Diverticular Disease and Colorectal Neoplasms: Association between Left Sided Diverticular Disease with Colorectal Cancers and Right Sided with Colonic Polyps.

BACKGROUND: Both colorectal cancer (CRC) and diverticular disease (DD) are common in the affluent West, and their prevalence is also increasing in the rest of the world with economic development. Both diseases have common epidemiologic characteristics; increasing incidence, more common with advancing age and related to specific dietary changes. However, studies of associations between the two have generated mixed results with some showing positive correlations, whilst others have shown no or negative links. Most of these studies have been from the West with study populations that were predominantly Caucasians. Here the focus was on DD and colorectal neoplasms, including CRC, in Brunei. MATERIALS AND METHODS: All patients who had undergone complete colonoscopy between 2011 and 2014 were identified and retrospectively reviewed. Patients under the age of 18 years old or had previous colonic surgeries (including previous CRC resection) were excluded. RESULTS: The total number of colonoscopies included in the study was 2,766 (mean age 53.2±14.8 years old, male 51.8%), of which DD, CRC and colonic polyps were detected in 17.3%, 4.7% and 28.2% respectively. The proportions of DD, polyps and CRC increased proportionally with age (<30 years, 30-49, 50-69 and ≥70). Overall, there was no association between the presence of DD and CRC (3.6% vs. 5.0%, p=0.179) but there was a significant association between CRC and left sided DD (p=0.034 by trend). There were also a significant association between presence of DD and polyps (36.1% vs. 28.2%, p=0.001), in particular with right-sided and pan-DD (p=0.001 for trend). CONCLUSIONS: Our study showed that the prevalence of DD, CRC and polyps increases with age. There were significant associations between presence of left-sided DD with CRC and right-sided or pan-DD with colonic polyps. This suggests shared risk factors. Further studies are required to assess links in other countries of the Asian Pacific region.

Profile of HER2 +ve Gastric Cancers in Brunei Darussalam.

BACKGROUND: Gastric cancer is the second most common gastrointestinal cancer and is still associated with significant morbidity and mortality due to late presentation and diagnosis at advanced stages. Studies have reported that a variable proportion of gastric cancer is positive for the human epidermal growth factor receptor 2 (HER2) and patients with HER2 positive (HER2 +ve) lesions can benefit from targeted therapy. This study was conducted to assess the prevalence of HER2 +ve gastric cancers in Brunei Darussalam, a developing Southeast Asian nation. MATERIALS AND METHODS: Patients were identified from the Department of Pathology registry and retrospectively reviewed. HER2 expression was assessed by immunohistochemistry and only those staining 3+ were considered positive. RESULTS: Our study included 103 cases (66 males and 37 females) with a mean age of 65.1 ± 14.8 years old. There were 14 cases positive for HER2 (10 males and 4 females) giving a prevalence of 13.6%. The HER2 +ve cases were significantly older (70.6 ± 19.3 years old) than the negative cases (64.2 ± 13.8, p=0.041) and had significantly more advanced disease (stages 3 and 4, p=0.026). There were no significant differences in gender distribution, presence of intestinal metaplasia, EBV status, Helicobacter pylori status, tumor location (proximal vs. distal) and degree of tumor differentiation (all p values >0.05). CONCLUSIONS: Our study showed that 13.6% of our gastric cancers are positive for HER2, the affected patients being older and having more advanced disease at diagnosis.

Spectrum of cancers among South Asians working in Brunei Darussalam.

