Resting heart rate is associated with colorectal advanced adenoma

Background and aims

Resting heart rate is an independent predictor of colorectal cancer (CRC) development and CRC-related mortality. However, little is known about the relationship between resting heart rate and colorectal adenoma development. We aimed to investigate this association in a population who underwent screening colonoscopy.

Methods

Among 39,021 patients who underwent both electrocardiogram and screening colonoscopy during routine health examinations at the Seoul National University Bundang Hospital, Health Promotion Center, Korea from January 2014 to July 2019, 1,344 patients had advanced adenoma. We performed 1:1 propensity score (PS) matching to establish a control group that mitigated the confounding effects of age and sex. We performed multivariate logistic regression analyses to identify the independent risk factors of advanced adenoma development.

Results

Resting heart rate was significantly higher in the advanced adenoma group than in the control group. The prevalence of advanced polyp increased across the quartiles of resting heart rate. Patients with higher resting heart rates were more likely to be older, smokers, and have increased blood pressure and DM and less likely to engage in active exercises than those with lower resting heart rates. Patients with higher resting heart rates had higher serum glucose, triglyceride, hemoglobin A1C, and insulin levels and lower high-density lipoprotein cholesterol levels. Patients with resting heart rate in the highest quartile (≥71 bpm) still showed significantly increased odds ratio (OR) of advanced adenoma development (OR: 1.379, 95% confidence interval: 1.099–1.731, p = 0.006).

Conclusions

High resting heart rate was a meaningful independent risk factor of advanced adenoma development.

NORMAL MEASUREMENTS OF PRESSURE IN ANAL CANAL DURING SPHINCTEROMETRY ON S4402 MSM AND WMP SOLAR GI DEVICES

AIM

To assess normal measurements of pressure in anal canal during sphincterometry on S4402 MSM and WPM Solar GI devices.

MATERIALS AND METHODS

The study included 126 patients with colonic polyps. inclusion criteria were absence of anal incon- tinence and defecation disorders. Seventy-three patients were assessed with S4402 MSM device, Included were 28 males (mean age 56,2±10,2 years) and 45 females (mean age 54,9±13,7 years). Fifty-three subjects were assessed via WPM Solar GI device: 23 women (mean age 51,4±11,1 years) and 30 males (mean age 65,1±15,9 years).

RESULTS

Sphincterometry results using S4402 MSM device in males were as follows: mean resting pressure - 52,1+198 mm Hg; maximal resting pressure - 60,3±21,9mm Hg; mean pressure at voluntary contraction - 118,2±41,5 mm Hg and maximal pressure at voluntary contraction - 174,2±56,8 mm Hg. Corresponding values in females were 37,1±15,3 mm Hg, 43,8±15,5 mm Hg; 75,1±29,5 mm Hg and 99,1±39,7 mm Hg, respectively. Using WPM Solar GI sphincterometry the following figures were obtained in males: resting pressure - 43-61 mm Hg; maximal voluntary contraction pressure - 121-227 mm Hg; mean pressure - 106-190 mm Hg; maximal pressure with coughing test - 45-175 mm Hg; at straining minimal pressure decreased to 19-43 mm Hg (20-60%). In females the results were as follows: resting pressure - 41-63 mm Hg; maximal pressure at voluntary contraction 110-178 mm Hg; mean pressure - 88-146 mm Hg; maximal pressure at coughing test - 76-126 mm Hg, pressure decrease at straining to 28-52 mm Hg, relaxation up to 19-40%.

Endoscopic and histologic characteristics of serrated lesions

In recent years, a second pathway for colonic carcinogenesis, distinct from the adenomatous pathway, has been explored. This is referred to as serrated pathway and includes three types of polyp, characterised by a serrated appearance of the crypts: hyperplastic polyps (HP), sessile serrated adenomas (SSA) or lesions, and traditional serrated adenomas. Each lesion has its own genetic, as well as macroscopic and microscopic morphological features. Because of their flat aspect, their detection is easier with chromoendoscopy (carmin indigo or narrow-band imaging). However, as we show in this review, the distinction between SSA and HP is quite difficult. It is now recommended to resect in one piece as it is possible the serrated polyps with a control in a delay depending on the presence or not of dysplasia. These different types of lesion are described in detail in the present review in general population, in polyposis and in inflammatory bowel diseases patients. This review highlights the need to improve characterization and understanding of this way of colorectal cancerogenesis.

[Immunohistochemical expression of p53, Bcl-2, and Ki-67 proteins in traditional serrated adenomas of colon]

BACKGROUND/AIMS

Serrated adenomas of the colon show mixed characteristics of both hyperplastic and adenomatous polyps. Serrated adenomas are known to progress via the serrated pathway than the adenoma-carcinoma pathway. The aim of this study was to evaluate the characteristics of traditional serrated adenomas compared to hyperplastic polyps and tubular adenomas by using immunohistochemical staining for p53, Bcl-2, and Ki-67.

METHODS

Age, sex, location, size and the immunoexpression of p53, Bcl-2, and Ki-67 were retrospectively analyzed in 20 traditional serrated adenomas, 20 hyperplastic polyps, and 20 tubular adenomas from January 2007 to December 2012 at The Catholic University of Korea, Yeouido St. Mary's Hospital.

