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Outcome of Endoscopic Resection for Early Invasive Colorectal Cancer Based on the Tumor Recurrence
Abstracts
W1132 How Adequate Is Digital Rectal Exam for Prostate Cancer Screening At Colonoscopy? Can Adequacy Be Improved? John B. Marshall
W1134 The Hidden Value of Upper Endoscopy: A ‘‘Teachable Moment’’ for Colorectal Cancer Screening Stacy B. Menees, A.M. Fendrick, Ruth Carlos, James Scheiman
Background: Screening for prostate cancer by digital rectal exam (DRE) has been advocated as a means of detecting prostate cancer at an early stage. It is not clear how often the prostate gland is completely felt when examined in the left lateral position at DRE at the time of colonscopy. Aim: To determine the adequacy of prostate palpation at DRE at colonscopy, and to devise a method of improving adequacy when the gland is incompletely felt. Methods: Adequacy of DRE in the left lateral position was assessed in 200 consecutive males 40 years or older undergoing colonoscopy, and was correlated with body mass index (BMI). If the prostate gland was incompletely palpated, the patient was asked to flex their right knee up toward their chest, and the exam was repeated. Results: The prostate gland was incompletely felt in 65 of 200 patients (32.5%). Raising the right knee toward the chest permitted complete palpation in 62 of the 65 cases (95.4%) in which there was incomplete initial palpation. Incomplete palpation showed a very strong correlation with National Institutes of Health (NIH) BMI categories: 3/36 (8%) for patients with normal body weight, 14/89 (16%) for overweight patients, 42/68 (62%) for patients with obesity, and 6/7 (86%) for patients with extreme obesity. There were 13 patients in which no part of the prostate gland could be felt on initial digital exam (1/89 overweight, 8/68 obesity, and 4/7 extreme obesity). The prostate was completely palpated in 11 of the 13 (85%) by raising the right knee. Prostate findings in four of the 200 study patients warranted urologic referral. Conclusions: The prostate gland is often incompletely palpated at DRE in the left lateral position at the time of colonoscopy, and shows a strong correlation with body mass index and NIH BMI categories. Adequacy can be dramatically improved by having the patient bring their right knee up toward the chest, a maneuver which just takes seconds to perform. The study also highlights the high prevalence of overweight and obesity among adult males 40 years and older in the midwest (82% in this study), and demonstrates yet another health hazzard of obesity– incomplete DRE at colonoscopy.
Background: Nearly half of Americans do not undergo colorectal cancer (CRC) screening as recommended by professional organizations. Those individuals inadequately screened for CRC who are referred for open access esophagoduodenoscopy (EGD) represent an opportunity for gastroenterologists to provide education regarding the benefits of CRC screening and ultimately enhance adherence rates. CRC screening rates for eligible individuals undergoing upper access EGD has not been established. Aims: 1. Determine the rate of CRC screening among a cohort of patients undergoing direct access EGD for whom screening is recommended; 2. Determine predictors of CRC screening in this population. Methods: A retrospective chart review of 1076 consecutive patients undergoing open access EGD from January 2003 to June 2004 was undertaken at a large Midwestern academic medical center to determine compliance with CRC screening recommendations. Only patients followed by a primary care provider (PCP) at this same institution for at least one year were eligible. Demographic, insurance coverage, duration of primary care physician relationship and other preventive care services were analyzed to determine predictors of CRC screening. Results: Of the 247 individuals undergoing EGD who met inclusion criteria and were eligible for CRC screening (57% women, 84% Caucasian, mean age 60 years, mean primary physician relationship 5.5 years), 68% were up to date with CRC screening. Significant predictors of screening included younger age (aged 55-59 and 60-64 (OR Z 3.01, 95% CI 2.22,7.42; OR Z 4.04, 95%CI 1.56,10.19), adherence to non-CRC cancer screening (OR Z 3.70, 95%CI 1.49,9.20) and a PCP relationship of 9 years or greater (OR Z 2.34, 95% CI 1.22,4.05). Female gender was a significant negative predictor of CRC screening (OR Z 0.38, 95%CI 0.18,0.80). Conclusion: At the time of open access EGD, one-third of patients who would benefit from CRC screening were not compliant with recommended guidelines. Male gender, younger age, longer doctor-patient relationships, and compliance with preventive health behaviors were associated with CRC screening. The EGD experience – especially for women - may represent a ‘‘teachable moment’’ to educate and facilitate CRC screening.