BACKGROUND: Worldwide the incidence of cancers is increasing and this seen more in developing nations. This study looks at the spectrum of cancers among South Asian nationals working in Brunei Darussalam, a developing Southeast Asia nation. MATERIALS AND METHODS: The cancer registry from 1994 to 2012 maintained by the State Laboratory was retrospectively reviewed. RESULTS: Over the period, there was a total of 123 cancer cases diagnosed among South Asians, giving an incidence of 1.5% (n = 123/8253). The mean age at diagnosis was 42.9 ± 17.1 with a gender ratio of (male 60; female 63). Among the South Asians, Indians accounted for the most (53.7%) cases, followed by Nepalese (39.8%), Pakistani (3.3%) and Sri Lankan (2.4%). The most common cancers were cancers of the female reproductive/gynecologic organs, gastrointestinal tract, and breast. Among the two major ethnic groups; cancers of the breast was the most common among Indians followed by gastrointestinal tract where among the Nepalese, these were gastrointestinal tract followed by gynecologic (esp. cervical cancers). Among the South Asian, the Nepalese were younger at diagnosis compared to the other groups. CONCLUSION: The spectrum of cancers among South Asian residing in Brunei is comparable to what have been reported from South Asia with the exception of lung cancers. The most common cancers were cancers of female reproductive/gynecologic organs, gastrointestinal tract and breast. South Asians were younger at diagnosis of cancers compared to non-South Asians.

Cancers among South-East Asian Nationals in Brunei Darussalam.

BACKGROUND: Worldwide, the incidence of cancers is increasing and is becoming a major public health issue, including those in the Asia Pacific region. South-East Asia is a region with diverse populations with different disease spectra. This study looked at the spectrum of cancers among South-East Asians working in Brunei Darussalam. MATERIALS AND METHODS: The cancer registry from 1994 to 2012 maintained by the State Laboratory was retrospectively reviewed. Crude incidence rates were calculated based on the population census of 2010. RESULTS: Altogether, there was a total of 418 cancer cases diagnosed among South-East Asians, giving an incidence of 5.1% (n=418/8,253). The affected nationals in decreasing frequency were Malaysians (53.1%), followed by Filipinos (25.8%), Indonesians (15.3%), Thais (3.8%), Myanmese (1.7%) and Vietnamese (0.2%) with no recorded cases for Singapore and the People's Republic of Laos. The overall mean age of diagnosis was 46.1±4.2 years old, with an increasing trend over the years (p<0.05 ANOVA). The overall gender ratio was 42.3:57.7 (male:female), more females among the Filipinos and Indonesians, more males among the Thais, and equal representation among the Malaysians and the Myanmese. The most common were cancers of the digestive system (19.9%), followed by female reproductive/gynecologic system (16.0%), breast (15.6%), hematological/lymphatic (12.0%) and head/neck (8.1%). There were differences in the prevalence of cancers among the various nationalities with highest crude incidence rate among the Myanmese (141.2/100,000), followed by the Malaysian (88.5/100,000), and the Filipinos (40.6/100,000) and the lowest among the Thais (18.4/100,000), Indonesians (10.5/100,000) and the Vietnamese (6.3/100,000). CONCLUSIONS: Cancers among South-East Asian residing in Brunei Darussalam accounted for 5.1% of all cancers. The most common cancers were cancers of the digestive, gynecologic/female reproductive system and breast with certain types slowly increasing in proportions. There mean age of diagnoses was increasing.

Increasing Incidence of Colorectal Cancer, Starting at a Younger Age for Rectal Compared to Colon Cancer in Brunei Darussalam.

BACKGROUND: Colorectal cancer (CRC) is the most common gastrointestinal malignancy and is a significant cause of mortality. Its incidence is generally increasing in Asia. Reports from the West have indicated that the incidence of rectal cancer is increasing in the younger population. This study assessed the time trend of CRC in Brunei Darussalam specifically assessing the different age groups at which the incidences start to increase. MATERIALS AND METHODS: The National Cancer registry was reviewed (1991 to 2014). The age standardized rate (ASR) and the age specific incidence rates (ASIRs) for three time periods (1991-1998), (1999-2006) and (2007-2014) were calculated. RESULTS: The mean age of diagnosis was 59.3±14.6 years old, incidences being slightly higher amongst men (57.6%) and Malays (67.1%). The most common tumor type was adenocarcinoma (96.4%). Rectal cancers accounted for 35.2% (n=372/1,056) of all cancers of the large bowel; more men were affected than women. The proportion of rectal cancer was also high among the indigenous group. In the three time periods, the ASR for CRC increased from 16 per 100,000 (1991-1998) to 19.6 per 100,000 (1999-2006) and 24.3 per 100,000 (2007-2014). The ASIRs for CRC increased markedly between the time periods 1998-2006 and 2007-2014, beginning in the 40-44 years age group. For rectal cancers, the ASIRs started to increase in the 25-29 age group onward whereas for colon cancers, the increase was observed at a later age, starting from the 45-49 age group. CONCLUSIONS: Our study showed an increase in the incidence of CRC including in the younger age groups. The increase was seen earlier in rectal cancer compared to colon cancer. These data mirror the trends reported from the West.

