RESUMEN
BACKGROUND: Colorectal cancers (CRCs) detected through the NHS Bowel Cancer Screening Programme (BCSP) have been shown to have a more favourable outcome compared to non-screen-detected cancers. The aim was to identify whether this was solely due to the earlier stage shift of these cancers, or whether other factors were involved. METHODS: A combination of a regional CRC registry (Northern Colorectal Cancer Audit Group) and the BCSP database were used to identify screen-detected and interval cancers (diagnosed after a negative faecal occult blood test, before the next screening round), diagnosed between April 2007 and March 2010, within the North East of England. For each Dukes' stage, patient demographics, tumour characteristics, and survival rates were compared between these two groups. RESULTS: Overall, 322 screen-detected cancers were compared against 192 interval cancers. Screen-detected Dukes' C and D CRCs had a superior survival rate compared with interval cancers (P=0.014 and P=0.04, respectively). Cox proportional hazards regression showed that Dukes' stage, tumour location, and diagnostic group (HR 0.45, 95% CI 0.29-0.69, P<0.001 for screen-detected CRCs) were all found to have a significant impact on the survival of patients. CONCLUSIONS: The improved survival of screen-detected over interval cancers for stages C and D suggest that there may be a biological difference in the cancers in each group. Although lead-time bias may have a role, this may be related to a tumour's propensity to bleed and therefore may reflect detection through current screening tests.
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Neoplasias Colorrectales/diagnóstico , Detección Precoz del Cáncer , Anciano , Neoplasias Colorrectales/mortalidad , Neoplasias Colorrectales/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Modelos de Riesgos ProporcionalesRESUMEN
BACKGROUND: The NHS Bowel Cancer Screening Programme (BCSP) offers biennial faecal occult blood testing (FOBt) followed by colonoscopy after positive results. Colorectal cancers (CRCs) registered with the Northern Colorectal Cancer Audit Group database were cross-referenced with the BCSP database to analyse their screening history. METHODS: The CRCs in the screening population between April 2007 and March 2010 were identified and classified into four groups: control (diagnosed before first screening invite), screen-detected, interval (diagnosed between screening rounds after a negative FOBt), and non-uptake (declined screening). Patient demographics, tumour characteristics and survival were compared between groups. RESULTS: In all, 511 out of 1336 (38.2%) CRCs were controls; 825 (61.8%) were in individuals invited for screening of which 322 (39.0%) were screen detected, 311 (37.7%) were in the non-uptake group, and 192 (23.3%) were interval cancers. Compared with the control and interval cancer group, the screen-detected group had a higher proportion of men (P=0.002, P=0.003 respectively), left colon tumours (P=0.007, P=0.003), and superior survival (both P<0.001). There was no difference in demographics, tumour location/stage, or survival between control and interval groups. CONCLUSION: The FOBt is better at detecting cancers in the left colon and in men. The significant numbers of interval cancers weren't found to have an improved outcome compared with the non-screened population.
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Neoplasias Colorrectales/diagnóstico , Anciano , Colonoscopía/métodos , Neoplasias Colorrectales/sangre , Detección Precoz del Cáncer/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Tamizaje Masivo/métodos , Persona de Mediana Edad , Sangre Oculta , Tasa de SupervivenciaRESUMEN
BACKGROUND: The aim was to determine the effect of the circumferential resection margin (CRM) on overall survival following surgical excision of rectal cancer. METHODS: The effect of CRM on survival was examined by case mix-adjusted analysis of patients undergoing potentially curative excision of a rectal cancer between 1998 and 2002. RESULTS: Of 1896 patients, 1561 (82.3 per cent) had recorded data on the CRM. In 232 patients (14.9 per cent) tumour was found 1 mm or less from the CRM. In 370 patients (23.7 per cent) it was over 1 mm but no more than 5 mm from the CRM, and in 288 (18.4 per cent) it was over 5 mm but no more than 10 mm from the CRM. The remaining 671 patients (43.0 per cent) had a CRM exceeding 10 mm. Overall 5-year survival rates for these groups were 43.2, 51.7, 66.6 and 66.0 per cent respectively. Compared with patients with a CRM exceeding 10 mm, the adjusted risk of death was significantly increased for patients with a CRM of 1 mm or less (hazard ratio (HR) 1.61, P < 0.001) and those with a margin greater than 1 mm but no larger than 5 mm (HR 1.35, P = 0.005). There was no added risk for patients with tumour more than 5 mm but 10 mm or less from the CRM (HR 1.02, P = 0.873). The adverse effect of a CRM greater than 1 mm but no larger than 5 mm was found particularly in mid-rectal cancers. CONCLUSION: A predicted CRM of 5 mm or less on preoperative staging should be considered for neoadjuvant treatment.
