For "difficult" benign colorectal lesions referred to surgical resection a second opinion by an experienced endoscopist is mandatory: A single centre experience.

AIM: To assess how many patients with benign "difficult" colorectal lesions (DCRLs) referred to surgical resection, may be treated with endoscopic resection (ER) rather than surgical resection. METHODS: The prospectively collected colonoscopy database of our Endoscopic Unit was reviewed to identify all consecutive patients who, between July 2011 and August 2013, underwent an endoscopic re-evaluation before surgical resection due to the presence of DCRLs with a histological confirmation of benignancy on forceps biopsy. ER was attempted when the lesion did not have definite features of deeply invasive cancer. The "nonlifting sign" excluded ER only in naive lesions without a prior attempted resection. Lesions were classified, using the Kyoto-Paris classification for mucosal neoplasia. For sessile and non-polypoid lesions the "inject and cut" resection technique was used. Pedunculated and semi-pedunculated lesions were transected at the stalk just below the polyps head and before or after resection, metal clips or a loop were applied on the stalk to prevent bleeding. The lesions were histologically classified according to the Vienna criteria and for the pedunculated lesions the Haggitt classification was used. RESULTS: Eighty-two patients (42 females, mean age 62 years) with 82 lesions (mean size 37 mm) were included in the study. Sixty-nine (84%) lesions were endoscopically resected, while 13 underwent surgical resection since ER was deemed unsuitable. On histology, cancer was found in 21/69 lesions (14 intra-mucosal, 7 sub-mucosal) and was associated with the size (P < 0.001) and with type 0-IIa +Is (P = 0.011) and 0-IIa + IIc (P < 0.001) lesions. All patients with sub-mucosal cancer, underwent surgical resection. Complications occurred in 11/69 patients (7 bleedings, 2 transmural burn syndromes, 2 perforations), all managed endoscopically or conservatively, and were associated with presence of invasive cancer (P = 0.021). During follow-up recurrence/residual tissue was found in 14/51 sessile or non-polypoid lesions (13 treated endoscopically, 1 underwent surgical resection) and was associated with type 0-IIa + Is lesions (P = 0.001), piecemeal resections (P = 0.01) and with lesion size (P = 0.004). Overall, 74% of patients avoided surgery. Surgical resection was significantly associated with type 0-IIa + Is (P = 0.01) and 0-IIa + IIc (P = 0.001) lesions, with sub-mucosal invasion on histology (P < 0.001), with presence of the "nonlifting sign" (P < 0.001), and related to the dimension of the lesions (P = 0.001). In the logistic regression analysis, the only independent predictor for surgical resection was the dimension of the lesions (P = 0.002). CONCLUSION: Before submitting patients to surgical resection for a benign DCRL, a second opinion by an experienced endoscopist is mandatory to avoid unnecessary surgery.

Role of stenting in gastrointestinal benign and malignant diseases.

Advances in stents design have led to a substantial increase in the use of stents for a variety of digestive diseases. Initially developed as a non-surgical treatment for palliation of esophageal cancer, the stents now have an emerging role in the management of malignant and benign conditions as well as in all segments of the gastrointestinal tract. In this review, relevant literature search and expert opinions have been used to evaluate the key-role of stenting in gastrointestinal benign and malignant diseases.

The role of lung metastasis resection in improving outcome of colorectal cancer patients: results from a large retrospective study.

BACKGROUND: The role of surgery for lung metastases (LM) secondary to colorectal cancer (CRC) remains controversial. The bulk of evidence is derived from single surgical series, hampering any definitive conclusions. The aim of this study was to compare the outcomes of CRC patients with LM submitted to surgery with those who were not. PATIENTS AND METHODS: Data from 409 patients with LM as the first evidence of advanced disease were extracted from a database of 1,411 patients. Patients were divided into three groups: G1, comprised of 155 patients with pulmonary and extrapulmonary metastases; G2, comprised of 104 patients with LM only and no surgery; G3, comprised of 50 patients with LM only and submitted to surgery. RESULTS: No difference in response rates emerged between G1 and G2. Median progression-free survival (PFS) times were: 10.3 months, 10.5 months, and 26.2 months for G1, G2, and G3, respectively. No difference in PFS times was observed between G1 and G2, whereas there was a statistically significant difference between G2 and G3. Median overall survival times were 24.2 months, 31.5 months, and 72.4 months, respectively. Survival times were longer in resected patients: 17 survived >5 years and three survived >10 years. In patients with LM only and no surgery, four survived for 5 years and none survived >10 years. CONCLUSIONS: Even though patients with resectable LM are more likely to be those with a better outcome, our study provides evidence suggesting an active role of surgery in improving survival outcomes in this patient subset.

