[Endoscopic Resection Techniques for Precancerous and Early Cancerous Lesions in the Rectum]

Today, endoscopy plays a decisive role not only in the detection of colorectal adenomas and carcinomas, but also in the treatment of precancerous lesions, in particular flat adenomas and early carcinomas. In recent years, endoscopic submucosal dissection (ESD) has become increasingly important alongside classic polypectomy and mucosal resection after saline injection using a snare (EMR). Using ESD the lesion is marked, injected submucosally using viscous substances and the mucosa incised and tunneled with a transparent cap and a fine diathermy knife. Particularly in the case of widespread and high-risk lesions ESD enables a quasi-surgical "en bloc" resection almost regardless of size, with a histological R0 resection rate of far over 90% in specialized centers. ESD enables an excellent histopathological evaluation and has a low recurrence risk of 1-3%. Endoscopic full-thickness resection using a dedicated device (FTRD system) represents another addition to the armamentarium. It can be used for circumscribed submucosal, suspicious or scarred changes up to 2 cm in the middle and upper rectum. Endoscopic intermuscular dissection (EID) enables histopathological analysis of the complete submucosa beyond the mucosa and upper submucosal layer by including the circular inner muscle layer within the resection specimen. It reduces basal R1 situations and offers a new perspective for T1 carcinomas through curative, organ-preserving endoscopic therapy, especially in the case of deep submucosal infiltration alone, without other risk factors for metastases. Indications, the procedure itself and significance of the various techniques for premalignant and early malignant lesions in the rectum are presented.

Unraveling cervical cancer screening dilemmas: histopathological insights from VIA and LEEP at bugando medical centre, Mwanza

BACKGROUND

The single-visit strategy, also known as the "screen-and-treat" approach, is widely used to screen for cervical cancer in low- and middle-income countries. The screen-and-treat approach leads to unnecessary or inadequate treatment. Thus, a study was conducted to determine the histopathological patterns of aceto-white lesions on visual inspection with acetic acid (VIA) in patients who underwent a Loop Electrosurgical Excision Procedure (LEEP) at Bugando Medical Centre between January 2016 and December 2020.

METHOD

A 5-year retrospective cross-sectional case record review was conducted on 329 women who had LEEP at Bugando Medical Centre following a positive VIA cervical screening test. A standard data abstraction form was used to collect patient information. Missing client information records and LEEP without histopathological results were exclusion criteria. For statistical analysis, STATA version 15 was used; in descriptive statistics, frequency, mean, and standard deviation were used. The Chi2 and Fisher's exact tests were used to investigate the relationship between patient characteristics and histopathological patterns, and a P-value of 0.05 was considered statistically significant in multinomial models.

RESULTS

This study looked at 329 patients who had LEEP following a VIA positive but were not eligible for cryotherapy. Our study participants had a mean age of 40 ± 8.2 SD. There were 203 (61.7%) patients with benign lesions, including 4 with schistosomiasis and 2 with cervical tuberculosis. The precancerous lesions were discovered in 100 cases (30.4%), and 26 (7.9%) already had invasive cervical cancer. Out of 100 patients with precancerous lesions, 58 (17.6%) and 42 (12.8%) have high- and low-grade squamous intraepithelial (HSIL and LSIL) lesions, respectively. The presence of a precancerous lesion was found to be associated with age 31-40 years (P-value 0.042) and HIV positivity (P-value 0.004).

CONCLUSION

Most patients in this study had benign cervical lesions, which do not require LEEP treatment. Nonetheless, a considerable percentage of invasive cervical malignancies and rare benign diseases such as schistosomiasis and cervical tuberculosis were identified. A screen-and-treat approach within well-equipped tertiary hospitals like Bugando Medical Centre should explore alternative options instead of relying solely on straight LEEP.

A Comprehensive Program to Improve Treatment of Precancerous Cervical Lesions in the Rio Grande Valley of Texas

OBJECTIVE

To assess the impact of a multicomponent intervention in women with cervical dysplasia who were treated with loop electrosurgical excision procedure (LEEP), as well as the time between colposcopy and treatment.

DESIGN

Retrospective cohort study.

INTERVENTION

Clinic participation in a multicomponent cervical cancer prevention program that included community outreach, patient in-reach, and navigation, as well as provider capacity building with in-person training and ongoing telementoring through Project ECHO.

MAIN OUTCOME MEASURES

Medical records were reviewed to evaluate women with cervical dysplasia undergoing treatment with LEEP within 90 days of colposcopy, as well as time between colposcopy and treatment. Baseline data from year 1 were compared with each subsequent year of implementation. Additional variables examined included patient's age, history of abnormal screening results, and percentage of families living below poverty line based on county of residence, parity, and clinic site. We performed logistic regression and multiple linear regression analyses to assess the programmatic impact in the outcomes of interest by year of program implementation.

RESULTS

A total of 290 women were included in the study. The proportion of women undergoing treatment within 90 days of colposcopy increased from 76.2% at baseline to 91.3% in year 3 and 92.9% in year 4 of program implementation. The odds of undergoing treatment within 90 days were 5.11 times higher in year 4 of program implementation than at baseline. The mean time between colposcopy and LEEP decreased from 62 days at baseline to 45 days by year 4 of program implementation.

CONCLUSIONS

Implementation of our multicomponent cervical cancer prevention program increased the proportion of women undergoing LEEP within 90 days of colposcopy and decreased the time between colposcopy and LEEP. This program has the potential to support cervical cancer prevention efforts and could be implemented in other low-resource settings.

Increased risk of upstage when combinations of breast lesions of uncertain malignant potential are found on core needle biopsy: The need for surgical excision

BACKGROUND

Management of breast lesions of uncertain malignant potential diagnosed at core needle biopsy (CNB) is controversial due to variable upstage rate (UR) with surgical excision (SE).

METHODS

We performed an IRB-approved retrospective analysis of adult women who underwent CNB demonstrating atypical ductal hyperplasia (ADH), flat epithelial atypia, radial scar, or intraductal papilloma then SE between 2010 and 2022. We evaluated CNB pathology for combination diagnoses (CD), defined as multiple primary lesions or primary with lobular neoplasia (LN), and surgical pathology for upstage.

RESULTS

719 patients were included. UR was 12.2% (88/719). CD experienced higher UR than pure (17.7% (45/254) vs. 9.2% (43/465), p ​= ​0.001). ADH/LN had the highest UR of all CD (34.6% (9/26), p ​= ​0.001). Increased size (15.6 vs. 10.5 ​mm, p ​< ​0.001), distance from nipple (79 vs. 66 ​mm, p ​< ​0.001), and personal history of breast cancer (p ​= ​0.04) were associated with UR.

CONCLUSIONS

CD was associated with increased UR. ADH/LN had the highest UR.

Clinical outcomes of oral epithelial dysplasia managed by observation versus excision

IMPORTANCE

Oral potentially malignant disorders, including oral epithelial dysplasia (OED), are a group of conditions with an increased risk of progression to oral cancer. Clinical management of OED is challenging and usually involves monitoring with repeated incisional biopsies or complete surgical excision.

OBJECTIVE

To determine if complete surgical excision of OED impacts malignant transformation or improves survival outcomes in lesions that progress to malignancy.

DESIGN

A retrospective review of all patients diagnosed with OED between 2009 and 2016 was completed, and patients were followed until January 2022 for disease course and outcomes.

RESULTS

Hundred and fifty-five cases of OED met the inclusion criteria. Among the 61 lesions managed by observation, 15 progressed to cancer. Among the 94 lesions managed by surgical excision, 27 progressed to cancer. The overall malignant transformation rate was 27%, with an annual rate of 6.4%. Surgical excision with or without histologically negative margins did not decrease malignant transformation but was associated with lower oncologic staging at the time of diagnosis and improved survival.

CONCLUSIONS AND RELEVANCE

Surgical excision of OED with or without negative margins did not reduce the rate of transformation to oral cancer but resulted in lower oncologic staging at diagnosis, leading to improved patient outcomes. Our results support the implementation of more extensive tissue sampling to improve cancer diagnosis and patient outcomes.

Prevalence of precancerous gynecological lesions and gynecological cancer in patients undergoing vaginal hysterectomy for pelvic organ prolapse

OBJECTIVES

This retrospective cohort study aimed to determine the prevalence of precancerous or malignant lesions of the cervix and/or endometrium among patients who underwent vaginal hysterectomy.

MATERIALS AND METHODS

Medical record of patients who had been diagnosed with pelvic organ prolapse (POP) and undergone vaginal hysterectomy from January 2009 to September 2018 in tertiary hospital was reviewed. The exclusion criteria included individuals who had previously received a diagnosis of gynecologic precancerous lesions or cancer, had abnormal preoperative findings, presented abnormal cervical cancer screening test results or abnormal results from preoperative endometrial biopsy, and had incomplete operative notes or pathological results.

