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Colorectal Cancer in Younger Patients: Characteristics Including Prognosis
Abstracts
or surgically between April 1985 and June 2008. Both the diagnosis and treatment were performed with magnifying scopes, mainly CF 260AZI (Olympus, Tokyo). Among them 1361 (5.0%) lesions were LSTs. They were devided into granular-type (LST-G) and nongranular-type (LST-NG) and evaluated for the magnifying endoscopic findings and association with submucosal invasion. Results: Out of 772 submucosally invasive cancers, LSTs accounted for 126 (16.3%) lesions. The rate of submucosal invasion was significantly higher in LST-NG than in LST-G (13.5% vs 6.8%; p!0.01). Presence of a large nodule in LST-G was associated with higher submucosal invasion. Large LST-NG lesions more than 20 mm in diameter were associated with high rate (43.8%) of submucosal invasion. The accuracy of pit patterns concerning the depth of cancer was nearly 90%. Pathologically the muscularis mucosae was the more highly destroyed in LST-NG than in LST-G (3.2% vs 1.8%). Residual adenomatous component was recognized in 83.3% of submucosally invasive cancers derived from granular-type LSTs but only in 17.2% of those derived from nongranular-type. When considering the most suitable therapeutic strategy for LSTs, LST-G can be treated with piecemeal EMR (EPMR) technique, due to its low rate of submucosal invasion. In contrast, LST-NG should be removed en bloc because of higher potential for invasion and greater difficulty in diagnosing depth of cancer and extent of invasion. Even pit pattern analysis with magnifying colonscopy was less useful in LST-NG compared with in LST-G. Conclusions: Clinicopathological characteristics of LSTs are different among subgroups; therefore you should be careful when detecting the treatment method.
T1365 Physicians Compliance to Their Own Colorectal Cancer Screening: What Is the Fulfillment of This Strategy Among Them? Luis E. Caro, Carolina Bolino Introduction: Colorectal Cancer (CRC) is the second leading cause of death from cancer in western countries. Screening is strongly recommended as early diagnosis improves survival and reduces mortality in 20%. However, its fulfillment in general population is about 50%. Physicians compliance to their own screening is low, being gastroenterologists, surgeons and radiologists the most compliant. Colonoscopy is the chosen method. Considering that Physicians attitudes about their habits and own health exert strong influence in their patients recommendations, it is necessary to improve education to perform this strategy. Objectives: 1. Estimate the percentage of physicians that had a screening test done. 2. Estimate the frequency distribution of tests used among professionals. Method: We conducted an anonymous survey among 269 physicians of 50 years or older from four hospitals and four national and international scientific conventions between March and November, 2008. The survey, validated from Spanish into English, included demography, and nine questions about specialty, family history of CRC, compliance to screening, signs or symptoms at the moment of screening, age and tests used, reasons for having or not done the screening and the results of the test. Statistical Analysis: SPSS Medcalc 9.1 and VCCstat 2.0. Results: 242 data surveys were included (response rate 90%); 83% of the participants were male; average age was 58 þ- 6 years, and 98% were in current practice. Specialties were grouped as follows: Internal Medicine 72%, Surgical 18% and others 9%.100 physicians had a test done (41% IC 95% 35-47%). The test most frequently used was colonoscopy in 70% (IC 95% 60-78%) followed by Barium Enema 10% (IC 95% 5-18%). Out of the whole screened physicians, 36% of them had family history of CRC, 63% didn’t and 1% was unaware of this fact. A half of screened physicians were between 50 and 55 years. Internal Medicine specialists were the most compliant. Health care providers recommendation was the main reason reported for screening. 59% of the professionals didn’t screen; the reasons for this were personal decision, fear of procedure, insufficient knowledge of guidelines on screening and lack of time. Conclusions: Physicians own compliance to CRC screening is suboptimal. The barriers mentioned would be a challenge to implement strategies in order to achieve healthy habits and compliance to preventive care programs among physicians.
