Update on the Recommendations on Breast Cancer Screening by the Cancer Expert Working Group on Cancer Prevention and Screening.

Breast cancer (BC) is the most common cancer among women in Hong Kong. The Food and Health Bureau commissioned The University of Hong Kong (HKU) to conduct the Hong Kong Breast Cancer Study (HKBCS) with the aim of identifying relevant risk factors for BC in Hong Kong and developing a locally validated BC risk assessment tool for Hong Kong Chinese women. After consideration of the most recent international and local scientific evidence including findings of the HKBCS, the Cancer Expert Working Group on Cancer Prevention and Screening (CEWG) has reviewed and updated its BC screening recommendations. Existing recommendations were preserved for women at high risk and slightly changed for women at moderate risk. The following major updates have been made concerning recommendations for other women in the general population: Women aged 44 to 69 with certain combinations of personalised risk factors (including presence of history of BC among first-degree relative, a prior diagnosis of benign breast disease, nulliparity and late age of first live birth, early age of menarche, high body mass index and physical inactivity) putting them at increased risk of BC are recommended to consider mammography screening every 2 years. They should discuss with their doctors on the potential benefits and harms before undergoing mammography screening. A risk assessment tool for local women (eg, one developed by HKU) is recommended to be used for estimating the risk of developing BC with regard to the personalised risk factors described above.

Recommendations on prevention and screening for breast cancer in Hong Kong.

In Hong Kong, breast cancer is the most common cancer among women and poses a significant health care burden. The Cancer Expert Working Group on Cancer Prevention and Screening (CEWG) was set up in 2002 by the Cancer Coordinating Committee to review and assess local and international scientific evidence, and to formulate recommendations for cancer prevention and screening. After considering the local epidemiology, emerging scientific evidence, and local and overseas screening practices, the CEWG concluded that it was unclear whether population-based breast cancer screening did more harm than good in local asymptomatic women at average risk. The CEWG considers that there is insufficient evidence to recommend for or against population-based mammography screening for such individuals. Women who consider breast cancer screening should be adequately informed about the benefits and harms. The CEWG recommends that all women adopt primary preventive measures, be breast aware, and seek timely medical attention for suspicious symptoms. For women at high risk of breast cancer, such as carriers of confirmed BRCA1/2 deleterious mutations and those with a family history of breast cancer, the CEWG recommends that they seek doctor's advice for annual mammography screening and the age at which the process should commence. Additional annual screening by magnetic resonance imaging is recommended for confirmed BRCA1/2 mutation carriers or women who have undergone radiation therapy to the chest between the age of 10 and 30 years. Women at moderate risk of breast cancer should discuss with doctors the pros and cons of breast cancer screening before making an informed decision about mammography screening every 2 to 3 years.

Recommendations on prevention and screening for colorectal cancer in Hong Kong.

Colorectal cancer is the commonest cancer in Hong Kong. The Cancer Expert Working Group on Cancer Prevention and Screening was established in 2002 under the Cancer Coordinating Committee to review local and international scientific evidence, assess and formulate local recommendations on cancer prevention and screening. At present, the Cancer Expert Working Group recommends that average-risk individuals aged 50 to 75 years and without significant family history consult their doctors to consider screening by: (1) annual or biennial faecal occult blood test, (2) sigmoidoscopy every 5 years, or (3) colonoscopy every 10 years. Increased-risk individuals with significant family history such as those with a first-degree relative diagnosed with colorectal cancer at age ≤60 years; those who have more than one first-degree relative diagnosed with colorectal cancer irrespective of age at diagnosis; or carriers of genetic mutations associated with familial adenomatous polyposis or Lynch syndrome should start colonoscopy screening earlier in life and repeat it at shorter intervals.

A systematic review of transabdominal levator division during abdominoperineal excision of the rectum (APER).