RESULTS

The electronic medical records of 530 patients were reviewed and included in the analysis. Nine of the 530 patients (1.7%) had precancerous or malignant lesions of the cervix and/or endometrium. The prevalence of atypical endometrial hyperplasia and endometrial carcinoma were 0.19% and 0.57%, respectively. All of the patients with endometrial cancer subsequently underwent complete surgical staging. Precancerous cervical lesions were found in five patients (0.95%): CIN II 0.38% and CIN III 0.57%. No cases of cervical cancer were identified.

CONCLUSIONS

It is possible to detect a minor prevalence of precancerous and malignant lesions following post-operative procedures in POP. The assessment of the elderly through the use of risk-based evaluation merits attention for the purpose of early identification. This study offers valuable insights that can be utilized in preoperative counseling and enhancing the preoperative evaluation process.

Preoperative evaluation of endoscopic submucosal dissection for early gastric cancer

OBJECTIVE

To retrospectively analyze the preoperative endoscopic evaluation of the size, nature, and depth of lesions in endoscopic submucosal dissection (ESD) for early gastric cancer and precancerous lesions, determine whether the lesions can be completely resected, and reduce the risk of additional surgery after ESD.

METHODS

A total of 114 patients with high-grade intraepithelial neoplasia(HGIN) and early gastric cancer treated with ESD in Hebei General Hospital from January 2016 to April 2021 were enrolled in this study. The lesions were evaluated preoperatively according to the endoscopic findings of white light, magnifying endoscopy, endoscopic features of narrow band imaging, and preoperative pathology. Lesion size, positive resection margin, lesion depth, and vascular invasion of postoperative pathology were used as criteria.

RESULTS

There were 121lesions in 114 patients. The coincidence rates of preoperative and postoperative pathology were 87.21% (75/86) for HGIN and 92.1% (35/38) for adenocarcinoma. There was no significant difference in the coincidence rate between preoperative pathological evaluation and postoperative pathology among the 3 lesions (χ2 = 10.614, P = .005). The type and malignancy of the lesion were not related to its location or size. Magnifying endoscopy combined with narrow-band imaging showed that HGIN and early gastric cancer had clear borders, irregular microvessels, and irregular surface microarchitecture on endoscopic features. Lesions > 3 cm, surface ulcers and spontaneous bleeding may be risk factors for deeper lesions.

CONCLUSION

ESD is not only a method for the treatment of early gastric cancer and precancerous lesions, but is also an important method for definite pathological diagnosis. Accurate preoperative assessment of lesion type, lesion extent and depth of invasion is helpful to improve the complete resection rate of ESD and reduce the risk of additional surgery.

EFFICACY ANALYSIS OF ENDOSCOPIC SUBMUCOSAL DISSECTION FOR THE EARLY GASTRIC CANCER AND PRECANCEROUS LESIONS

BACKGROUND

Endoscopic treatment of precancerous lesions and early gastric cancer has been widely accepted in recent years. Endoscopic submucosal dissection (ESD), following established indication criteria, can lead to cure of the disease in more than 90% of cases.

OBJECTIVE

This study aimed to analyze the use of ESD in patients with early gastric cancer and precancerous lesions, as well as the results of the procedure, its complications and effectiveness in controlling the disease.

METHODS

This is a retrospective cohort study composed of 41 patients aged from 53 to 87 years (mean age: 65 years; 58.53% male) who were analyzed from 2008 to 2019. The variables collected from the medical records were: comorbidities, classification of the lesion regarding resection criteria, type of resection, histology, degree of invasion, resection margin, complications, disease recurrence. Statistical analysis was performed using the Kruskal-Wallis test, the McNemar's test, and the Mann-Whitney test, with 5% statistical significance (P<0.05).

RESULTS

The most frequent site of the lesion was the gastric antrum and the predominant presentation by the Japanese or Paris classification was the one with depressed components in 56.09%. Adenocarcinoma occurred in 75.6% of the biopsies, and the remainder were adenomas without neoplasia. En-bloc resection occurred in 97.57% of cases, and compromise of the safety margin occurred in one patient. The main pre-existing comorbidity was liver cirrhosis in 29.26% of cases. There was a significant increase in post- ESD adenocarcinoma compared to pre-resection diagnosis. The mean follow-up time was 38.4 months, with one recurrence (2.43%) and two metachronous lesions (4.87%). Complications during and after the procedure occurred in three patients (7.31%), being due to bleeding (two cases) and perforation (one case). There was one death due to a cardiac event not directly related to the procedure.

CONCLUSION

Endoscopic submucosal dissection proved to be a safe procedure, with a low complication and recurrence rate. Its recommendation must occur within the established criteria; however, it can be indicated for patients outside the criteria, if there is a high risk for surgical treatment.

Current Evidence in the Management of Premalignant Cystic Lesions of the Pancreas in Patients Undergoing Liver Transplantation

ABSTRACT

Incidental premalignant pancreatic cystic lesions (pPCLs) are increasingly being detected in patients undergoing orthotopic liver transplantation (OLT). The impact of chronic immunosuppression upon pPCLs may elevate risk of progression to pancreatic cancer. This systematic review assesses prevalence, outcome, and management of pPCLs in patients undergoing OLT. Systematic literature searches were performed in accordance with Cochrane review guidelines. Data on 658 patients were identified from 13 articles. Median age was 59 years with a prevalence of 6.2%. Most studies focused on branch-duct intraductal papillary mucinous neoplasms. Average cyst size at diagnosis was 10.3 mm. Six patients (0.9%) underwent pancreatic resection, post-OLT, for suspected "worrisome features" on imaging. One death was due to pancreatic-related cancer, post-OLT. Based on the review, the authors suggest the following: (1) patients with pPCLs undergoing OLT, without "worrisome features," should be followed conservatively; (2) presence of pPCLs alone should not preclude eligibility for OLT, nor should chronic immunosuppression be altered; (3) follow-up should parallel standard approach applied in immunocompetent patients, as development of "worrisome features" of cancer is rare and does not appear to be hastened by immunosuppression; (4) resection is recommended for surgically fit patients without portal hypertension that develop "worrisome features."

Efficacy of endoscopic submucosal dissection in treating early colorectal cancer and precancerous lesions

PURPOSE

To compare the efficacy and safety between endoscopic submucosal dissection (ESD) and conventional surgical treatment in the treatment of colorectal cancer (CRC) and the precancerous lesions.

METHODS

A retrospective analysis was performed on the clinical data of 65 patients with CRC or precancerous lesions (ESD group) and another 65 patients receiving surgical treatment at the same period (Surgery group). The surgical indicators, incidence of complications, and quality of life score were compared between the two groups, and the survival and tumor progression were followed up and recorded.

RESULTS

The rate of en bloc tumor resection was 89.2% (58/65) and 100% (65/65) and the rate of tumor curative resection was 92.3% (60/65) and 100% (65/65) in ESD group and Surgery group. Moreover, ESD group had markedly shorter operation time and mean hospital stay. After treatment, ESD group had higher scores of emotional functioning, fatigue, constipation, and diarrhea symptoms and general quality of life on the European Organization for Research and Treatment of Cancer quality of life questionnaire Core 30 (EORTC QLQ-C30) than Surgery group. The follow-up results showed no statistically significant difference in the 5-year recurrence rate between ESD group and Surgery group (7.7% vs. 0%, p=0.208).

CONCLUSION

ESD and surgery have similar long-term clinical efficacy in treating early CRC and precancerous lesions, but ESD is more minimally invasive and safer, and is superior in accelerating postoperative recovery and improving the overall survival of patients.

Prognostic implications of the coexisting precursor lesion types in invasive gallbladder cancer

Invasive gallbladder carcinoma (GBC) is preceded by two main types of precursor lesions: intracholecystic papillary-tubular neoplasms (ICPNs) and biliary intraepithelial neoplasias (BilINs). Invasive GBCs with an ICPN component have more favorable prognoses than those without an ICPN component. Some BilINs show a relatively exophytic papillary pattern but do not meet the ICPN criteria; at our institution, we call these papillary neoplasias. To clarify the clinical significance of papillary neoplasia, we herein examined 80 invasive GBCs and classified them into three groups based on the type of preinvasive lesions: those with ICPN (ICPN group, n = 35), those with papillary neoplasia (pap-neoplasia group, n = 13), and those without ICPN/papillary neoplasia (group without ICPN/pap-neoplasia, n = 32). We then compared the prognostic differences and characterized the tumors of each group by determining the immunohistochemical expressions of various biomarkers. The overall survival periods of the ICPN and pap-neoplasia groups were significantly longer than that of the group without ICPN/pap-neoplasia (P < 0.0001, P = 0.0036, respectively). Multivariate analysis revealed that lacking ICPN/papillary neoplasia was independently associated with poor prognosis (P = 0.0007), as were poor differentiation (P = 0.0395), presence of preoperative symptoms (P = 0.0488), and advanced stage (P = 0.0234). Invasive components of the ICPN and pap-neoplasia groups were characterized by higher expressions of p16 and p53 compared with those of the group without ICPN/pap-neoplasia. The prognoses of the invasive GBCs with either papillary neoplasia or ICPN were thus more favorable than those of the invasive GBCs without ICPN/pap-neoplasia. Invasive GBCs with exophytic papillary preinvasive lesions (ICPN and papillary neoplasia) may be biologically different from those without such lesions.

