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Findings in the rectosigmoid in patients with advanced proximal colon neoplasia
April 2000
AGAA265
1517
1519
IS AN INCREASED FREQUENCY OF POST·POLYPECTOMY COLONOSCOPIC SURVEILLANCE COST·EFFECTIVE IN PA· TIENTS WITH A FAMILY IllSTORY OF COLORECTAL CANCER? Reid M. Ness, Robert W. Klein, Ann M. Holmes, Robert S. Dittus, Indiana University, Indianapolis, IN; Med Decision Modeling, Inc, Indianapolis, IN; Vanderbilt Univ, Nashville, TN. Patients with a family history of colorectal neoplasia (CRN) in a firstdegree relative have an increased risk of developing colorectal cancer (CRC). The number of affected relatives and their ages at diagnosis determine the magnitude of this increased risk. We examined the costutility (CIU) of post-polypectomy colonoscopic surveillance (PPCS) in patients with one or more affected first-degree relatives using our simulation model of the natural history of CRN. Quality-adjusted life-years (QALYs) were computed as the measure of effectiveness. We created hypothetical cohorts of lOOK patients. In each cohort, all of the simulated patients had the same combination of gender, adenoma (AD) count at screening colonoscopy (I, 2, >2), and underlying level of risk for developing CRC (IX, 2X, 3X, 5X the baseline risk for the entire U.S. population). We modeled alternative PPCS strategies (never, q5, q7, qlO, q3/5, q317, q3/1O years) to calculate their mean CIU. The label "q317" means survey every 3 years until <2 ADs are found then switch to every 7 years. Each simulated patient was initially screened at age 40 and then the PPCS strategy was followed until death. We discounted both costs and QALYs at 3%/yr. The most effective PPCS strategies with a marginal CIU <$50Kl QALY are shown below for each combination of gender, AD count and level of underlying risk. PPCS involving more frequent colonoscopy than is cost-effective for the standard-risk population is cost-effective in patients with an increased risk of developing CRC because of one or more affected first-degree relatives. The magnitude of this increase in the optimal frequency of surveillance is dependent on the level of increased risk suggested by the family history, patient gender and number of ADs found at screening.
IS RECTAL BLEEDING SIMILAR TO FAMILY mSTORY AS A RISK FACTOR FOR COLORECTAL ADENOMAS? Fiona B. Nicholson, Melvyn G. Korman, Anthony 1. Stem, Jack Hansky, Monash Med Ctr, Melbourne, Australia. Rectal bleeding is often attributed to minor causes or unreported. However, rectal bleeding may signal the presence of colorectal cancer(CRC) or adenomas and warrants appropriate investigation. Bowel cancer prevention is mainly based on the removal of adenomas. This paper reports whether rectal bleeding is a similar risk factor to family history for the presence of adenomas in a bowel cancer prevention program. AIM: To compare the incidence of adenomas(>5mm)in individuals with previously uninvestigated rectal bleeding to those with a family history of CRC or polyps. METHODS: Individuals were identified by responses to a mailed questionnaire in a bowel cancer prevention program. There were 907 individuals with one first degree relative with CRC or polyps(543 males and 364 females aged 40-75, mean age 55 years) and 323 individuals with rectal bleeding (228 males and 95 females, aged 40-75 mean age 55 years). No individual had been previously investigated and all had a complete colonoscopy. RESULTS: See table SUMMARY:1) The incidence of adenomas was similar if the indication was rectal bleeding or a positive family history of CRC or polyps. 2) In those with either rectal bleeding or a family history, approximately 25% of adenomas were found only in the right colon. CONCLUSIONS: Rectal bleeding and family history are equally significant risk factors for the presence of adenomas. Flexible sigmoidoscopy is an unsuitable examination for rectal bleeding as it will miss at least 25% of adenomas. The lower incidence of adenomas in women needs confirmation in larger studies.
