Gastrointestinal tract cancer in the elderly

Erythropoietin-induced hepatocyte receptor A2 regulates effect of pyroptosis on gastrointestinal colorectal cancer occurrence and metastasis resistance

Erythropoietin-induced hepatocyte receptor A2 (EphA2) is a receptor tyrosine kinase that plays a key role in the development and progression of a variety of tumors. This article reviews the expression of EphA2 in gastrointestinal (GI) colorectal cancer (CRC) and its regulation of pyroptosis. Pyroptosis is a form of programmed cell death that plays an important role in tumor suppression. Studies have shown that EphA2 regulates pyrodeath through various signaling pathways, affecting the occurrence, development and metastasis of GI CRC. The overexpression of EphA2 is closely related to the aggressiveness and metastasis of GI CRC, and the inhibition of EphA2 can induce pyrodeath and improve the sensitivity of cancer cells to treatment. In addition, EphA2 regulates intercellular communication and the microenvironment through interactions with other cytokines and receptors, further influencing cancer progression. The role of EphA2 in GI CRC and its underlying mechanisms provide us with new perspectives and potential therapeutic targets, which have important implications for future cancer treatment.

Risk factors of colorectal cancer among Saudi Population: Case-control study

Background:

Colorectal cancer (CRC) incidence and related mortalities have been steadily increasing in KSA over the past 20 years. CRC in the Kingdom of Saudi Arabia (KSA) population presents in younger ages and in more advanced disease states as compared to other countries. This study was aimed to determine factors (demographic, habitual, environmental, nutritional, and genetic) associated with CRC in Riyadh, KSA.

Materials and Methods:

A matched case-control study conducted in the major hospitals in Riyadh (King Khalid university Hospital, King Faisal Specialist Hospital, Riyadh Military Hospital, Security Force Hospital, King Fahd Medical City). Here most of CRC cases are managed. The cases (n = 121) group included all recently diagnosed and pathologically confirmed Saudi cases of CRC identified during the period 1^st of January 2017 till 31^st of December 2018 who agreed to participate and fulfilled the inclusion criteria. A similar number of controls attending the study settings were selected consecutively from the clinics where cases were managed and matched on a 1:1 basis with cases based on age (+/-3 years) and gender. Data were collected using a structured questionnaire. Conditional logistic regression models were fitted to determine factors associated with risk of CRC.

Result:

This study included similar number of males and females in both groups: males 69 (57%) and females 52 (43%) in each group (Chi-square test P = 1.0). The mean (S.D) age in the cases group was 53.6 (S.D = 12.9) and 53.3 (S.D = 12.9) in the controls group (Student test P = 0.86). In the final multivariate conditional logistic regression model, variables independently associated with risk of colorectal cancer were body mass index (OR = 0.93; 95% CI 0.87–0.98; P = 0.011) employment status (inverse relation: OR = 0.33; 95% CI 0.14–0.77; P = 0.010), colon polyps (OR = 4.09; 95% CI 1.06–15.82; P = 0.041), and constipation (OR = 4.98; 95% CI 1.91–15.99; P = 0.001).

Conclusion:

Factors associated with CRC in the major referral hospitals in KSA were colon polyps, chronic constipation, and unemployment. These factors should be considered when screening for patients at risk for CRC.

Simplified preoperative tool predicting discharge destination after major oncologic gastrointestinal surgery

BACKGROUND

Preoperatively identifying patients who will require discharge to extended care facilities (ECFs) after major cancer surgery is valuable. This study compares existing models and derives a simple, preoperative tool for predicting discharge destination after major oncologic gastrointestinal surgery.

METHODS

The American College of Surgeon National Surgical Quality Improvement datasets were used to evaluate existing risk stratification and frailty assessment tools between the years 2011 and 2015. A novel tool for predicting discharge to ECF was developed in the 2011-2015 dataset and subsequently validated in the 2016 dataset.