Radiofrequency ablation for low-grade dysplasia in Barrett's esophagus: long-term outcome of a randomized trial

BACKGROUND AND AIMS

A prior randomized study (Surveillance versus Radiofrequency Ablation study [SURF study]) demonstrated that radiofrequency ablation (RFA) of Barrett's esophagus (BE) with confirmed low-grade dysplasia (LGD) significantly reduces the risk of esophageal adenocarcinoma. Our aim was to report the long-term outcomes of this study.

METHODS

The SURF study randomized BE patients with confirmed LGD to RFA or surveillance. For this retrospective cohort study, all endoscopic and histologic data acquired at the end of the SURF study in May 2013 until December 2017 were collected. The primary outcome was rate of progression to high-grade dysplasia (HGD)/cancer. All 136 patients randomized to RFA (n = 68) or surveillance (n = 68) in the SURF study were included. After closure of the SURF study, 15 surveillance patients underwent RFA based on patient preference and study outcomes.

RESULTS

With 40 additional months (interquartile range, 12-51), the total median follow-up from randomization to last endoscopy was 73 months (interquartile range, 46-85). HGD/cancer was diagnosed in 1 patient in the RFA group (1.5%) and in 23 in the surveillance group (33.8%) (P = .000), resulting in an absolute risk reduction of 32.4% (95% confidence interval [CI], 22.4%-44.2%) with a number needed to treat of 3.1 (95% CI, 2.3-4.5). Seventy-five of 83 patients (90%; 95% CI, 82.1%-95.0%) treated with RFA for BE reached complete clearance of BE and dysplasia. BE recurred in 7 of 75 patients (9%; 95% CI, 4.6%-18.0%), mostly minute islands or tongues, and LGD in 3 of 75 (4%; 95% CI, 1.4%-11.1%).

CONCLUSIONS

RFA of BE with confirmed LGD significantly reduces the risk of malignant progression, with sustained clearance of BE in 91% and LGD in 96% of patients, after a median follow-up of 73 months. (Clinical trial registration number: NTR1198.).

Risk-stratified analysis of pasireotide for patients undergoing pancreatectomy

BACKGROUND AND OBJECTIVES

Pasireotide was shown in a randomized trial to decrease the rate of postoperative pancreatic fistula (POPF). However, retrospective series from other centers have failed to confirm these results.

METHODS

Patients who underwent pancreatoduodenectomy or distal pancreatectomy between January 2014 and February 2019 were included. Patients treated after November 2016 routinely received pasireotide and were compared to a retrospective cohort. Multivariate analysis was performed for the outcome of clinically relevant POPF (CR-POPF), with stratification by fistula risk score (FRS).

RESULTS

Ninety-nine of 300 patients received pasireotide. The distribution of high, intermediate, low, and negligible risk patients by FRS was comparable (P = .487). There were similar rates of CR-POPF (19.2% pasireotide vs 14.9% control, P = .347) and percutaneous drainage (12.1% vs 10.0%, P = .567), with greater median number of drain days in the pasireotide group (6 vs 4 days, P < .001). Multivariate modeling for CR-POPF showed no correlation with operation or pasireotide use. Adjustment with propensity weighted models for high (OR, 1.02, 95% CI, 0.45-2.29) and intermediate (OR, 1.02, CI, 0.57-1.81) risk groups showed no correlation of pasireotide with reduction in CR-POPF.

CONCLUSIONS

Pasireotide administration after pancreatectomy was not associated with a decrease in CR-POPF, even when patients were stratified by FRS.

Surgery versus radical endotherapies for early cancer and high-grade dysplasia in Barrett's oesophagus

BACKGROUND

Barrett's oesophagus is one of the most common pre-malignant lesions in the world. Currently the mainstay of therapy is surgical management of advanced cancer but this has improved the five-year survival very little since the 1980s. As a consequence, improved survival relies on early detection through endoscopic surveillance programmes. Success of this strategy relies on the fact that late-stage pre-malignant lesions or very early cancers can be cured by intervention. Currently there is considerable controversy over which method is best: that is conventional open surgery or endotherapy (techniques involving endoscopy).

OBJECTIVES

We used data from randomised controlled trials (RCTs) to examine the effectiveness of endotherapies compared with surgery in people with Barrett's oesophagus, those with early neoplasias (defined as high-grade dysplasia (HGD) and those with early cancer (defined as carcinoma in-situ, superficially invasive, early cancer or superficial cancer T-1m (T1-a) and T-1sm (T1-b)).

SEARCH METHODS

We used the Cochrane highly sensitive search strategy to identify RCTs in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science, EBMR, Controlled Trials mRCT and ISRCTN, and LILACS, in July and August 2008. The searches were updated in 2009 and again in April 2012.

SELECTION CRITERIA

Types of studies: RCTs comparing endotherapies with surgery in the treatment of high-grade dysplasia or early cancer. All cellular types of cancer were included (i.e. adenocarcinomas, squamous cell carcinomas and more unusual types) but will be discussed separately.

TYPES OF PARTICIPANTS

patients of any age and either gender with a histologically confirmed diagnosis of early neoplasia (HGD and early cancer) in Barrett's or squamous lined oesophagus. Types of interventions; endotherapies (the intervention) compared with surgery (the control), all with curative intent.

DATA COLLECTION AND ANALYSIS

Reports of studies that meet the inclusion criteria for this review would have been analysed using the methods detailed in Appendix 9.

MAIN RESULTS

We did not identify any studies that met the inclusion criteria. In total we excluded 13 studies that were not RCTs but that compared surgery and endotherapies.

AUTHORS' CONCLUSIONS

This Cochrane review has indicated that there are no RCTs to compare management options in this vital area, therefore trials should be undertaken as a matter of urgency. The problems with such randomised methods are standardising surgery and endotherapies in all sites, standardising histopathology in all centres, assessing which patients are fit or unfit for surgery and making sure there are relevant outcomes for the study (i.e. long-term survival (over five or more years)) and no progression of HGD.

Serrated polyps of the colon and rectum: Remove or not?

In recent years, the serrated neoplasia pathway where serrated polyps arise as a colorectal cancer has gained considerable attention as a new carcinogenic pathway. Colorectal serrated polyps are histopathologically classified into hyperplastic polyps (HPs), sessile serrated lesions, and traditional serrated adenomas; in the serrated neoplasia pathway, the latter two are considered to be premalignant. In western countries, all colorectal polyps, including serrated polyps, apart from diminutive rectosigmoid HPs are removed. However, in Asian countries, the treatment strategy for colorectal serrated polyps has remained unestablished. Therefore, in this review, we described the clinicopathological features of colorectal serrated polyps and proposed to remove HPs and sessile serrated lesions ≥ 6 mm in size, and traditional serrated adenomas of any size.

Prognostic Significance of ALDH1, Bmi1, and OCT4 Expression in Oral Epithelial Dysplasia and Oral Squamous Cell Carcinoma

BACKGROUND

Increasing evidence suggests the involvement of cancer stem cells (CSCs) in both oral epithelial dysplasia (OED) and oral squamous cell carcinoma (OSCC). Among the various CSC markers, aldehyde dehydrogenase (ALDH) 1, B cell-specific Moloney murine leukaemia virus integration site 1 (Bmi1), and octamer-binding protein 4 (OCT4) have been noted to increase in OSCC. The aim of the study was to analyze ALDH1, Bmi1, and OCT4 expression in OED and OSCC with clinicopathologic correlation and survival analysis.

METHODS

A total of 40 cases each of OED and OSCC were retrieved from departmental archives. Expression of ALDH1, Bmi1, and OCT4 was analyzed using immunohistochemistry and was correlated with clinicopathological parameters. A follow-up ranging from 6 to 52 months was considered for Kaplan-Meier survival analysis. The log-rank test was performed to analyze significant difference in survival rates.

RESULTS

The expression levels of ALDH1, Bmi1, and OCT4 increased significantly from OED through OSCC (P < .05). The expression of ALDH1 and OCT4 showed a significant correlation with lymph node metastasis. Positive cases of ALDH1 showed a significantly reduced survival rate compared to cases showing negative expression. Kaplan-Meier survival analysis showed a significant reduction of survival rate (P = .00) in patients showing a positive expression for all the 3 markers.

CONCLUSION

ALDH1 and OCT4 could be used as individual prognostic markers for assessing prognosis. ALDH1, Bmi1, and OCT4 could be used as a collective panel of markers to enable surgeons in predicting the prognosis of patients and thereby carry out prompt follow-up for such cases.

