Sessile serrated polyp detection rates after fecal immunochemical test or multitarget stool DNA test: Systematic review and meta-analysis

Background and study aims Published studies report a higher adenoma detection rate (ADR) for FIT-DNA as compared with FIT. Data are less replete about the performance of stool-based tests for sessile serrated polyp (SSP) detection. We performed a meta-analysis to evaluate the performance of FIT and FIT-DNA testing for SSP detection rate (SSPDR) in patients undergoing colonoscopy for follow up of positive noninvasive tests. Methods A comprehensive literature search of multiple databases (until September 2022) was performed to identify studies reporting SSPDR in patients with positive FIT or FIT-DNA tests. The outcome was overall colonoscopy detection of any SSPs and advanced serrated polyps (ASP: SSP ≥ 10 mm and/or dysplasia). Results Included were 482,405 patients (52.4% females) with a mean age of 62.3 ± 4.4 years from 23 studies. The pooled SSPDR for all positive stool-based tests was 5.3% and higher for FIT-DNA (15.0%, 95% confidence interval [CI] 8.3-25.7) versus FIT (4.1%, 95% CI 3.0-5.6; P = 0.0002). The overall pooled ASP detection rate was 1.4% (95% CI 0.81-2.3) and higher for FIT-DNA (3.8 %, 95% CI 1.7-8.6) compared with FIT (0.71%, 95% CI 0.36-1.4; P <0.01). SSPDR with FIT-DNA was also significantly higher than FIT when the FIT cutoff was >10 ug/g and in FIT-positive patients in studies conducted in North America ( P <0.05). Conclusions FIT-DNA outperformed FIT in both SSP and ASP detection including FIT with a lower threshold cutoff of >10 ug/g. Further comparative studies are needed to assess the impact of our findings on colorectal cancer reduction.

Risk of Proctectomy After Ileorectal Anastomosis in Familial Adenomatous Polyposis in the Modern Era

BACKGROUND

Prophylactic surgery for familial adenomatous polyposis has evolved over several decades. Restorative proctocolectomy with IPAA provides an alternative to total abdominal colectomy with ileorectal anastomosis. We have previously shown that the rate of proctectomy and rectal cancer after total abdominal colectomy with ileorectal anastomosis in the "pre-pouch era" was 32% and 13%, respectively.

OBJECTIVE

To determine the rate of proctectomy and rectal cancer among familial adenomatous polyposis patients and relative rectal sparing (fewer than 20 rectal polyps) selected for total abdominal colectomy with ileorectal anastomosis in the modern era.

DESIGN

Retrospective cohort study.

SETTING

Single tertiary care institution with a hereditary colorectal cancer registry.

PATIENTS

Patients with familial adenomatous polyposis who underwent total abdominal colectomy with ileorectal anastomosis between 1993 and 2020.

MAIN OUTCOME MEASURES

Incidence of proctectomy for any indication and rectal cancer.

RESULTS

A total of 197 patients with a median age of 24 years (range, 10-67) were included. The median follow-up after total abdominal colectomy with ileorectal anastomosis was 13 years (interquartile range, 6-17). Sixteen patients (8%) underwent proctectomy. Indications included rectal cancer in 6 patients (3%; 2 stage I and 4 stage III), polyps with high-grade dysplasia in 4 (2%), progressive polyp burden in 3 (1.5%), defecatory dysfunction in 2 (1%), and anastomotic leak in 1 (0.5%). Among 30 patients (18%) with 20 or more rectal polyps at the time of total abdominal colectomy with ileorectal anastomosis, 8 patients (26%) underwent proctectomy and 3 patients developed rectal cancer (10%). Among 134 patients (82%) with fewer than 20 polyps, 8 patients (6%) underwent proctectomy and 3 patients developed rectal cancer (2%). Number of rectal polyps at the time of total abdominal colectomy with ileorectal anastomosis was associated with the likelihood of proctectomy (OR 1.1, p < 0.001) but not incident rectal cancer ( p = 0.3).

LIMITATION

Retrospective data collection.

CONCLUSIONS

Patients with familial adenomatous polyposis selected for total abdominal colectomy with ileorectal anastomosis by rectal polyp number have low rates of proctectomy and rectal cancer compared to historical controls. With appropriate selection criteria and surveillance, total abdominal colectomy with ileorectal anastomosis remains an important and safe treatment option for patients with familial adenomatous polyposis. See Video Abstract .