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Neoplasias del Recto/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/mortalidad , Cuidados Preoperatorios/mortalidad , Radioterapia Adyuvante/mortalidad , Neoplasias del Recto/mortalidad , Factores de RiesgoRESUMEN
BACKGROUND: Significant associations between caseload and surgical outcomes highlight the conflict between local cancer care and the need for centralization. This study examined the effect of hospital volume on short-term outcomes and survival, adjusting for the effect of surgeon caseload. METHODS: Between 1998 and 2002, 8219 patients with colorectal cancer were identified in a regional population-based audit. Outcomes were assessed using univariable and multivariable analysis to allow case mix adjustment. Surgeons were categorized as low (26 or fewer operations annually), medium (27-40) or high (more than 40) volume. Hospitals were categorized as low (86 or fewer), medium (87-109) or high (more than 109) volume. RESULTS: Some 7411 (90.2 per cent) of 8219 patients underwent surgery with an anastomotic leak rate of 2.9 per cent (162 of 5581), perioperative mortality rate of 8.0 per cent (591 of 7411) and 5-year survival rate of 46.8 per cent. Medium- and high-volume surgeons were associated with significantly better operative mortality (odds ratio (OR) 0.74, P = 0.010 and OR 0.66, P = 0.002 respectively) and survival (hazard ratio (HR) 0.88, P = 0.003 and HR 0.93, P = 0.090 respectively) than low-volume surgeons. Rectal cancer survival was significantly better in high-volume versus low-volume hospitals (HR 0.85, P = 0.036), with no difference between medium- and low-volume hospitals (HR 0.96, P = 0.505). CONCLUSION: This study has confirmed the relevance of minimum volume standards for individual surgeons. Organization of services in high-volume units may improve survival in patients with rectal cancer.
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Neoplasias del Colon/cirugía , Tamaño de las Instituciones de Salud/estadística & datos numéricos , Neoplasias del Recto/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Anastomosis Quirúrgica , Neoplasias del Colon/mortalidad , Femenino , Humanos , Estimación de Kaplan-Meier , Tiempo de Internación , Masculino , Persona de Mediana Edad , Neoplasias del Recto/mortalidad , Dehiscencia de la Herida Operatoria/etiología , Resultado del Tratamiento , Adulto JovenRESUMEN
Aberrant CpG island (CGI) methylation occurs early in colorectal neoplasia. Quantitative methylation-specific PCR profiling applied to biopsies was used to quantify low levels of CGI methylation of 18 genes in the morphologically normal colonic mucosa of neoplasia-free subjects, adenomatous polyp patients, cancer patients and their tumours. Multivariate statistical analyses distinguished tumour from mucosa with a sensitivity of 78.9% and a specificity of 100% (P=3 x 10(-7)). In morphologically normal mucosa, age-dependent CGI methylation was observed for APC, AXIN2, DKK1, HPP1, N33, p16, SFRP1, SFRP2 and SFRP4 genes, and significant differences in CGI methylation levels were detected between groups. Multinomial logistic regression models based on the CGI methylation profiles from normal mucosa correctly identified 78.9% of cancer patients and 87.9% of non-cancer (neoplasia-free+polyp) patients (P=4.93 x 10(-7)) using APC, HPP1, p16, SFRP4, WIF1 and ESR1 methylation as the most informative variables. Similarly, CGI methylation of SFRP4, SFRP5 and WIF1 correctly identified 61.5% of polyp patients and 78.9% of neoplasia-free subjects (P=0.0167). The apparently normal mucosal field of patients presenting with neoplasia has evidently undergone significant epigenetic modification. Methylation of the genes selected by the models may play a role in the earliest stages of the development of colorectal neoplasia.