Esophageal Cancer in Brunei Darussalam over a three Decade Period: an Epidemiologic Study of Trends and Differences between Genders and Racial Groups.

BACKGROUND: Carcinoma of the esophagus is associated with significant morbidity and mortality. The most common subtype is squamous cell carcinoma (SCC). In the past three decades, the incidence of SCC has been reported to be decreasing whereas esophageal adenocarcinoma (AC) is increasing. This study assessed the trend of esophageal cancer in Brunei Darussalam over a three decades period. MATERIALS AND METHODS: The National Cancer registry was searched for esophageal cancers from 1986 to 2012. Data on age, gender, racial groups (Malays, Chinese, Indigenous and foreign nationals) and histology type were collected. The rate (ASR) and Age Specific Incidence rate (ASIR) were calculated. RESULTS: The predominant tumor type was SCC which accounted for 89% of all esophageal cancer. The gender ratio was 2.25: 1 (male: female) and the mean age at diagnosis was 66.9±12.9 years, significantly younger for esophageal AC (57.2±16.0) compared to SCC (68.1±12.0, p<0.05), and among the foreign nationals (p<0.05 for trend). The proportions of SCC among all esophageal cancers in the various racial groups were: Malays (87.8%), Chinese (100%), Indigenous (100%) and foreign nationals (20%). None of the Chinese and Indigenous groups were diagnosed with esophageal AC. The overall ASR for esophageal cancer was 2.1/100,000; 2.0/100,000 for SCC with a declining trend and 0.17/100,000 for esophageal AC, without any trend observed. Among the two major racial groups; the Chinese has higher ASR (3.42/100,000) compared to the Malays (ASR 0.95/100,000). CONCLUSIONS: SCC is the predominant tumor type of esophageal cancer in Brunei Darussalam and more common among the Chinese. There was a declining trend in the incidence of SCC but not for esophageal AC.

Characteristics of young colorectal cancer in Brunei Darussalam: an epidemiologic study of 29 years (1986-2014).

BACKGROUND: Colorectal cancer (CRC) is the most common gastrointestinal cancer and the incidence is increasing. CRC is more common with increasing age, but a proportion occurs in young adults, termed young CRC. This study assessed the incidence and the demographic of young CRC in Brunei Darussalam. MATERIALS AND METHODS: All histologically proven CRC between 1986 and 2014 registered with the Department of Pathology cancer registry were reviewed and data extracted for analyses. Young CRC was defined as cancer in patients aged less than 45 years. The various population groups were categorized into locals (Malays, Chinese and Indigenous) and expatriates. RESULTS: Over the study period, there were 1,126 histologically proven CRC (mean age 59.1 ± 14.7 years, Male 58.0%, Locals 91.8% and 8.2% expatriates). Young CRC accounted for 15.1% with the proportion declining over the years, from 29% (1986-1990) to 13.2% (2011-2014). The proportion of young CRC was highest among the indigenous (30.8%), followed by the expatriates (29.3%), Malays (14.3%) and lowest among the Chinese (10.8%). The mean age of young CRC was 35.9 ± 6.2; lowest among the indigenous (33.5 ± 6.7), expatriate (34.9 ± 6.0) groupd and the Malays (35.6 ± 6.5) compared to the Chinese (38.6 ± 4.6), a similar trend being observed in the non-young CRC groups. There were no difference between the genders and tumor locations (rectum or colon) between the young and the non-young CRC cases. Female young CRC was significantly younger than male (p<0.05) without any significant variation between the various population groups (p>0.05). CONCLUSIONS: Our study showed that the young CRC accounted for 15.1% of all CRC with declining trend observed over recent years. Young CRC was more common among indigenous, expatriates and Malays and least common among the Chinese. There were no differences in the gender and tumor locations.

