Synchronous colorectal neoplasms in patients with colorectal cancer: predisposing individual and familial factors

Genomic alterations in oral multiple primary cancers

Oral squamous cell carcinoma (OSCC) is the predominant type of oral cancer, while some patients may develop oral multiple primary cancers (MPCs) with unclear etiology. This study aimed to investigate the clinicopathological characteristics and genomic alterations of oral MPCs. Clinicopathological data from patients with oral single primary carcinoma (SPC, n = 202) and oral MPCs (n = 34) were collected and compared. Copy number alteration (CNA) analysis was conducted to identify chromosomal-instability differences among oral MPCs, recurrent OSCC cases, and OSCC patients with lymph node metastasis. Whole-exome sequencing was employed to identify potential unique gene mutations in oral MPCs patients. Additionally, CNA and phylogenetic tree analyses were used to gain preliminary insights into the molecular characteristics of different primary tumors within individual patients. Our findings revealed that, in contrast to oral SPC, females predominated the oral MPCs (70.59%), while smoking and alcohol use were not frequent in MPCs. Moreover, long-term survival outcomes were poorer in oral MPCs. From a CNA perspective, no significant differences were observed between oral MPCs patients and those with recurrence and lymph node metastasis. In addition to commonly mutated genes such as CASP8, TP53 and MUC16, in oral MPCs we also detected relatively rare mutations, such as HS3ST6 and RFPL4A. Furthermore, this study also demonstrated that most MPCs patients exhibited similarities in certain genomic regions within individuals, and distinct differences of the similarity degree were observed between synchronous and metachronous oral MPCs.

Transcriptomic and genomic profiling of multiple primary colorectal cancers reveals intratumor heterogeneity and a distinct immune microenvironment

This study reported on the intratumor genomic and immunological heterogeneity of different tumor lesions from a single patient with multiple primary colorectal cancer (MPCC). The goal of this study was to explore the molecular and microenvironment characteristics of tumor lesions from different primary sites in a patient with MPCC. A total of three tumor lesions located in the hepatic flexure of the transverse colon, sigmoid colon, and rectum were collected from a 72-year-old male patient with MPCC. All three tumor samples were examined by using whole-exome sequencing (WES) and single-cell RNA sequencing (scRNA-seq). The transcriptome data of The Cancer Genome Atlas (TCGA) colon cancer (COAD) dataset were explored to characterize the biological impacts of certain immune cells. Only three nonsynonymous mutations were shared by all of the tumor lesions, whereas a number of single nucleotide variant (SNV) and copy number variation (CNV) mutations were shared by tumor samples from the sigmoid colon and rectum. Transcriptomic analysis showed that tumor lesions derived from the transverse colon had decreased levels of RTK, ERK, and AKT pathway activity, thus suggesting lower oncogenic properties in the transverse lesion compared to the other two samples. Further immune landscape evaluation by using single-cell transcriptomic analysis displayed significant intratumor heterogeneity in MPCC. Specifically, more abundant mucosal-associated invariant T (MAIT) cell infiltration was found in transverse colon tumor lesions. Afterwards, we found that higher MAIT cell infiltration may correlate with a better prognosis of patients with colon cancer (immunohistochemical status was MSI-L/pMMR) by using a publicly available TCGA dataset.

Synchronous Neoplasia Rates at Colonoscopic Diagnosis of Early-Onset vs Average-Onset Colorectal Cancer

Importance

The incidence of early-onset colorectal cancer (CRC) (age, <50 years) continues to increase globally within high-income countries.

Objective

To examine and compare rates of synchronous neoplasia found in patients at colonoscopic diagnosis of early-onset CRC with rates found at diagnosis of average-onset CRC.

Design, Setting, and Participants

In this multisite retrospective and cross-sectional study conducted at Mayo Clinic sites and in the Mayo Clinic Health System from January 1, 2012, to December 31, 2022, 150 randomly selected patients with early-onset CRC were identified from the electronic health record and matched with 150 patients with average-onset CRC based on sex and colonoscopic indication. Patients with known hereditary syndromes, past history of CRC, or inflammatory bowel disease were excluded.

Main Outcomes and Measures

Colonoscopic findings (polyp size, number, site) and related histopathologic findings (adenoma, advanced adenoma, sessile serrated polyp) were analyzed in association with cancer clinicopathologic features and molecular data (mismatch repair status, KRAS, and BRAFV600E).

Results

Among 300 patients (156 men [52%]), the median age at diagnosis was 43 years (IQR, 39-47 years) for those with early-onset CRC and 67 years (IQR, 57-76) for those with average-onset CRC. Overall, 85% of patients were symptomatic at CRC diagnosis. Cancer stage, grade, molecular features, body mass index, and family history did not differ significantly between these groups. Among patients with colon cancer, the overall prevalence of synchronous neoplasia was similar, yet advanced adenomas were 3 times more frequent in those with early-onset vs average-onset cancers (31 of 75 [41%] vs 10 of 75 [13%]; P < .001). This difference was not associated with cancer stage or primary location. Among patients with rectal cancer, nonadvanced adenomas were less frequent among the early-onset group than the average-onset group (21 of 75 [28%] vs 36 of 75 [48%]), and although the prevalence of advanced adenomas was similar (11 of 75 [15%] vs 14 of 75 [19%]), they were more commonly located in the rectum (early onset, 5 of 11 [45%] vs average onset, 1 of 14 [7%]). Patients with early-onset cancer of the colon were significantly more likely than those with early-onset cancer of the rectum to have a synchronous advanced adenoma (31 of 75 [41%] vs 11 of 75 [15%]; P < .001).

Conclusions and Relevance

In this cross-sectional study, synchronous advanced adenomas were more commonly found in patients with early-onset colon cancer compared with average-onset colon cancer, and they were distributed throughout the colon. In contrast, advanced adenomas were not increased in patients with rectal cancer and, when detected, were predominantly located in the rectum.

Surgical resection for second primary colorectal cancer: a population-based study

Background

Second primary colorectal cancer (CRC) is attributed to a crucial component of the CRC population. Still, its treatments remain unclear due to the troublesome conditions originating from multiple primary cancers and the lack of quality evidence. This study aimed to determine that which type of surgical resection is the eligible treatment for second primary CRC among patients with a prior cancer history.

Methods

This cohort study retrospectively collected patients with second primary stage 0-III CRC in the Surveillance, Epidemiology, and End Results database from 2000 to 2017. Prevalence of surgical resection in second primary CRC, overall survival (OS) and disease-specific survival (DSS) of patients who received different surgical interventions were estimated.