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Adenocarcinoma/genética , Colon/metabolismo , Neoplasias del Colon/genética , Islas de CpG/genética , Adenocarcinoma/metabolismo , Pólipos Adenomatosos/genética , Pólipos Adenomatosos/metabolismo , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias del Colon/metabolismo , Islas de CpG/fisiología , Metilación de ADN , Epigénesis Genética , Femenino , Perfilación de la Expresión Génica , Humanos , Mucosa Intestinal/metabolismo , Masculino , Persona de Mediana EdadRESUMEN
OBJECTIVE: Surgical training in the UK is undergoing substantial changes. This study assessed: 1) the training opportunities available to trainees in operations for colorectal cancer, 2) the effect of colorectal specialization on training, and 3) the effect of consultant supervision on anastomotic complications, postoperative stay, operative mortality and 5-year survival. METHOD: Unadjusted and adjusted comparisons of outcomes were made for unsupervised trainees, supervised trainees and consultants as the primary surgeon in 7411 operated patients included in the Northern Region Colorectal Cancer Audit between 1998 and 2002. RESULTS: Surgery was performed in 656 (8.8%) patients by unsupervised trainees and in 1578 (21.3%) patients by supervised trainees. Unsupervised operations reduced from 182 (12.4%) in 1998 to 82 (6.1%) in 2002 (P < 0.001). Consultants with a colorectal specialist interest were more likely than nonspecialists to be present at surgical resections (OR 1.35, 1.12-1.63, P = 0.001) and to provide supervised training (OR 1.34, 1.17-1.53, P < 0.001). Patients operated on by unsupervised trainees were more often high-risk patients, however, consultant presence was not significantly associated with operative mortality (OR 0.83, 0.63-1.09, P = 0.186) or survival (HR 1.02, 0.92-1.13, P = 0.735) in risk-adjusted analysis. Supervised trainees had a case-mix similar to consultants, with shorter length of hospital stay (11.4 vs 12.4 days, P < 0.001), but similar mortality (OR 0.90, 0.71-1.16, 0.418) and survival (HR 0.96, 0.89-1.05, P = 0.378). CONCLUSION: One third of patients were operated on by trainees, who were more likely to perform supervised resections in colorectal teams. There was no difference in anastomotic leaks rates, operative mortality or survival between unsupervised trainees, supervised trainees and consultants when case-mix adjustment was applied. This study would suggest that there is considerable underused training capacity available.
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Competencia Clínica , Neoplasias Colorrectales/mortalidad , Neoplasias Colorrectales/cirugía , Procedimientos Quirúrgicos del Sistema Digestivo/educación , Educación de Postgrado en Medicina/métodos , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Procedimientos Quirúrgicos del Sistema Digestivo/mortalidad , Procedimientos Quirúrgicos Electivos , Tratamiento de Urgencia , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria/tendencias , Humanos , Internado y Residencia , Complicaciones Intraoperatorias/epidemiología , Masculino , Auditoría Médica , Cuerpo Médico de Hospitales , Persona de Mediana Edad , Oportunidad Relativa , Complicaciones Posoperatorias/epidemiología , Probabilidad , Medición de Riesgo , Análisis de Supervivencia , Resultado del Tratamiento , Reino UnidoRESUMEN
BACKGROUND: Several studies have shown a relationship between surgeon volume and outcomes in colorectal cancer surgery. The aim of this study was to determine the impact of surgeon volume and specialization on primary tumour resection rate, restoration of bowel continuity following rectal cancer resection, anastomotic leakage and perioperative mortality. METHODS: The Northern Region Colorectal Cancer Audit Group conducts a population-based audit of patients with colorectal cancer managed by surgeons. This study examined 8219 patients treated between 1998 and 2002. Outcomes were modelled using multivariate logistic regression analysis. RESULTS: Tumour resection was performed in 6949 (93.8 per cent) of 7411 patients. High-volume surgeons with an annual caseload of at least 18.5 (odds ratio (OR) 1.53 (95 per cent confidence interval (c.i.) 1.10 to 2.12); P = 0.012) and colorectal specialists (OR 1.42 (95 per cent c.i. 1.06 to 1.90); P = 0.018) were more likely to perform elective sphincter-saving rectal surgery. In elective surgery, the risk of perioperative death was lower for high-volume surgeons (OR 0.58 (95 per cent c.i. 0.44 to 0.76); P < 0.001), but this was not the case in emergency surgery. CONCLUSION: High-volume surgeons had lower perioperative mortality rates for elective surgery, and were more likely to use restorative rectal procedures.
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Neoplasias Colorrectales/cirugía , Cirugía Colorrectal/estadística & datos numéricos , Cuerpo Médico de Hospitales/estadística & datos numéricos , Especialización/estadística & datos numéricos , Adulto , Anciano , Anastomosis Quirúrgica , Consultores/estadística & datos numéricos , Inglaterra , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estomía/métodos , Estudios Prospectivos , Dehiscencia de la Herida Operatoria/etiología , Resultado del TratamientoRESUMEN
Hereditary non-polyposis colorectal cancer (HNPCC) is an autosomal dominant condition in which affected individuals develop colorectal cancer or extracolonic cancers, most commonly endometrial, at an early age. Recent advances in molecular genetics have led to the identification and sequencing of four genes thought to be responsible for the majority of cases of hereditary non-polyposis colorectal cancer. A description of the disease along with details of the underlying genetics and pathological features are presented. Current management and screening policies in these pedigrees are not clearly established. This article discusses some of the controversies in the light of predictive testing.