Preoperative predictors of endometrial cancer at time of hysterectomy for endometrial intraepithelial neoplasia or complex atypical hyperplasia

BACKGROUND

Endometrial intraepithelial neoplasia, also known as complex atypical hyperplasia, is a precancerous lesion of the endometrium associated with a 40% risk of concurrent endometrial cancer at the time of hysterectomy. Although a majority of endometrial cancers diagnosed at the time of hysterectomy for endometrial intraepithelial neoplasia are low risk and low stage, approximately 10% of patients ultimately diagnosed with endometrial cancers will have high-risk disease that would warrant lymph node assessment to guide adjuvant therapy decisions. Given these risks, some physicians choose to refer patients to a gynecologic oncologist for definitive management. Currently, few data exist regarding preoperative factors that can predict the presence of concurrent endometrial cancer in patients with endometrial intraepithelial neoplasia. Identification of these factors may assist in the preoperative triaging of patients to general gynecology or gynecologic oncology.

OBJECTIVE

To determine whether preoperative factors can predict the presence of concurrent endometrial cancer at the time of hysterectomy in patients with endometrial intraepithelial neoplasia; and to describe the ability of preoperative characteristics to predict which patients may be at a higher risk for lymph node involvement requiring lymph node assessment at the time of hysterectomy.

MATERIALS AND METHODS

We conducted a retrospective cohort study of women undergoing hysterectomy for pathologically confirmed endometrial intraepithelial neoplasia from January 2004 to December 2015. Patient demographics, imaging, pathology, and outcomes were recorded. The "Mayo criteria" were used to determine patients requiring lymphadenectomy. Unadjusted associations between covariates and progression to endometrial cancer were estimated by 2-sample t-tests for continuous covariates and by logistic regression for categorical covariates. A multivariable model for endometrial cancer at the time of hysterectomy was developed using logistic regression with 5-fold cross-validation.

RESULTS

Of the 1055 charts reviewed, 169 patients were eligible and included. Of these patients, 87 (51.5%) had a final diagnosis of endometrial intraepithelial neoplasia/other benign disease, whereas 82 (48.5%) were ultimately diagnosed with endometrial cancer. No medical comorbidities were found to be strongly associated with concurrent endometrial cancer. Patients with endometrial cancer had a thicker average endometrial stripe compared to the patients with no endometrial cancer at the time of hysterectomy (15.7 mm; standard deviation, 9.5) versus 12.5 mm; standard deviation, 6.4; P = .01). An endometrial stripe of ≥2 cm was associated with 4.0 times the odds of concurrent endometrial cancer (95% confidence interval, 1.5-10.0), controlling for age. In all, 87% of endometrial cancer cases were stage T1a (Nx or N0). Approximately 44% of patients diagnosed with endometrial cancer and an endometrial stripe of ≥2 cm met the "Mayo criteria" for indicated lymphadenectomy compared to 22% of endometrial cancer patients with an endometrial stripe of <2 cm.

CONCLUSION

Endometrial stripe thickness and age were the strongest predictors of concurrent endometrial cancer at time of hysterectomy for endometrial intraepithelial neoplasia. Referral to a gynecologic oncologist may be especially warranted in endometrial intraepithelial neoplasia patients with an endometrial stripe of ≥2 cm given the increased rate of concurrent cancer and potential need for lymph node assessment.

Reviewing the Evidence that Polypectomy Prevents Cancer

Colonoscopic polypectomy is fundamental to effective prevention of colorectal cancer. Polypectomy reduces colorectal cancer incidence and mortality by altering the natural history and progression of precancerous precursor polyps. Epidemiologic data from the United States, where colorectal cancer rates have been steadily declining in parallel with screening efforts, provide indisputable evidence about the effectiveness of polypectomy. Randomized controlled trials of fecal occult blood tests and flexible sigmoidoscopy, and observational colonoscopy studies, provide additional support. Longitudinal studies have shown variable levels of protection after polypectomy, highlighting the central importance of high quality and adequate surveillance of higher-risk patients.

Colorectal cancer surveillance in inflammatory bowel disease: Practice guidelines and recent developments

Patients with long-standing inflammatory bowel disease (IBD) involving at least 1/3 of the colon are at increased risk for colorectal cancer (CRC). Advancements in CRC screening and surveillance and improved treatment of IBD has reduced CRC incidence in patients with ulcerative colitis and Crohn’s colitis. Most cases of CRC are thought to arise from dysplasia, and recent evidence suggests that the majority of dysplastic lesions in patients with IBD are visible, in part thanks to advancements in high definition colonoscopy and chromoendoscopy. Recent practice guidelines have supported the use of chromoendoscopy with targeted biopsies of visible lesions rather than traditional random biopsies. Endoscopists are encouraged to endoscopically resect visible dysplasia and only recommend surgery when a complete resection is not possible. New technologies such as virtual chromoendoscopy are emerging as potential tools in CRC screening. Patients with IBD at increased risk for developing CRC should undergo surveillance colonoscopy using new approaches and techniques.

Current Status of Endoscopic Resection of Gastric Subepithelial Tumors

Most gastrointestinal (GI) subepithelial tumors (SETs) are identified incidentally during endoscopic examination and are located in the stomach. Some SETs are malignant or have the potential to become malignant. Tumors originating from deeper layers, such as the muscularis propria or serosa, are not easy to diagnose and resect. Current guidelines recommend yearly endoscopic surveillance of SETs smaller than 2 cm. This recommendation may not be cost-effective in managing GI SETs. Endoscopic resection results not only in obtaining sufficient tissue for pathological diagnosis but also in resection and curing the tumor. Many different endoscopic methods for resection of GI SETs have been published in the literature. To avoid confusion, we have divided these methods into standard endoscopic submucosal dissection, modified endoscopic submucosal dissection, submucosal tunneling endoscopic resection, and nonexposed and exposed endoscopic full-thickness resection. These procedures offer less invasive approaches than surgery for resection of GI SETs and may be the most cost-effective in taking care of patients with GI SETs.

Pine-cone and villi patterns are endoscopic signs suggestive of ulcerative colitis-associated colorectal cancer and dysplasia

BACKGROUND AND AIMS

The appropriate site for targeted biopsy during surveillance colonoscopy for ulcerative colitis (UC) is still unclear. We aimed to clarify key endoscopic findings suggestive of neoplastic lesions for targeted biopsy in UC.

METHODS

First, we created 769 stereomicroscopic pictures (509 neoplastic, 260 non-neoplastic) mimicking magnifying colonoscopic images from surgically resected specimens, including areas surrounding 25 neoplastic lesions in 15 patients with colitis-associated cancer at a single referral center. Second, we validated the results by using 113 magnifying endoscopic images (64 neoplastic, 49 non-neoplastic) from 39 lesions in 26 patients. Two evaluators, blinded to the pathologic diagnosis, independently classified them according to Kudo's pit pattern and surface morphology, such as pine-cone/villi patterns. The correlation between stereomicroscopic and pathologic findings (neoplastic vs non-neoplastic) for each image was investigated. The interobserver agreement was assessed using kappa statistics.

RESULTS

In the stereomicroscopic analysis, neoplastic pit patterns (types III-V) were significantly correlated with the presence of neoplasia (sensitivity 77.4%, specificity 89.5%, kappa value 0.677). Pine-cone/villi patterns also showed high specificity (96.8%) but low sensitivity (21.4%, kappa value 0.625) for neoplasia. Endoscopic validation showed similar trends. A revision of the endoscopic findings of flat dysplasia with non-neoplastic pit patterns revealed that a reddish area may facilitate the identification of such lesions.

CONCLUSIONS

Targeted biopsies are recommended, especially for lesions showing pine-cone/villi patterns in addition to neoplastic pit patterns. For flat "non-neoplastic pit patterns," a reddish area may be an indication for a biopsy.

Solutions for submucosal injection: What to choose and how to do it

During the past decades, endoscopic resection techniques have gradually improved and gained more importance for the management of premalignant lesions and early cancers. These endoscopic resection techniques can be divided in 3 major groups: snare polipectomy, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). The use of submucosal injection is essential for the majority of EMR techniques and is an integral part of ESD, whereas during polipectomy it is not crucial in most cases except to prevent bleeding in large polyps and/or those with large stalks as an alternative to mechanical methods. Injection provides a lifting up effect of the lesion separating it from the muscular layer, thereby reducing thermal injury and the risk of perforation and bleeding while also facilitating en-bloc resection by improving technical feasibility. With this work, we aim to review the most common endoscopic resection techniques and the importance of submucosal injection in each one of them. For that, we present some of the most commonly used submucosal injection solutions, taking into account their advantages and disadvantages. We also discuss, based on current recommendations and our own experience, how and when to preform submucosal injection, depending on lesions features and endoscopic resection technique that´s being used, to assure complete resection and to prevent associated adverse events. Finally, we also present and discuss some new proposed submucosal injection solutions, endoscopic resection techniques and devices that may have a major impact on the future of therapeutic endoscopy.