T1366 Progress Towards the Ideal Submucosal Injection Solution for Endoscopic Mucosal Resection (EMR) - A Randomized Blinded Trial of Succinylated Gelatin (SG) Versus Normal Saline (NS) for Colonic EMR in a Porcine Model Alan Moss, Michael J. Bourke, Vu Kwan, Kayla Tran, Craig Godfrey, Gary McKay, Andrew D. Hopper Background and Aim: The ideal submucosal injection solution should be inexpensive, readily available, nontoxic, easy to inject and provide a durable submucosal cushion with maximal lesion elevation. Despite its limitations, NS is the current standard, with alternatives limited by expense, toxicity or administration difficulties. More viscous colloidal solutions are less likely to disperse beyond the lesion footprint and by maximizing lesion elevation relative to the surrounding mucosa, may provide important incremental gains in the maximum size of en bloc snare excision (20 mm in human colon). En bloc resection is known to reduce
AB278 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
recurrence. SG is an inexpensive colloid used for intravenous resuscitation. This double-blind, randomized trial aims to evaluate the safety, efficacy and impact on EMR specimen size of SG. Methods: Animal Ethics Committee approval was obtained. 10 pigs (mean weight 53 kg) received bowel preparation with polyethylene glycol and sodium picosulfate via orogastric tube. Under general anesthesia, 6 EMRs of the largest en bloc resection of normal mucosa possible using a 25 mm spiral snare (Olympus, Tokyo, Japan) were performed in each animal, by random blinded assignment, consisting of 1 SG and 1 NS at each 5 cm level above the anus (total 60 resections). 8 mL was injected for each EMR (adrenaline (1: 10,000) 1mL, methylene blue 0.5 mL and SG or NS 6.5 mL). Following euthanasia on day 10, EMR specimens and colon resection sites were assessed for inflammation, necrosis or muscularis propria involvement by a specialist GI histopathologist also blinded to injectants used. Statistical analysis compared outcomes between solutions at each level of the colon within each pig, thus excluding potential bias from inter-animal or inter-level variation. Results: See Table. Conclusions: SG is safe and superior to NS in a direct comparison for colonic EMR, resulting in a 42% increased surface area for en bloc EMR. Given its other favorable properties, it represents a significant step towards defining the ideal EMR solution. A study in human subjects for EMR of large sessile colonic lesions is currently underway.
Table (Results)
SG
NS
P value
EMR specimen length (mm) mean EMR specimen width (mm) mean EMR specimen surface area (cm2) mean Submucosal cushion duration (minutes) median Procedure duration (minutes) median Ratio of vertical elevation to lateral spread of injectant (3 point scale subjective assessment) Ease of resection (10 point scale subjective assessment) Adverse effects / hypersensitivity reactions / bleeding (number) Perforation (number), treated with clips Excessive inflammation or necrosis
37 32 9.5 60 2.6 3
31 26 6.7 15 2.5 2
0.031 0.022 0.044 0.005 0.515 0.228
8
7
0.216
0
0
1
2 0
1 0
1 1
T1367 Colorectal Cancer in Younger Patients: Characteristics Including Prognosis Yuichi Mori, Hiroshi Kashida, Shin-Ei Kudo Goal: The aim of this study is to clarify the clinicopathological characteristics of colorectal cancer in younger patients. Methods: A total of 1693 colon cancer lesions were resected endoscopically or surgically at our center from April 2001 until August 2008, which were divided into two groups. The younger aged group consisted of patients aged 40 yrs or less, while the comparison group consisted of patients aged 41 yrs or older. Patients with inflammatory bowel disease or FAP were excluded from the study. Characteristics considered were gender, presence of symptoms, family history, lesion location, tumor size, differentiation of cancer, invasion depth and survival period. Results: There were 71 lesions in the younger aged group (4.2%) and 1622 lesions in the comparison group (95.8%). The average ages in the two groups were 36.8 3.0 yrs and 65.4 10.2 yrs respectively. There was no significant difference concerning gender. Comparing the two groups, the younger aged group showed a significantly higher percentage of symptomatic patients(56.3% vs. 37%, P!.01), a higher rate of family history (10.9% vs. 3.5%, PZ.0153), a higher percentage of rectal cancers (40.8% vs. 28.2%, PZ.0209), a larger tumor size (29.7 mm vs. 23.5 mm, PZ.0033), and a higher percentage of cancers invading beyond the submucosal layer (33.8% vs. 23.2%, PZ.0392). Differentiation of cancer showed no significant difference between the two groups. The overall 5-year survival of the younger aged group was 86.3%, but when considered separately by stage, it was only 31.0% in those at Dukes’ classification of C-D, in contrast of 65.9% in the comparison group (PZ.0775). Conclusion: Characteristics of colorectal cancer in younger patients showed a high incidence of symptoms, a high rate of family history of colon cancer, a high presence of cancer in the rectum, larger size, and deeper invasion, and a trend toward poor prognosis in advanced cases.