BACKGROUND: The aim of the present study was to evaluate the surgical technique, short-term oncological and perioperative outcomes for the transabdominal division of the levator ani muscles during abdominoperineal excision of the rectum (APER). METHODS: A systematic review was performed to identify studies reporting on transabdominal division of the levator ani during APER. A comprehensive literature search was performed using a combination of free-text terms and controlled vocabulary when applicable on the following databases: MEDLINE, EMBASE, Science Citation Index Expanded and Cochrane Central Register of Controlled Trials in the Cochrane Library. The search period was from January 1945 to December 2015. The following search headings were used: "transabdominal", "transpelvic", "abdominal" or "pelvic" combined with either "levator" or "extralevator" and with "abdominoperineal". RESULTS: Nine publications were identified reporting on 99 participants. The male/female distribution was 1.44:1, respectively, and the mean age was 56.6 (30-77) years. All tumours were less than 5 cm from the anal verge. The preoperative radiological staging was T2 in 18% of cases, T3 in 53.5% and T4 in 28.5%. Transabdominal division of the levators was performed laparoscopically in 55 cases, robotically in 34 and open in 10. The mean operating time was 255 (177-640) min. Mean intraoperative blood loss was 140 (92-500) ml. There were no conversions to open. Circumferential resection margins were positive in two cases, and there was one intraoperative perforation. Mean post-operative length of stay was 9.3 (3-67) days. Follow-up (from 0 to 31 months) revealed 19 perineal wound infections, 15 cases of sexual dysfunction and 7 cases of urinary retention. There was no mortality and 1 readmission. CONCLUSIONS: Transabdominal division of the levators during APER is feasible and reproducible, with acceptable perioperative and good early oncological outcomes. Further comparative studies are needed.

Randomized clinical trial of chewing gum after laparoscopic colorectal resection.

BACKGROUND: Chewing gum may enhance intestinal motility after surgery. This trial studied whether chewing gum could lead to a further reduction in ileus in patients who had a laparoscopic colorectal resection and followed an enhanced recovery programme. METHODS: Patients undergoing laparoscopic colorectal resection were randomized to a control or intervention group. Patients in the control group received a standardized recovery programme. Patients in the intervention group were, in addition, given chewing gum three times daily from day 1 until discharge. Primary outcome measures were time to first flatus and first bowel motion. Time to feeling hungry and hospital stay were secondary outcome measures. RESULTS: Forty-one patients were randomized into each group. Thirty-seven patients underwent rectal resection and 45 had a colonic resection. Time to passage of flatus was shorter (18 versus 34 h; P = 0·007), first bowel motion occurred earlier (19 versus 44 h; P = 0·001) and time to feeling hungry was earlier (16 versus 25 h; P = 0·001) in the intervention group. There was no difference in the duration of hospital stay (5 days in the intervention group versus 5·5 days in the control group). Subgroup analyses revealed that the benefits of chewing gum were clearer in patients who had a colonic resection, with a shorter time to first flatus (20 versus 35 h; P = 0·043), first bowel motion (19 versus 53 h; P = 0·014) and feeling hungry (14 versus 40 h; P = 0·001). No adverse events were attributed to chewing gum. CONCLUSION: Chewing gum is a simple intervention that speeds intestinal transit in patients managed with a recovery programme after laparoscopic colorectal resection. REGISTRATION NUMBER: NCT02419586 (https://clinicaltrials.gov/).

Distributions of colorectal cancer in two Chinese cities with contrasting colorectal cancer epidemiology.

BACKGROUND AND AIM: The incidence of colorectal cancer (CRC) is rising rapidly in Chinese. We studied the anatomic distributions and characteristics of CRC in Hong Kong (HK) and Chongqing (CQ) with different CRC epidemiology. METHODS: It was a retrospective study conducted in three large regional hospitals of the two cities. We identified all patients newly diagnosed with CRC between 2003 and 2012. The distribution and characteristics of CRC of the two cities were compared. RESULTS: Of CRC, 3664 new cases were diagnosed within the study period. CRC was more common in men (>56%) in both cities. The mean age at diagnosis was significantly younger in CQ, the lower prevalence area, than in HK (62.1 vs 70.4 years; P < 0.001). Rectal cancer was the predominant (61.3%) cancer in CQ, but only 18% of cancers in HK were rectal cancer (P = 0.0001). Right-sided colonic cancer, however, was more common in HK than CQ (27.2% vs 17.4%; P < 0.001). Women had more right-sided colonic cancer than men in both cities (P < 0.002), and there was an age-related increase in right-sided colonic cancer in HK but not in CQ. Multivariate analysis showed that older age, female, and living in HK were independent risk factors associated with right-sided colonic cancer. CONCLUSIONS: There are significant differences in the distribution of CRC between HK and CQ. The discrepancy may be partly accounted by older population and an increase in proximal colonic cancer, particularly in women, in HK.