Results

A total of 38,669 patients with second primary CRC were identified. Most of the patients (93.2%) underwent surgical resection as initial treatment. Approximately 39.2% of the second primary CRCs (N = 15,139) were removed with segmental resection, while 54.0% (N = 20,884) were removed through radical colectomy/proctectomy. Surgical resection was associated with a significantly favorable OS and DSS compared to those not receiving any surgical operations for second primary CRC [OS: adjusted Hazard ratios (adjusted HR): 0.35; 95% CI: 0.34-0.37, p < 0.001; DSS: adjusted HR: 0.27; 95% CI: 0.25-0.29, p < 0.001]. Segmental resection considerably outperformed radical resection in terms of OS and DSS (OS: adjusted HR: 0.97; 95% CI: 0.91-1.00, p = 0.07; DSS: adjusted HR: 0.92; 95% CI: 0.87-0.97, p = 0.002). Segmental resection was also associated with a significantly reduced cumulative mortality of postoperative non-cancer comorbidities.

Conclusion

Surgical resection demonstrated excellent oncological superiority for second primary CRC and was used to remove the vast majority of second primary CRCs. In comparison to radical resection, segmental resection offered a better prognosis and reduced postoperative non-cancer complications. The second primary colorectal cancers should be resected if the patients can afford surgical operations.

Efficacy of endoscopic surveillance in the detection of local recurrence after radical rectal cancer surgery is limited? A retrospective study

Background

Rectal cancer, one of most common neoplasms, is characterized by an overall survival rate exceeding 60%. Nonetheless, local recurrence (LR) following surgery for rectal cancer remains a formidable clinical problem. The aim of this study was to assess the value of postoperative endoscopic surveillance (PES) for the early detection of LR in rectal cancer after radical anterior resection with sigmoid-rectal anastomosis.

Methods

We performed an anterior resection in 228 patients with stages I‑III rectal cancer who had undergone surgery from 2001 to 2008 in the Oncology Center in Bydgoszcz, Poland. Of these patients, 169 had perioperative radiotherapy or radiochemotherapy. All patients underwent PES with abdominal and pelvic imaging (abdominal ultrasound, computed tomography, magnetic resonance) and clinical examination. Sensitivities, specificities, positive likelihood ratios, negative likelihood ratios, and receiver operating characteristic curves were calculated to compare the value of colonoscopy versus imaging techniques for the diagnosis of LR.

Results

During the 5-year follow-up, recurrences occurred in 49 (21%) patients; of these, 15 (6%) had LR, which was most often located outside the intestinal lumen (n = 10, 4%). Anastomotic LR occurred in 5 (2%) patients. The mean time to anastomotic LR was 30 months after initial surgery, similar to that of other locations (29 months). Both imaging and endoscopy were shown to be efficient techniques for the diagnosis of LR in anastomotic sites. In the study group, endoscopy did not provide any additional benefit in patients who were receiving radiation therapy.

Conclusions

The benefit of PES for the detection of LR after curative treatment of rectal cancer is limited and not superior to imaging techniques. It remains a useful method, however, for the histopathological confirmation of suspected or confirmed recurrence.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-021-02413-0.

A 10-Year Evaluation of Short-Term Outcomes After Synchronous Colorectal Cancer Surgery: a Dutch Population-Based Study

BACKGROUND

Synchronous colorectal cancer (CRC) has been associated with higher postoperative morbidity and mortality rates compared to solitary CRC. The influence of improved CRC care and introduction of screening on these outcomes remains unknown. This study aimed to evaluate time trends in incidence, population characteristics, and short-term outcomes of synchronous CRC patients at the population level over a 10-year time period.

METHODS

Data of all patients that underwent resection for primary CRC were extracted from the Dutch ColoRectal Audit (2010-2019). Analyses were stratified for solitary and synchronous colon and rectal cancer. Multilevel logistic regression analyses were used to determine factors associated with pathological and surgical outcomes.

RESULTS

Among 100,474 patients, 3.1% underwent surgery for synchronous CRC. A screening-related decrease for surgically treated left-sided solitary and synchronous colon cancer and a temporary increase for exclusively right-sided colon cancer were observed. Synchronous CRC patients had higher rates of complicated postoperative course, failure to rescue, and mortality. Bilateral synchronous colon cancer was more often treated with subtotal colectomy (25.4%) and demonstrated higher rates of surgical complications, reinterventions, prolonged hospital stay, and mortality than other synchronous tumor locations.

DISCUSSION

National bowel screening resulted in contradictory effects on surgical resections for synchronous CRCs depending on sidedness. Bilateral synchronous colon cancer required more often extended resection resulting in significantly worse outcomes than other synchronous tumor locations. Identification of low volume, high complex CRC subpopulations is relevant for individualized care and has implications for case-mix correction and benchmarking in clinical auditing.

Risk Stratification Based on Synchronous Neoplasia and Clinical Physicochemical Characteristics Predicts a Higher Incidence of Metachronous Advanced Neoplasia in Patients Undergoing Colorectal Resection for Colorectal Cancer

Purpose

Patients who undergo primary colorectal cancer (CRC) resection remain at increased risk for metachronous advanced neoplasia (MAN) in the remnant colorectum. This study aimed to investigate the incidence and clinicopathological characteristics predictive of MAN development in the residual colon after surgery.

Patients and Methods

We retrospectively reviewed 450 primary CRC cases referred to our hospital during a 4-year period. Univariate and multivariate analyses were performed to identify risk factors for MAN. The cumulative incidence of MAN was evaluated by the Cox proportional hazards model.

Results

MAN development was confirmed in 78 of the 450 patients (17.3%). Overall 1-, 2-, 3-, and 5-year cumulative probabilities were 0.9%, 4.8%, 9.8%, and 16.1%, respectively, for MAN. Among the clinical and colonoscopic factors at baseline, the independent factors that were significantly associated with MAN were synchronous neoplasia, carcinoembryonic antigen (CEA) level ≥10.0 ng/mL, and index cancer size ≥50 mm. The cumulative probability of MAN was significantly higher for patients with synchronous advanced neoplasia (SAN) than for those without synchronous neoplasia (P = 0.000). A subgroup analysis of patients based on the CEA level and index cancer size indicated that CEA ≥10 ng/mL and index cancer ≥50 mm resulted in a significantly higher cumulative probability of MAN (P = 0.039).

Conclusion

Patients with SAN or high preoperative serum CEA levels and large index cancer are at increased risk for early-onset MAN. More intensive surveillance strategies may be appropriate for these groups. Risk stratification based on synchronous neoplasia and clinical physicochemical characteristics requires further investigations involving modified appropriate postoperative colonoscopic surveillance schedules.