T1368 Comparison of a Guaiac-Based and a Quantitative Immunochemical Fecal Occult Blood Testing in Average-Risk Population for Colorectal Cancer Screening Dongil Park, Seungho Ryu, Young-Ho Kim, Chang Kyun Lee, Chang Soo Eun, Dong Soo Han, Suck-Ho Lee Background/Aims: Faecal occult blood testing (FOBT) is an established method of colorectal cancer screening. Guaiac-based tests are limited by poor patient compliance, low sensitivity, specificity and positive predictive value. Quantitative, immunochemical FOBT (qi-FIBT) has good sensitivity and specificity for detecting advanced colorectal neoplasms (ACRN; cancer and advanced adenoma). However,
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or surgically between April 1985 and June 2008. Both the diagnosis and treatment were performed with magnifying scopes, mainly CF 260AZI (Olympus, Tokyo). Among them 1361 (5.0%) lesions were LSTs. They were devided into granular-type (LST-G) and nongranular-type (LST-NG) and evaluated for the magnifying endoscopic findings and association with submucosal invasion. Results: Out of 772 submucosally invasive cancers, LSTs accounted for 126 (16.3%) lesions. The rate of submucosal invasion was significantly higher in LST-NG than in LST-G (13.5% vs 6.8%; p!0.01). Presence of a large nodule in LST-G was associated with higher submucosal invasion. Large LST-NG lesions more than 20 mm in diameter were associated with high rate (43.8%) of submucosal invasion. The accuracy of pit patterns concerning the depth of cancer was nearly 90%. Pathologically the muscularis mucosae was the more highly destroyed in LST-NG than in LST-G (3.2% vs 1.8%). Residual adenomatous component was recognized in 83.3% of submucosally invasive cancers derived from granular-type LSTs but only in 17.2% of those derived from nongranular-type. When considering the most suitable therapeutic strategy for LSTs, LST-G can be treated with piecemeal EMR (EPMR) technique, due to its low rate of submucosal invasion. In contrast, LST-NG should be removed en bloc because of higher potential for invasion and greater difficulty in diagnosing depth of cancer and extent of invasion. Even pit pattern analysis with magnifying colonscopy was less useful in LST-NG compared with in LST-G. Conclusions: Clinicopathological characteristics of LSTs are different among subgroups; therefore you should be careful when detecting the treatment method.
T1365 Physicians Compliance to Their Own Colorectal Cancer Screening: What Is the Fulfillment of This Strategy Among Them? Luis E. Caro, Carolina Bolino Introduction: Colorectal Cancer (CRC) is the second leading cause of death from cancer in western countries. Screening is strongly recommended as early diagnosis improves survival and reduces mortality in 20%. However, its fulfillment in general population is about 50%. Physicians compliance to their own screening is low, being gastroenterologists, surgeons and radiologists the most compliant. Colonoscopy is the chosen method. Considering that Physicians attitudes about their habits and own health exert strong influence in their patients recommendations, it is necessary to improve education to perform this strategy. Objectives: 1. Estimate the percentage of physicians that had a screening test done. 2. Estimate the frequency distribution of tests used among professionals. Method: We conducted an anonymous survey among 269 physicians of 50 years or older from four hospitals and four national and international scientific conventions between March and November, 2008. The survey, validated from Spanish into English, included demography, and nine questions about specialty, family history of CRC, compliance to screening, signs or symptoms at the moment of screening, age and tests used, reasons for having or not done the screening and the results of the test. Statistical Analysis: SPSS Medcalc 9.1 and VCCstat 2.0. Results: 242 data surveys were included (response rate 90%); 83% of the participants were male; average age was 58 þ- 6 years, and 98% were in current practice. Specialties were grouped as follows: Internal Medicine 72%, Surgical 18% and others 9%.100 physicians had a test done (41% IC 95% 35-47%). The test most frequently used was colonoscopy in 70% (IC 95% 60-78%) followed by Barium Enema 10% (IC 95% 5-18%). Out of the whole screened physicians, 36% of them had family history of CRC, 63% didn’t and 1% was unaware of this fact. A half of screened physicians were between 50 and 55 years. Internal Medicine specialists were the most compliant. Health care providers recommendation was the main reason reported for screening. 59% of the professionals didn’t screen; the reasons for this were personal decision, fear of procedure, insufficient knowledge of guidelines on screening and lack of time. Conclusions: Physicians own compliance to CRC screening is suboptimal. The barriers mentioned would be a challenge to implement strategies in order to achieve healthy habits and compliance to preventive care programs among physicians.