RESULTS

Major resections were analyzed for 61 683 malignancies: 6.9% esophagus, 5.3% stomach, 20.0% liver, 21.0% pancreas, and 46.8% colon/rectum. The overall ECF discharge rate was 9.1%. The American Society of Anesthesiologist score, 11-point modified frailty index (mFI), and 5-point abbreviated modified frailty index (amFI) demonstrated only moderate discrimination in predicting ECF discharge (c-statistic: 0.63-0.65). In contrast, our weighted cancer cancer abbreviated modified frailty index (camFI) score demonstrated improved discrimination with c-statistic of 0.73. The camFI displayed >90% negative predictive value for ECF discharge at every operative site.

CONCLUSION

The camFI is a simple tool that can be used preoperatively to counsel patients on their risk of ECF discharge, and to identify patients with the least need for ECF discharge after major oncologic gastrointestinal surgery.

Age-related risks of complications after distal pancreatectomy for neuroendocrine and cystic neoplasms

BACKGROUND

Distal pancreatic neuroendocrine tumors (PNET) and pancreatic cystic neoplasms (PCN) are often incidentally found in older adults, requiring careful consideration between operative management and watchful waiting. This study analyzes the short-term complications associated with distal pancreatectomy (DP) for PNET and PCN in older adults to inform clinical decision-making.

METHODS

Patients undergoing DP for PNET and PCN were analyzed using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database and the pancreatectomy procedure-targeted dataset. Associations between decade of age and 30-day outcomes were evaluated.

RESULTS

1626 patients were analyzed from 2014 to 2015. 692 (42.6%) were younger than 60 years, 507 (31.2%) were sexagenarians, 342 (21.0%) were septuagenarians, and 85 (5.2%) were octogenarians. Minimally invasive approaches were used in 62.7%. While septuagenarians and octogenarians constituted 26.3% of the cohort, they were affected by 55.6% of reintubations, 66.7% of failures to wean, 82.4% of myocardial infarctions, and 57.1% of septic shock. Septuagenarians and octogenarians had longer hospital stays, as compared to those younger than 60 years.

CONCLUSION

Septuagenarians and octogenarians are disproportionately affected by perioperative complications after DP for PNET and PCN. Careful patient selection and thorough counseling should be provided when surgery is considered.

Colonic endoscopic mucosal resection of large polyps: Is it safe in the very elderly?

BACKGROUND

Outcomes on colon endoscopic mucosal resection in the very elderly patient population are unknown.

AIMS

Aims of this study were to evaluate the outcomes and safety of colon endoscopic mucosal resection in this target population.

METHODS

Observational, retrospective study of patients ≥ 80 years of age that underwent colon endoscopic mucosal resection ≥ 2 cm. Demographics, American Society of Anesthesiologists classification, procedural data, and surgical treatment data were collected.

RESULTS

One-hundred-and-thirty-one colon endoscopic mucosal resections were performed on 99 patients ≥ 80 years of age with a mean age of 84. The majority of American Society of Anesthesiologists class was II. Mean lesion size was 3.3 cm (range, 2-12.5 cm), more procedures were performed in the right colon and adenoma/tubulovillous adenoma was the most common pathology. En bloc resection was performed on 26.7% of polyps (N=35). Eight procedure-related adverse events (8/131, 6.1%) occurred. No anaesthesia related adverse events or deaths occurred. Six patients required a colonic operation, and overall, 94% of the patient cohort evaded a colon operation.

CONCLUSIONS

Colon endoscopic mucosal resection in very elderly patients can be performed at experienced endoscopy centres with a low rate of complications and offers these patients a non-surgical option of management of colorectal lesions.

Gastrointestinal diseases in the elderly

PURPOSE OF REVIEW

The subject of gastrointestinal disorders in the elderly is timely and important because of the demographic reality that soon over 20% of our population will be older than 65 years of age, utilizing perhaps 50% of our total healthcare costs. The purpose of this review is to draw attention to some areas of clinical information that point in the direction of better clinical care for the elderly. Medicine is finally advancing from the era when most symptoms in older patients were ascribed to the aging process itself. Indeed, within gastroenterology there are few changes that occur inevitably as part of aging.