Clinicopathological and molecular features of colorectal cancer with synchronous adenoma

OBJECTIVE

To investigate the clinicopathological and molecular features of colorectal cancer (CRC) with synchronous adenoma and to describe features of synchronous adenomas in CRC patients.

METHODS

Single-centre retrospective cohort of 180 patients were included. The clinicopathological and endoscopic data were collected. The expression mismatch repair (MMR) proteins were detected by immunohistochemistry. The determination of microsatellite instability (MSI) was performed by multiple fluorescence PCR, and the mutations of genes were detected by real-time PCR.

RESULTS

Among all cases, 49 were diagnosed as CRC with synchronous adenoma, and 131 were diagnosed as solitary CRC. Some of the differences between the groups are: higher incidence was found in male (71.4 vs. 52.6%, p = .023) and in patients with habit drinking (34.7 vs. 14.5%, p = .030) and with other neoplastic diseases (42.7 vs. 26%, p = .028). Less tumors in the synchronous group were diagnosed as stage III and IV than in the solitary group (28.6 vs. 45%, p = .045). One and four mutant subtypes of KRAS gene mutations were detected insynchronous group and solitary group respectively.The prevalence of BRAF mutations in solitary group was higher than that in the synchronous group (7.4 vs. 0%, p = .045). A total of 123 adenomas were found in synchronous group and they tend to be smaller than 10 mm (74%).

CONCLUSION

Gender, a habit of drinking and other neoplastic diseases are risk factors for the development of a synchronous adenoma. With a low rate of BRAF mutations, the responses to monoclonal antibody and prognosis of patients with synchronous adenomas may be better than that of solitary CRC.

Quality of Preoperative Colonoscopy Affects Missed Postoperative Adenoma Detection in Colorectal Cancer Patients

BACKGROUND

Despite thorough preoperative screening, 19-30% of synchronous polyps or adenomas are detected after colon cancer surgery. Remnant synchronous lesions require additional colonoscopy procedures or surgery.

AIM

To investigate factors of preoperative colonoscopy potentially affecting the detection of missed lesions in patients subjected to colorectal cancer surgery.

METHODS

Of 1147 colorectal cancer patients subjected to curative open or laparoscopic colectomy and colonoscopy at the Chungnam National University Hospital from January 2012 to December 2016, 518 patients underwent pre- and postoperative colonoscopy. The index colonoscopy was defined as the last preoperative endoscopy performed. We analyzed pre- and postoperative medical charts for colonoscopy and pathological data. The effects of patient, procedure, and tumor factors on the postoperative adenoma detection rate, advanced adenoma detection rate, and adenoma miss rate (AMR) were analyzed.

RESULTS

The overall AMR was 25.7% (95% confidence interval, 22.2-29.8%). Comparing optimal and non-optimal bowel preparation groups, the latter had greater postoperative polyp missed rate (PMR), AMR (p < 0.01), and AAMR (p = 0.272). The optimal preparation group allowed identification of more synchronous adenomas than in the fair (OR 5.72) and poor (OR 11.39) preparation groups. On univariate analysis, patient age and left-sided colectomy (p < 0.01) influenced AMR. Multivariate analysis showed that age, preoperative bowel preparation, and left colon resection influenced postoperative AMR.

CONCLUSION

A better quality of index colonoscopy had a positive effect on lowering the detection rate of postoperative adenoma. Older age and suboptimal bowel preparation at the index colonoscopy and left-sided colectomy had negative effects on lowering the postoperative AMR.

Mouse models of colorectal cancer: Past, present and future perspectives

Colorectal cancer (CRC) is the third most common diagnosed malignancy among both sexes in the United States as well as in the European Union. While the incidence and mortality rates in western, high developed countries are declining, reflecting the success of screening programs and improved treatment regimen, a rise of the overall global CRC burden can be observed due to lifestyle changes paralleling an increasing human development index. Despite a growing insight into the biology of CRC and many therapeutic improvements in the recent decades, preclinical in vivo models are still indispensable for the development of new treatment approaches. Since the development of carcinogen-induced rodent models for CRC more than 80 years ago, a plethora of animal models has been established to study colon cancer biology. Despite tenuous invasiveness and metastatic behavior, these models are useful for chemoprevention studies and to evaluate colitis-related carcinogenesis. Genetically engineered mouse models (GEMM) mirror the pathogenesis of sporadic as well as inherited CRC depending on the specific molecular pathways activated or inhibited. Although the vast majority of CRC GEMM lack invasiveness, metastasis and tumor heterogeneity, they still have proven useful for examination of the tumor microenvironment as well as systemic immune responses; thus, supporting development of new therapeutic avenues. Induction of metastatic disease by orthotopic injection of CRC cell lines is possible, but the so generated models lack genetic diversity and the number of suited cell lines is very limited. Patient-derived xenografts, in contrast, maintain the pathological and molecular characteristics of the individual patient’s CRC after subcutaneous implantation into immunodeficient mice and are therefore most reliable for preclinical drug development – even in comparison to GEMM or cell line-based analyses. However, subcutaneous patient-derived xenograft models are less suitable for studying most aspects of the tumor microenvironment and anti-tumoral immune responses. The authors review the distinct mouse models of CRC with an emphasis on their clinical relevance and shed light on the latest developments in the field of preclinical CRC models.

Synchronous Neoplastic Lesions In Referred Patients With Colorectal Cancer: A Retrospective Cohort Study

Background

Synchronous neoplastic lesions are usually present in patients with colorectal cancer (CRC) at diagnosis or postoperative follow-up endoscopy. However, few studies have been published about the clinicopathological features of synchronous lesions, especially those of synchronous advanced neoplasia. This study aimed to describe synchronous lesions in patients with CRC because this knowledge may be useful for preventing the development of metachronous cancer.

Material and methods

We retrospectively reviewed 261 primary CRC cases with synchronous lesions referred to our hospital during a 4-year period. Personal history, habits, family history, characteristics of index cancer, and synchronous lesions were assessed.

Results

In total, the 261 patients with CRC had 812 synchronous adenomas and 146 advanced neoplasia. Diminutive, small, and large polyps made up 66.7%, 20.2%, and 13.1% of all lesions, respectively; 9.3% of diminutive and small adenomas were advanced neoplasia, and 45.2% of synchronous advanced lesions were subcentimeter polyps. Both synchronous non-advanced lesions and advanced lesions developed most frequently in the distal colon, followed by the proximal colon, and were least frequently found in the rectum (P < 0.001). Older age (P = 0.04) and male gender (P = 0.001) were associated with the presence of advanced neoplasia in CRC cases with synchronous neoplastic lesions. Meanwhile, the use of aspirin may be associated with a lower incidence of advanced neoplasia (P = 0.04).