Detection of colorectal adenoma by narrow band imaging (HQ190) vs. high-definition white light colonoscopy: a randomized controlled trial.

OBJECTIVES: The benefits of narrow band imaging (NBI) on enhancing colorectal adenoma detection remain questionable. We tested whether the new generation of NBI (190-NBI), which is twice as bright as the previous version, would improve adenoma detection when compared with high-definition white light (HD-WL) colonoscopy. METHODS: It was a randomized controlled trial with tandem colonoscopy. We recruited patients who underwent colonoscopy for symptoms, screening, or surveillance. Patients were randomized for the use of either 190-NBI or HD-WL on withdrawal. Tandem colonoscopy was performed by using the same assigned colonoscope and withdrawal method. Lesions detected on first-pass and second-pass examination were used for adenoma detection and miss rates, respectively. The primary outcomes were adenoma and polyp detection rates. RESULTS: A total of 360 patients were randomized to undergo either 190-NBI or HD-WL colonoscopy. Both the adenoma and polyp detection rates were significantly higher in the 190-NBI group compared with the HD-WL group (adenoma: 48.3% vs. 34.4%, P=0.01; polyps: 61.1% vs. 48.3%, P=0.02). The mean number of polyps detected per patient was higher in the 190-NBI group (1.49% vs. 1.13, P=0.07). There was no significant difference in the adenoma miss rates between the two groups (21.8% vs. 21.2%). Multivariate analysis showed that the use of 190-NBI (odds ratio (OR) 1.85; 95% confidence interval (CI) 1.10-3.12), withdrawal time (OR 1.29; CI 1.19-1.38), patient's age (OR 1.04; CI 1.01-1.06), and male gender (OR 2.38; CI 1.42-3.99) were associated with adenoma detection. CONCLUSIONS: 190-NBI colonoscopy was superior to the conventional HD-WL in detecting colorectal adenomas or polyps, but there was no significant difference in adenoma miss rates.

Long-term outcome of stenting as a bridge to surgery for acute left-sided malignant colonic obstruction.

AIM: This study aimed to evaluate both the short- and long-term outcomes associated with colonic stenting as a bridge to surgery in patients with obstructing adenocarcinoma of the colon. METHOD: Patients with potentially curable acute left-sided colonic obstruction treated with stenting as a bridge to surgery (n = 28) or with emergency surgical resection (n = 39) from January 1998 to December 2008 were identified from a prospectively maintained database. Short-term data on postoperative mortality, morbidity, necessity of intensive care and length of hospital stay were compared. Overall survival and disease-free survival were also analysed. RESULTS: Patients in the two study arms had similar demographic profiles. Those receiving preoperative stenting had a higher likelihood of a laparoscopic resection (P < 0.001). The emergency surgery group had a higher rate of postoperative complications (P = 0.024), rate of intensive care unit admission (P = 0.013) and longer total length of hospital stay (9 vs 12 days, P = 0.001). With a median follow-up of 26.5 and 31.3 months for the stenting and surgical resection groups, there was no difference in overall and disease-free survival (overall survival 30 vs 31 months, P = 0.858; disease-free survival 13 vs 12 months, P = 0.989). There was no difference in the rate of systemic recurrence (8 vs 13, P = 0.991). CONCLUSION: Stenting as a bridge to surgery is a safe strategy for acute left-sided colonic obstruction with improved short-term outcome and comparable long-term oncological results.

The effects of intra-operative dexmedetomidine on postoperative pain, side-effects and recovery in colorectal surgery.

In this double-blind, randomised study, 100 patients undergoing open or conventional laparoscopic colorectal surgery received an intra-operative loading dose of dexmedetomidine 1 µg.kg(-1) followed by an infusion of 0.5 µg.kg(-1) .h(-1) , or a bolus and infusion of saline 0.9% of equivalent volume. Forty-six patients in the dexmedetomidine group and 50 in the saline group completed the study. The area under the curve of numerical rating scores for pain at rest for 1-48 h postoperatively was significantly lower in the patients receiving dexmedetomidine (p = 0.041). There was no difference in morphine consumption, duration of recovery ward or hospital stay. From the data obtained in this study, we calculated a number needed to treat for effective pain relief of 4. Intra-operative dexmedetomidine in colorectal surgery resulted in a reduction in resting pain scores, but there was no morphine-sparing effect or improvement in patients' recovery outcome measures.