RIESGO DE PROCTECTOMA DESPUS DE ANASTOMOSIS ILEORRECTAL EN POLIPOSIS ADENOMATOSA FAMILIAR EN LA ERA MODERNA

ANTECEDENTES:La cirugía profiláctica para la poliposis adenomatosa familiar (PAF) ha evolucionado durante varias décadas. La proctocolectomía restauradora con anastomosis anal con bolsa ileal (IPAA) proporciona una alternativa a la colectomía abdominal total con anastomosis ileorrectal (TAC/IRA). Anteriormente hemos demostrado que la tasa de proctectomía y cáncer de recto después de TAC/IRA en la era "pre-bolsa" era del 32% y el 13%, respectivamente.OBJETIVO:Determinar la tasa de proctectomía y cáncer de recto entre pacientes con PAF y pacientes con preservación rectal relativa (<20 pólipos rectales) seleccionados para TAC/IRA en la era moderna.DISEÑO:Estudio de cohorte retrospectivo.ÁMBITO:Institución única de atención terciaria con un registro de cáncer colorrectal hereditario.PACIENTES:Pacientes con PAF que se sometieron a TAC/IRA entre 1993 y 2020.MEDIDAS DE RESULTADO PRINCIPALES:Incidencia de proctectomía por cualquier indicación y cáncer de recto.RESULTADOS:Se incluyeron 197 pacientes con una mediana de edad de 24 años (rango 10-67). La mediana de seguimiento tras TAC/IRA fue de 13 años (RIC 6-17). 16 pacientes (8%) fueron sometidos a proctectomía. Las indicaciones incluyeron cáncer de recto en 6 (3%) (2 en estadio I y 4 en estadio III); pólipos con displasia de alto grado en 4 (2%); carga progresiva de pólipos en 3 (1,5%), disfunción defecatoria en 2 (1%); y fuga anastomótica en 1 (0,5%). Entre 30 pacientes (18%) con ≥20 pólipos rectales en el momento de TAC/IRA, 8 pacientes (26%) se sometieron a proctectomía y 3 pacientes desarrollaron cáncer de recto (10%). Entre 134 pacientes (82%) con <20 pólipos, 8 pacientes (6%) se sometieron a proctectomía y 3 pacientes desarrollaron cáncer de recto (2%). El número de pólipos rectales en el momento de TAC/IRA se asoció con la probabilidad de proctectomía (OR 1,1, p <0,001), pero no con la incidencia de cáncer de recto (p = 0,3).LIMITACIÓN:Recopilación de datos retrospectivos.CONCLUSIÓN:Los pacientes con PAF seleccionados para TAC/IRA por el número de pólipos rectales tienen tasas bajas de proctectomía y cáncer de recto en comparación con los controles históricos. Con criterios de selección y vigilancia adecuados, TAC/IRA sigue siendo una opción de tratamiento importante y segura para los pacientes con PAF. (Pre-proofed version ).

Risk Factors Associated with Advanced Colorectal Neoplasia in Adults Younger than Age 45

BACKGROUND

Colorectal cancer (CRC) is rising in young adults between ages 20 to 49 years. CRC screening is endorsed for average-risk individuals beginning at ages 45 to 49 years. Targeting screening for individuals <45 years may be warranted if risk factors for advanced neoplasia can be identified.

AIM

To identify factors associated with advanced colorectal neoplasia in adults aged <45 years.

METHOD

Individuals ages 18 to 44 years who underwent colonoscopy at Cleveland Clinic between 2011 and 2021 with ≥1 advanced neoplasm (AN) were included. Patients with inflammatory bowel disease or inherited CRC syndromes were excluded. Demographics, comorbidities, family history of CRC, and colonoscopy indication were obtained. Patients with a normal colonoscopy constituted the control group. A multivariable logistic regression model was used to investigate the relationship between clinical variables and the presence of advanced colorectal neoplasia.

RESULTS

In all, 13,006 patients were included, of which 651 (5%) patients had AN: 404 (62%) with tubular adenoma ≥10 mm, 29 (4.5%) tubular adenoma with high-grade dysplasia, 210 (32%) tubulovillous adenomas, 27 (4%) traditional serrated adenomas, 82 (13%) sessile serrated lesions ≥10 mm, 7(2%) sessile serrated lesions with dysplasia, and 29 (4.4%) patients had a CRC. Factors associated with AN were older age (means 38.5 vs. 36.6 y), history of smoking, diabetes, non-White race, higher body mass index (29.9 vs. 28.5 kg/m2), and lower vitamin D (27.6 vs. 32.2 ng/dl), all P<0.001. In the reduced multivariable model, factors associated with AN included tobacco use (OR 2.026 (current vs. never, P<0.0001), age (OR increase by 1.06 per year, P<0.0001), male gender (OR 1.476, P<0.0001), family history of CRC (OR 3.91, P<0.0001), aspirin use (1.31, P=0.035), and diabetes (OR 2.106, P 0.001).

CONCLUSION

Increasing age, male gender, exposure to tobacco, family history of CRC, diabetes, and aspirin use were independently associated with advanced neoplasia in adults younger than 45. Targeted early screening to young adults with these risk factors may be justified. Large collaborative prospective studies are needed to validate our findings.

Frequency of endoscopic photodocumentation of large colorectal polyps

BACKGROUND AND AIMS

Colonoscopy quality affects colorectal cancer (CRC) incidence and mortality. The U.S. Multi-Society Task Force on Colorectal Cancer strongly recommends photodocumentation (PD) of lesions ≥10 mm in size (ie, large polyps [LPs]) pre-resection and suggests PD postresection to enhance the quality of colonoscopy. No studies have assessed the frequency of LP PD. We evaluated the frequency of and factors associated with PD of LPs.

METHODS

Reports from endoscopists performing ≥50 colonoscopies with LP resection between 2016 and 2021 were reviewed. The frequency of LP PD pre-resection and post-resection and factors associated with PD were collected. A composite score of 2 quality metrics (PD of completeness of examination and bowel preparation quality) was created. Endoscopists were divided into 2 tiers based on the frequency of the score on all included examinations: Tier 1, ≥95% of examinations; and Tier 2, <95% of examinations. Univariate and multivariate analyses were used to assess factors associated with PD.