Conclusion

Patients diagnosed with CRC require detailed clearing of the remainder of the colon at baseline coloscopy or postoperative follow-up examination, and we should take a more cautious approach to synchronous subcentimeter polyps in this group of patients.

Synchronous colorectal cancer using CT colonography vs. other means: a systematic review and meta-analysis

OBJECTIVES

The objective of our study was to systematically review the evidence about synchronous colorectal cancer diagnosed with or without computed tomography colonography (CTC).

MATERIALS AND METHODS

Two systematic searches were performed (PubMed and EMBASE) for studies reporting the prevalence of synchronous colorectal cancer (CRC): one considering patients who underwent CTC and the another one considering patients who did not undergo CTC. A three-level analysis was performed to determine the prevalence of patients with synchronous CRC in both groups of studies. Heterogeneity was explored for multiple variables. Pooled prevalence and 95% confidence interval (CI) were calculated. A quality assessment (STROBE) was done for the studies.

RESULTS

For CTC studies, among 2645 articles initially found, 21 including 1673 patients, published from 1997 to 2018, met the inclusion criteria. For non-CTC studies, among 6192 articles initially found, 27 including 111,873 patients published from 1974 to 2015 met the inclusion criteria. The pooled synchronous CRC prevalence was 5.7% (95% CI 4.7%-7.1%) for CTC studies, and 3.9% (95% CI 3.3%-4.4%) for non-CTC studies, with a significant difference (p = 0.004). A low heterogeneity was found for the CTC group (I² = 10.3%), whereas a high heterogeneity was found in the non-CTC group of studies (I² = 93.5%), and no significant explanatory variables were found. Of the 22 STROBE items, a mean of 18 (82%) was fulfilled by CTC studies, and a mean of 16 (73%) by non-CTC studies.

CONCLUSIONS

The prevalence of synchronous CRC was about 4-6%. The introduction of CTC is associated with a significant increase of the prevalence of synchronous CRCs.

Factors related to colorectal cancer in advanced adenomas and serrated polyps: a further step toward individualized surveillance

AIM

The risk of presenting synchronous or metachronous neoplasm, either adenoma or carcinoma, increases after an initial colonic lesion develops. It is known as tumor multicentricity and constitutes the rationale for surveillance programs. This study was designed to identify the clinical, pathologic, and molecular features related to previous or synchronous colorectal cancer (CRC) in patients with advanced adenomas (AA) or serrated polyps (SP).

PATIENTS AND METHODS

We carried out a prospective analysis of 4143 colonoscopies performed at our medical department between 1 September 2014 and 30 September 2015. Patients with AA/SP associated with previous or synchronous CRC are compared with patients with solitary AA/SP. We also performed immunohistochemical for the mismatch repair proteins in 120 AA or SP, 60 of them related to CRC.

RESULTS

Three-hundred and seventy-nine AA or SP were removed. Among these, 66 (17.3%) were associated with a previous (n=31) or synchronous CRC (n=35). Age older than or equal to 65 years (odds ratio: 1.15, 95% confidence interval: 1.05-1.26, P=0.002) and male sex (odds ratio: 2.13, 95% confidence interval: 1.3-3.49, P=0.003) were found to be independent predictive factors for CRC in patients with AA/SP by multivariate analysis. Only one of the 120 AA/SP available for immunohistochemical testing showed loss of staining and it was not related to CRC.

CONCLUSION

In patients with AA or SP, it is possible to identify a subgroup that is more likely to be associated with CRC and then prone to tumor multicentricity. These results have potential implications for establishing criteria for a more targeted surveillance.

Risk factors for metachronous adenoma in the residual colon of patients undergoing curative surgery for colorectal cancer

PURPOSE

Adenoma detection in colorectal cancer survivors is poorly characterised with insufficient evidence to inform frequency of surveillance schedule. The aim of this study was to examine adenoma incidence and recurrence in patients who have undergone colorectal cancer resection with curative intent. Survival outcomes were compared to determine if the presence of adenomas could be used to identify patients at higher risk of local recurrence.

METHODS

This is a retrospective observational cohort study at a single tertiary institution between 2006 and 2012. Five hundred fifteen consecutive patients with stage I-III colorectal cancer who had preoperative colonoscopy and curative surgery were included (median follow-up 56 months (36-75 months).

RESULTS

In total, 352/515 (68%) patients underwent postoperative surveillance colonoscopy in the first 5 years after resection. Male gender was associated with greater risk of detecting synchronous adenoma at index colonoscopy or in the resection specimen (OR 2.35, p < 0.001). In the first 5 years after cancer surgery, synchronous adenoma, male gender and right sided primary tumour were independent predictors of metachronous lesions (OR 2.13, p = 0.009; OR 2.07, p = 0.027 and OR 2.34, p = 0.004, respectively). Presence of synchronous or metachronous adenoma had no impact upon incidence of local recurrence, overall or disease free survival.

CONCLUSIONS

Patients with synchronous adenoma remain at high risk of adenoma recurrence despite undergoing colonic resection and should be considered for early endoscopic surveillance. Men and those undergoing right-sided resection have a higher risk of metachronous adenoma in the long term and may benefit from more frequent endoscopic surveillance post resection.

Predicting the risk for lymphoma development in Sjogren syndrome: An easy tool for clinical use

The heightened risk of non-Hodgkin lymphoma (NHL) development in primary Sjogren syndrome (SS) is well established. Several adverse clinical and laboratory predictors have been described. In the current work, we aimed to formulate a predictive score for NHL development, based on clinical, serological, and histopathological findings at the time of SS diagnosis. In the present case-control study of 381 primary SS patients and 92 primary SS patients with concomitant NHL, clinical, serological, and histopathological variables at the time of SS diagnosis were retrospectively recorded. For the identification of predictors for NHL development univariate and multivariate models were constructed. Salivary gland enlargement (SGE), lymphadenopathy, Raynaud phenomenon, anti-Ro/SSA or/and anti-La/SSB autoantibodies, rheumatoid factor (RF) positivity, monoclonal gammopathy, and C4 hypocomplementemia were shown to be independent predictors for NHL development. On the basis of the number of independent risk factors identified, a predictive risk score for NHL development was formulated. Thus, patients presenting with ≤2 risk factors had a 3.8% probability of NHL development, those with 3 to 6 risk factors 39.9% (OR (95%CI): 16.6 [6.5-42.5], P < 0.05), while in the presence of all 7 risk factors the corresponding probability reached 100% (OR [95%CI]: 210.0 [10.0-4412.9], P < 0.0001). In conclusion, an easy to use diagnostic scoring tool for NHL development in the context of SS is presented. This model is highly significant for the design of early therapeutic interventions in high risk SS patients for NHL development.