RESULTS

There was no difference in Bcl-2 and p53 expression between traditional serrated adenomas and hyperplastic polyps. Ki-67 Expression of traditional serrated adenomas was higher than that of hyperplastic polyps (p=0.001). Ki-67 and p53 expression was similar between traditional serrated and tubular adenomas. Bcl-2 expression of traditional serrated adenomas was lower than that of tubular adenomas (p=0.001). Regarding the expression of p53, Bcl-2, and Ki-67 in traditional serrated adenomas, there were no statistical differences among age, sex, location, and size.

CONCLUSIONS

Our study suggested that Ki-67 may be helpful in distinguishing traditional serrated adenomas from hyperplastic polyps, and p53 expression may be ineffective in distinguishing between traditional serrated and tubular adenomas. From Bcl-2 expression, it is suggested that the tumorigenesis of traditional serrated adenomas is lower than that of tubular adenomas.

STAT1 expression is not required for polyp formation in Min mice

Recent studies have suggested the importance of interleukin (IL)-6 signaling in the development of colon cancer. Expression of IL-6 and the IL-6 receptor have been found to be elevated in colorectal carcinoma tissue, and IL-6 has been found to be critical for tumor formation in mouse models of colon cancer. IL-6 mediated activation of the transcription factor STAT1 has been shown to be important in protection of colorectal carcinoma cells from apoptotic signals. To test the hypothesis that the IL-6-STAT1 axis plays a role in early stages of colon cancer development, we examined the role of this pathway in the mouse multiple intestinal neoplasia (Min) model of intestinal tumorigenesis. Due to low fecundity, we were unable to generate Min mice lacking expression of IL-6. We then focused on the role of STAT1 in intestinal polyp formation in these animals. Min mice lacking STAT1 or heterozygous for STAT1 developed polyps in similar numbers as those expressing STAT1. Furthermore, the anatomic distribution and histological characteristics of these polyps did not vary among these populations. These results indicate that STAT1 does not play a role in the pathogenesis of the Min model for colon cancer. However, they do not rule out the possibility that STAT1 plays a role in other stages of colon cancer development.

Is there any relation between hyperinsulinemia, insulin resistance and colorectal lesions in patients with acromegaly?

INTRODUCTION

Pathogenesis of colonic lesions in patients with acromegaly remains still unclear. There are suggestions that apart from somatotropin axis hormones (GH and IGF-1), other agents also take part in this process. Molecular and animal studies indicate a vital role of hyperinsulinemia in development of colorectal neoplasms.

AIM OF THE STUDY

To evaluate a relation between insulin level, insulin resistance and its anthropometric markers and colorectal lesions in patients with acromegaly.

MATERIAL AND METHODS

The study consisted of 40 patients with active, newly diagnosed acromegaly; 24 women and 16 men aged from 24 to 77 years (mean age 50.1, SD+/-12.1). The analysis included the results of somatotropin axis function (GH and IGF-1 level), carbohydrate metabolism assessment (fasting serum glucose and insulin levels, oral glucose tolerance test, HOMA-IR for insulin resistance), the results of anthropometric measurement (BMI, WHR) and colonoscopy.

RESULTS

Colon pathologies (60 polyps and 2 flat lesions) were discovered in 19 (47.5%) patients with acromegaly, 8 of them had multiple polyps. Hyperplastic polyps were revealed in 11 (27.5%), while adenomas in 8 (20%) acromegalics. Patients with colorectal lesions were found to have higher WHR then subjects with normal colon (p=0.033). Positive correlation between the number of hyperplastic polyps in the patients with multiple changes in the colon and IGF-1 (p=0.025), insulin level (p=0.005) and HOMA-IR (p=0.001) was found. Multiple adenomas correlated positively with insulin level (p=0.007), HOMA-IR (p=0.006) and BMI (p=0.015).

CONCLUSIONS

The study results show a relation between hyperinsulinemia, insulin resistance and colon pathologies in acromegaly. Fasting insulin level and HOMA-IR correlate positively with the number of hyperplastic polyps and adenomas in acromegalic patients with multiply colorectal lesions.

Evidence of prolonged orocecal transit time and small intestinal bacterial overgrowth in acromegalic patients

CONTEXT

Gastrointestinal abnormalities in acromegaly include dolichomegacolon, slow colonic transit, and increased prevalence of colonic polyps. Conversely, no data are available on the small intestine.

OBJECTIVE

The aim of the study was to investigate the orocecal transit time (OCTT) and the presence of small intestinal bacterial overgrowth (SIBO).

PATIENTS

A total of 41 acromegalic patients and 30 sex- and age-matched control subjects entered the study. Acromegalic patients were classified according to the medical treatment with somatostatin analogs as "treated" (n = 22) and "untreated" (n = 19), whereas according to the disease control, as "controlled" (n = 17), "uncontrolled" (n = 10), and "partially controlled" (n = 14). Patients and controls completed a questionnaire and underwent a standardized 10-g lactulose hydrogen breath test to determine the OCTT and presence of SIBO. SIBO-positive patients underwent eradication with rifaximine.