RESULTS

A total of 1322 colonoscopies, 1693 LPs, and 25 endoscopists were included in this study. PD of LPs occurred in 1392 (82%) pre-resection and in 878 (52%) post-resection. Factors associated with pre-resection PD include endoscopist subspecialty (colorectal surgery vs gastroenterology: odds ratio [OR], .12; 95% confidence interval [CI], .04-.42); >1 LP on examination (2 vs 1 LP: OR, .41 [95% CI, .27-.61]; and ≥3 vs 1 LP: OR, .41 [95% CI, .24-.70]), and longer withdrawal time (OR, 1.02; 95% CI, 1.01-1.04).

CONCLUSIONS

We provide the first data on PD of LP pre-resection and post-resection, which can inform future benchmarking in this area. The implications of PD on metachronous advanced neoplasia need to be studied.

Referral, Uptake, and Outcome of Genetic Counseling and Testing in Patients With Early-Onset Colorectal Cancer

BACKGROUND

The incidence of early-onset colorectal cancer (EOCRC) is rapidly increasing. Pathogenic germline variants (PGVs) are detected in 16% to 20% of patients who have EOCRC, highlighting a need for genetic counseling (GC) and multigene panel testing in these patients. We aimed to determine the rate of referral to GC and uptake and outcomes of germline testing in patients with EOCRC.

METHODS

We conducted a retrospective cohort study of patients aged <50 years diagnosed with colorectal cancer (CRC) from 2010 to 2019 at Cleveland Clinic. Demographic data were extracted, including age, sex, self-reported race, and family history of CRC. The proportions of patients with GC referral and completion of GC and genetic testing were investigated, and genetic testing results were analyzed. Multivariable logistic regression analysis was conducted to identify factors independently associated with GC referral and uptake.

RESULTS

A total of 791 patients with EOCRC (57% male and 43% female) were included; 62% were referred for GC, and of those who were referred, 79% completed a GC appointment and 77% underwent genetic testing. Of those who underwent testing, 21% had a PGV detected; 82% were in known CRC-associated genes, with those associated with Lynch syndrome and familial adenomatous polyposis the most common, and 11% were in other actionable genes. Referral to GC was positively associated with family history of CRC (odds ratio [OR], 2.11; 95% CI, 1.51-2.96) and more recent year of diagnosis (2010-2013 vs 2017-2019; OR, 5.36; 95% CI, 3.59-8.01) but negatively associated with older age at diagnosis (OR, 0.89; 95% CI, 0.86-0.92).

CONCLUSIONS

Referral to GC for patients with EOCRC is increasing over time; however, even in recent years, almost 25% of patients were not referred for GC. We found that 1 in 5 patients with EOCRC carry actionable PGVs, highlighting the need for health systems to implement care pathways to optimize GC referral and testing in all patients with EOCRC.

Upper Gastrointestinal Neoplasia and Worrisome Thyroid Nodules are Common in Colonic Polyposis of Unknown Etiology (CPUE)

BACKGROUND

Colonic polyposis of unknown etiology (CPUE) is defined as ≥10 cumulative colonic adenomas without a detectable germline pathogenic variant. Surveillance for patients with >100 adenomas is recommended, similar to patients with familial adenomatous polyposis. The utility of extra-colonic screening in patients with 10 to <100 adenomas is not well established.

METHODS

All CPUE patients seen at our center between 2003 and 2022 were included. Patients were categorized based on the range of cumulative colorectal adenoma count: 10 to 19, 20 to 99, and ≥100.

RESULTS

In all, 150 patients were identified of which 20(13.3%) had 10 to 19 cumulative adenomas, 79(52.7%) had 20 to 99 adenomas, and 51(34.0%) had ≥100 adenomas. Compared with patients with 10 to 19 and 20 to 99, patients with ≥100 adenomas were younger (mean 51 vs. 52 vs. 42 y, respectively). Of patients who underwent esophagogastroduodenoscopy, duodenal adenomas were found in 33.3%, 10.1%, and 38% in the 3 groups, respectively, P=0.002. Ampullary adenomas were significantly more common in the ≥100 adenoma group (14.8%, P=0.019) compared with 8.3% and 2.9% in the 10 to 19 and 20 to 99 groups, respectively. Thyroid nodules ≥1 cm were not detected in patients with 10 to 19 adenomas but were found in 23.3% and 14.3% of patients with 20 to 99 and ≥100 adenomas, respectively (P=0.254).

CONCLUSION

In our cohort, duodenal and gastric adenomas occurred in CPUE patients with adenoma count 10 to ≥100 at a relatively high proportion. We recommend a baseline esophagogastroduodenoscopy in all patients with CPUE. While clinically significant thyroid nodules were not detected in patients with 10 to 19 adenomas, they occurred in about one-fifth of the patients with ≥20 adenomas, indicating that thyroid ultrasound is prudent.

Frequency of Use and Outcomes of Colonoscopy in Individuals Older Than 75 Years

Importance

The benefits from colorectal cancer (CRC) screening may take 10 to 15 years to accrue. Therefore, screening is recommended for older adults who are in good health.