Laparoscopy-assisted versus open surgery for multiple colorectal cancers with two anastomoses: a cohort study

Laparoscopy-assisted surgery has been widely accepted in the treatment of colorectal cancer. The aim of the present study was to investigate the feasibility and outcomes of laparoscopy-assisted combined resection for multiple colorectal cancers in comparison to open surgery. We retrospectively reviewed patients with synchronous multiple colorectal cancers who underwent combined resection resulting in two anastomotic sites by either open or laparoscopy-assisted surgery in the University of Tokyo Hospital between April 2005 and March 2015. Nine patients underwent laparoscopic surgery using five ports, whereas 16 underwent open surgery. Blood loss was less (median 65 vs 295 mL, p = 0.0015), but the operative time was longer (median 429 vs 310 min, p = 0.09) in the laparoscopic surgery group than in the open surgery group. No intergroup difference was observed in the number of lymph nodes retrieved (median 32 vs 27, p = 0.50). The frequency of clinically significant postoperative complications was also similar between the two groups. Our results suggest that laparoscopy-assisted combined resection is an acceptable alternative to open surgery for multiple colorectal cancers.

Multiple primary colorectal cancer: Individual or familial predisposition?

Colorectal carcinoma (CRC) is one of the most frequent cancers. Along the surface of the large bowel, several foci of CRC may appear simultaneously or over the time. The development of at least two different tumours has been defined as multiple primary CRC (MPCRC): When more than one tumour is diagnosed at the same time, it is known as synchronous CRC (SCRC), while when a second neoplasm is diagnosed some time after the resection and/or diagnosis of the first lesion, it is called metachronous CRC (MCRC). Multiple issues can promote the development of MPCRC, ranging from different personal factors, such as environmental exposure, to familial predisposition due to hereditary factors. However, most studies do not distinguish this dichotomy. High- and low-pentrance genetic variants are involved in MPCRC. An increased risk for MPCRC has been described in Lynch syndrome, familial adenomatous polyposis, and serrated polyposis. Non-syndromic familial CRCs should also be considered as risk factors for MPCRC. Environmental factors can promote damage to colon mucosae that enable the concurrence of MPCRC. Epigenetics are thought to play a major role in the carcinogenesis of sporadic MPCRC. The methylation state of the DNA depends on multiple environmental factors (e.g., smoking and eating foods cooked at high temperatures), and this can contribute to increasing the MPCRC rate. Certain clinical features may also suggest individual predisposition for MPCRC. Different etiopathogenic factors are suspected to be involved in SCRC and MCRC, and different familial vs individual factors may be implicated. MCRC seems to follow a familial pattern, whereas individual factors are more important in SCRC. Further studies must be carried out to know the molecular basis of risks for MPCRC in order to modify, if necessary, its clinical management, especially from a preventive point of view.

Clinical and laboratory predictors of distinct histopathogical features of lupus nephritis

The authors aimed to explore whether distinct clinical, serological, and urinalysis findings are associated with specific histological classes of lupus nephritis. Clinical and laboratory features were recorded at the time of clinical diagnosis from 297 consecutive patients with biopsy-confirmed lupus nephritis. Univariate and logistic regression analyses were performed and a risk score was developed to estimate the risk for developing different classes of lupus nephritis. Variables independently associated with class II included absence of malar rash, negative anti-dsDNA, and ≤5 urine leucocytes/high power field (hpf); with III/IV: age at nephritis diagnosis ≤32 years old, presence of musculoskeletal features, new-onset hypertension, positive anti-dsDNA, >5 urine leucocytes/hpf, creatinine >1.2 mg/dL, cellular casts >1/hpf, and absence of nephrotic range proteinuria; with V: age at nephritis diagnosis >32 years, malar rash, absence of musculoskeletal complaints or serum C3 hypocomplementemia, nephrotic range proteinuria, and ≤9 urine erythrocytes/hpf. A risk predictive score of specific histological classes was calculated for each patient. Associations between 2, 3 or more risk factors with specific histological classes were also revealed [Odds ratios (95% confidence interval) (≥2 risk factors) was 6.7 (2.8-17.4) for class II nephritis, 15.6 (5.1-47.8), and 8.2 (3.6-19.0) for classes III/IV and for class V, respectively (≥3 risk factors)]. The identification of independent factors associated with specific classes of lupus nephritis can provide guidance in selecting specific therapeutic modalities, particularly in cases in which renal biopsy is contraindicated.

Epidemiology and familial risk of synchronous and metachronous colorectal cancer: a population-based study in Utah

BACKGROUND & AIMS

Patients diagnosed with colorectal cancer (CRC) are at risk for synchronous and metachronous lesions at the time of diagnosis or during follow-up evaluation. We performed a population-based study to evaluate the rate, predictors, and familial risk for synchronous and metachronous CRC in Utah.

METHODS

All newly diagnosed cases of CRC between 1980 and 2010 were obtained from the Utah Cancer Registry and linked to pedigrees from the Utah Population Database.

RESULTS

Of the 18,782 patients diagnosed with CRC, 134 were diagnosed with synchronous CRC (0.71%) and 300 were diagnosed with metachronous CRC (1.60%). The risk for synchronous CRC was significantly higher in men (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.02-2.06) and in patients aged 65 years or older (OR, 1.50; 95% CI, 1.02-2.21). Synchronous CRCs were located more often in the proximal colon (OR, 1.70; 95% CI, 1.20-2.41). First-degree relatives of cases with synchronous (OR, 1.86; 95% CI, 1.37-2.53), metachronous (OR, 2.34; 95% CI, 1.62-3.36), or solitary CRC (OR, 1.75; 95% CI, 1.63-1.88) were at increased risk for developing CRC, compared with relatives of CRC-free individuals. Four percent of first-degree relatives of patients with synchronous or metachronous cancer developed CRC at younger ages than the age recommended for initiating CRC screening (based on familial risk), and therefore would not have been screened.

CONCLUSIONS

Of patients diagnosed with CRC, 2.3% are found to have synchronous lesions or develop metachronous CRC during follow-up evaluation. Relatives of these patients have a greater risk of CRC than those without a family history of CRC. These results highlight the importance of obtaining a thorough family history and adhering strictly to surveillance guidelines during management of high-risk patients.