Chronic Splenic Abscess as the First Manifestation of Pancreatic Tail Tumor.

Pancreatic carcinoma is still associated with a poor survival due to the late presentation. Excluding head of pancreas tumor, manifestations are often vague resulting in delayed diagnosis. Manifestations as infective complications are rare, and in topic countries where infection remains common, diagnosis will be further delayed. We report a rare case of pancreatic tail carcinoma that manifested as chronic splenic abscess.

Gastric Cancer and Paraneoplastic Pemphigus.

Paraneoplastic pemphigus is a relatively rare but significant acquired autoimmune mucocutaneous disorder that is characterised by diffuse erythema, painful blistering and sores of the skin and mucus membranes. The underlying pathogenesis is believed to be triggered by altered immune system in response to underlying neoplasm. The manifestations can predate, occur at the same time or after the diagnosis of cancer. Associations with gastric cancer have only been reported twice. A 78-year-old lady presented with a month's history of extensive skin lesions that started off as bullous lesions and biopsy revealed bullous pemphigus. Endoscopy for anemia revealed gastric cancer. This case reinforced the need to consider underlying malignancy in elderly patient with new onset dermatological presentation.

Gastric cancer in Brunei Darussalam: epidemiological trend over a 27 year period (1986-2012).

BACKGROUND: Gastric cancer is the second most common gastrointestinal cancer and is more common in the East, compared to the West. This study assesses the trend of gastric cancers in Brunei Darussalam, a developing nation with a predominantly Malay population. MATERIALS AND METHODS: The cancer registry from 1986 to 2012 maintained by the Department of Pathology, the only State Laboratory at the RIPAS Hospital, Ministry of Health, was reviewed and data extracted for analyses. The age standardised rate (ASR) and age specific incidence rate were calculated based on the projected population. Cancers diagnosed below 45 years were categorised as young gastric cancer. RESULTS: Over the study period, there were a total of 551 cases of gastric cancer diagnosed. The most common type was adenocarcinoma (87.9%), followed by lymphoma (6.1%) and gastrointestinal stromal tumour (2.8%). The overall mean age at diagnosis was 61.9 years old (range 15 to 98) with an increasing trend observed, but this was not significant (ANOVA). There were differences in the mean age at diagnosis for the different races (p=0.003 for trend), but not the gender (p=0.105). Young gastric cancer accounted for 14.9%, being more common in women, and in Expatriate and Malay populations compared to the Chinese. There was a decrease in the ASR, from 17.3/100,000 in 1986-1990 to 12.5/100,000 in 2006-2010. Chinese had a higher overall ASR (20.2/100,000) compared to the Malays (11.8/100,000). The age specific rates were comparable between men and women until the age group 55-59 years when the rates started to diverge, becoming higher in men. Chinese men had higher rates then Malay men whereas, the rates were higher or comparable between the women until the age group >70 when the rate for Chinese women overtook their Malay counterpart. CONCLUSIONS: Our study showed that there is a declining trend in the incidence of gastric cancer and higher rates were observed in men and Chinese.

Cancers of the young population in Brunei Darussalam.