Objective

To determine the number of screening colonoscopies done in patients older than 75 years with a life expectancy of fewer than 10 years, diagnostic yield, and associated adverse events within 10 days and 30 days of the procedure.

Design

This cross-sectional study with a nested cohort between January 2009 and January 2022 in an integrated health system assessed asymptomatic patients older than 75 years who underwent screening colonoscopy in the outpatient setting. Reports with incomplete data, any indication other than screening, patients who had a colonoscopy within the previous 5 years, and patients with a personal history of inflammatory bowel disease or CRC were excluded.

Exposures

Life expectancy based on a prediction model from previous literature.

Main Outcomes and Measures

The primary outcome was the percentage of screened patients who had limited (<10 years) life expectancy. Other outcomes included colonoscopy findings and adverse events that developed within 10 days and 30 days of the procedure.

Results

A total of 7067 patients older than 75 years were included. The median (IQR) age was 78 (77-79) years, 3967 (56%) were women, and 5431 (77%) were White with an average of 2 comorbidities (taken from a select group of comorbidities). The proportion of colonoscopies performed on patients with a life expectancy of fewer than 10 years aged 76 to 80 years was 30% in both sexes and increased with age-82% of men and 61% of women aged 81 to 85 years (71% total), and 100% of patients beyond the age of 85 years. Adverse events requiring hospitalizations were common at 10 days (13.58 per 1000) and increased with age, particularly among patients older than 85 years. The detection of advanced neoplasia varied from 5.4% among patients aged 76 to 80 years to 6.2% in those aged 81 to 85 years and 9.5% among patients older than 85 years (P = .02). Of the total population, 15 patients (0.2%) had invasive adenocarcinoma; among patients with a life expectancy of fewer than 10 years, 1 of 9 was treated, whereas 4 of 6 patients with a life expectancy of greater than or equal to 10 years were treated.

Conclusions and Relevance

In this cross-sectional study with a nested cohort, most screening colonoscopies performed in patients older than 75 years were in patients with limited life expectancy and associated with increased risk of complications. Colorectal cancer was exceedingly rare.

Longitudinal Analysis of Cancer Risk in Children and Adults With Germline PTEN Variants

Importance

Identifying hereditary cancer predisposition facilitates high-risk organ-specific cancer surveillance and prevention. In PTEN hamartoma tumor syndrome (PHTS), longitudinal studies remain lacking, and there are insufficient data on cancers in children and young adults, as well as individuals with neurodevelopmental disorders (NDD).

Objective

To evaluate lifetime cancer risks, including second malignant neoplasms (SMN), among patients with PHTS.

Design, Setting, and Participants

Prospective longitudinal cohort study (September 1, 2005, through January 6, 2022). General population risks from the Surveillance, Epidemiology, and End Results database. Patients with PHTS, molecularly defined as carrying germline PTEN variants, were accrued from community and academic medical centers throughout North America, South America, Europe, Australia, and Asia. Data were analyzed from July 2022 to February 2023.

Exposures

Review of physical and electronic medical records, and follow-up through clinical visits or telephone interviews.

Main Outcomes and Measures

Lifetime cancer risks in PHTS relative to the general population.

Results

A total of 7302 patients were prospectively accrued, 701 of whom had germline PTEN variants (median [IQR] age at consent, 38 [12-52] years; 413 female patients [59%]). Longitudinal follow-up data could be obtained for 260 patients (37%), with a median (IQR) follow-up of 4 (2-8) years. Of the 701 patients, 341 (49%) received at least 1 cancer diagnosis, with 144 (42%) of those having SMN. The study found significantly elevated lifetime risks for breast (91%), endometrial (48%), thyroid (33%), kidney (30%), and colorectal cancers (17%), as well as melanoma (5%). Cancer diagnoses were also observed in children and young adults with PHTS (15%) and in patients with PHTS with neurodevelopmental disorders (11%). Elevated risks (P < .001) of thyroid (age-adjusted standardized incidence ratios [SIR], 32.1; 95% CI, 26.0-39.0), kidney (SIR, 26.5; 95% CI, 18.8-36.3), endometrial (SIR, 26.0; 95% CI, 19.5-34.1), breast (SIR, 20.3; 95% CI, 17.3-23.7), and colorectal (SIR, 7.9; 95% CI, 5.2-11.7) cancers, and melanoma (SIR, 6.3; 95% CI, 3.5-10.5) were observed. Of the 341 patients with PHTS with cancer, 51 (15%) had 1 or more cancers diagnosed at age 29 years or younger, and 16 (31.4%) of those developed SMN at final follow-up. Twenty-three patients with PHTS with NDD and cancer were identified, with 5 (22%) having developed SMN at final follow-up. Individuals with PHTS and NDD showed higher lifetime cancer risks compared with individuals with PHTS but without NDD (hazard ratio, 2.7; 95% CI, 1.7-4.2; P < .001).

Conclusions and Relevance

This cohort study found consistently elevated lifetime cancer risks in PHTS. Organ-specific surveillance should continue in patients with PHTS. Additional study is required to ascertain elevated cancer risks in patients with PHTS with NDD.