Synchronous colorectal cancer: Clinical, pathological and molecular implications

Synchronous colorectal carcinoma refers to more than one primary colorectal carcinoma detected in a single patient at initial presentation. A literature review has shown that the prevalence of the disease is approximately 3.5% of all colorectal carcinomas. This disease has a male to female ratio of 1.8:1. The mean age at presentation of patients with synchronous colorectal cancer is in the early half of the seventh decade. Patients with inflammatory bowel diseases (ulcerative colitis and Crohn’s disease), hereditary non-polyposis colorectal cancer, familial adenomatous polyposis and serrated polyps/hyperplastic polyposis are known to have a higher risk of synchronous colorectal carcinoma. These predisposing factors account for slightly more than 10% of synchronous colorectal carcinomas. Synchronous colorectal carcinoma is more common in the right colon when compared to solitary colorectal cancer. On pathological examination, some synchronous colorectal carcinomas are mucinous adenocarcinomas. They are usually associated with adenomas and metachronous colorectal carcinomas. Most of the patients with synchronous colorectal cancer have two carcinomas but up to six have been reported in one patient. Patients with synchronous colorectal carcinoma have a higher proportion of microsatellite instability cancer than patients with a solitary colorectal carcinoma. Also, limited data have revealed that in many synchronous colorectal carcinomas, carcinomas in the same patient have different patterns of microsatellite instability status, p53 mutation and K-ras mutation. Overall, the prognosis of patients with synchronous colorectal carcinoma is not significantly different from that in patients with solitary colorectal carcinoma, although a marginally better prognosis has been reported in patients with synchronous colorectal carcinoma in some series. A different management approach and long-term clinical follow-up are recommended for some patients with synchronous colorectal cancer.

Multiple sporadic colorectal cancers display a unique methylation phenotype

Epigenetics are thought to play a major role in the carcinogenesis of multiple sporadic colorectal cancers (CRC). Previous studies have suggested concordant DNA hypermethylation between tumor pairs. However, only a few methylation markers have been analyzed. This study was aimed at describing the epigenetic signature of multiple CRC using a genome-scale DNA methylation profiling. We analyzed 12 patients with synchronous CRC and 29 age-, sex-, and tumor location-paired patients with solitary tumors from the EPICOLON II cohort. DNA methylation profiling was performed using the Illumina Infinium HM27 DNA methylation assay. The most significant results were validated by Methylight. Tumors samples were also analyzed for the CpG Island Methylator Phenotype (CIMP); KRAS and BRAF mutations and mismatch repair deficiency status. Functional annotation clustering was performed. We identified 102 CpG sites that showed significant DNA hypermethylation in multiple tumors with respect to the solitary counterparts (difference in β value ≥0.1). Methylight assays validated the results for 4 selected genes (p = 0.0002). Eight out of 12(66.6%) multiple tumors were classified as CIMP-high, as compared to 5 out of 29(17.2%) solitary tumors (p = 0.004). Interestingly, 76 out of the 102 (74.5%) hypermethylated CpG sites found in multiple tumors were also seen in CIMP-high tumors. Functional analysis of hypermethylated genes found in multiple tumors showed enrichment of genes involved in different tumorigenic functions. In conclusion, multiple CRC are associated with a distinct methylation phenotype, with a close association between tumor multiplicity and CIMP-high. Our results may be important to unravel the underlying mechanism of tumor multiplicity.

Risk factors for acute kidney injury in severe rhabdomyolysis

Background

Acute kidney injury (AKI) is a life-threatening complication of severe rhabdomyolysis. This study was conducted to assess risk factors for AKI and to develop a risk score for early prediction.

Methods

Retrospective observational cohort study with a 9-year follow-up, carried out in an acute-care teaching-affiliated hospital. A total of 126 patients with severe rhabdomyolysis defined as serum creatine kinase (CK) > 5,000 IU/L fulfilled the inclusion criteria. Univariate and logistic regression analyses were performed to determine risk factors for AKI. Based on the values obtained for each variable, a risk score and prognostic probabilities were estimated to establish the risk for developing AKI.

Results

The incidence of AKI was 58%. Death during hospitalization was significantly higher among patients with AKI, compared to patients without AKI (19.2% vs 3.6%, p = 0.008). The following variables were independently associated with AKI: peak CK (odds ratio [OR] 4.9, 95%CI 1.4-16.8), hypoalbuminemia (< 33 mg/dL, [OR 5.1, 95%CI 1.4-17-7]), metabolic acidosis (OR 5.3, 95%CI 1.4-20.3), and decreased prothrombin time (OR 4.4, 95% CI 1.3-14.5). A risk score for AKI was calculated for each patient, with an OR of 1.72 (95%CI 1.45-2.04). The discrimination value of the predictive model was established by means of a ROC curve, with the area under the curve of 0.871 (p<0.001).

Conclusions

The identification of independent factors associated with AKI and a risk score for early prediction of this complication in patients with severe rhabdomyolysis may be useful in clinical practice, particularly to implement early preventive measures.

Population-based data from the Swedish Colon Cancer Registry

BACKGROUND

Evaluating the external validity of clinical trials requires knowledge not only of the study population but also of a relevant reference population. The main aim of this study was to present data from a large, contemporary, population-based cohort of patients with colonic cancer.

METHODS

Data on patients diagnosed between 2007 and 2011 were extracted from the Swedish Colon Cancer Registry. The data, registered prospectively in a national population of almost 10 million, included over 99 per cent of all diagnosed adenocarcinomas of the colon.

RESULTS

This analysis included 18,889 patients with 19,526 tumours (3·0 per cent had synchronous tumours). The sex distribution was fairly equal, and the median age was 74·1 (interquartile range 65-81) years. The overall and relative (cancer-specific) survival rates after 3 years were 62·7 and 71·4 per cent respectively. Some 88·0 per cent of the patients were operated on, and 83·8 per cent had tumours resected. Median blood loss during bowel resection was 200 (mean 311) ml, and the median operating time was 160 min; 5·6 per cent of the procedures were laparoscopic. Preoperative chemotherapy was administered to 2·1 per cent of patients; postoperative chemotherapy was planned in 90·1 per cent of fit patients aged less than 75 years with stage III disease. In patients operated on in an emergency setting (21·5 per cent), the preoperative evaluation was less extensive, the proportion of R0 resections was lower, and the outcomes were poorer, in both the short and long term.

CONCLUSION

These population-based data represent good-quality reference points.