Treatment for gastric ‘indefinite for neoplasm/dysplasia’ lesions based on predictive factors

BACKGROUND

Gastric ‘indefinite for neoplasm/dysplasia’ (IFND) is a borderline lesion that is difficult to diagnose as either regenerative or neoplastic. There is a need for guidance in the identification of a subset of patients, who have an IFND lesion with a higher risk of malignant potential, to enable risk stratification and optimal management.

AIM

To determine the clinical and pathologic factors for the accurate diagnosis of gastric IFND lesions.

METHODS

In total, 461 gastric lesions diagnosed via biopsy as IFND lesions were retrospectively evaluated. Endoscopic resection (n = 134), surgery (n = 22), and follow-up endoscopic biopsy (n = 305) were performed to confirm the diagnosis. The time interval from initial biopsy to cancer diagnosis was measured, and diagnostic delays were categorized as > 2 wk, > 2 mo, > 6 mo, and > 1 year. The IFND lesions presenting as regenerating atypia (60%) or atypical epithelia (40%) at initial biopsy were adenocarcinomas in 22.6%, adenomas in 8.9%, and gastritis in 68.5% of the cases.

RESULTS

Four clinical factors [age ≥ 60 years (2.445, 95%CI: 1.305-4.580, P = 0.005), endoscopic size ≥ 10 mm (3.519, 95%CI: 1.891-6.548, P < 0.001), single lesion (5.702, 95%CI: 2.212-14.696, P < 0.001), and spontaneous bleeding (4.056, 95%CI: 1.792-9.180, P = 0.001)], and two pathologic factors [atypical epithelium (25.575, 95%CI: 11.537-56.695, P < 0.001], and repeated IFND diagnosis [6.022, 95%CI: 1.822-19.909, P = 0.003)] were independent risk factors for gastric cancer. With two or more clinical factors, the sensitivity and specificity for carcinoma were 91.3% and 54.9%, respectively. Ten undifferentiated carcinomas were initially diagnosed as IFND. In the subgroup analysis, fold change (5.594, 95%CI: 1.458-21.462, P = 0.012) predicted undifferentiated or invasive carcinoma in the submucosal layers or deeper. Diagnostic delays shorter than 1 year were not associated with worse prognoses. Extremely well-differentiated adenocarcinomas accounted for half of the repeated IFND cases and resulted in low diagnostic accuracy even on retrospective blinded review.

CONCLUSION

More than two clinical and pathologic factors each had significant cut-off values for gastric carcinoma diagnosis; in such cases, endoscopic resection should be considered.

Cryotherapy in the management of premalignant and malignant conditions of the esophagus

Endoscopic cryotherapy is a relatively new thermal ablative modality used for the treatment of neoplastic lesions of the esophagus. It relies on cycles of rapid cooling and thawing to induce tissue destruction with a cryogen (liquid nitrogen or carbon dioxide) leading to intra and extra-cellular damage. Surgical treatment was once considered the standard therapeutic intervention for neoplastic diseases of the esophagus and is associated with considerable rates of morbidity and mortality. Several trials that evaluated cryotherapy in Barrett’s esophagus (BE) associated neoplasia showed reasonable efficacy rates and safety profile. Cryotherapy has also found applications in the treatment of esophageal cancer, both for curative and palliative intent. Cryotherapy has also shown promising results as salvage therapy in cases refractory to radiofrequency ablation treatment. Cryoballoon focal ablation using liquid nitrogen is a novel mode of cryogen delivery which has been used for the treatment of BE with dysplasia and squamous cell carcinoma. Most common side effects of cryotherapy reported in the literature include mild chest discomfort, esophageal strictures and bleeding. In conclusion, cryotherapy is an effective and safe method for the treatment of esophageal neoplastic processes, ranging from early stages of low grade dysplasia to esophageal cancer.

Efficacy and safety of endoscopic submucosal tunnel dissection for superficial esophageal squamous cell carcinoma and precancerous lesions

AIM

To evaluate the clinical outcomes of patients who underwent endoscopic submucosal tunnel dissection (ESTD) for esophageal squamous cell carcinoma (ESCC) and precancerous lesions.

METHODS

ESTD was performed in 289 patients. The clinical outcomes of the patients and pathological features of the lesions were retrospectively reviewed.

RESULTS

A total of 311 lesions were included in the analysis. The en bloc rate, complete resection rate, and curative resection rate were 99.04%, 81.28%, and 78.46%, respectively. The ESTD procedure time was 102.4 ± 35.1 min, the mean hospitalization time was 10.3 ± 2.8 d, and the average expenditure was 3766.5 ± 846.5 dollars. The intraoperative bleeding rate was 6.43%, the postoperative bleeding rate was 1.61%, the perforation rate was 1.93%, and the postoperative infection rate was 9.65%. Esophageal stricture and positive margin were severe adverse events, with an incidence rate of 14.79% and 15.76%, respectively. No tumor recurrence occurred during the follow-up period.

CONCLUSION

ESTD for ESCC and precancerous lesions is feasible and relatively safe, but for large mucosal lesions, the rate of esophageal stricture and positive margin is high.

Cryotherapy for persistent Barrett's esophagus after radiofrequency ablation: a systematic review and meta-analysis

BACKGROUND AND AIMS

A small but significant proportion of patients with Barrett's esophagus (BE) have persistent dysplasia or intestinal metaplasia (IM) after treatment with radiofrequency ablation (RFA). Cryotherapy is a cold-based ablative modality that is increasingly being used in this setting. We aimed to better understand the efficacy of second-line cryotherapy in patients with BE who have persistent dysplasia or IM after RFA by conducting a systematic review and meta-analysis.

METHODS

We performed a systematic literature search of Pubmed, EMBASE, and Web of Science through September 1, 2017. Articles were included for meta-analysis based on the following inclusion criteria: ≥5 patients with BE treated with RFA had persistent dysplasia or IM; they subsequently underwent ≥1 session of cryotherapy with follow-up endoscopy; the proportions of patients achieving complete eradication of dysplasia (CE-D) and/or IM (CE-IM) were reported. The main outcomes were pooled proportions of CE-D and CE-IM by using a random effects model.

RESULTS

Eleven studies making up 148 patients with BE treated with cryotherapy for persistent dysplasia or IM after RFA were included. The pooled proportion of CE-D was 76.0% (95% confidence interval [CI] 57.7-88.0), with substantial heterogeneity (I2 = 62%). The pooled proportion of CE-IM was 45.9% (95% CI, 32.0-60.5) with moderate heterogeneity (I2 = 57%). Multiple preplanned subgroup analyses did not sufficiently explain the heterogeneity. Adverse effects were reported in 6.7% of patients.

CONCLUSION

Cryotherapy successfully achieved CE-D in three fourths and CE-IM in half of patients with BE who did not respond to initial RFA. Considering its favorable safety profile, cryotherapy may be a viable second-line option for this therapeutically challenging cohort of patients with BE, but higher-quality studies validating this remain warranted.

Gastritis Cystica Polyposa: A Possible Precancerous Lesion

Twenty polypoid lesions at gastroenterostomy stomas (the so-called gastritis cystica polyposa - GCP) were endoscopically removed from gastroenterostomy stomas of 16 male and two female patients previously operated for benign lesions. The interval from surgery ranged from 3 to 40 years (mean: 16.2 years). At light microscopy GCP showed 2 histologic patterns: a) with cystic glands limited to the mucosal layer (gastritis cystica superficialis); b) with cystic glands also spreading into the submucosa (gastritis cystica profunda). Atrophy of specific gastric glands, intestinal metaplasia and dysplastic changes also occurred. Local chronic ischemia and inflammatory reaction as a consequence of gastric surgery and suture at gastroenterostomy together with bile reflux were considered responsible for the development of GCP. The sites and the histologic features of GCP resembled those of experimental stomal polyps proceeding carcinoma in rats after partial gastrectomy. The sites of formation, the sex incidence, the interval from previous operation as well as the histologic findings suggest that GCP is a possible precancerous lesion.