RESULTS

An increased prevalence of SIBO (18 of 41 vs. 1 of 30; P < 0.0001) and a significantly delayed OCTT (169.53 +/- 8.15 vs. 107.25 +/- 6.56 min; P < 0.0001) were evidenced in patients compared with controls. No significant statistical differences were found between "treated" or "untreated" patients positive for SIBO or between "controlled," "partially controlled," and "uncontrolled" patients. OCTT was significantly delayed in "treated" vs. "untreated" patients (183.21 +/- 9.01 and 158.89 +/- 6.38, respectively; P = 0.02) and in patients compared with controls (105.75 +/- 6.34; P < 0.0001). Rifaximine eradicated SIBO in more than 50% of patients who underwent treatment.

CONCLUSIONS

These data demonstrate for the first time that SIBO occurs more frequently in acromegalic patients, however, it can be successfully treated by a specific antibiotic. Medical therapy with somatostatin analogs does not affect SIBO prevalence. OCTT resulted significantly prolonged in both "treated" and "untreated" patients, suggesting that acromegaly determines per se an impairment of the intestinal motility. Indeed, disease control seems irrelevant on the delayed OCTT, suggesting that this alteration might be an irreversible complication of acromegaly, probably related to an autonomic intestinal disorder, as we have previously demonstrated at the cardiac level.

Function and quality of life after transanal excision of rectal polyps and cancers

PURPOSE

The purpose of this study was to determine the functional outcomes and health-related quality of life of patients after transanal excision of rectal cancers or polyps and to assess the relationship between functional outcomes and health-related quality of life.

METHODS

All patients having a transanal excision at the Mount Sinai Hospital from 1989 to 2002 were included if the indication for surgery was a benign or malignant neoplasm. Physician charts were reviewed, and patients and their physicians were contacted to obtain follow-up information. Continence was assessed by using the Continence Score described by Jorge and Wexner and the Fecal Incontinence Quality of Life instrument by Rockwood and Lowry.

RESULTS

Eighty-two patients fit the inclusion criteria (42 males; mean age, 71 +/- 13.7 years). Of these, 29 had villous adenomas, 2 had carcinoids, and 1 had a hyperplastic polyp. Fifty had cancers, including 34 with T1, 14 with T2, and 2 with T3 cancers. Seven patients had a low anterior resection or abdominoperineal resection within two months of transanal excision because of advanced features of cancer. Five patients had salvage abdominoperineal resections or low anterior resections for local recurrences. Five patients died of rectal cancer (including 3 who had salvage surgery) and an additional seven patients died of other causes. Functional results were assessed in 58 of 61 eligible patients. The mean Continence Score postoperatively was 3.5 +/- 3.9 compared with 2.4 +/- 3.7 preoperatively (P = 0.03). The mean Fecal Incontinence Quality of Life scores after surgery in all patients were 3.9 +/- 0.3, 3.6 +/- 0.6, 3.7 +/- 0.3, 3.7 +/- 0.6 in the domains of lifestyle, coping, depression, and embarrassment, respectively, after surgery, indicating high quality of life. Using Spearman's correlation, we found that the continence scores after surgery correlated well with the Fecal Incontinence Quality of Life scores. In the domains of lifestyle (Spearman's correlation = -0.69), coping and behavior (Spearman's correlation = -0.7), and embarrassment (Spearman's correlation = -0.61) but did not correlate well with the domain of depression (Spearman's correlation = -0.17).

CONCLUSIONS

Although functional results are worsened in a minority of patients after transanal excision, quality of life is high in the majority of patients.

Flat adenomas

This article was presented at the conjoint CSSA and RACS (colorectal section) spring meeting Queensland, Australia, September 2004. The adenoma-carcinoma sequence describes a succession of events from polypoid adenoma to colorectal cancer. However, this model only accounts for up to two-thirds of colorectal cancers. There is growing evidence that flat adenomas are precursor lesions to a flat type of colorectal cancer and certain subtypes of these polyps are at greater risk of malignant transformation. If confirmed, the implications for screening, endoscopic recognition and management will become of increasing importance if we are to decrease the incidence of colorectal cancer.

[Clinical significance of the functional and structural changes in the intestines in chronic cholecystitis]

The aim of the study was to determine the clinical significance of intestinal functional and structural alterations in biliary pathology. Clinical, endoscopic, morphological, and morphometric methods were used. The subjects of the study were 62 patients with functional gall bladder disorder, 90 patients with chronic calculous cholecystitis, and 90 patients who had undergone cholecystectomy for cholelithiasis. The study found that biliary lithogenesis was associated with intestinal dysbiosis, changes in the qualitative density of erythrocytes immunopositive to motilin and substance P, and inflammatory changes in the intestines. After cholecystectomy, changes in intestinal microecology progressed, inflammatory and atrophic changes in the intestinal mucosa appeared or deepened, the qualitative density of erythrocytes immunopositive to motilin and substance P decreased, and colon polyps appeared more frequently.

A study of colorectal polyps

OBJECTIVE

To determine various features of colorectal polyps and to evaluate the safety of colonoscopic polypectomy.

DESIGN

Case series.

PLACE AND DURATION OF STUDY

The Department of Gastroenterology and Hepatology, Federal Postgraduate Medical Institute, Shaikh Zayed Hospital, Lahore, from January 1987 to January 2004.