Gender Male Female
# ofAD
1Xrisk
2Xrisk
3Xrisk
5Xrisk
1 2 >2 1 2 >2
q7 q7 q7 q10 q7 93/7
q7 q3/7 q3/7 q3110 q3/7 93/7
q7 q3/7 q3/5 q3/7 q3/7 95
q5 q3/5 q3/5 q3/7 q3/7 95
1518 FINDINGS IN THE RECTOSIGMOID IN PATIENTS WITH AD· VANCED PROXIMAL COLON NEOPLASIA. Peter Netzer, Barabara Buergi, Christoph A. Maurer, Adrian Schmassmann, Inselspital, Univ of Bern, Berne, Switzerland. Background: Sigmoidoscopy, with a subsequent colonoscopy when adenomatous polyps (indexpolyp) are detected, is the most widely recommended endoscopic screening procedure for colorectal cancer prevention. However, in the absence of indexpolyps such a screening program will miss all neoplasms above the sigmoid. Thus, we were interested in determining how often patients with advanced (adv.) proximal (prox.) neoplasia (polyp > lcm or villous histology or high grad-dysplasia or cancer) had an indexpolyp in the rectosigmoid in our endoscopic population. Subjects and Methods: Endoscopic and histological data as well as medical and surgical reports were analyzed from pts with colorectal neoplasia on whom coloscopy was performed between 1981-1996. Pis with previous polypectomy, colon resection, colorectal cancer, familiar polyposis or inflammatory bowel disease were excluded. Results: 1486 pts had at least one neoplasm (mean age of 66; sex ratio: m:f = 1.5:1). Proximal colon neoplasms were found in 631 pts (42.5% of all pts). In these patients 68.9% (or 29.2% of all pts) did not have an indexpolyp. No indexpolyp was found in 73.2% (or 22.7 % of all pts) of pts with advanced proximal neoplasms. On the other hand, 13.6% (or 7.6% of all pts) pts with an advanced indexpolyp (n=883) had an advanced proximal neoplasm, as opposed to 5.0% (or 0.8% of all pts) of those with a small indexpolyp (n=218). Further details are summarized in the Table. Conlusion: Since about % of patients in our study population with proximal advanced colonic neoplasia did not have an indexpolyp, screening sigmoidoscopy should be carefully weighed up against screening colonoscopy despite its higher initial costs, discomfort and potential side-effects.
Patlentl
All pts with prox neoplasm • without indexpolyp • with Indexpolyp • adv indexpolyp • smallindexpolyp
Allprox. Neoplasia
Prox. adv. neoplasma
Prox. carcinoma
Prox. adv. Adenoma
(%)
(%)
(%)
(%)
631 (100) 436 (68.9) 196 (31.1) 167 (26.5) 29(4.6)
462 (100) 338 (73.2) 124 (73.2) 113 (24.4) 11 (2.4)
260(100) 221 (85) 39 (15) 34(13.1) 5(1.9)
202 (100) 117 (57.9) 85(42.1) 79 (39.1) 6 (3)
GROUP
SEX
RECTAL BLEEDING MEN WOMEN TOTAL FAMiLY HISTORY MEN WOMEN TOTAL
NO.
543 364 907 228 95 323
ADENOMAS 91 (16.8%) 27(7.4%) 118(13%) 35 (15.4%) 7(7.4%) 42(13%)
LEFT
SITE: L.&R.
RIGHT
59% 70% 69% 72% 71% 72%
14% 3% 4% 6% 0% 3%
27% 27% 27% 23% 29% 25%
1520 PREDICTIVE EVALUATION OF PREOPERATIVE SERUM SIALOSYL-TN ANTIGEN EXPRESSION IN THE PATIENTS WITH ADVANCED GASTRIC CANCER, MyungHwan Noh, Dong-A Univ, Pusan, South Korea. Objectives: Sialosyl-Tn (s'Tn), a mucin-associated carbohydrate antigen, is not expressed by normal mucin-producing cells of the stomach but is expressed in metaplastic, premalignant and malignant gastic tissues. In general, the rate of immunohistochemical expression of sTn in gastric cancer tissue is about 50-70%, and its prognostic role in gastric cancer is variable. And there is no report in Korea about serum sTn expression of gastric cancer patients, so we have examined the expression of sTn with the serum of gastric cancer patients and examined the possibilty of tumor maker and of factors for prognosis Methods: Serum sTn expression was examined by enzyme linked immuno-sorbent assay (ELISA) in 46 patients with abvanced cacner, confirmed at the Dong-A University Hospital, between June, 1997 and June, 1998. We examined the correlations between the expression of serum sTn antigen and patients age, sex, tumor location and size, degree of differentiation, stage, seroral invasion, peritonal dissemination, hepatic metastasis, lymph node metastasis and Borrman type. Results: The overall serum sTn expression was higher on cases of advanced gastric cancer than controls(p<0.05). Advanced stage had hugher serum sTn expression than lower stages (p=O.OOOI). And in cases of seroral invasion, peritoneal dissemination and hepatic metastasis, the serum sTn expression was higher than not (p<0.05). Lymph node metastasis, one of detereminant factors of stage, has high serum sTn expression but it had not statistical significance (p=0.067), and in cases of sex, tumor location and size, histologic grade and gross finding of tumor (Borrmann type) had not high expression of serum sTn (p>0.05). Conclusions: Higher expression of serum sTn in advanced gastric cancer can be proposed the possibility of the role as a tumor maker. And its higher expressions in many fiels of independent prognostic factors also can be proposed the possibility of another prognostic factor.