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Neoplasias del Colon , Neoplasias Colorrectales Hereditarias sin Poliposis , Neoplasias del Colon/diagnóstico , Neoplasias del Colon/genética , Neoplasias del Colon/patología , Neoplasias Colorrectales Hereditarias sin Poliposis/diagnóstico , Neoplasias Colorrectales Hereditarias sin Poliposis/genética , Neoplasias Colorrectales Hereditarias sin Poliposis/patología , HumanosRESUMEN
Decreased production of butyric acid by colonic carbohydrate fermentation may predispose to colonic carcinogenesis, with the implicit assumption that the decrease in faecal butyrate found predates the development of the tumour. The influence of the genetic predisposition to colonic tumours and the presence of colonic polyps on in vitro fermentation of carbohydrates was examined. Stool samples from 11 normal controls and 20 patients with familial adenomatous polyposis (FAP) were incubated anaerobically with a range of carbohydrates. Fermentation patterns were similar for glucose and raffinose. These sugars produced different short chain fatty acid (SCFA) patterns from the two polysaccharides, starch and arabinogalactan, which differed one from the other. The FAP gene carriers with polyps produced less butyrate than normal controls (p < 0.005) and gene carriers without polyps (p < 0.05). There were corresponding decreases in the molar ratios of butyrate. Gene carriers without polyps produced less absolute amounts of acetate than normal controls (p < 0.05) and slightly less total SCFAs (p < 0.05) but were otherwise not significantly different. The decreased production of butyrate noted by other workers may be secondary to the tumours rather than a contributory cause.
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Poliposis Adenomatosa del Colon/metabolismo , Metabolismo de los Hidratos de Carbono , Colon/metabolismo , Adolescente , Adulto , Butiratos/metabolismo , Niño , Ácidos Grasos Volátiles/metabolismo , Femenino , Fermentación/fisiología , Humanos , Concentración de Iones de Hidrógeno , Técnicas In Vitro , Masculino , Persona de Mediana Edad , Factores de TiempoRESUMEN
The rarity of familial adenomatous polyposis (FAP) means that many clinicians may be unaware of the major advances that have taken place in screening for the condition over the past five years. This review is not only to document the current scene but also to give details of those involved in establishing registries throughout the country. FAP is a hereditary disorder which carries with it almost a 100% risk of colorectal cancer. The aim of screening is to detect gene carriers before they present with symptoms attributable to colonic polyps. In this way the incidence of colorectal cancer can be greatly reduced. The use of gene probes to identify patients with FAP is in its infancy but in selected pedigrees gene carriers can be identified using a venous blood sample. The recognition that congenital hypertrophy of the retinal pigment epithelium is an extracolonic manifestation of FAP in most pedigrees allows non-invasive ophthalmological screening of relatives at risk. The combination of these new screening methods with an effective regional registry for FAP can increase the number of patients detected by screening rather than by symptoms. This facilitates appropriate prophylactic surgery and reduces mortality related to colorectal cancer.
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Poliposis Adenomatosa del Colon/prevención & control , Pruebas Genéticas/métodos , Poliposis Adenomatosa del Colon/cirugía , Neoplasias Colorrectales/prevención & control , Heterocigoto , Humanos , Sistema de RegistrosRESUMEN
Medical therapy of Ménétrier's disease is often unsatisfactory and may lead to surgical treatment. Two cases, previously unresponsive to H2 antagonists, are presented showing a marked response to omeprazole.
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Gastritis Hipertrófica/tratamiento farmacológico , Omeprazol/uso terapéutico , Adulto , Femenino , Mucosa Gástrica/patología , Gastritis Hipertrófica/diagnóstico , Humanos , Masculino , Factores de TiempoAsunto(s)
Urgencias Médicas , Neoplasias/diagnóstico , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
A series of eight cases of benign hepatocellular tumors from the New Orleans area is presented. Clinical and histological features of these unusual tumors are discussed. Also, a series of 56 similar cases reported in the literature is reviewed. We conclude that these tumors have shown definite evidence of hormonal sensitivity and there is strong circumstantial evidence that oral contraceptive medications have contributed to their recent increased incidence. Although the risk of this problem in the overall population of women taking oral contraceptives seems to be quite small, further clinical and experimental research on this problem is clearly indicated.