PATIENTS AND METHODS

This study was based on data analysis of 393 patients who underwent colonoscopic polypectomy at our institution during 17 years from January 1987 to January 2004. Presenting complaints of patients were noted. Polyps were evaluated in terms of size, site, number and histopathology.

RESULTS

Among 393 patients, 268 were male and 125 female. Presenting complaints were bleeding per rectum in 339 patients, diarrhea with blood in 34 and without blood in 6 patients, and lower abdominal pain in 12 patients. Two patients were being investigated for iron deficiency anemia. Two hundred and sixty-four patients had juvenile polyps, 39 had adenomatous polyps, 39 hyperplastic polyps, 39 inflammatory polyps, 3 malignant polyps and 2 patients had familial polyposis. Histopathological reports were not available in 7 patients. Size of the polyps ranged from 0.3 cm to 3.0 cm. Left colon was involved in 353 patients, transverse colon in 15, right colon in 8 patients and diffuse involvement of colon found in 17 patients. Bleeding following polypectomy occurred in 2% of the patients. No other procedure related complication occurred.

CONCLUSION

Juvenile polyps were the commonest variety of polyps in our study. Colonoscopic polypectomy has very low complication rate.

Humoral immune response to MUC5AC in patients with colorectal polyps and colorectal carcinoma

BACKGROUND

MUC5AC is a secreted mucin aberrantly expressed by colorectal polyps and carcinoma. It has been hypothesized that aberrant expression of MUC5AC in colorectal carcinoma tissues increased the overall survival of patients with colorectal carcinoma. The present study investigates the incidence of naturally occurring MUC5AC antibodies in the sera of normal individuals, patients with colonic polyps and patients with advanced colorectal carcinoma. A second aim was to determine the relationship of MUC5AC antibody with the prognosis of colorectal carcinoma.

METHODS

Free circulating MUC5AC antibodies were measured using an enzyme-linked immunosorbent assay with a synthetic peptide corresponding to an 8 aa. segment of MUC5AC tandem repeat region. Immunohistochemical analysis was completed to demonstrate MUC5AC expression in the polyp specimens.

RESULTS

MUC5AC antibodies were detected in 6 of 22 (27.3%) healthy subjects, 9 of 20 (45%) polyp patients, 18 of 30 (60%) patients with colorectal cancer. The presence of circulating free MUC5AC antibody levels was significantly correlated with expression of MUC5AC in polyp sections. Serum MUC5AC antibody positivity was higher in patients with colon located tumors, advanced stage and poorly differentiated tumors were found negatively affecting patient survival in our study. MUC5AC antibody positivity was higher in patients with poor prognostic parameters. Disease free survival and overall survival were shorter in this group of patients. In the multivariate analysis MUC5AC antibody positivity didn't find an independent prognostic factor on prognosis.

CONCLUSION

Decreased survival in colorectal carcinoma patients with MUC5AC antibody positivity may be due to a decrease in the MUC5AC expression in tumor tissues of surviving carcinoma patients.

Multinucleated epithelial giant cells in colorectal polyps: a potential mimic of viropathic and/or dysplastic changes

Multinucleated epithelial giant cells (MEG) simulating viral cytopathic effect and/or dysplasia have been reported in the esophagus in association with inflammation, but the occurrence of similar cells in the colon has not been documented. Twenty-three colon specimens (22 biopsies and 1 partial colectomy) featuring MEG from 21 patients were evaluated for a variety of histologic features and correlated with clinical, endoscopic, and follow-up data. Patients included 9 males and 12 females (mean age, 64.9 years; range, 45-86 years). Eleven cases were obtained from 10 asymptomatic patients undergoing surveillance biopsies. Presenting symptoms in the remaining patients were dyspepsia, anemia, abdominal pain, and hematochezia. Over half (13 of 23) of the specimens were from descending and rectosigmoid colon, and almost all were visualized as polyps on endoscopy. Microscopically, all but 1 of the cases featured multiple MEG (range, 6 to >50 cells per biopsy) in the base and mid crypt zones of inflamed polyps with serrated architecture. Immunohistochemical stains for CMV, HSV, adenovirus, EBV, and polyoma virus were negative and no viral particles were identified on ultrastructural examination. Nuclear staining for hMLH1 and hMSH2, markers of microsatellite instability, was similar in distribution to adjacent serrated crypts, but reduced staining intensity was noted in occasional multinucleated cells. Expression of Ki-67 and cleaved caspase 3 was consistent with a quiescent or low proliferative state. Clinical follow-up was available for 9 patients (mean duration, 22.7 months). One patient died of heart failure; all others were well at last follow-up. Bizarre MEG may occasionally be seen within the crypts of inflamed polyps with serrated architecture, raising concern for dysplasia or viral infection. Immunohistochemical and ultrastructural studies fail to establish a viral etiology, and follow-up does not indicate clinically aggressive disease. These changes appear to represent a nonspecific, possibly degenerative response to inflammation and injury, and should be distinguished from dysplasia.

From Colonic Polyps to Colon Cancer: Pathophysiology, Clinical Presentation, and Diagnosis

Epidemiologists, basic researchers, clinicians, and public health administrators unite! Develop and implement a simple, safe, and effective preventive and screening test for colon cancer. The public will willingly and enthusiastically accept such a test. Many thousands of lives are at stake every year.