Pulmonary artery sarcoma diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration.

Pulmonary artery sarcoma is a rare disease with poor prognosis that has not been reported in Hong Kong. Its clinical and radiological presentation frequently mimics pulmonary embolism. Diagnosis is usually delayed until surgery, which is the treatment option that provides the best survival. Endobronchial ultrasound-guided transbronchial needle aspiration is an effective non-surgical technique for lymph node staging of lung cancer and diagnosis of mediastinal lesions via bronchoscopy. Here we discuss a case of pulmonary artery sarcoma diagnosed by this method, the second one in the literature, which serves to illustrate its potential use for early and minimally invasive diagnosis of the condition. Although such aspiration is a safe procedure, tissue sampling of extravascular extensions is advisable wherever possible.

The impact of POSSUM score on the long-term outcome of patients with rectal cancer.

AIM: The TMN staging system is the most important tool for predicting the long-term survival of colorectal cancer patients. However, physiological conditions and the operation may also influence survival. This study evaluated the impact of the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) and the colorectal version (CR-POSSUM) on the long-term survival of patients with rectal cancer. METHOD: Prospectively collected data were included of consecutive patients who underwent rectal cancer resection between 2000 and 2004. The relationship between the POSSUM and CR-POSSUM scores and the physiological components with outcomes and survivals was analysed. RESULTS: The study included 343 patients (196 men, 263 open resections, 74 laparoscopic resections, six local resections) with a mean follow-up of 56.5 months. Thirty-five patients had had neoadjuvant chemoradiation and 115 had adjuvant chemotherapy. Their median POSSUM score was 34 (interquartile range 31-39) and the median CR-POSSUM score was 19 (interquartile range 18-21). The log rank test showed a significant difference (P < 0.05) in long-term survival for patients who belonged to different POSSUM score groups and POSSUM physiological score groups. Factors found on multivariate analysis to have significant association with long-term survival included TNM stage, perineural invasion, local invasion, obstruction, emergency operation, POSSUM score and POSSUM physiological score. CONCLUSION: The mortality of patients after rectal cancer surgery can be predicted by POSSUM, P-POSSUM (a subsequent version of POSSUM) or CR-POSSUM with no significant difference between them. Both POSSUM and the POSSUM physiological score were significantly related to survival. The POSSUM score was one of the factors that independently predicted long-term survival.

Tailored rectal cancer treatment--a time for implementing contemporary prognostic factors?

AIM: To report data supporting the development of tailored treatment strategies for rectal cancer. METHOD: A comprehensive review of the literature on the impact of prognostic factors cur-rently not included in international guidelines in rectal cancer management. RESULTS: There is considerable variation in treatment guidelines for rectal cancer worldwide, especially for Stage II and Stage III disease. Long-term side effects of chemoradiotherapy are not considered in any guideline. Detailed knowledge, and the prognostic impact, of the circumferential resection margin, tumour grade and venous invasion should be factored into the development of a treatment strategy. CONCLUSION: Factors additional to the TNM system should improve decision making for contemporary rectal cancer treatment. Optimized radiological and pathological evaluations, and a focus on detailed clinical factors, should be the basis for treatment decisions. International guidelines should consider all known prognostic factors for long-term oncological and functional outcomes.

Laparoscopic surgery for colorectal cancer.

BACKGROUND: Laparoscopic surgery for colorectal cancer has undergone tremendous advancement in the last two decades, with maturation of techniques and integration into current practice. SOURCES OF DATA: Worldwide English-language literature on laparoscopic surgery for the management of colon and rectal cancer was reviewed. AREAS OF AGREEMENT: A large body of evidence has attested to the improved short-term outcomes and long-term oncological safety of laparoscopic surgery for colon cancer. Laparoscopic colectomy can be recommended to suitable patients where expertise is available. Laparoscopic resection for rectal cancer is feasible, with good evidence of faster post-operative recovery and adequate surgical quality, but requires more data on long-term oncological outcomes. This review examines the evidence and current practice of laparoscopic surgery for colorectal cancer. AREAS OF CONTROVERSY: Does laparoscopic surgery confer a survival advantage for colorectal cancer patients? GROWING POINTS: The role of single-incision laparoscopic surgery and robotic surgery in colorectal cancer. AREAS TIMELY FOR DEVELOPING RESEARCH: Barriers to the adoption of the laparoscopic technique.