Temporal trends and disparities in gastroenterology care use before, during, and after COVID-19 lockdown

Socioeconomic disparities adversely affected healthcare use during COVID-19 lockdown. However, trends in these disparities post lockdown are unknown. Therefore, our aim was to study temporal trends and factors associated with gastroenterology healthcare access and disparities during and after COVID-19 lockdown. This cohort study consisted of patients receiving outpatient care in the Cleveland Clinic gastroenterology department between March 2020 and June 2020 and corresponding time periods in 2019 and 2021. Patient demographics and socioeconomic factors were extracted and analyzed. There were 47,031 patients (mean age 56.3±17.6 years, 61.9% female and 76.4% white) included. Patients ≥65 years sought healthcare less frequently during and after the lockdown (40.1% vs 34.8% vs 35.2% in 2019, 2020, and 2021 respectively). Missed visits (4.2% vs 10% vs 10.4%), tobacco (11.4% vs 15.9% vs 16.1%), alcohol (38.6% vs 45.5% vs 50.9%), and illicit drug use (3.5% vs 5.8% vs 10.7%) have steadily increased during and after the lockdown compared with prepandemic levels. Factors associated with reduced telehealth use were black race (OR 0.89, 95% CI 0.81 to 0.99), Hispanic race (OR 0.63, 95% CI 0.51 to 0.77)), Medicaid/other public insurance (OR 0.87, 95% CI 0.79 to 0.95)), unemployed status (OR 0.85, 95% CI 0.79 to 0.92)), and non-English/Spanish speakers (OR 0.66, 95% CI 0.46 to 0.94)). In conclusion, socioeconomic and ethnic disparities persist in healthcare use even a year after the onset of the COVID-19 pandemic. There is an alarming increase in missed visits and substance abuse. Therefore, efforts should be targeted on improving healthcare access for these aforementioned vulnerable groups.

Chemoprevention Considerations in Patients with Hereditary Colorectal Cancer Syndromes

Secondary prevention of colorectal neoplasia with chemoprevention is long-studied area of research and clinical use in patients with the 2 most common hereditary colorectal cancer syndromes including Lynch syndrome and familial adenomatous polyposis. No medication is currently approved for use for the prevention of colorectal polyps or cancer in either the general population or individuals with the hereditary colorectal cancer syndromes. Emerging data in animal models and limited data in humans suggest vaccines may be the next breakthrough for neoplasia prevention in patients with hereditary colorectal cancer. Clinicians must acknowledge chemoprevention is an adjunct and does not supplant endoscopic surveillance.

The Significance of Sessile Serrated Polyps in Inflammatory Bowel Disease

BACKGROUND

The significance of serrated lesions in inflammatory bowel disease (IBD) remains unclear. We aim to characterize synchronous and metachronous lesions in IBD patients with an index serrated polyp and compare them to sporadic subjects with SSP.

METHODS

Serrated lesions in patients with IBD were identified from a pathology database and, after review, were reclassified as hyperplastic (HP), sessile serrated (SSPs), or serrated polyps unclassifiable (SPU).

RESULTS

One hundred thirty-four IBD patients were found to have 147 serrated polyps at index colonoscopy. SSPs were more likely to be located in the right colon: SSP (76.0%), SPU (41.7%) and HP (27.8%); P = 0.002. Synchronous multifocal visible dysplasia occurred more frequently in the SSP or SPU groups (44.5% and 66%) compared to the HP group (12%); P = 0.031. Among 13 IBD patients with index SSP followed over a median of 6 years, 61.5% developed metachronous visible dysplasia or additional SSPs. Larger index SSP size was associated with higher risk of developing subsequent visible dysplasia with a 10% increase for every 1 mm increase in size (HR = 1.1; P = 0.028), but was not associated with developing subsequent SSP (P = 0.50). The risk of subsequent SSP or visible dysplasia was no different between the IBD and non-IBD groups, but there was a trend suggesting SSP may be a marker of increased early risk of metachronous visible dysplasia in IBD patients.

CONCLUSIONS

IBD patients with an index SSP and SPU have a heightened risk of synchronous multifocal visible dysplasia. Additionally, IBD patients with SSP may be at risk of early metachronous visible dysplasia.

Using Genetics to Identify Hereditary Colorectal Polyposis and Cancer Syndromes in Your Patient

The majority of patients with colorectal polyps and cancer do not have a Mendelian cause of the disease. Age, lifestyle, and environmental factors interact with complex genetic traits to contribute to the etiology. However, approximately 5-10 % of patients with colorectal cancer (CRC) and more than 40 % of patients meeting specific clinical features of the hereditary polyposis syndromes have a discoverable, actionable genetic cause which will significantly alter their medical management.

Colorectal cancer screening and prevention in women

Colorectal cancer (CRC) is one of the leading cancers and cause of cancer deaths in American women and men. Females and males share a similar lifetime cumulative risk of CRC however, substantial differences in risk factors, tumor biology, and effectiveness of cancer prevention services have been observed between them. This review distills the evidence documenting the unique variation observed between the genders relating to CRC risk factors, screening and prevention. Consistent evidence throughout the world demonstrates that women reach equivalent levels of adenomas and CRC as men but it occurs nearly a decade later in life than in their male counterparts. Women have a higher proportion of tumors which are hypermethylated, have microsatellite instability and located in the proximal colon suggesting the serrated pathway may be of greater consequence in them than in men. Other CRC risk factors such as smoking, diet and obesity have been shown to have disparate effects on women which may related to interactions between estrogen exposure, body fat distribution, and the biologic underpinnings of their tumors. There is data showing the uptake, choice, and efficacy of different CRC screening methods in women is dissimilar to that in men. The mortality benefit from FOBT, sigmoidoscopy, and protection from interval CRC by colonoscopy appears to be lower in women than men. A greater understanding of these gender idiosyncrasies will facilitate an personalized approach to CRC prevention and should ultimately lead to a reduced burden of disease.