W1133 Outcome of Endoscopic Resection for Early Invasive Colorectal Cancer Based on the Tumor Recurrence Takahisa Matsuda, Yutaka Saito, Fabian Emura, Takayuki Yoshino, Yasushi Sano, Takahiro Fujii Background: Endoscopic resection can provide complete cure of early invasive colorectal cancer (EI-CRC) in lesions limited to !1000um of invasion of the submucosal layer, without lymphovascular invasion and poorly differentiated component. However, the rate of recurrence and the recurrence in high risk patients for lymph node metastases (LNM) is still unknown in a large series. Aim: To determine both the local and distant recurrence rate (RR) after endoscopic resection for EI-CRC and the RR in high risk patients for LNM in our center. Subjects and Methods: Endoscopic resection (ER) or ERCSurgical Resection (ER-SR) for EI-CRC performed between 1980 and 2002 were analyzed. Patients were subdivided in two groups based on the risk of LNM: high risk (depth of invasion O1000um and/or lymphovascular invasion and/or poorly differentiated component) and low risk (depth of invasion !1000um, no lymphovascular invasion and no poorly differentiated component). Recurrent lesions were identified by endoscopic examinations, CT scan or abdominal ultrasound. Exclusion criteria were: FAP, HNPCC, advanced cancer and patients followed less than one year. Results: There were 210 EI-CRC cases. The overall RR was 2.4% (5 patients). ER was performed in 112 patients, RR: 3.6% (4 patients), mean follow-up period: 3.6 years. Among these recurrent cases, there were 3 out of 4 patients in the high risk group and 1 out of 4 in the low risk group. On the other hand, ER-SR was performed in 98 patients, RR: 1% (1 patient), mean follow-up period: 5.4 years. This patient was classified as high risk group. According to the subgroup analysis, in the ER group there were 60 (54%) high risk patients, RR: 5% (3 patients). Meanwhile, there were 52 (46%) patients in the low risk group, RR was found in 1.9% (1 patient). On the other hand, in the ER-SR group there were 82 (84%) high risk patients, RR: 1.2% (1 patient). Meanwhile, there were 16 (16%) low risk patients, RR: 0%. Distant recurrence was identified in 3 patients (liver: 1, liver and lung: 1, pelvic LN: 1) and local and distant in 2 patients (local and liver: 1, local and lung: 1). There were no cases of local recurrence alone. Conclusions: The overall recurrence rate after endoscopic resection of EI-CRC is relatively low. EI-CRC cases can be successfully followed after endoscopic treatment when they are classified in the low risk group. On the other hand, additional surgical treatment is undoubtedly recommended in high risk patients.
AB260 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
W1135 Chronic Renal Failure as a Risk of Colorectal Neoplasia Tamiya Morikawa, Jun Kato, Hiroshi Matsushima, Yasushi Shiratori Background: Chronic renal failure was known as a risk of malignancy. However, few studies on the relationship between chronic renal failure and colonic neoplasia have been reported. In this study, we investigated the prevalence and characteristics of colorectal neoplasia in patients with chronic renal failure on regular hemodialysis treatment. Methods: We conducted a case-control study. Patients with hemodialysis who received screening colonoscopy at Okayama University hospital and Shigei Medical Research hospital from August 2003 to October 2004 were prospectively enrolled. As control subjects, patients who were asymptomatic and underwent first-time complete colonoscopy at the same hospitals during the same period were also enrolled. Results: Thirty-five hemodialysis patients (average age of 67 (41-86) years) and 215 controls (average age of 61 (41-89) years) were enrolled. There were no significant differences in age and gender distributions between the two groups. The prevalence of colorectal neoplasia in hemodialysis patients (26/35, 74%) was significantly higher than that in controls (105/215, 49%) (odds ratio, 3.03; 95% confidence interval [CI], 1.356.76). Hemodialysis patients showed high prevalence of multiple polyps (single polyp in 27% and multiple polyps in 73%) compared with control patients (single polyp in 65% and multiple polyps in 35%) (P ! 0.05). Moreover, multiple polyps found in hemodialysis patients were likely to be located at both left (descending colon, sigmoid colon, and rectum) and right (transverse colon, ascending colon, and cecum) colon (left only: right only: both Z 1:1:2.4) compared to polyps found in control subjects (left only: right only: both Z 2.5:1.5:1) (P ! 0.05). In addition, hemodialysis patients had more advanced neoplasia (adenoma G10 mm, adenoma with villous component, adenoma with high grade dysplasia, and cancer) than control subjects (odds ratio, 2.26; 95% CI, 1.08-4.09). Conclusions: Our results indicated that the status of chronic renal failure is strongly associated with the risk of colorectal neoplasia. Therefore, total colonoscopy should be recommended as screening test for colorectal neoplasia in patients with chronic renal failure, especially those on hemodialysis treatment.