AGAA265
1517
1519
IS AN INCREASED FREQUENCY OF POST·POLYPECTOMY COLONOSCOPIC SURVEILLANCE COST·EFFECTIVE IN PA· TIENTS WITH A FAMILY IllSTORY OF COLORECTAL CANCER? Reid M. Ness, Robert W. Klein, Ann M. Holmes, Robert S. Dittus, Indiana University, Indianapolis, IN; Med Decision Modeling, Inc, Indianapolis, IN; Vanderbilt Univ, Nashville, TN. Patients with a family history of colorectal neoplasia (CRN) in a firstdegree relative have an increased risk of developing colorectal cancer (CRC). The number of affected relatives and their ages at diagnosis determine the magnitude of this increased risk. We examined the costutility (CIU) of post-polypectomy colonoscopic surveillance (PPCS) in patients with one or more affected first-degree relatives using our simulation model of the natural history of CRN. Quality-adjusted life-years (QALYs) were computed as the measure of effectiveness. We created hypothetical cohorts of lOOK patients. In each cohort, all of the simulated patients had the same combination of gender, adenoma (AD) count at screening colonoscopy (I, 2, >2), and underlying level of risk for developing CRC (IX, 2X, 3X, 5X the baseline risk for the entire U.S. population). We modeled alternative PPCS strategies (never, q5, q7, qlO, q3/5, q317, q3/1O years) to calculate their mean CIU. The label "q317" means survey every 3 years until <2 ADs are found then switch to every 7 years. Each simulated patient was initially screened at age 40 and then the PPCS strategy was followed until death. We discounted both costs and QALYs at 3%/yr. The most effective PPCS strategies with a marginal CIU <$50Kl QALY are shown below for each combination of gender, AD count and level of underlying risk. PPCS involving more frequent colonoscopy than is cost-effective for the standard-risk population is cost-effective in patients with an increased risk of developing CRC because of one or more affected first-degree relatives. The magnitude of this increase in the optimal frequency of surveillance is dependent on the level of increased risk suggested by the family history, patient gender and number of ADs found at screening.
IS RECTAL BLEEDING SIMILAR TO FAMILY mSTORY AS A RISK FACTOR FOR COLORECTAL ADENOMAS? Fiona B. Nicholson, Melvyn G. Korman, Anthony 1. Stem, Jack Hansky, Monash Med Ctr, Melbourne, Australia. Rectal bleeding is often attributed to minor causes or unreported. However, rectal bleeding may signal the presence of colorectal cancer(CRC) or adenomas and warrants appropriate investigation. Bowel cancer prevention is mainly based on the removal of adenomas. This paper reports whether rectal bleeding is a similar risk factor to family history for the presence of adenomas in a bowel cancer prevention program. AIM: To compare the incidence of adenomas(>5mm)in individuals with previously uninvestigated rectal bleeding to those with a family history of CRC or polyps. METHODS: Individuals were identified by responses to a mailed questionnaire in a bowel cancer prevention program. There were 907 individuals with one first degree relative with CRC or polyps(543 males and 364 females aged 40-75, mean age 55 years) and 323 individuals with rectal bleeding (228 males and 95 females, aged 40-75 mean age 55 years). No individual had been previously investigated and all had a complete colonoscopy. RESULTS: See table SUMMARY:1) The incidence of adenomas was similar if the indication was rectal bleeding or a positive family history of CRC or polyps. 2) In those with either rectal bleeding or a family history, approximately 25% of adenomas were found only in the right colon. CONCLUSIONS: Rectal bleeding and family history are equally significant risk factors for the presence of adenomas. Flexible sigmoidoscopy is an unsuitable examination for rectal bleeding as it will miss at least 25% of adenomas. The lower incidence of adenomas in women needs confirmation in larger studies.