Self-expanding metallic stents for acute left-sided large-bowel obstruction: a review of 130 patients.

AIM: The aim of this study was to evaluate the outcomes of self-expanding metallic stent (SEMS) placement in acute left-sided large-bowel obstruction. METHOD: From 1997 to 2008, 130 patients [mean 67 (SD 14.7)] underwent SEMS insertion for acute left-sided large-bowel obstruction. One-hundred and one procedures were palliative, and 29 patients underwent stent insertion as a bridge for surgery. The success rate and the outcome were analysed. RESULTS: The chief causes of obstruction were primary (67%) and recurrent (16%) colorectal carcinoma. The success rate was 88% after insertion of the first stent. In nine patients, insertion of a second stent was required. Complications occurred in 20% of the insertions, with migration (10.8%) being the most common. Perforation occurred in two patients and one developed a colovesical fistula. In patients with palliative stenting, 14 (13.9%) required subsequent surgery, with a stoma placed in all except three. Among the 29 patients who underwent SEMS insertion as a bridge to surgery, subsequent surgical resection was performed in 26 patients at a mean interval of 12 days (SD 18.0). Primary anastomosis was performed in 24 patients. The mean survival for those who underwent SEMS insertion as a bridge to surgery was 40 (95% confidence interval: 24-55) months. CONCLUSION: SEMS placement is safe and effective in relieving acute left-sided colonic obstruction. It allows subsequent definitive surgery on an elective setting and also serves as good palliation for advanced or disseminated disease.

Prognostic value of lymph node ratio in stage III colorectal cancer.

AIM: Recent reports show that a positive metastatic to examined lymph nodes ratio (LNR) has prognostic value in malignancies. This study aimed to evaluate the prognostic value of LNR in patients having resection for stage III colorectal cancer. METHOD: From January 2000 to December 2006, patients who underwent resection for stage III colorectal carcinoma were included. All clinicopathological and follow-up data were prospectively collected. The impact of LNR and other clinicopathological factors on survival were evaluated. RESULTS: The study included 533 (52.3% male) patients with a median age of 70 years. The median number of lymph nodes harvested and the median number of positive lymph nodes examined were 11 and 2, respectively. The median LNR was 0.263 (range, 0.03-1). After a median follow up of 52.65 months, the 5-year overall survival and disease-free survival were 55.9% and 49.4%. The patients were stratified into four groups according to LNR quartiles (1, LNR ≤ 0.125; 2, 0.1250.500). The 5-year overall and disease-free survival were 72.8%, 63.1%, 50.0%, 39.6% (P<0.001) and 68.5%, 54.1%, 47.2%, 29.9% (P<0.001), respectively, with increasing LNR groups. On multivariate analysis, age, T stage and LNR were independent predictors of both overall and disease-free survival. Subgroup analysis revealed that the LNR had a prognostic value for disease-free survival irrespective of number of lymph nodes harvested and location of tumour. CONCLUSION: The LNR is an independent prognostic factor for survival in colorectal cancer and is superior to the pN category in TNM staging.

Single incision laparoscopic left colectomy for carcinoma of distal transverse colon.

OBJECTIVE: We report a single-incision laparoscopic left colectomy for a patient with a distal transverse colon cancer. METHOD: A 78-year-old man with carcinoma of the transverse colon close to the splenic flexure underwent a single-incision laparoscopic left colectomy with full mobilization of splenic flexure using the TriPort Access System and ordinary laparoscopic instruments. RESULTS: The operation was successfully performed. The patient recovered uneventfully and was discharged after 3 days. Histopathological examination showed a T3N1 tumour with clear resection margins. CONCLUSION: This case demonstrates that single-incision laparoscopic colectomy can be applied safely to large bowel cancer close to the splenic flexure. The technique warrants further investigation.