Cost-effectiveness and short-term clinical outcomes of argon plasma coagulation compared with endoscopic submucosal dissection in the treatment of gastric low-grade dysplasia

Endoscopic treatment such as endoscopic submucosal dissection (ESD) or argon plasma coagulation (APC) is widely performed to treat gastric low-grade dysplasia (LGD). We aimed to evaluate the clinical efficacy of APC versus ESD for gastric LGD in terms of cost-effectiveness. This was a retrospective review of patients with gastric LGD who were treated with endoscopic intervention (APC or ESD) between March 2011 to December 2015. Fifty-nine patients treated with APC and 124 patients treated with ESD were included. Patients in the APC group were significantly older (mean age, 67.68 vs 63.90 years, respectively, P < .01), had an increased rate of Helicobacter pylori infection (27.1 vs 10.5%, respectively, P < .01), and had a higher mean Charlson Comorbidity Index score (2.32 vs 0.38, respectively, P < .01) than those in the ESD group. The 2 groups did not differ in tumor size, location, macroscopic morphology, or surface configuration. The procedure time (11.31 vs56.44 minutes, respectively, P < .01), and hospital stay (3.2 vs 5.6 days, respectively, P < .01) were significantly, shorter in the APC group than in the ESD group. Additionally, the cost incurred was significantly, lower in the APC group than in the ESD group (962.03 vs 2,534.80 dollars, respectively, P < .01). APC has many advantages related to safety, and cost-effectiveness compared with ESD. Therefore, APC can be considered an alternative treatment option for gastric LGD.

Metaplastic Cells in the Stomach Arise, Independently of Stem Cells, via Dedifferentiation or Transdifferentiation of Chief Cells

Spasmolytic polypeptide-expressing metaplasia (SPEM) develops in patients with chronic atrophic gastritis due to infection with Helicobacter pylori; it might be a precursor to intestinal metaplasia and gastric adenocarcinoma. Lineage tracing experiments of the gastric corpus in mice have not established whether SPEM derives from proliferating stem cells or differentiated, post-mitotic zymogenic chief cells in the gland base. We investigated whether differentiated cells can give rise to SPEM using a nongenetic approach in mice. Mice were given intraperitoneal injections of 5-fluorouracil, which blocked gastric cell proliferation, plus tamoxifen to induce SPEM. Based on analyses of molecular and histologic markers, we found SPEM developed even in the absence of cell proliferation. SPEM therefore did not arise from stem cells. In histologic analyses of gastric resection specimens from 10 patients with adenocarcinoma, we found normal zymogenic chief cells that were transitioning into SPEM cells only in gland bases, rather than the proliferative stem cell zone. Our findings indicate that SPEM can arise by direct reprogramming of existing cells-mainly of chief cells.

The presence of papillary features in thyroid nodules diagnosed as atypia of undetermined significance or follicular lesion of undetermined significance increases cancer risk and should influence treatment

BACKGROUND

The objective of this study was to evaluate the influence of papillary features on risk of malignancy (ROM) within the Atypia of Undetermined Significance or Follicular Lesion of Undetermined Significance (AUS-FLUS) Bethesda System for Reporting Thyroid Cytopathology (BSRTC) diagnostic category.

METHODS

A Retrospective review of cases with an AUS-FLUS diagnosis that underwent a thyroidectomy was carried out, and cases were subcategorized based upon the presence of papillary features.

RESULTS

For the entire study population there were 93 (22%) of 427 FNAB specimens that had an AUS-FLUS diagnosis, and a 32% associated ROM. Papillary features were identified in 44 FNAB specimens (47% of the AUS-FLUS cases or 10% of the entire study population), and when present had a 45% ROM. The 49 FNAB specimens (53%) that did not exhibit papillary features had a significantly lower ROM (20%) than those that did have papillary features (p = 0.0069).

CONCLUSIONS

The presence of papillary features in a thyroid FNAB with an AUS-FLUS diagnosis is common, and is associated with a higher ROM than is currently suggested by the BSRTC.

Surgical Management of Oral Cancer

Today, most head and neck cancer subsites, such as the larynx, hypopharynx, nasopharynx, and oropharynx, are treated with radiation therapy with or without chemotherapy as a primary treatment modality. Surgery is reserved for the salvage of recurrent tumors that occur within the head and neck in the absence of distant (ie, lung, liver) metastasis. However, unlike all other head and neck subsites, oral cancer should ideally be managed with primary surgery with the possibility of adjuvant radiation therapy with or without chemotherapy depending on the presence of certain high-risk pathologic features.

Metformin for endometrial hyperplasia

BACKGROUND

Endometrial cancer is one of the most common gynaecological cancers in the world. Rates of endometrial cancer are rising, in part because of rising obesity rates. Endometrial hyperplasia is a precancerous condition in women that can lead to endometrial cancer if left untreated. Endometrial hyperplasia occurs more commonly than endometrial cancer. Progesterone tablets currently used to treat women with endometrial hyperplasia are associated with adverse effects in up to 84% of women. The levonorgestrel intrauterine device (Mirena Coil, Bayer HealthCare Pharmaceuticals, Inc., Whippany, NJ, USA) may improve compliance, but it is invasive, is not acceptable to all women, and is associated with irregular vaginal bleeding in 82% of cases. Therefore, an alternative treatment for women with endometrial hyperplasia is needed. Metformin, a drug that is often used to treat people with diabetes, has been shown in some human studies to reverse endometrial hyperplasia. However, the effectiveness and safety of metformin for treatment of endometrial hyperplasia remain uncertain.

OBJECTIVES

To determine the effectiveness and safety of metformin in treating women with endometrial hyperplasia.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Google Scholar, OpenGrey, Latin American Caribbean Health Sciences Literature (LILACS), and two trials registers from inception to 10 January 2017. We searched the bibliographies of all included studies and reviews on this topic. We also handsearched the conference abstracts of the European Society of Human Reproduction and Embryology (ESHRE) 2015 and the American Society for Reproductive Medicine (ASRM) 2015.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cross-over trials comparing metformin (used alone or in combination with other medical therapies) versus placebo or no treatment, any conventional medical treatment, or any other active intervention for women with histologically confirmed endometrial hyperplasia of any type.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for eligibility, extracted data from included studies, and assessed the risk of bias of included studies. We resolved disagreements by discussion or by deferment to a third review author. When study details were missing, review authors contacted study authors. The primary outcome of this review was regression of endometrial hyperplasia histology (with or without atypia) towards normal histology. Secondary outcome measures included recurrence of endometrial hyperplasia, progression of endometrial hyperplasia to endometrial cancer, hysterectomy rate, abnormal uterine bleeding, health-related quality of life, and adverse effects during treatment.

MAIN RESULTS

We included three RCTs in which a total of 77 women took part. We rated the quality of the evidence as very low for all outcomes owing to very serious risk of bias (associated with poor reporting, attrition, and limitations in study design) and imprecision.We performed a meta-analysis of two trials with 59 participants. When metformin was compared with megestrol acetate in women with endometrial hyperplasia, we found insufficient evidence to determine whether there were differences between groups for the following outcomes: regression of endometrial hyperplasia histology towards normal histology (odds ratio (OR) 3.34, 95% confidence interval (CI) 0.97 to 11.57, two RCTs, n = 59, very low-quality evidence), hysterectomy rates (OR 0.91, 95% CI 0.05 to 15.52, two RCTs, n = 59, very low-quality evidence), and rates of abnormal uterine bleeding (OR 0.91, 95% CI 0.05 to 15.52, two RCTs, n = 44 , very low-quality evidence). We found no data for recurrence of endometrial hyperplasia or health-related quality of life. Both studies (n = 59) provided data on progression of endometrial hyperplasia to endometrial cancer as well as one (n = 16) reporting some adverse effects in the metformin arm, notably nausea, thrombosis, lactic acidosis, abnormal liver and renal function among others.Another trial including 16 participants compared metformin plus megestrol acetate versus megestrol acetate alone in women with endometrial hyperplasia. We found insufficient evidence to determine whether there were differences between groups for the following outcomes: regression of endometrial hyperplasia histology towards normal histology (OR 9.00, 95% CI 0.94 to 86.52, one RCT, n = 16, very low-quality evidence), recurrence of endometrial hyperplasia among women who achieve regression (OR not estimable, no events recorded, one RCT, n = 8, very low-quality evidence), progression of endometrial hyperplasia to endometrial cancer (OR not estimable, no events recorded, one RCT, n = 13, very low-quality evidence), or hysterectomy rates (OR 0.29, 95% CI 0.01 to 8.37, one RCT, n = 16, very low-quality evidence). Investigators provided no data on abnormal uterine bleeding or health-related quality of life. In terms of adverse effects, three of eight participants (37.5%) in the metformin plus megestrol acetate study arm reported nausea.

AUTHORS' CONCLUSIONS

At present, evidence is insufficient to support or refute the use of metformin alone or in combination with standard therapy - specifically, megestrol acetate - versus megestrol acetate alone, for treatment of endometrial hyperplasia. Robustly designed and adequately powered randomised controlled trials yielding long-term outcome data are needed to address this clinical question.