Gender Male Female
# ofAD
1Xrisk
2Xrisk
3Xrisk
5Xrisk
1 2 >2 1 2 >2
q7 q7 q7 q10 q7 93/7
q7 q3/7 q3/7 q3110 q3/7 93/7
q7 q3/7 q3/5 q3/7 q3/7 95
q5 q3/5 q3/5 q3/7 q3/7 95
1518 FINDINGS IN THE RECTOSIGMOID IN PATIENTS WITH AD· VANCED PROXIMAL COLON NEOPLASIA. Peter Netzer, Barabara Buergi, Christoph A. Maurer, Adrian Schmassmann, Inselspital, Univ of Bern, Berne, Switzerland. Background: Sigmoidoscopy, with a subsequent colonoscopy when adenomatous polyps (indexpolyp) are detected, is the most widely recommended endoscopic screening procedure for colorectal cancer prevention. However, in the absence of indexpolyps such a screening program will miss all neoplasms above the sigmoid. Thus, we were interested in determining how often patients with advanced (adv.) proximal (prox.) neoplasia (polyp > lcm or villous histology or high grad-dysplasia or cancer) had an indexpolyp in the rectosigmoid in our endoscopic population. Subjects and Methods: Endoscopic and histological data as well as medical and surgical reports were analyzed from pts with colorectal neoplasia on whom coloscopy was performed between 1981-1996. Pis with previous polypectomy, colon resection, colorectal cancer, familiar polyposis or inflammatory bowel disease were excluded. Results: 1486 pts had at least one neoplasm (mean age of 66; sex ratio: m:f = 1.5:1). Proximal colon neoplasms were found in 631 pts (42.5% of all pts). In these patients 68.9% (or 29.2% of all pts) did not have an indexpolyp. No indexpolyp was found in 73.2% (or 22.7 % of all pts) of pts with advanced proximal neoplasms. On the other hand, 13.6% (or 7.6% of all pts) pts with an advanced indexpolyp (n=883) had an advanced proximal neoplasm, as opposed to 5.0% (or 0.8% of all pts) of those with a small indexpolyp (n=218). Further details are summarized in the Table. Conlusion: Since about % of patients in our study population with proximal advanced colonic neoplasia did not have an indexpolyp, screening sigmoidoscopy should be carefully weighed up against screening colonoscopy despite its higher initial costs, discomfort and potential side-effects.
Patlentl
All pts with prox neoplasm • without indexpolyp • with Indexpolyp • adv indexpolyp • smallindexpolyp
Allprox. Neoplasia
Prox. adv. neoplasma
Prox. carcinoma
Prox. adv. Adenoma
(%)
(%)
(%)
(%)
631 (100) 436 (68.9) 196 (31.1) 167 (26.5) 29(4.6)
462 (100) 338 (73.2) 124 (73.2) 113 (24.4) 11 (2.4)
260(100) 221 (85) 39 (15) 34(13.1) 5(1.9)
202 (100) 117 (57.9) 85(42.1) 79 (39.1) 6 (3)
GROUP
SEX
RECTAL BLEEDING MEN WOMEN TOTAL FAMiLY HISTORY MEN WOMEN TOTAL
NO.
543 364 907 228 95 323
ADENOMAS 91 (16.8%) 27(7.4%) 118(13%) 35 (15.4%) 7(7.4%) 42(13%)
LEFT
SITE: L.&R.
RIGHT
59% 70% 69% 72% 71% 72%
14% 3% 4% 6% 0% 3%
27% 27% 27% 23% 29% 25%
1520 PREDICTIVE EVALUATION OF PREOPERATIVE SERUM SIALOSYL-TN ANTIGEN EXPRESSION IN THE PATIENTS WITH ADVANCED GASTRIC CANCER, MyungHwan Noh, Dong-A Univ, Pusan, South Korea. Objectives: Sialosyl-Tn (s'Tn), a mucin-associated carbohydrate antigen, is not expressed by normal mucin-producing cells of the stomach but is expressed in metaplastic, premalignant and malignant gastic tissues. In general, the rate of immunohistochemical expression of sTn in gastric cancer tissue is about 50-70%, and its prognostic role in gastric cancer is variable. And there is no report in Korea about serum sTn expression of gastric cancer patients, so we have examined the expression of sTn with the serum of gastric cancer patients and examined the possibilty of tumor maker and of factors for prognosis Methods: Serum sTn expression was examined by enzyme linked immuno-sorbent assay (ELISA) in 46 patients with abvanced cacner, confirmed at the Dong-A University Hospital, between June, 1997 and June, 1998. We examined the correlations between the expression of serum sTn antigen and patients age, sex, tumor location and size, degree of differentiation, stage, seroral invasion, peritonal dissemination, hepatic metastasis, lymph node metastasis and Borrman type. Results: The overall serum sTn expression was higher on cases of advanced gastric cancer than controls(p<0.05). Advanced stage had hugher serum sTn expression than lower stages (p=O.OOOI). And in cases of seroral invasion, peritoneal dissemination and hepatic metastasis, the serum sTn expression was higher than not (p<0.05). Lymph node metastasis, one of detereminant factors of stage, has high serum sTn expression but it had not statistical significance (p=0.067), and in cases of sex, tumor location and size, histologic grade and gross finding of tumor (Borrmann type) had not high expression of serum sTn (p>0.05). Conclusions: Higher expression of serum sTn in advanced gastric cancer can be proposed the possibility of the role as a tumor maker. And its higher expressions in many fiels of independent prognostic factors also can be proposed the possibility of another prognostic factor.