Angiogenesis in colon hyperplastic polyp

Despite the significance of tumor angiogenesis and the extensive knowledge on the molecular basis of blood vessel formation in carcinoma of colorectum, no data exist in hyperplastic polyp. This prompted us to examine angiogenesis in hyperplastic polyp. Eleven small hyperplastic polyps, 13 large hyperplastic polyps and their adjacent normal mucosas were included in this study. Angiogenesis was assessed by immunohistochemistry using monoclonal antibody against CD34. Angiogenic factor, thymidine phosphorylase was also examined by immunohistochemistry. Intra-tumoral microvessel density (IMD) in large hyperplastic polyp was significantly higher than that in small hyperplastic polyp (P<0.01) and that in normal mucosa (P<0.01). DAD in small hyperplastic polyp was also significantly higher than that in normal mucosa (P<0.01). Expression of dThdPase was almost observed in stromal cells in normal, small and large hyperplastic polyp. In addition, the proportion of the stromal cells expressing dThdPase in large hyperplastic polyp was significantly higher than that in small hyperplastic polyp and normal tissue (P<0.01, respectively). The proportion of the stromal cells expressing dThdPase in small hyperplastic polyp was significantly higher than that in normal tissue (P<0.01). The present study provides that angiogenesis may have an important role(s) in the development of hyperplastic polyp and dThdPase in stromal cells may support angiogenesis in hyperplastic polyp. Anti-angiogenic therapy might be available for suppression of hyperplastic polyp.

National Polyp Study data: evidence for regression of adenomas

The data of the National Polyp Study, a large longitudinal study on surveillance of adenoma patients, is used for testing assumptions on the adenoma-carcinoma sequence. The observed adenoma and colorectal cancer incidence in the National Polyp Study were compared with the simulated outcomes of the MISCAN-COLON model of epidemiology and control of colorectal cancer for the U.S. population based on expert opinion. Variants of this model were explored in order to identify assumptions on the adenoma-carcinoma sequence that are consistent with the study observations. The high observed adenoma detection rates at surveillance and low observed colorectal cancer incidence in the National Polyp Study could only be explained by assuming a high incidence rate of adenomas accompanied by regression of adenomas. The National Polyp Study data suggest that adenoma prevalence results from a dynamic process of both formation as well as regression of adenomas. This lowers the expectations for the effects of colorectal cancer screening strategies that focus on adenoma detection.

Expression of survivin correlates with apoptosis, proliferation, and angiogenesis during human colorectal tumorigenesis

BACKGROUND

To identify the role of survivin, a novel inhibitor of apoptosis (IAP) in colorectal tumorigenesis, the authors investigated tissue expression of survivin in human colorectal tumors including 43 hyperplastic polyps, 171 adenomas with low dysplasia, 42 adenomas with high dysplasia, and 60 carcinomas in adenoma, and examined whether the expression of survivin correlated with tumor cell apoptosis, proliferation, and angiogenesis, which is known to initiate the imbalance between cell proliferation and apoptosis.

METHODS

Immunohistochemical staining for the paraffin sections by using the monoclonal antibodies, survivin, p53, bcl-2, Ki-67, and CD34, was performed by the standard avidin-biotin-peroxidase technique. The apoptotic cells were detected by terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling method, using an Apop Tag in situ detection kit.

RESULTS

The immunoreactivity of survivin significantly increased in the transition from adenoma with low dysplasia to high dysplasia/carcinoma (P < 0.001). Similar changes in protein expression were observed for p53 but not for bcl-2, which was expressed throughout the colorectal tumorigenesis. This transition was associated with a significant decrease in the apoptotic index (AI) and significant increases in the Ki-67 labeling index (LI) and microvessel density (MVD; P < 0.001 for both). The expression of survivin inversely correlated with AI and was positively correlated with Ki-67 LI and MVD (P < 0.001 for both).

CONCLUSIONS

These results suggest that, like p53, survivin plays an important role in transition from adenoma with low dysplasia to high dysplasia during human colorectal tumorigenesis.

Comparison of the expression of ABH/Lewis-related antigens in polypoid and non-polypoid growth types of colorectal carcinoma

BACKGROUND AND AIMS

Colorectal tumors can be classified based on their growth pattern into the polypoid growth-type (PG-type) and non-polypoid growth-type (NPG-type). To ascertain whether there is any relationship between the expression of particular blood group-related antigens (A, B, H, Lewis (Le)a, sialyl Le(a), Le(x), sialyl Le(x)) in a colorectal tumor, and a tumor having polypoid or non-polypoid growth, we examined 78 PG-type and NPG-type colorectal cancers.

METHODS

Fourteen PG-type and 64 NPG-type colorectal carcinomas were subjected to immunohistochemical analyses by using monoclonal antibodies against A, B, H, Le(a), sialyl Le(a), Le(x) and sialyl Le(x).