BACKGROUND: Globally, the overall incidence of cancer is increasing as a result of ageing populations and changing lifestyles. Cancer is one of the leading causes of death, especially in the developed nations. Cancers affecting the young population are generally considered uncommon. This study assessed the demography and trends of cancers of the young in Brunei Darussalam, a small and developing Southeast Asia nation. MATERIALS AND METHODS: All patients diagnosed with cancers between 2000 and 2012 were identified from the cancer registry maintained by the State Histopathology Laboratory. Cancers of the young was defined as any cancers diagnosed under the age of 40 years. Demographic data and the type of cancers were collected and analysed using SPSS Statistics 17.0. RESULTS: Among the 6,460 patients diagnosed with cancer over the study period, 18.7% (n=1,205) were categorized as young with an overall decline in the proportion from 26.6% in 2000 to 18.8% in 2012 (p<0.001 for trend). Among all cancers of the young, the most common systems affected were gynecological (24.1%), hematological/lymphatic (15.8%), subcutaneous/dermatological/ musculoskeletal (10.5%), breast (10.5%) and gastrointestinal (9.9%). Overall, among the different systems, neurological (54.9%) had the highest proportion of cancers of the young followed by gynecological/reproductive (30.6%), hematological/ lymphatic (39.9%), endocrine (38.7%), subcutaneous/dermatological/ musculoskeletal (22.3%) and the head and neck region (20.1%). There was a female predominance (66.9%) and the incidence was significantly higher among the Malays (20.1%) and expatriates (25.1%) groups compared to the Chinese (10.7%) and indigenous (16.8%) groups (p<0.001 for trend). CONCLUSIONS: Cancers of the young (<40 years) accounted for almost a fifth of all cancers in Brunei Darussalam with certain organ systems more strongly affected. There was a female preponderance in all racial groups. Over the years, there has been a decline in the overall proportion of cancers of the young. Selective screening programs should nevertheless be considered.

Profiles of Epstein-Barr virus associated gastric carcinomas in Brunei Darussalam.

BACKGROUND: Gastric cancer is the second most common gastrointestinal cancer and is largely attributed to Helicobacter pylori (H. pylori) infection. In addition, studies have also shown association with Epstein-Barr virus (EBV) in 10% of gastric cancers. This study assessed the characteristics of EBV associated gastric cancers (EBVaGC) in Brunei Darussalam. MATERIALS AND METHODS: This study included gastric cancers diagnosed between 2008 and 2012, registered with the Department of Pathology RIPAS Hospital, Brunei Darussalam. Clinical case notes were systematically reviewed. Histology specimens were all stained for EBV and also assessed for intestinal metaplasia and H. pylori. RESULTS: There were a total of 81 patients (54 male and 27 females) with a mean age of 65.8±14.8 years included in the study. Intestinal metaplasia and active H. pylori infection were detected in 40.7% and 30.9% respectively. A majority of the tumors were proximally located (55.6%), most poorly differentiated (well differentiated 16%, moderately differentiated 30.9% and poorly differentiated 53.1%) and the stages at diagnosis were; stage I (44.4%), stage II (23.5%), stage III (8.6%) and stage IV (23.5%). EBV positivity (EBVaGC) was seen in 30.9%. Between EBVaGC and EBV negative gastric cancers, there were no significant differences (age, gender, ethnic group, presence of Intestinal metaplasia, tumor locations, stages of disease and degree of tumor differentiation). CONCLUSIONS: This study showed that a third of gastric cancers in Brunei Darussalam were positive for EBV, higher than what have been reported in the literature. However, there were no significant differences between EBVaGC and EBV negative gastric cancers. This suggests that the role of EBV in gastric cancer may be mostly incidental rather than any causal relation. However, further studies are required.

Rising incidence of primary liver cancer in Brunei Darussalam.

BACKGROUND: Primary liver cancer (PLC) is the fifth most common malignancy worldwide and is still associated with high mortality. Hepatocellular carcinoma (HCC) and cholangiocarcinoma are the two most common PLCs, and their incidence varies across regions. Currently there are no published data available on the incidence of PLC in Brunei Darussalam. MATERIALS AND METHODS: All proven PLCs between 2000 and 2009 were identified from the National Cancer Registry and reviewed. Metastatic diseases were excluded. A total of 123 cases (male 65.8%, female 34.2%) were identified and their data collected for calculation of the age standardised rate (ASR). RESULTS: The most common type of PLC was HCC (87.8%) followed by cholangiocarcinoma (10.6%). There were two cases of hepatoblastoma. The mean age at diagnosis was 63.2 years. The overall ASR of PLC was 8.2/100,000, increasing from 4.5/100,000 population in 2000 to 11.4/100,000 population in 2009. The rates were higher among males (12.0/100,000) than females (4.7/100,000). Among the ethnic groups, Chinese had the highest rates (overall 13.1/100,000 with none recorded in 2000 to 30.3/100,000 in 2009) compared to the Malays (overall 8.5/100,000 increasing from 4.5/100,000 in 2000 to 12.3/100,000 in 2009) and the indigenous groups. The incidence increased after the age of 50 and was highest among the 75-79 age groups. Increase was seen for HCC but not for cholangiocarcinoma. CONCLUSIONS: The most common type of PLC is HCC and the annual incidence of PLC is increasing in Brunei Darussalam,rates being higher in males and Chinese.