Hereditary colorectal cancer syndromes and genetic testing

Colorectal cancer (CRC) is a leading cause of cancer and cancer deaths in the Western world. Approximately 5-10% of CRC are hereditary, due to a defined genetic cause. Individuals and families affected with a hereditary CRC syndrome exhibit benign and malignant extra-intestinal tumors, require aggressive cancer screening and benefit from management by a multi-disciplinary team of professionals. The clinical manifestations, genetic causes and current management of patients with hereditary colon cancer syndrome is provided.

Risk of colonic neoplasia after liver transplantation for primary sclerosing cholangitis

BACKGROUND

Primary sclerosing cholangitis (PSC) confers an increased risk of colon cancer in patients with inflammatory bowel disease (IBD). However, there is a scarcity of data to determine whether the rate of colon cancer changes after liver transplantation (LT) in IBD patients with PSC. The aims were 1) to estimate the risk of colon neoplasia after LT in IBD patients with PSC; 2) to identify the factors associated with colon neoplasia after LT in IBD patients with PSC.

METHODS

We identified patients with IBD/PSC who underwent LT from 1998-2005 (n = 43). Two control groups were identified. Control 1 was IBD/PSC who did not undergo LT, matched 1:1 for age, gender, and type of IBD. Control 2 was patients with chronic liver disease other than PSC who underwent LT, matched 1:1 for age, gender, and follow-up time since LT. All patients were monitored by serial colonoscopy. Logistic regression analysis was used.

RESULTS

During a mean follow-up of 54.7 ± 47.7 months, patients with IBD/PSC who underwent LT had similar rate of colon neoplasia compared to those who did not have LT (34% versus 30%, P = 0.24). The rate of colon neoplasia in LT recipients was higher in PSC patients compared to those with other forms of chronic liver disease (34% versus 0%, P = 0.018). Post-LT cytomegalovirus infection was associated with higher likelihood of colon neoplasia post-LT in IBD/PSC patients (hazard ratio = 4.4, P = 0.024). There was no significant difference in survival outcome between the three study groups.

CONCLUSIONS

IBD/PSC patients remain at an increased risk of colon neoplasia after LT.

Total tumor volume predicts recurrence of hepatocellular carcinoma after liver transplantation in patients beyond Milan or UCSF criteria

BACKGROUND

The aim of tumor-based selection criteria in patients with hepatocellular carcinoma (HCC) is to prevent orthotopic liver transplantation (OLT) in patients likely to experience recurrence and to maximize OLT opportunities for those with a high likelihood of cure.

OBJECTIVE

Our aim was to assess total tumor volume (TTV) as a selection criterion for OLT in patients with HCC beyond Milan or University of California San Francisco criteria.

METHODS

We identified patients who underwent OLT for HCC between 2002 and 2008. TTV was calculated as the sum of the volumes of all tumors on pretransplant imaging before any therapy [(4/3)πr(3), where r is the maximum radius of each HCC]. Univariable and multivariable Cox proportional hazards regression analysis was used to assess factors associated with recurrence of HCC.

RESULTS

107 patients were included in the study. The mean follow-up was 21 months (interquartile range, 11.8-32.5), during which 13 patients (12.1%) experienced recurrence of HCC. Twenty-nine patients (27.1%) had HCC beyond the Milan criteria. A TTV cutoff value of 33.5 cm(3) was chosen on the basis of the risk of recurrence by using a receiver operating characteristic curve. Patients beyond the Milan criteria with TTV <33.5 experienced less recurrence (13.3% vs 42.8%; P < .001) and higher survival (13.3% vs 57.1%; P = .006) than those who were beyond the Milan criteria with TTV ≥33.5. Similarly, TTV predicted HCC recurrence and survival in those beyond the UCSF criteria.

CONCLUSION

TTV is useful in identifying patients at risk of tumor recurrence and poor survival among those with tumor burden beyond traditional criteria, and it may improve the selection of OLT candidates.

Recurrence of Disease Following Liver Transplantation: Nonalcoholic Steatohepatitis vs Hepatitis C Virus Infection

BACKGROUND

Nonalcoholic steatohepatitis (NASH) is an increasing indication for orthotopic liver transplantation (OLT) in the United States and other countries. However, the incidence of disease recurrence and natural course following OLT remains incompletely understood.

OBJECTIVE

To estimate the incidence of recurrent disease, outcome and identify risk factors associated with disease recurrence in patients undergoing OLT for NASH as compared to those undergoing OLT for HCV cirrhosis.

