross-sectional study of sporadic young-onset CRC over 11 years from 1 January 2006 to 31 December 2017 in Kelantan. Formalin-fixed paraffin-embedded tissue blocks were immunohistochemically stained with antibodies for MMR (MLH1, MSH2, MSH6, and PMS2) and BRAF V600E. These expressions were correlated with clinicopathological parameters.

Results

Our patient sample included 31 patients with a mean age of 31.5 years. More than half (61.3%) of the patients were women. The majority presented with abdominal pain (41.9%), and 71.0% had a tumor located on the right side of the colon, with 83.9% being moderately differentiated adenocarcinoma. The majority of patients presented at stage IV (54.8%). The most frequent pattern was all MMR protein expressions, which constituted patients in the microsatellite stable group (64.5%). Nine (29.0%) were microsatellite instability (MSI-high), and two (6.5%) were MSI-low. Positive BRAF V600E expression was observed in 83.9% of patients. Only histopathological subtypes revealed a significant association with BRAF V600E positive expression (p = 0.015).

Conclusions

The majority of sporadic young-onset CRC presented with abdominal pain and advanced cancer stage. Most were microsatellite stable, and most cases showed positive expressions in all MMR markers and BRAF V600E by immunohistochemistry method. This finding will pave the way for further research on this disease.

Cost effectiveness of using Faecal Immunochemical Testing (FIT) as an initial diagnostic investigation for patients with lower gastrointestinal symptoms suggestive of malignancy

Background

There has been an increase in the numbers of patients presenting to primary care with suspected colorectal malignancy and subsequently an increase in demand for endoscopy. This study aims to forecast the cost of faecal immunochemical testing (FIT) compared to conventional diagnostic tests as a primary investigation for patients with symptoms suggestive of colorectal malignancy.

Methods

Retrospectively, 1950 patients with symptoms suggestive of colorectal malignancy who were referred through primary care and underwent investigations through standard endoscopic evaluation were included. These patients were used to forecast the cost of faecal immunochemical testing creating theoretical data for sensitivity and specificity. Outcome measures included: the number of investigations under current protocol; cost of current investigations; number of predicted false negatives and false positives and positive/negative predictive values using current sensitivity data for FIT; the cost forecast of using FIT as the primary investigation for colorectal malignancy.

Results

Median age was 65 (IQR 47–82) with 43.7% male and 56.3% female. A total of 1950 investigations were carried out with a diagnostic yield of 26 cancers (18 colon, 8 rectal), 138 polyps and 29 high risk adenomas (HGD ±  > 10 mm). In total, £713,948 was spent on the investigations. The commonest investigation was colonoscopy totalling £533,169. The total cost per cancer diagnosis was £27,459. Sensitivity (92.1% CI 86.9–95.3) and specificity (85.8% CI 78.3–90.1) for FIT in colorectal cancer was taken from NICE and was costed via the manufacturer(s). The projected total cost of FIT for the same population using a ≥ 4 μg haemoglobin cut off was £415,680 (£15,554 per cancer). The total cost of high-risk polyps using ≥ 4 μg cut off was £404,427 (sensitivity 71.2% CI 60.5–87.2, specificity 79.8%CI 76.1–83.7) or £13,945 per polyp.

Conclusions

FIT is a cheaper and effective alternative test with the potential to replace current expensive methods. The forecast is based on the limited data available for sensitivity/specificity in the current literature. FIT has now been commenced for symptomatic patients in the UK and therefore sensitivity may change in the future.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01435-7.