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W1132 How Adequate Is Digital Rectal Exam for Prostate Cancer Screening At Colonoscopy? Can Adequacy Be Improved? John B. Marshall
W1134 The Hidden Value of Upper Endoscopy: A ‘‘Teachable Moment’’ for Colorectal Cancer Screening Stacy B. Menees, A.M. Fendrick, Ruth Carlos, James Scheiman
Background: Screening for prostate cancer by digital rectal exam (DRE) has been advocated as a means of detecting prostate cancer at an early stage. It is not clear how often the prostate gland is completely felt when examined in the left lateral position at DRE at the time of colonscopy. Aim: To determine the adequacy of prostate palpation at DRE at colonscopy, and to devise a method of improving adequacy when the gland is incompletely felt. Methods: Adequacy of DRE in the left lateral position was assessed in 200 consecutive males 40 years or older undergoing colonoscopy, and was correlated with body mass index (BMI). If the prostate gland was incompletely palpated, the patient was asked to flex their right knee up toward their chest, and the exam was repeated. Results: The prostate gland was incompletely felt in 65 of 200 patients (32.5%). Raising the right knee toward the chest permitted complete palpation in 62 of the 65 cases (95.4%) in which there was incomplete initial palpation. Incomplete palpation showed a very strong correlation with National Institutes of Health (NIH) BMI categories: 3/36 (8%) for patients with normal body weight, 14/89 (16%) for overweight patients, 42/68 (62%) for patients with obesity, and 6/7 (86%) for patients with extreme obesity. There were 13 patients in which no part of the prostate gland could be felt on initial digital exam (1/89 overweight, 8/68 obesity, and 4/7 extreme obesity). The prostate was completely palpated in 11 of the 13 (85%) by raising the right knee. Prostate findings in four of the 200 study patients warranted urologic referral. Conclusions: The prostate gland is often incompletely palpated at DRE in the left lateral position at the time of colonoscopy, and shows a strong correlation with body mass index and NIH BMI categories. Adequacy can be dramatically improved by having the patient bring their right knee up toward the chest, a maneuver which just takes seconds to perform. The study also highlights the high prevalence of overweight and obesity among adult males 40 years and older in the midwest (82% in this study), and demonstrates yet another health hazzard of obesity– incomplete DRE at colonoscopy.
Background: Nearly half of Americans do not undergo colorectal cancer (CRC) screening as recommended by professional organizations. Those individuals inadequately screened for CRC who are referred for open access esophagoduodenoscopy (EGD) represent an opportunity for gastroenterologists to provide education regarding the benefits of CRC screening and ultimately enhance adherence rates. CRC screening rates for eligible individuals undergoing upper access EGD has not been established. Aims: 1. Determine the rate of CRC screening among a cohort of patients undergoing direct access EGD for whom screening is recommended; 2. Determine predictors of CRC screening in this population. Methods: A retrospective chart review of 1076 consecutive patients undergoing open access EGD from January 2003 to June 2004 was undertaken at a large Midwestern academic medical center to determine compliance with CRC screening recommendations. Only patients followed by a primary care provider (PCP) at this same institution for at least one year were eligible. Demographic, insurance coverage, duration of primary care physician relationship and other preventive care services were analyzed to determine predictors of CRC screening. Results: Of the 247 individuals undergoing EGD who met inclusion criteria and were eligible for CRC screening (57% women, 84% Caucasian, mean age 60 years, mean primary physician relationship 5.5 years), 68% were up to date with CRC screening. Significant predictors of screening included younger age (aged 55-59 and 60-64 (OR Z 3.01, 95% CI 2.22,7.42; OR Z 4.04, 95%CI 1.56,10.19), adherence to non-CRC cancer screening (OR Z 3.70, 95%CI 1.49,9.20) and a PCP relationship of 9 years or greater (OR Z 2.34, 95% CI 1.22,4.05). Female gender was a significant negative predictor of CRC screening (OR Z 0.38, 95%CI 0.18,0.80). Conclusion: At the time of open access EGD, one-third of patients who would benefit from CRC screening were not compliant with recommended guidelines. Male gender, younger age, longer doctor-patient relationships, and compliance with preventive health behaviors were associated with CRC screening. The EGD experience – especially for women - may represent a ‘‘teachable moment’’ to educate and facilitate CRC screening.