METHODS

We identified all patients with end-stage liver disease secondary to NASH (n=53) or HCV (n=95) cirrhosis who underwent OLT at our institution between 1998 and 2005. Protocol liver biopsies were performed (Day 7, Month 4 and yearly) after OLT, and as clinically indicated. Kaplan-Meier survival analysis was performed to assess the fibrosis progression and survival. Cox regression analysis was performed to identify factors associated with disease recurrence.

RESULTS

Five-year survival was 90.5% in NASH vs 88.4% in HCV group (p=0.97). The median (25%ile, 75%ile) follow-up to last available biopsy was 12.7 (5.9, 26.3) months, during which 17 (32%) of NASH patients developed persistent fatty infiltration in their graft, 8 (15%) of whom had accompanying histologic features of recurrent NASH. There was no difference in the prevalence of post-OLT steatosis between HCV and NASH patients after adjusting for time of histologic follow-up (p=0.33). Patients with HCV infection were more likely to develop hepatic fibrosis post-OLT than those with NASH (62.1% vs 18.9%, p<0.001). Multivariate analysis identified post-OLT diabetes (HR=2.0, 95% CI: 1.2-3.2, p=0.007) as an independent risk factor for fibrosis development. Additionally, NASH subjects who received steroids had a significantly higher risk of developing hepatic fibrosis post-OLT than NASH patients who did not receive steroids and all HCV subjects (p<0.001).

CONCLUSION

Recurrence of steatosis post-OLT is common. Corticosteroid use may contribute to fibrosis progression in this population.

Urinary cotinine in narguila or chicha tobacco smokers

Urinary levels of nicotine metabolites were measured in nonsmokers and smokers of tobacco either as cigarettes or as the Middle-Eastern water pipes (narguila). Levels of urinary cotinine were similar for the smokers of cigarettes (median 30 cigarettes per day) and narguila (median 2 pipes per day, or around 40 grams of tobacco). Use of water pipes may remove a small amount of nicotine, but smokers appear to titrate dose to effect. It is unlikely that narguila smoking confers any less risk.

An epidemic of hyperthyroidism following salt iodination in Lebanon

Salt iodination, in Lebanon, started partially in late 1992, and was implemented in a uniform manner by January 1995. Following salt iodination, an epidemic of iodine-induced thyrotoxicosis occurred, as noted by the author, in his private clinic. The number of thyrotoxic patients increased sharply by 2 to 6 folds, and the yearly incidence rose from a baseline of 0.02% up to 0.07%. The younger patients have predominantly Graves' disease (32% of the cases), while 17% have solitary thyroid nodules, and 44% of the cases were elderly subjects with multinodular goiter. The pathogenesis and possible causes of this epidemic are discussed.

Primary endocrine-secreting pancreatic tumors

Insulinoma, glucagonoma, gastrinoma (Zollinger-Ellison syndrome), vipoma, somatostatinoma and a tumor that secretes human pancreatic polypeptide are the primary endocrine-secreting tumors of the pancreas. hormones are produced by specific tumor cell types and cause a variety of dramatic clinical pictures. Diagnosis often requires hormone assays. Computerized tomography may be helpful. Definitive surgical treatment is possible, but metastases may be present.

Plasma high density lipoprotein cholesterol in thyroid disease

The plasma levels of high density lipoprotein cholesterol (HDL-C) were reduced in 16 hyperthyroid female patients compared to 37 euthyroid women (33.5 +/- 8 vs. 51.5 +/- 13 mg/dl (mean +/- SD); P less than 0.001). When 5 patients were restudied after restoration of the euthyroid state, plasma HDL-C increased from 29 +/- 5 to 43 +/- 11.5 mg/dl (P less than 0.05). In addition, in 22 hypothyroid women, HDL-C levels were also diminished compared to the euthyroid group (43.4 +/- 15.5 vs. 51.5 +/- 13 mg/dl; P less than 0.05). Nine patients were restudied after L-T4 replacement therapy; their levels of HDL-C increased but not to a statistically significant degree. The daily administration of 0.3 mg L-T4 to eight normal male volunteers for 1 month did not significantly affect HDL-C levels.

In vitro effect of dopamine and pimozide on human chorionic gonadotropin secretion

In human placental explants cultured in vitro, dopamine inhibited human chorionic gonadotropin (hCG) secretion into the culture media. In the control flasks, the level of hCG secretion was 751 +/- 215 mIU/gm of tissue. When 1 mM of dopamine was added, hCG levels decreased to 321 +/- 57.6 mIU/gm of tissue (n = 6, P less than 0.1)--5 and 10 mM of dopamine significantly inhibited hCG secretion. In contrast, 1 mM of pimozide enhanced hCG secretion by 1.8-fold compared to control levels (1,707 +/- 343 versus 3,117 +/- 0.005). This in vitro effect on hCG is similar to the effect of dopamine and pimozide on hCS secretion by placental explants.

Cimetidine induced prolactin (PRL) release in thyroid disease

Effects of acute intravenous administration of cimetidine on serum levels or PRL, TSH, LH and FSH were investigated in six healthy euthyroid, five hypothyroid and five hyperthyroid patients. Cimetidine failed to alter serum TSH levels in the hypothyroid patients. There was no change in LH and FSH levels except in two euthyroid subjects in whom significant rise in LH occurred. However, in all subjects, whether euthyroid, hypo- or hyperthyroid, the serum PRL concentration increased two to three fold above basal levels. The peak levels of serum PRL occurred at 15 min following the drug administration. The response was not blunted in the older age group. We conclude that unlike the TRH-mediated PRL release, the cimetidine-induced PRL release is independent of the levels of thyroid hormone.