Seeking genetic susceptibility variants for colorectal cancer: the EPICOLON consortium experience

The EPICOLON consortium was initiated in 1999 by the Gastrointestinal Oncology Group of the Spanish Gastroenterology Association. It recruited consecutive, unselected, population-based colorectal cancer (CRC) cases and control subjects matched by age and gender without personal or familial history of cancer all over Spain with the main goal of gaining knowledge in Lynch syndrome and familial CRC. This epidemiological, prospective and multicentre study collected extensive clinical data and biological samples from ∼2000 CRC cases and 2000 controls in Phases 1 and 2 involving 25 and 14 participating hospitals, respectively. Genetic susceptibility projects in EPICOLON have included candidate-gene approaches evaluating single-nucleotide polymorphisms/genes from the historical category (linked to CRC risk by previous studies), from human syntenic CRC susceptibility regions identified in mouse, from the CRC carcinogenesis-related pathways Wnt and BMP, from regions 9q22 and 3q22 with positive linkage in CRC families, and from the mucin gene family. This consortium has also participated actively in the identification 5 of the 16 common, low-penetrance CRC genetic variants identified so far by genome-wide association studies. Finishing their own pangenomic study and performing whole-exome sequencing in selected CRC samples are among EPICOLON future research prospects.

Impact of previous gastric or colonic resection on polyethylene glycol bowel preparation for colonoscopy

INTRODUCTION

Adequate bowel preparation is essential for successful completion of colonoscopy. This study examines whether previous bowel resection affects the quality of bowel preparation.

METHODS

This study prospectively included patients who had gastric or colonic resection (bowel resection group, n = 92) and a control group (n = 92). All patients received 4 L polyethylene glycol (PEG) for bowel preparation. Quality of colonic preparation was assessed using the Aronchick scale (excellent, good, fair, or poor) and was categorized as satisfactory (excellent or good) or unsatisfactory (fair or poor). We analyzed whether previous gastric or colonic resection is associated with unsatisfactory preparation.

RESULTS

Bowel preparation quality was significantly different between the resection group (0, 39.1, 43.5, and 17.4%, for excellent, good, fair, and poor) and control group (3.3, 53.3, 38.0, and 5.5% for excellent, good, fair, and poor, P = 0.011). Inadequate bowel preparation was significantly higher in the resection group than in the control group (60.9% vs. 43.5%, P = 0.018). Univariate analysis revealed height, weight, body mass index, and bowel resection to be predictors of unsatisfactory preparation. Multivariate analysis revealed bowel resection [odds ratio (OR) 2.12; 95% confidence interval (CI): 1.16-3.86] and obesity (body mass index ≥ 25 kg/m(2)) (OR 2.16; 95% CI: 1.13-4.12) to be independent predictors of unsatisfactory preparation. The prevalence of unsatisfactory and poor bowel preparation quality was 79.3 and 37.9% in obese patients with previous bowel resection.

CONCLUSIONS

Previous bowel resection was an independent predictor of unsatisfactory PEG bowel preparation. More attention is needed for patients with previous bowel resection, especially for obese patients.

A study of aspects on gender and prognosis in synchronous colorectal cancer

AIM

To assess differences in demography, pathology and prognosis with tumor multiplicity in colorectal cancer.

METHOD

A retrospective single centre study of all patients surgically treated for a colorectal cancer during 1999-2008 (n = 2524). Patient characteristics, pathology and follow-up data were retrieved. Survival was assessed by overall and cancer specific survival.

RESULTS

60 (2.4%) patients had a synchronous cancer (SC), associated with right colon, higher age, more assessed lymph nodes but a lower frequency of stage III/IV disease (42% vs. 52%). There was no overall prognostic difference between single or multiple cancer patients but females with SC had better survival than corresponding males (P < 0.046).

CONCLUSION

The incidence of synchronous cancers was 2.4% with the second cancer often located in right colon. The SC patients were older than single tumor patients, had a lower frequency of stage III/IV disease and the females with SC had a better survival prognosis than corresponding males.

Prevalence and prognosis of synchronous colorectal cancer: a Dutch population-based study

BACKGROUND

A noticeable proportion of colorectal cancer (CRC) patients are diagnosed with synchronous CRC. Large population-based studies on the incidence, risk factors and prognosis of synchronous CRC are, however, scarce, and are needed for better determination of risks of synchronous CRC in patients diagnosed with colonic neoplasia.

METHODS

All newly diagnosed CRC between 1995 and 2006 were obtained from the Rotterdam Cancer Registry in The Netherlands, and studied for synchronous CRC.

RESULTS

Of the 13,683 patients diagnosed with CRC, 534 patients (3.9%) were diagnosed with synchronous CRC. The risk of having synchronous CRC was significantly higher in men (OR 1.54, 95% CI 1.29-1.84) and in patients aged >70 years (OR 1.83, 95% CI 1.39-2.40). Synchronous CRC patients had a significantly higher risk of distant metastases (OR 1.69, 95% CI 1.27-2.26). In 34% (184/534) the two tumours were located in different surgical segments. Five-year relative survival of synchronous CRC was similar to patients with solitary CRC after multivariate adjustment for the presence of distant metastases.

CONCLUSION

One out of 25 patients diagnosed with CRC presents with synchronous CRC. In the multivariate analysis, survival of patients with synchronous CRC was similar to patients with solitary CRC, when corrected for the presence of distant metastases at first presentation. One third of the synchronous CRC were located in different surgical segments, which stresses the importance of performing total colon examination preferably prior to surgery.

[Do metachronous colorectal adenomas show proximal shift?]

OBJECTIVE

To study the possibility of shift toward more proximal sites in colorectal cancer (CRC) after resection of tumors and synchronous lesions.

MATERIAL AND METHODS

We reviewed 382 resected CRC diagnosed and followed-up with complete colonoscopies. The localization of metachronous adenomas was compared with that of synchronous lesions overall and by sex, tumoral size and the number of synchronous lesions. The frequency of exclusively proximal localization in first-, second- and third-generation metachronous adenomas was compared with that of synchronous adenomas.

RESULTS

A total of 54.5% of patients with CRC had synchronous adenomas. After a median follow-up of 48 months, with 2.74+/-1.47 colonoscopies/case, 42.4% developed metachronous adenomas, 16.8% second-generation adenomas and 7.3% third-generation lesions. Proximal shift was found in metachronous adenomas in both sexes, independently of tumoral size and the number of initial lesions. The frequency of exclusively proximal localization in adenomas was 21.2% in synchronous lesions, 39.5% in first-generation metachronous adenomas (p=0.0001; OR=2.46 [1.50-3.95]), 42.6% in second-generation metachronous adenomas (p=0.0008; OR=2.77 [1.44-5.31]) and 39.3% in third-generation metachronous lesions (p=0.0003; OR=2.41 [0.97-5.93]).

CONCLUSIONS

We found a high incidence of synchronous and metachronous adenomas. Metachronous adenomas showed a proximal shift, independently of sex, tumoral size and the number of synchronous lesions. This tendency was maintained in successive generations of metachronous adenomas, thus demonstrating the need to perform complete colonoscopies throughout the postoperative follow-up period.