RESULTS

The patients with NPG-type carcinomas had a significantly younger age of onset, significantly smaller maximal tumor diameter, significantly higher rate of lymph node metastasis and significantly worse prognosis than those with PG-type carcinomas. Among the 32 tumors of patients with blood type A or AB, isoantigen A was expressed in a significantly larger percentage of NPG-type carcinomas than PG-type carcinomas (95.8 vs 62.5%, respectively; P=0.014). Among all 78 tumors, sialyl Le(x) antigen was expressed in a significantly larger percentage of NPG-type than PG-type carcinomas (90.6 vs 64.3%, respectively; P=0.010). Multivariate analysis using the logistic regression model revealed that isoantigen A and sialyl Le(x) expression were independent predictive risk factors for the development of NPG-type colorectal carcinoma.

CONCLUSIONS

These data suggest that the expression of isoantigen A and sialyl Le(x) in a colorectal carcinoma partially determines whether the tumor will have polypoid or non-polypoid growth.

Myofibroblasts: paracrine cells important in health and disease

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Endoclip-assisted resection of large pedunculated colon polyps

BACKGROUND

Large pedunculated colorectal polyps are often difficult to remove endoscopically.

METHODS

Four patients with giant pedunculated polyps (>3 cm) underwent an endoscopic procedure in which the polyp stalk was ligated with multiple clips and resected with a needle-knife papillotome.

RESULTS

No complications occurred either during or immediately after the procedure. Mean size of the resected polyps was 4.8 +/- 1.2 cm (range 3 to 6 cm). Mean time for the entire procedure was 31 +/- 5 minutes (range 25 to 45). No bleeding was found after a mean follow-up period of 4.3 +/- 1.1 months (range 3 to 6 months).

CONCLUSIONS

Although technical refinements are necessary to make the procedure easier and faster, this approach might represent the only option for selected patients who would otherwise need surgical resection of large pedunculated colonic polyps.

Polypoid dysplasia and adenomas in inflammatory bowel disease: a clinical, pathologic, and follow-up study of 89 polyps from 59 patients

Dysplasia in inflammatory bowel disease (IBD) is categorized as either flat or associated with a raised lesion or mass (dysplasia-associated lesion or mass [DALM]). One specific subtype of a dysplasia-associated lesion or mass consists of isolated discrete nodules or polyps that are difficult to distinguish from sporadic adenomas. Because the clinical management of these two lesions is different, we performed this study to (1) evaluate the clinical presentation, pathologic features, and natural history of polypoid dysplastic lesions and sporadic adenomas in patients with IBD and (2) determine whether there are clinical, endoscopic, or pathologic findings useful in differentiating between these two lesions. The morphologic features of 89 benign polypoid epithelial neoplasms from 59 patients with IBD (51 with ulcerative colitis, 8 with Crohn's colitis) were evaluated and correlated with the clinical, endoscopic, and follow-up data. In a separate analysis, patients were categorized arbitrarily as having (1) a probable sporadic adenoma if the polypoid epithelial neoplasm was not located within areas of histologically proven colitis, (2) a probable IBD-associated polypoid dysplasia if the lesion developed within an area of colitis, and associated flat dysplasia or an adenocarcinoma was detected during follow-up evaluation or (3) an indeterminate polyp, which was seen in the remainder of the cases. The clinical, endoscopic, and histologic data were compared among these three patient and polyp subgroups. There were 35 males and 24 females (median age, 57 years; range, 27-85 years). Median duration of disease was 10 years. Forty-nine percent of the patients had pancolitis; 66% had histologically active disease at the time of presentation. Nearly 70% of patients had only one polyp; the majority occurred in either the left colon or the rectum (66%). Most polyps were described as a sessile nodule, whereas only 7 (7.8%) were pedunculated. Polyps ranged from 2 mm to 50 mm (median, 5 mm); most had a tubular architecture (84.3%) and contained low-grade dysplasia (64%). In addition, most polyps had mildly increased lamina propria and intraepithelial neutrophilic and mononuclear inflammation. At follow-up evaluation (40 patients; median follow-up time, 13 months; range, 1-78 months), a further neoplastic lesion developed in 20%; low-grade flat dysplasia was seen in 5 (12.5%), and adenocarcinoma developed in 3 (7.5%). However, dysplasia or adenocarcinoma did not develop in the patients who had polyps located outside of areas of histologically proven colitis. In addition, at least one more benign polypoid epithelial neoplasm developed in 15 of 40 patients (37.5%). Patients with probable IBD-associated polypoid dysplasia had a statistically significant (p < 0.05), longer disease duration than patients with probable sporadic adenoma. A statistically significant, higher proportion of polyps with tubullovillous or villous architecture, an admixture of normal and dysplastic epithelium at the surface of the polyps, and increased lamina propria mononuclear inflammation was noted in probable IBD-associated polypoid dysplastic lesions compared with those considered to be sporadic adenomas. Several clinical and pathologic features may be useful to help categorize a polypoid dysplastic lesion as a sporadic adenoma or an IBD-related neoplasm in a patient with IBD. This distinction is important because the natural history of these two lesions (as shown by the results of this study) and their subsequent management are quite different.

Abnormal mucus in cap polyposis

BACKGROUND

Cap polyposis is a rare disease characterised by mucoid and bloody diarrhoea, with polyps covered by a cap of mucoid and fibrinopurulent exudate. The pathogenesis is not known.

AIMS

To pour some light on cap polyposis pathogenesis, by examining the mucus of patients and analysing the expression of five mucin genes, MUC2, MUC3, MUC4, MUC5AC, and MUC5B.