Failure of somatostatin to affect human chorionic somatomammotropin and human chorionic gonadotropin secretion in vitro

The effect of somatostatin (SRIF) on human chorionic somatomammotropin (hCS) secretion was studied in human placental explants cultured in vitro. In the experimental flasks, SRIF was added in a concentration of 10, 100, and 1000 ng/ml media; hCS levels measured by RIA were not different from those found in the control flasks. In separate experiments, we investigated the action of SRIF on hCG secretion by a human malignant choriocarcinoma cell line maintained in tissue culture. SRIF (1000 ng/ml) did not inhibit basal or dibutyryl cAMP-induced stimulation of hCG secretion. These results suggest that somatostatin does not suppress hCS or hCG release in vitro from normal or malignant trophoblast, respectively.

In vitro effect of dopamine and pimozide on human chorionic somatomammotropin (hCS) secretion

In human placental explants cultured in vitro, dopamine inhibited human chorionic somatomammotropin (hCS) secretion into the culture media. In the control flasks, the level of hCS secretion was 130.5 +/- 7.8 micrograms/g tissue (n = 6). When 1 mM dopamine was added, hCS levels decreased to 80.2 +/- 11.5 micrograms/g tissue (P less than 0.01). Dopamine (5 and 10 mM) further lowered hCS levels. In contrast, 1 mM pimozide enhanced hCS secretion by 2-fold as compared to control levels (248.2 +/- 44.8 vs. 130.5 +/- 7.8, P less than 0.02). The simultaneous addition of dopamine did not alter the stimulatory effect of pimozide on hCS secretion. In separate experiments, arginine (1 and 5 mM) and somatostatin (1 microgram/ml culture media) did not alter hCS secretion from placental explants. These results suggest that hCS secretion is modulated by dopaminergic receptors.

Skull x-ray in the evaluation of endocrine diseases

The skull x-ray remains invaluable as a first step in the diagnosis of many endocrine disorders. Pituitary tumors commonly cause enlargement or distortion of the sella turcica, which can be seen on skull x-ray. Pinealomas and craniopharyngiomas may also be detected. Hyperparathyroidism can cause granular decalcification in the skull. Hypoparathyroidism produces calcification of the basal ganglia and cerebellum. Lesions due due to metastatic malignancies or eosinophilic granulomas may be noted in cases of diabetes insipidus. Sellar enlargement may be due to the "empty sella" syndrome. Twenty-five percent of all cases of enlarged sella may be accounted for by this syndrome.

Hyponatremia of hypothyroidism. Appropriate suppression of antidiuretic hormone levels

A hypothyroid, 72-year-old woman with idiopathic hypopituitarism manifested severe hyponatremia, plasma hypoosmolality, and inappropriately elevated urine osmolality suggestive of a syndrome of inappropriate antidiuretic hormone secretions. The hyponatremia did not respond to demeclocycline hydrochloride, and antidiuretic hormone (ADH) levels measured by a specific radioimmunoassay were appropriately suppressed. Subsequent replacement therapy with levothyroxine sodium resulted in correction of the hyponatremia. Thus, both direct assay as well as hormone blockade failed to show an action of ADH in mediating the water retention.

What not to do in pheochromocytoma

Use of a screening VMA procedure rather than a specific assay may yield false-positive results. Plasma catecholamine levels should be obtained in the unstressed, supine patient. Pharmacologic tests are less reliable than chemical tests. In the presence of a pheochromocytoma, phenoxybenzamine should be administered before any manipulative procedures, as well as prior to surgery. This agent should be given along initially; propranolol may be added preoperatively.

Receptor dysfunction and hormone resistance in human diseases--a review

Studies of the hormone-receptor interaction have introduced a new chapter in endocrine and metabolic disorders. Receptor (R) dysfunction in human diseases, due either to an alteration in the number or affinity of the R, or to antibodies against the R, is reviewed and classified in the first part of this paper. Disorders where hormone resistance has been implicated, but where R studies are still unavailable are also presented.

Vitiligo and juvenile diabetes mellitus

Five juvenile diabetics had vitiligo. In two children, the vitiligo preceded the onset of diabetes. Four of the five patients had thyroid, adrenal, or gastric antibodies or a combination of these. In three children HLA-B8 antigens were detected, and one additional patient had HLA-Bw15. Of eight nondiabetic children with vitiligo, one had abnormal glucose tolerance. To the evidence supporting an autoimmune form of diabetes mellitus we add another observation: the association of insulin-dependent diabetes and childhood vitiligo.

The starved kidney: a defect in renal concentrating ability

The renal tubular responsiveness to antidiuretic hormone was assessed in seven obese patients during starvation and feeding by an overnight dehydration test followed by exogenous vasopressin. All seven subjects showed a mean reduction of one-third in their maximum urinary osmolality on day 4 of starvation. Thes- data show that the renal tubule is partially insensitive to antidiuretic hormone at a time when it is also insensitive to mineralocorticoids.?Author