T1366 Progress Towards the Ideal Submucosal Injection Solution for Endoscopic Mucosal Resection (EMR) - A Randomized Blinded Trial of Succinylated Gelatin (SG) Versus Normal Saline (NS) for Colonic EMR in a Porcine Model Alan Moss, Michael J. Bourke, Vu Kwan, Kayla Tran, Craig Godfrey, Gary McKay, Andrew D. Hopper Background and Aim: The ideal submucosal injection solution should be inexpensive, readily available, nontoxic, easy to inject and provide a durable submucosal cushion with maximal lesion elevation. Despite its limitations, NS is the current standard, with alternatives limited by expense, toxicity or administration difficulties. More viscous colloidal solutions are less likely to disperse beyond the lesion footprint and by maximizing lesion elevation relative to the surrounding mucosa, may provide important incremental gains in the maximum size of en bloc snare excision (20 mm in human colon). En bloc resection is known to reduce
AB278 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
recurrence. SG is an inexpensive colloid used for intravenous resuscitation. This double-blind, randomized trial aims to evaluate the safety, efficacy and impact on EMR specimen size of SG. Methods: Animal Ethics Committee approval was obtained. 10 pigs (mean weight 53 kg) received bowel preparation with polyethylene glycol and sodium picosulfate via orogastric tube. Under general anesthesia, 6 EMRs of the largest en bloc resection of normal mucosa possible using a 25 mm spiral snare (Olympus, Tokyo, Japan) were performed in each animal, by random blinded assignment, consisting of 1 SG and 1 NS at each 5 cm level above the anus (total 60 resections). 8 mL was injected for each EMR (adrenaline (1: 10,000) 1mL, methylene blue 0.5 mL and SG or NS 6.5 mL). Following euthanasia on day 10, EMR specimens and colon resection sites were assessed for inflammation, necrosis or muscularis propria involvement by a specialist GI histopathologist also blinded to injectants used. Statistical analysis compared outcomes between solutions at each level of the colon within each pig, thus excluding potential bias from inter-animal or inter-level variation. Results: See Table. Conclusions: SG is safe and superior to NS in a direct comparison for colonic EMR, resulting in a 42% increased surface area for en bloc EMR. Given its other favorable properties, it represents a significant step towards defining the ideal EMR solution. A study in human subjects for EMR of large sessile colonic lesions is currently underway.
Table (Results)
SG
NS
P value
EMR specimen length (mm) mean EMR specimen width (mm) mean EMR specimen surface area (cm2) mean Submucosal cushion duration (minutes) median Procedure duration (minutes) median Ratio of vertical elevation to lateral spread of injectant (3 point scale subjective assessment) Ease of resection (10 point scale subjective assessment) Adverse effects / hypersensitivity reactions / bleeding (number) Perforation (number), treated with clips Excessive inflammation or necrosis
37 32 9.5 60 2.6 3
31 26 6.7 15 2.5 2
0.031 0.022 0.044 0.005 0.515 0.228
8
7
0.216
0
0
1
2 0
1 0
1 1
T1367 Colorectal Cancer in Younger Patients: Characteristics Including Prognosis Yuichi Mori, Hiroshi Kashida, Shin-Ei Kudo Goal: The aim of this study is to clarify the clinicopathological characteristics of colorectal cancer in younger patients. Methods: A total of 1693 colon cancer lesions were resected endoscopically or surgically at our center from April 2001 until August 2008, which were divided into two groups. The younger aged group consisted of patients aged 40 yrs or less, while the comparison group consisted of patients aged 41 yrs or older. Patients with inflammatory bowel disease or FAP were excluded from the study. Characteristics considered were gender, presence of symptoms, family history, lesion location, tumor size, differentiation of cancer, invasion depth and survival period. Results: There were 71 lesions in the younger aged group (4.2%) and 1622 lesions in the comparison group (95.8%). The average ages in the two groups were 36.8 3.0 yrs and 65.4 10.2 yrs respectively. There was no significant difference concerning gender. Comparing the two groups, the younger aged group showed a significantly higher percentage of symptomatic patients(56.3% vs. 37%, P!.01), a higher rate of family history (10.9% vs. 3.5%, PZ.0153), a higher percentage of rectal cancers (40.8% vs. 28.2%, PZ.0209), a larger tumor size (29.7 mm vs. 23.5 mm, PZ.0033), and a higher percentage of cancers invading beyond the submucosal layer (33.8% vs. 23.2%, PZ.0392). Differentiation of cancer showed no significant difference between the two groups. The overall 5-year survival of the younger aged group was 86.3%, but when considered separately by stage, it was only 31.0% in those at Dukes’ classification of C-D, in contrast of 65.9% in the comparison group (PZ.0775). Conclusion: Characteristics of colorectal cancer in younger patients showed a high incidence of symptoms, a high rate of family history of colon cancer, a high presence of cancer in the rectum, larger size, and deeper invasion, and a trend toward poor prognosis in advanced cases.
T1368 Comparison of a Guaiac-Based and a Quantitative Immunochemical Fecal Occult Blood Testing in Average-Risk Population for Colorectal Cancer Screening Dongil Park, Seungho Ryu, Young-Ho Kim, Chang Kyun Lee, Chang Soo Eun, Dong Soo Han, Suck-Ho Lee Background/Aims: Faecal occult blood testing (FOBT) is an established method of colorectal cancer screening. Guaiac-based tests are limited by poor patient compliance, low sensitivity, specificity and positive predictive value. Quantitative, immunochemical FOBT (qi-FIBT) has good sensitivity and specificity for detecting advanced colorectal neoplasms (ACRN; cancer and advanced adenoma). However,
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