PATIENT AND METHODS

The study was performed on biopsy specimens taken from a patient with recurrent cap polyposis. Histochemical examination, electron microscopy, and mRNA in situ hybridisation were used.

RESULTS

The mucus of cap polyposis differed in three respects from that of normal adult colon: abnormal ultrastructure of the mucus in the goblet cells, predominance of non-sulphated mucins, abnormal expression of the MUC4, MUC3, and MUC5AC genes.

CONCLUSIONS

Most of these abnormalities have been reported for other pathological situations, suggesting that the abnormalities observed in the mucus of this patient with cap polyposis are probably secondary phenomena rather than primary. However, the mucin abnormalities detected, which reflect deregulation of the expression of three apomucin genes, abnormal glycosylation, and abnormalities of the secretion process, are also probably involved in the clinical manifestations of cap polyposis.

Factors influencing bowel function following total abdominal colectomy

PURPOSE

The purpose of this study was to determine which factors influenced bowel function following total abdominal colectomy.

METHODS

Thirty-two patients who had undergone total abdominal colectomy were studied with regard to factors that are classically thought to influence bowel function, namely, residual stump length, transit time, and rectal stump manometry. In a limited subset of patients, anal manometry was done also.

RESULTS

Transit time was the best predictor of bowel function following total abdominal colectomy. This was followed by stump length. If transit time was short, then stump length became important in predicting the occurrence of diarrhea following total abdominal colectomy.

CONCLUSIONS

Two factors have an important influence on bowel function following total abdominal colectomy: transit time and rectal stump length. Rectal stump length is an anatomic factor that can be controlled by the surgeon. In total abdominal colectomy, rectal stump length of at least 20 cm is necessary if the patient is to have satisfactory postoperative bowel function. This may not always be possible. In these patients, modification of diet to influence transit time and methods to increase rectal compliance will be necessary.

Vitamin C status and colonic neoplasia

PURPOSE

A subnormal status of vitamin C has been associated with an increased risk for several malignant diseases and may play a causative role in their development. The aim of the present study was to investigate whether this occurs also in neoplasms of the colon.

METHODS

We have studied dietary intake and status of vitamin C in a consecutive group of patients with adenomatous colonic polyps (n = 31) and compared it with that of patients with no such history and a normal colonic mucosa, as confirmed by colonoscopy (n = 54).

RESULTS

Dietary intake of this vitamin, as assessed by the dietary recall method, was similar in the two groups, as were the levels of vitamin C in plasma and leukocytes. There were no significant differences in intake of dietary fiber, fat, vitamin A, or calcium between the two groups. Lack of association between vitamin C intake or status and colonic polyps persisted after adjustment for potential confounders.

CONCLUSION

We conclude that in this population, a deficient status of vitamin C is not an important factor in colonic neoplasia.

[Comparative evaluation of the anal sphincter function after sphincter-sparing operations in diffuse polyposis]

Experience in treating 76 patients who were subjected to various sphincter-preserving operations is analysed. It is shown that after subtotal resection of the large intestine with ++abdomino-anal resection of the rectum and pull-through of the right parts of the colon into the anal canal as well as after pull-through of the segment of the transverse colon into the anal canal, the neuro-reflex activity of the musculus sphincter ani internus is destroyed in 55% and reduces in 25% of patients while the reflex activity of the musculus sphincter ani externus is disturbed in 45% of patients and is not restored later. The results bear evidence that the condition of the rectal obturation apparatus does not depend on the segment of the colon subjected to the pull-through operation (cecum, ascending colon, transverse colon). Experience has shown that the results of sphicterometry, electromyography, and electromanometry in various periods after colectomy, mucosectomy of the rectum, and formation of ileorectal anastomosis are much better than those after pull-through operations on various parts of the colon, and return to normal values in 18 months.

Investigations of the anal sphincter before and after restorative proctocolectomy

Twenty-eight patients who underwent sphincter-saving proctocolectomy and formation of an ileoanal reservoir had clinical evaluation of resting and maximal anal sphincter pressures and perfused catheter manometry. The clinical estimate of resting tone, heretofore believe to be a good predictive parameter of postoperative function, was inaccurate. This suggests the advisability of manometric evaluation. There were significant changes in sphincter pressures postoperatively. Operation did not effect the preoperative electromyographic findings of the puborectalis muscle and external sphincter in our small postoperative population. The mechanism by which operation might influence these parameters has been discussed. Factors such as parity and the descending perineum syndrome may effect continence. Due to the length of time the sphincter is required to function in these patients and the multiplicity of factors involved, we believe that long-term studies are needed.