W1133 Outcome of Endoscopic Resection for Early Invasive Colorectal Cancer Based on the Tumor Recurrence Takahisa Matsuda, Yutaka Saito, Fabian Emura, Takayuki Yoshino, Yasushi Sano, Takahiro Fujii Background: Endoscopic resection can provide complete cure of early invasive colorectal cancer (EI-CRC) in lesions limited to !1000um of invasion of the submucosal layer, without lymphovascular invasion and poorly differentiated component. However, the rate of recurrence and the recurrence in high risk patients for lymph node metastases (LNM) is still unknown in a large series. Aim: To determine both the local and distant recurrence rate (RR) after endoscopic resection for EI-CRC and the RR in high risk patients for LNM in our center. Subjects and Methods: Endoscopic resection (ER) or ERCSurgical Resection (ER-SR) for EI-CRC performed between 1980 and 2002 were analyzed. Patients were subdivided in two groups based on the risk of LNM: high risk (depth of invasion O1000um and/or lymphovascular invasion and/or poorly differentiated component) and low risk (depth of invasion !1000um, no lymphovascular invasion and no poorly differentiated component). Recurrent lesions were identified by endoscopic examinations, CT scan or abdominal ultrasound. Exclusion criteria were: FAP, HNPCC, advanced cancer and patients followed less than one year. Results: There were 210 EI-CRC cases. The overall RR was 2.4% (5 patients). ER was performed in 112 patients, RR: 3.6% (4 patients), mean follow-up period: 3.6 years. Among these recurrent cases, there were 3 out of 4 patients in the high risk group and 1 out of 4 in the low risk group. On the other hand, ER-SR was performed in 98 patients, RR: 1% (1 patient), mean follow-up period: 5.4 years. This patient was classified as high risk group. According to the subgroup analysis, in the ER group there were 60 (54%) high risk patients, RR: 5% (3 patients). Meanwhile, there were 52 (46%) patients in the low risk group, RR was found in 1.9% (1 patient). On the other hand, in the ER-SR group there were 82 (84%) high risk patients, RR: 1.2% (1 patient). Meanwhile, there were 16 (16%) low risk patients, RR: 0%. Distant recurrence was identified in 3 patients (liver: 1, liver and lung: 1, pelvic LN: 1) and local and distant in 2 patients (local and liver: 1, local and lung: 1). There were no cases of local recurrence alone. Conclusions: The overall recurrence rate after endoscopic resection of EI-CRC is relatively low. EI-CRC cases can be successfully followed after endoscopic treatment when they are classified in the low risk group. On the other hand, additional surgical treatment is undoubtedly recommended in high risk patients.
AB260 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
W1135 Chronic Renal Failure as a Risk of Colorectal Neoplasia Tamiya Morikawa, Jun Kato, Hiroshi Matsushima, Yasushi Shiratori Background: Chronic renal failure was known as a risk of malignancy. However, few studies on the relationship between chronic renal failure and colonic neoplasia have been reported. In this study, we investigated the prevalence and characteristics of colorectal neoplasia in patients with chronic renal failure on regular hemodialysis treatment. Methods: We conducted a case-control study. Patients with hemodialysis who received screening colonoscopy at Okayama University hospital and Shigei Medical Research hospital from August 2003 to October 2004 were prospectively enrolled. As control subjects, patients who were asymptomatic and underwent first-time complete colonoscopy at the same hospitals during the same period were also enrolled. Results: Thirty-five hemodialysis patients (average age of 67 (41-86) years) and 215 controls (average age of 61 (41-89) years) were enrolled. There were no significant differences in age and gender distributions between the two groups. The prevalence of colorectal neoplasia in hemodialysis patients (26/35, 74%) was significantly higher than that in controls (105/215, 49%) (odds ratio, 3.03; 95% confidence interval [CI], 1.356.76). Hemodialysis patients showed high prevalence of multiple polyps (single polyp in 27% and multiple polyps in 73%) compared with control patients (single polyp in 65% and multiple polyps in 35%) (P ! 0.05). Moreover, multiple polyps found in hemodialysis patients were likely to be located at both left (descending colon, sigmoid colon, and rectum) and right (transverse colon, ascending colon, and cecum) colon (left only: right only: both Z 1:1:2.4) compared to polyps found in control subjects (left only: right only: both Z 2.5:1.5:1) (P ! 0.05). In addition, hemodialysis patients had more advanced neoplasia (adenoma G10 mm, adenoma with villous component, adenoma with high grade dysplasia, and cancer) than control subjects (odds ratio, 2.26; 95% CI, 1.08-4.09). Conclusions: Our results indicated that the status of chronic renal failure is strongly associated with the risk of colorectal neoplasia. Therefore, total colonoscopy should be recommended as screening test for colorectal neoplasia in patients with chronic renal failure, especially those on hemodialysis treatment.
www.mosby.com/gie