Signet Ring Cell Lymphoma of the Small Bowel: A case report.

Gastrointestinal lymphoma of the bowel is uncommon compared to adenocarcinoma. Signet ring cell lymphoma (SRCL) is a rare variant of non-Hodgkin's lymphoma that is characterized by clear cytoplasm with displaced nuclei to the periphery giving a signet ring appearance. Small bowel involvement has not been previously reported. We report the rare case of a 78-year-old female who presented with short history of fever, loss of appetite, nausea, vomiting, mild weight loss with abdominal discomfort and was later diagnosed to have SRCL of the ileum.

Oesophageal ulcers secondary to doxycycline and herpes simplex infection in an immunocompetent patient.

Oesophageal ulcerations are generally rare occurrences that are most commonly associated with gastro-oesophageal reflux disorder. Other causes include medications and infections in immunocompromised patients. Among the medications used in daily practice, doxycycline is most commonly implicated. Multiple aetiologies are generally uncommon. We report a case of mid-oesophageal ulcerations secondary to doxycycline and herpes simplex virus infection in an immunocompetent patient.

Profiles of autoimmune hepatitis in Brunei Darussalam.

BACKGROUND: Autoimmune hepatitis (AIH) is a chronic inflammatory disease of the liver. Data on the disease remain scarce in the Southeast Asia region. This study was undertaken to assess the profiles of AIH in Brunei Darussalam. METHODS: Nineteen patients with AIH treated at the hepatology clinic, RIPAS Hospital (up until December 2008) were reviewed. Demographic, laboratory, histologic, clinical, and therapeutic data of the patients were collected. RESULTS: The median age of the 19 patients at diagnosis was 52 years (range 33-70) with a male to female ratio of 1:3.75. All patients were diagnosed with type I AIH. The prevalence rate of the disease was 5.61/100 000 and was higher in the Chinese than in Malays and Indigenous people. Commonly seen presentations were abnormal liver function (52.6%), icteric hepatitis (36.8%), and decompensated liver disease (10.5%). Histologically advanced fibrosis was found in 47.4% and cirrhosis in 21.1% of the patients. Immune-mediated diseases were present in 36.8%. In a follow-up for 31 months (range 0.25-102), three patients died, 2 had progressive liver failure and 1 had lymphoma. Complete biochemical response was seen in 75% of the patients, partial response in 12.5%, and no response in 12.5%. HLA DRB1*03 (DR3) was detected in 18.2% of the patients and DRB1*04 (DR4) in 45.5%. There were significant associations between HLA Cw7 (P=0.038) and DQB1*04 (P=0.007). CONCLUSIONS: The data of the 19 patients were comparable to those reported in the literature. Most of the patients were found to have abnormal biochemistry. There were significant associations between HLA Cw7 and DQB1*04, but not between DRB1*03 (DR3) and DRB1*04 (DR4).

Solitary duodenal hamartomatous polyp with malignant transformation: report of a case.

A solitary duodenal hamartomatous polyp is rare and it is considered to be either a variant of Peutz-Jeghers syndrome (PJS) or a separate entity. Patients do not have cutaneous manifestations and have only one hamartomatous polyp. The presentation is nonspecific and it resembles common conditions, such as a peptic ulcer disease. Most are incidentally diagnosed during endoscopy for other indications. Malignant transformation has been reported. This report describes the case of a 46-year-old man who presented with chronic intermittent abdominal pain. The initial endoscopy showed an abnormal twisting of the duodenum with a dilated duodenum. He was later diagnosed to have a solitary duodenal hamartomatous polyp with malignant transformation, which was treated by surgery. A review of the literature on the pertinent cases of this type of lesion is also presented.