The mucosal blood flow in pelvic pouches in man. A methodologic study of fluorescein flowmetry

Fluorescein flowmetry implies the measurement of capillary blood flow, expressed as an index between the maximum fluorescence after the first circulatory passage of sodium fluorescein (NaF) and the rise time, defined as the time interval between ten and 90 percent of the maximum fluorescence. A mathematic model based on fluorescein flowmetry was deduced to distinguish a mucosal and muscular blood flow in an intact (unopened) intestine during surgery in man. The hypothesis was that if, at a certain point in time, there is a fixed relationship between the seromuscular fluorescence and the mucosal maximum fluorescence, obtained during the first circulatory passage of NaF, and if the rise times were equal, then a mucosal blood flow could be calculated based on the seromuscular fluorescence. The model was tested in intestinal anastomoses on 16 patients. A fixed relationship between the numeric value of the mucosal maximum fluorescence and the seromuscular fluorescence was found. After five minutes, the ratio was 1:1 and the correlation coefficient at its highest (0.97). It was also found that the rise times were practically identical (r = 0.92). The validity of the model was then tested by comparing it with fluorescein flowmetry, and the correlation coefficient was 0.85. The model was therefore accepted and named indirect mucosal fluorescein flowmetry. Indirect mucosal fluorescein flowmetry was applied to measure blood flow in pelvic pouches in 14 patients, and fluorescein flowmetry in the ileoanal anastomoses in eight patients. The mucosal blood flow in the reservoir, compared with the normal intestine, was reduced to 58 percent if the ileocolic artery or distal branches of the mesenteric artery were ligated, and to 88 percent if the vessels were left intact (P less than 0.05). In the ileoanal anastomosis the mucosal blood flow was reduced to 23 percent compared with the normal intestine (P less than 0.01). The results suggest that stretching and compressing the mesentery might be critical for circulation in the ileoanal anastomoses.

Total colectomy, rectal mucosectomy and ileoanal anastomosis for familial polyposis coli--use of tube ileostomy

Radical cancer-preventive management of familial polyposis coli is total removal of the colon and rectum. We have carried out this procedure with ileoanostomy for seven young patients with familial polyposis coli. There was no significant morbidity and all ileoanal anastomoses were completed without any problems of leakage or abscesses. Side-to-end anastomosis is very effective in preventing complications of ileoanostomy. Simple tube-ileostomy is also effective and is recommended rather than loop ileostomy. Restoration of anal function was excellent except in one patient whose internal sphincter muscle was injured during rectal mucosectomy. Our results show that ileoanal anastomosis without postoperative complications has no effect on the postoperative social rehabilitation of the patient, although the frequency of defecation is three or four times a day.

Classification and risk assessment of individuals with familial polyposis, Gardner's syndrome, and familial non-polyposis colon cancer from [3H]thymidine labeling patterns in colonic epithelial cells

A probabilistic analysis has been developed to assist the binary classification and risk assessment of members of familial colon cancer kindreds. The analysis is based on the microautoradiographic observation of [3H]thymidine-labeled epithelial cells in colonic mucosa of the kindred members. From biopsies of colonic mucosa which are labeled with [3H]thymidine in vitro, the degree of similarity of each subject's cell-labeling pattern measured over entire crypts was automatically compared to the labeling patterns of high-risk and low-risk reference populations. Each individual was then presumptively classified and assigned to one of the reference populations, and a degree of risk for the classification was provided. In carrying out the analysis, a linear score was calculated for each individual relative to each of the reference populations, and the classification was based on the polarity of the score difference; the degree of risk was then quantitated from the magnitude of the score difference. When the method was applied to kindreds having either familial polyposis or familial non-polyposis colon cancer, it effectively segregated individuals affected with disease from others at low risk, with sensitivity and specificity ranging from 71 to 92%. Further application of the method to asymptomatic family members believed to be at 50% risk on the basis of pedigree evaluation revealed a biomodal distribution to nearly zero or full risk. The accuracy and simplicity of this approach and its capability of revealing early stages of abnormal colonic epithelial cell development indicate potential for preclinical screening of subjects at risk in cancer-prone kindreds and for assisting the analysis of modes of inheritance.

12-O-Tetradecanoylphorbol-13-acetate stimulation of DNA synthesis in cultured preneoplastic familial polyposis colonic epithelial cells but not in normal colonic epithelial cells

We have developed a method for the routine primary culture of human colonic epithelial cells. Cultured cells exhibited characteristic epithelial structures, including a brush border and junctional complexes. Flask-like goblet cells containing mucus were also seen within the epithelial monolayer. [3H]Thymidine labeling indices were used to distinguish between cultured cells from familial polyposis patients, other patients at high risk to develop colon cancer, and low-risk control subjects. 12-O-Tetradecanoylphorbol-13-acetate (TPA) at 10 ng/ml enhanced DNA synthesis an average of 8-fold when assayed by labeling index in colonic epithelial cells from five of six familial polyposis patients. No such stimulation by TPA was seen in cells from 13 high-risk patients without familial polyposis or in cells from five low-risk subjects. Hundreds of benign polyps can be found in the colons of familial polyposis patients. One such benign tubular adenoma exhibited the same enhancement of DNA synthesis by TPA as normal-appearing epithelial cells from a biopsy adjacent to that polyp. Mitogenic response to TPA had been seen earlier in cells from each of four tubular adenomas (Friedman, E. Cancer Res., 41: 4588-4599, 1981). Both familial polyposis epithelial cells and adenoma cells are considered preneoplastic, but they are not identical because their patterns of actin cytoskeletal organization differ. These results imply that familial polyposis epithelial cells are precursors of tubular adenoma cells, and their transition to the more advanced preneoplastic cells of this benign tumor is influenced by endogeneous tumor promoters.