British Society of Gastroenterology position statement on serrated polyps in the colon and rectum

Serrated polyps have been recognised in the last decade as important premalignant lesions accounting for between 15% and 30% of colorectal cancers. There is therefore a clinical need for guidance on how to manage these lesions; however, the evidence base is limited. A working group was commission by the British Society of Gastroenterology (BSG) Endoscopy section to review the available evidence and develop a position statement to provide clinical guidance until the evidence becomes available to support a formal guideline. The scope of the position statement was wide-ranging and included: evidence that serrated lesions have premalignant potential; detection and resection of serrated lesions; surveillance strategies after detection of serrated lesions; special situations-serrated polyposis syndrome (including surgery) and serrated lesions in colitis; education, audit and benchmarks and research questions. Statements on these issues were proposed where the evidence was deemed sufficient, and re-evaluated modified via a Delphi process until >80% agreement was reached. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool was used to assess the strength of evidence and strength of recommendation for finalised statements. Key recommendation: we suggest that until further evidence on the efficacy or otherwise of surveillance are published, patients with sessile serrated lesions (SSLs) that appear associated with a higher risk of future neoplasia or colorectal cancer (SSLs ≥10 mm or serrated lesions harbouring dysplasia including traditional serrated adenomas) should be offered a one-off colonoscopic surveillance examination at 3 years (weak recommendation, low quality evidence, 90% agreement).

Risk factors for metachronous gastric carcinoma development after endoscopic resection of gastric dysplasia: Retrospective, single-center study

AIM

To determine the gastric adenocarcinoma (GAC) occurrence rate and related factors, we evaluated the follow-up results of patients confirmed to have gastric dysplasia after endoscopic resection (ER).

METHODS

We retrospectively analyzed the medical records, endoscopic examination records, endoscopic procedure records, and histological records of 667 cases from 641 patients who were followed-up for at least 12 mo, from among 1273 patients who were conformed to have gastric dysplasia after Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) of gastric mucosal lesions between January 2007 and August 2013 at the Chungnam National University Hospital.

RESULTS

The mean follow-up period was 33.8 mo, and the median follow-up period was 29 mo (range: 12-87). During the follow-up period, the occurrence of metachronous GAC was 4.0% (27/667). The mean and median interval periods between the occurrence of metachronous GAC and endoscopic treatment of gastric dysplasia were 36.3 and 34 mo, respectively (range: 16-71). The factors related to metachronous GAC occurrence after ER for gastric dysplasia were male sex (5.3% vs 1.0%), open-type atrophic gastritis (9.5% vs 3.4%), intestinal metaplasia (6.8% vs 2.4%), and high-grade dysplasia (HGD; 8.4% vs 3.2%). Among them, male sex [OR: 5.05 (1.18-21.68), P = 0.029], intestinal metaplasia [OR: 2.78 (1.24-6.23), P = 0.013], and HGD [OR: 2.70 (1.16-6.26), P = 0.021] were independent related factors in multivariate analysis. Furthermore, 24 of 27 GAC cases (88.9%) occurred at sites other than the previous resection sites, and 3 (11.1%) occurred at the same site as the previous resection site.

CONCLUSION

Male sex, intestinal metaplasia, and HGD were significantly related to the occurrence of metachronous GAC after ER of gastric dysplasia, and most GACs occurred at sites other than the previous resection sites.

Case of pediatric traditional serrated adenoma resected via endoscopic submucosal dissection

Traditional serrated adenoma (TSA) is a type of serrated polyp of the colorectum and is thought to be a precancerous lesion. There are three types of serrated polyps, namely, hyperplastic polyps, sessile serrated adenomas/polyps, and TSAs. TSA is the least common of the three types and accounts for about 5% of serrated polyps. Here we report a pediatric case of TSA that was successfully resected by endoscopic submucosal dissection (ESD). This rare case report describes a pediatric patient with no family history of colonic polyp who was admitted to our hospital with hematochezia. On colonoscopy, we found a polypoid lesion measuring 10 mm in diameter in the lower rectum. We selected ESD as a surgical option for en bloc resection, and histopathological examination revealed TSA. The findings in this case suggest that TSA with precancerous potential can occur in children, and that ESD is useful for treating this lesion.

Two cases of colon LST in transplanted liver patients

Long-life immunosuppressive therapy increases the risk of de novo tumors in liver transplant recipients by decreasing the immune surveillance against malignant cells and oncogenic viruses. However, no cases of colon precancerous lesions have been reported in these subjects. Patient n. 1, a 73 yrs old male treated with calcineurin and purine synthesis inhibitors, showed at a per-protocol colono-scopy a 3 cm laterally spreading tumor (LST). Patient n. 2, a 73 yrs old male treated with calcineurin inhibitors, showed at a screening colonoscopy an LST occupying one third of the lumen circumference. Both subjects were asymptomatic, had been transplanted 14 years before, and in both cases, lesions showed severe dysplasia. LSTs represent 17.2% of advanced colorectal neoplasia (CRC) and risk factors are multifactorial. Immunosuppression may play a role which is however not completely understood. Based on this report, surveillance colonoscopy in liver transplanted patients should be considered.

[Value of endoscopy application in the management of complications after radical gastrectomy for gastric cancer]

Endoscopy plays an important role in the diagnosis and treatment of postoperative complications of gastric cancer. Endoscopic intervention can avoid the second operation and has attracted wide attention. Early gastric anastomotic bleeding after gastrectomy is the most common. With the development of technology, emergency endoscopy and endoscopic hemostasis provide a new treatment approach. According to the specific circumstances, endoscopists can choose metal clamp to stop bleeding, electrocoagulation hemostasis, local injection of epinephrine or sclerotherapy agents, and spraying specific hemostatic agents. Anastomotic fistula is a serious postoperative complication. In addition to endoscopically placing the small intestine nutrition tube for early enteral nutrition support treatment, endoscopic treatment, including stent, metal clip, OTSC, and Over-stitch suture system, can be chosen to close fistula. For anastomotic obstruction or stricture, endoscopic balloon or probe expansion and stent placement can be chosen. For esophageal anastomotic intractable obstruction after gastroesophageal surgery, radial incision of obstruction by the hook knife or IT knife, a new method named ERI, is a good choice. Bile leakage caused by bile duct injury can be treated by placing the stent or nasal bile duct. In addition, endoscopic methods are widely used as follows: abdominal abscess can be treated by the direct intervention under endoscopy; adhesive ileus can be treated by placing the catheter under the guidance of endoscopy to attract pressure; alkaline reflux gastritis can be rapidly diagnosed by endoscopy; gastric outlet obstruction mainly caused by cancer recurrence can be relieved by metal stent placement and the combination of endoscopy and X-ray can increase success rate; pyloric dysfunction and spasm caused by the vagus nerve injury during proximal gastrectomy can be treated by endoscopic pyloromyotomy, a new method named G-POEM, and the short-term outcomes are significant. Endoscopic submucosal dissection (ESD) allows complete resection of residual gastric precancerous lesions, however it should be performed by the experienced endoscopists.

Antibiotics for infection prevention after excision of the cervical transformation zone

BACKGROUND

Excision of the transformation zone of the cervix is the most commonly used approach to treat cervical precancerous lesions (cervical intraepithelial neoplasia (CIN)) to reduce the risk of developing cervical cancer. As the excision of the transformation zone leaves a raw area on the cervix, there is a risk of infection following the procedure. The incidence of infection after cold knife conization (CKC) is 36%, whereas the incidence for large loop excision of the transformation zone (LLETZ, also known as loop electrical excision procedure (LEEP)) is much lower (0.8% to 14.4%). Prophalytic antibiotics may prevent an infection developing and are often prescribed for CKC. However, there are no formal recommendations regarding the use of prophylactic antibiotics for infection prevention in women undergoing surgical excisional treatment for cervical precancerous lesions.

OBJECTIVES

To evaluate the effectiveness and safety of antibiotics for infection prevention following excision of the cervical transformation zone.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2016, Issue 4), MEDLINE, Embase, LILACS to May 2016. We also checked registers of clinical trials, citation lists of included studies, key textbooks and previous systematic reviews for potentially relevant studies SELECTION CRITERIA: We included randomised controlled trials (RCTs) evaluating the effectiveness and safety of prophylactic antibiotics versus a placebo or no treatment in women having excision of the cervical transformation zone, regardless of the type of surgical excisional method used.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently selected potentially relevant trials, extracted data, and assessed risk of bias, compared results and resolved disagreements by discussion. We contacted investigators for additional data, where possible.

MAIN RESULTS

Of the 370 records that we identified as a result of the search (excluding duplicates), we regarded six abstracts and titles as potentially relevant studies. Of these six studies, three met the inclusion criteria involving 708 participants; most trials were at moderate or high risk of bias (risk mainly due to lack of blinding and high rate of incomplete data). We did not identify any ongoing trials. Although all included studies had been published in peer-reviewed journals at the time of the search and data extraction, numerical data regarding the outcome measured in one trial involving 77 participants were insufficient for inclusion in a meta-analyses.The difference in the rates of prolonged vaginal discharge or presumed cervicitis (one study; 348 participants; risk ratio (RR), 1.29; 95% confidence interval (CI) 0.72 to 2.31; low-quality evidence) and severe vaginal bleeding (two studies; 638 participants; RR 1.21; 95% CI 0.52 to 2.82; very low-quality evidence) among the two comparison groups did not reach the level for clinically important effect. In addition, there was no difference in adverse events related to antibiotics i.e. nausea/vomiting, diarrhoea, and headache among the two comparison groups (two studies; 638 participants; RR 1.69; 95% CI 0.85 to 3.34; very low-quality evidence). There were no differences in the incidence of fever (RR, 2.23; 95% CI 0.20 to 24.36), lower abdominal pain (RR, 1.03; 95% CI 0.61 to 1.72), unscheduled medical consultation (RR 2.68, 95% CI 0.97 to 7.41), and additional self-medication (RR 1.22; 95% CI 0.56 to 2.67) between the two comparison groups (one study; 290 participants; low to very low-quality evidence).