RECENT FINDINGS

Progress has been made in several areas of gastrointestinal pathophysiology. These include: the pathophysiology of swallowing and evacuation disorders and the beginning of the application of techniques derived from physiological studies to improve function; recognizing the importance of reflux esophagitis and its complications and improving treatment; understanding the importance of disorders of malabsorption and their impact upon nutrition in the elderly; major issues in the diagnosis and management of inflammatory bowel disease in this age group; and approaches to the prevention and treatment of gastrointestinal cancer, particularly colorectal cancer.

SUMMARY

As we pay more attention to these areas and encourage clinical research we expect to improve the treatment of older patients with these diseases and to reduce the burden of morbidity in this population.

Incidental diagnosis of gastric cancer in transplant recipients improves patient survival

BACKGROUND

Gastric cancer in the United States is often diagnosed at advanced stages, resulting in dismal outcomes. In the immunosuppressed transplant recipient population, little is known about the clinical staging and outcome of these compromised patients.

METHODS

All US cases reported to the Israel Penn International Transplant Tumor Registry were retrospectively examined for patient demographics, immunosuppressive therapy, tumor characteristics, therapeutic modalities, and mortality. Statistical analysis was performed with Students t test, chi-square analysis, and log-rank analysis by the method of Kaplan-Meier.

RESULTS

Gastric cancer was identified in 34 recipients: 28 (82%) were male; 24 (71%) were white. Mean age at diagnosis was 58 +/- 11 years. Twenty-four (71%) patients received kidney transplants, 7 (21%) received heart transplants, and 3 (9%) received liver transplants. Fifty percent received induction therapy, whereas 94% were maintained on calcineurin inhibitors and corticosteroids. Thirty-five percent of patients were diagnosed during evaluation for gastrointestinal symptoms, with the remaining cases discovered incidentally during endoscopy (53%) or during computed tomography (12%) performed for other reasons. Stage varied at presentation as follows: stage I (n = 6), stage II (n = 11), stage III (n = 13), and stage IV (n = 4). Incidental diagnoses resulted in a lower stage malignancy (P <.001) and greater 1-year and 5-year survivals (P <.05) compared with those patients whose were diagnosed after being evaluated of gastrointestinal symptoms.

CONCLUSION

In the United States, because gastric cancer in the transplant recipient is frequently identified at an earlier stage (50% were stages I and II) than in the general population, survivals are equivalent despite continued administration of immunosuppression. This early identification may be attributed to more frequent presymptom diagnosis and staging, resulting from incidental detection of these malignancies during posttransplant upper endoscopy or computed tomography. Early detection has resulted in a 29% 5-year survival for the entire transplant recipient group compared with a 5% to 15% 5-year survival in the general population.

Pancreatic disease in the elderly

Pancreatic diseases occur in patients of every age. Older individuals suffer more often from gallstone related acute pancreatitis, ischaemic and idiopathic acute pancreatitis, whereas alcohol-induced acute pancreatitis occurs only in a minority of cases. Similarly, alcohol-related chronic pancreatitis in elderly people is rare and late-onset idiopathic chronic pancreatitis is the most common form of the disease. This form of chronic pancreatitis is characterized by faster progression to endocrine and exocrine pancreatic insufficiency and less severe pain compared to the clinical picture found in younger patients. Ductal pancreatic adenocarcinomas, which are responsible for more than 90% of exocrine pancreatic tumours, are typically a disease of the elderly patient. Today pancreatic resection still offers the only hope for cure and also can be performed safely in elderly patients. Age, by itself, is not a reason for withholding surgical intervention from an individual patient. Today, denial of pancreatic resection is much more likely to be based on severe co-morbidity.