Patient factors predictive of inadequate bowel preparation using polyethylene glycol: a prospective study in Korea

BACKGROUND

Inadequate bowel preparation is important because it can result in missed lesions, cancelled procedures, increased procedural time, and a potential increase in complication rates. This prospective study was designed to look at the quality of colon preparation using polyethylene glycol solution and evaluate potential associations between specific patient characteristics and inadequate bowel preparation.

METHODS

A total of 362 patients who were compliant with preparation instructions were enrolled. All colonoscopic examinations were performed by an experienced endoscopist and the quality of the preparation was graded by the endoscopist (excellent to poor). Patient demographic and medical history information was gathered before the procedure. Possible predictors of inadequate colonic preparation were analyzed using univariate statistics and multivariate logistic regression models.

RESULTS

An inadequate bowel preparation was reported in 28.2% of observed colonoscopies. In multivariate regression analysis, age greater than 60 years [odds ratio (OR) 2.8, 95% confidence interval (CI) 1.04-7.4], a history of diabetes (OR 8.6, 95% CI 6.3-19.4), a history of appendectomy (OR 4.6, 95% CI 2.0-10.5), a history of colorectal resection (OR 7.5, 95% CI 3.4-17.6), and a history of hysterectomy (OR 3.4, 95% CI 1.1-10.4) were independent predictors of an inadequate colon preparation.

CONCLUSIONS

This prospective study identified several factors that may predict inadequate polyethylene glycol preparation independent of compliance with preparation instructions and procedure starting time. This result may help to identify patients at an increased risk for inadequate bowel preparation for whom alternative preparation protocols would be beneficial.

Colorectal polyps: the scope and management of the problem

Colorectal cancer affects over 150,000 individuals yearly, and accounts for over 50,000 deaths. Much of the benefit of colorectal cancer screening has been attributed to detection and removal of adenomatous polyps, highlighting the importance of colorectal polyps as targets for intervention and as biomarkers for colorectal cancer risk. This review details the epidemiology of sporadic colorectal polyps, rationale behind use of polyps as an important surrogate for colorectal cancer risk, the benefits and limitations of secondary prevention of colorectal polyps through chemopreventive and dietary interventions, as well as colon surveillance.

Detection of metachronous neoplasms in colorectal cancer patients: identification of risk factors

PURPOSE

Patients with colorectal cancer have a high risk of developing metachronous neoplasms. Identification of predictive factors associated with such conditions would allow individualized follow-up strategies in these patients. This study was designed to identify individual and familial factors associated with the development of metachronous colorectal neoplasms in patients with colorectal cancer.

METHODS

In the context of a prospective, multicenter, general population-based study-the EPICOLON project-all patients with colorectal cancer attended in ten Spanish hospitals during a one-year period were included. Patients with familial adenomatous polyposis or inflammatory bowel disease were excluded. All patients were monitored by colonoscopy within two years of the diagnoses. Demographic, clinical, pathologic, molecular (microsatellite instability status and immunohistochemistry for MSH2 and MLH1), and familial characteristics (fulfillment of Amsterdam I or II criteria, and revised Bethesda guidelines) were analyzed.

RESULTS

A total of 353 patients were included in the study. At two years of follow-up, colonoscopy revealed the presence of adenomas in 89 (25 percent) patients and colorectal cancer in 14 (3.9 percent) patients, in 7 cases restricted to anastomosis. Univariate analysis demonstrated that development of metachronous neoplasm (adenoma or colorectal cancer) was associated with personal history of previous colorectal cancer (odds ratio, 5.58; 95 percent confidence interval, 1.01-31.01), and presence of previous or synchronous adenomas (odds ratio, 1.77; 95 percent confidence interval, 1.21-3.17). Although nonstatistical significance was achieved, metachronisms were associated with gender (P<0.09) and differentiation degree (P<0.08). Multivariate analysis identified previous or synchronous adenomas (odds ratio, 1.98; 95 percent confidence interval, 1.16-3.38) as independent predictive factor. Neither presence of tumor DNA microsatellite instability nor family history correlated with the presence of metachronous neoplasms.

CONCLUSIONS

Patients with previous or synchronous colorectal adenoma have an increased risk of developing metachronous colorectal neoplasms. Accordingly, this subgroup of patients may benefit from specific surveillance strategies.

The impact of colon preparation timing on colonoscopic detection of colorectal neoplasms--a prospective endoscopist-blinded randomized trial

OBJECTIVES

Timing of colon preparation might influence the cleansing condition of the colon and therefore affect the quality and diagnostic yield of colonoscopy. This study compared two different timings of colon preparation to assess the efficacy of colon cleansing and diagnostic yield of colorectal neoplasms during colonoscopy.

METHODS

One hundred twenty-one eligible subjects who had colorectal neoplasms detected at a screening colonoscopy were randomly assigned to receive colon preparation with polyethylene glycol electrolyte lavage solution (PEG-ELS) either on the day of (on the day group) or the night before (previous night group) a second colonoscopy. The condition of colon preparation and the diagnostic yield of colorectal neoplasms were recorded and compared between the two groups for the initial and second colonoscopies.

RESULTS

Fifty-nine subjects received colon preparation on the night before and 60 subjects received colon preparation the day of a second colonoscopy. Colon preparation for the second colonoscopy was better in the on-the-day group than in the previous night group (P= 0.003). Colon preparation for the second colonoscopy was better for each group in comparison with the initial colonoscopy (P < 0.0001). An interobserver variability analysis using 20 randomly selected colonoscopies from the two groups revealed good correlation among four colonoscopists. More lesions were detected in group A during the second colonoscopy (P= 0.028).

CONCLUSION

Colon preparation on the day of colonoscopy has a better cleansing quality and higher diagnostic yield. Subjects who had lesions detected during the initial screening colonoscopy had better colon cleansing for the second colonoscopy regardless of the timing of preparation.

Colorectal Cancer: Epidemiology and Health Services Research

The causes of colorectal carcinoma are multifactorial. Numerous lines of epidemiologic evidence support the role of dietary factors, with strong associations revealed for folate and calcium, more equivocal evidence exists for dietary antioxidants. Lifestyle factors such as physical activity, alcohol in-take, and tobacco use are also positively correlated with the risk of colorectal carcinoma. Health services research examines epidemiologic issues,clinical evidence regarding prevention and treatment, patient preferences,and other factors with the goal of improving the quality of care. Observations based on epidemiologic studies and health services research will in the future provide the basis for reducing personal and social burdens caused by colorectal carcinoma.