AUTHORS' CONCLUSIONS

As only limited data are available from three trials with overall moderate to high risk of bias, there is insufficient evidence to support use of antibiotics to reduce infectious complications following excision of the cervical transformation zone. In addition, there were minimal data about antibiotic-related adverse events and no information on the risk of developing antibiotic resistance. Antibiotics given for infection prevention after excision of the cervical transformation zone should only be used in the context of clinical research, to avoid unnecessary prescription of antibiotics and to prevent further increases in antibiotic resistance.

Epidemiological aspects of endoscopic resections of colorectal polyps in patients at an endoscopy training center in the Santos region, Brasil

INTRODUCTION

Colorectal polyps are structures that project from the surface of the mucosal layer of the large intestine. They are classified as neoplastic or non-neoplastic. Early detection of pre-neoplastic lesions is important for preventing colorectal cancer. These can be resected so as to decrease the morbidity and mortality rates. Colonoscopy is the gold-standard procedure for diagnosing and resecting precursor lesions.

OBJECTIVE

To evaluate the epidemiological, endoscopic and histological aspects of endoscopic resection of lesions of the colon and rectum at a training center.

MATERIALS AND METHOD

A search was conducted in the database of our institution covering the period from January 2011 to July 2014. Cases that underwent endoscopic resection of polyps and/or colorectal lesions were selection. The following variables were defined: general data on the patients (age, gender and indication from the examination) and data on the polypoid lesion (number, histological type and topographic distribution).

RESULTS

678 lesions were identified in 456 examinations. Regarding sex, 242 (53.1%) were female and 214 (46.9%) were male. The mean age was 64.54 years, with extremes of 5 and 94 years. The most frequent locations were the rectum (21%) and sigmoid (20%). Histologically, 34.7% were hyperplastic polyps and 58.9% were adenomatous polyps, of which 74.1% were tubular, 10.6% tubulovillous, 2% villous and 13% indeterminate; and 1.7% were adenocarcinomas. In 65.4% of the cases, the examination showed that only one polyps was present, while 34.6% had two or more lesions.

CONCLUSION

In our clinic, with a mean of 250 examinations/month, the parameters evaluated were compatible with the results reported in the literature.

A retrospective study of endoscopic resection for 368 patients with early esophageal squamous cell carcinoma or precancerous lesions

BACKGROUND

To retrospectively investigate the clinicopathological features and prognosis of early esophageal squamous cell neoplasm (ESCN) treated with endoscopic resection (ER), especially, to compare the prognosis in patients with sm2 cancer and non-sm2 cancer.

METHODS

From 2007 to 2013, 368 patients were included in our analysis.

RESULTS

The patients were 252 (68.5 %) men and 116 (31.5 %) women with a median age of 61 (range 16-84 years) years. Hyperplasia, mild dysplasia, moderate dysplasia, severe dysplasia, m1, m2, m3, sm1, and sm2 were diagnosed in 47 (12.8 %), 27 (7.3 %), 34 (9.2 %), 61 (16.6 %), 54 (14.7 %), 38 (10.3 %), 63 (17.1 %), 12 (3.3 %), and 32 (8.7 %) cases. The mean (range) follow-up time was 29 (0-84) months. The cumulative overall 1-, 3-, and 5-year metachronous esophageal lesion rates were 4.1, 12.9, and 32.6 %. The incidence of lymph node or distant metastasis was 1.54 % in m3, 6.25 % in sm2, and 0 in other subgroups. The overall 1-, 3-, and 5-year survival rates were 99.5, 97.3, and 87.5 %. There was significant difference between sm2 and non-sm2 patients in metastatic rate (P = 0.021); however, no difference existed between m3 patients and sm2 patients (P = 0.252). The difference of metachronous esophageal lesion (P = 0.401) and survival (P = 0.634) between sm2 and non-sm2 patients was not obvious.

CONCLUSIONS

Our study showed that ER was an effective and relatively safe treatment for superficial ESCN. ER is still appropriate in select sm2 patients. To monitor the second primary cancer in sm2 is necessary during the follow-up.

Understanding Teamwork in the Provision of Cancer Care: Highlighting the Role of Trust

Team science research has indicated that trust is a critical variable of teamwork, contributing greatly to a team's performance. Trust has long been examined in health care with research focusing on the development of trust by patients with their health care practitioners. Studies have indicated that trust is linked to patient satisfaction, adherence to treatment, continuity of care, and improved outcomes. We explore the construct of trust using a case example of a patient who received a surgical procedure for a precancerous polyp. We apply the principle of trust to the case as well as present the literature on trust and key definitions for understanding trust. Additionally, we apply the definitions presented to the specific case example by highlighting moments where trust is developed or violated. Lastly, we offer insights to health care practitioners on the development of trust in their own patient interactions to improve care.

Endotherapies for Barrett esophagus

Barrett esophagus (BE) is becoming an increasingly common complication. It places patients at higher risk for esophageal adenocaricnoma. Surveillance and acid suppression has been the mainstay of treatment. Recent advances in endoscopic therapies have allowed irradication of BE and reduction in cancer risk. This article reviews the available endotherapies and their efficacy.

[The molecular genetic alterations in mucosa of intestines as markers of oncologic progression and estimate of effectiveness of anti-reflux operations in patients with Barrett's esophagus]

The development of disease of Barrett's esophagus is based on processes of metaplasia of epithelium of esophagus when as a result of reflux of gastric juice and bile acids the normal planocellular epithelium of esophagus is replaced by cylindrical epithelium of intestinal type. Thereupon, Barrett's esophagus is progressing up to dysplasia and adenocarcinoma of esophagus. The progression from precancerous states up to tumor is related to development of genome disorders in cells associated with malignant transformation. The genetic and epigenetic alterations conditioning tumor growth can be used as markers of prognosis of clinical course of disease. To receive possible markers of progression of Barrett's esophagus the study was organized concerning methylation of such genes-suppressors of tumor growth as MGMT, CDH1, p16/CDKN2A, DAPK, RAR-β and RUNX3 in patients with Barrett's esophagus and adenocarcinoma of esophagus. The effectiveness of applied anti-reflux surgical treatment was evaluated too. The abnormal methylation of studied genetic panel in patients with Barrett's esophagus prior to surgical treatment was observed reliably more frequently in altered epithelium as compared with unaltered epithelium (p<0.0001), under dysplasia as compared with metaplasia (p<0.0358) and in the presence of long (>3 cm) segments of altered epithelium as compared with short (<3 cm) segments (p=0.0068). In normal epithelium, prior to operation, abnormal methylation of panel of genes was detected in 7/60 (12%) of patients. Against the background of surgical treatment number of long and short segments of altered epithelium of esophagus reliably decreased (p<0.05). At that, in short segments after operation rate of methylation increased significantly (p=0.0068). Though after operation number of patients with Barrett's esophagus and dysplasia and metaplasia decreased, the rate of abnormal methylation in the other patients increased. It is demonstrated that anti-reflux operation ameliorates condition of mucous membrane of esophagus under Barrett's esophagus. However, in cases without regression significant increasing of rate of abnormal methylation of studied panel of genes is occurred. This is a proof that abnormal methylation of system of genes is related to worse response to application of anti-reflux surgical treatment.

Comparative Histologic Assessment of Proctocolectomy Specimens from Japanese and American Patients with Ulcerative Colitis with or Without Dysplasia

There have been no reports of histologic differences in ulcerative colitis (UC) between Japanese and American patients. We therefore compared histology in proctocolectomy resection specimens between Japanese patients with UC (19 cases with and 21 without dysplasia) at the Kitasato University East Hospital and American patients with UC (21 cases with and 24 without dysplasia) at the University of Washington Medical Center. In cases of UC with, but not without dysplasia, cryptitis (p = 0.010) and epithelial apoptosis (p < 0.001) in the nondysplastic mucosa were more frequently observed in Japanese than in American cases, whereas lamina propria fibrosis was more prominent in American counterparts (p = 0.008). In patients with UC with dysplasia, the duration of disease was significantly longer in American than in Japanese patients (median, 17 vs 14 years, respectively; p = 0.038). This might, in part, explain the histologic variation. Another possibility for the differences is that the preoperative medications may have differed in the populations.