Adjuvant treatment for elderly patients with colon cancer. An observational study.

BACKGROUND: Adjuvant 5-fluoruracil-based chemotherapy significantly reduces mortality in patients with stage II-III colon cancer, but is less prescribed with rising age. In this study we were interested in the pattern of adjuvant treatment and possible effects on survival among elderly patients. PATIENTS AND METHODS: From January to December 2004, 63 questionnaires on the management of stage II-III resected colon cancer patients aged over 70 years, collected from 10 Italian Centres, were retrospectively examined. Determinants of receipt of adjuvant chemotherapy and their relation to survival were considered. RESULTS: The proportion of elderly patients receiving adjuvant chemotherapy was 79.4%, distinct of age, gender, educational level and comorbidities. Grade 3-4 toxicities were the following: haematological in 4 (8.5.%) patients, mucositis in 4 (8.5%), diarrhoea in 2 (4.2%) and nausea in 1 (2.1%). The disease-free survival (DFS) and overall survival (OS) at two years were 79.9% and 95.6%, respectively. Due to the paucity of events, the impact of prognostic factors (patient's age and comorbidity, tumour stage and grade) on DFS and OS could not be assessed. CONCLUSION: An increasing proportion of elderly patients with colon cancer may be treated with a tolerability and OS similar to those observed in the younger population. Development of age-based guidelines and increased awareness of both physicians and patients through education is important to prevent undertreatment of those elderly patients who are eligible for chemotherapy.

Palliative treatment for elderly patients with colon cancer in ten Italian medical oncology units.

BACKGROUND: Palliative chemotherapy significantly reduces mortality in patients with stage IV colon cancer, but is less prescribed with rising age. In this paper, we highlight the pattern of palliative treatment and possible effects on survival among elderly patients. PATIENTS AND METHODS: From January to December 2004, 78 files on the management of stage IV colorectal cancer (CRC) patients over 70 years, collected from 10 Italian Centres, were retrospectively examined. Determinants of receipt of palliative chemotherapy and their relation to toxicity and survival were considered. RESULTS: The proportion of elderly patients receiving first-line palliative chemotherapy was 98.7% and it was evaluated according to age, gender, educational level and comorbidities; patients receiving second-line therapy comprised 47.4%, those receiving third-line therapy 14.1% and those treated with a fourth-line therapy totalled 2.6%. Forty-one percent of patients received best supportive care (BSC) alone. CONCLUSION: In Italy, a proportion of elderly patients with metastatic chemonaive CRC are usually treated with a tolerability and overall survival similar to those for the younger population. Among progressive patients after second-line therapy, 45.8% usually undergo third line therapy; the remaining 54.2% undergo BSC.

Colorectal cancer treatment in elderly patients: results of a retrospective analysis addressed to the chiefs of medical oncology units in Italy.

BACKGROUND: The aim of this retrospective analysis was to evaluate the differences of 1-year treatment and chemotherapy related-toxicity in elderly colorectal cancer (CRC) patients in different Italian medical oncology units. PATIENTS AND METHODS: An open questionnaire on the management of CRC patients over 70 years of age, from January to December 2004, was sent to Italian centres. One hundred and seventy-five files from 10 centres were analysed. Variables considered were age, gender, educational level, comorbidities and modality of therapy administration. RESULTS: In only a minority of units were there some staff specifically dedicated to the older patients in close cooperation with geriatricians and the Multidimensional Geriatric Assessment (MGA) was not routinely used (11.2%-16.8% of cases). Only 5.7% patients were routinely enrolled in a protocol. In total, 95 out of 175 (54.3%) of CRC underwent adjuvant chemotherapy and 80 out of 175 (45.7%) received palliative chemotherapy. Of the patients who underwent adjuvant chemotherapy, 75.6% immediately accepted postoperative treatment while 12.2% were initially dubious but subsequently agreed. Only 5.5 and 9.7% of these patients reported very bad or bad tolerability, respectively. At disease progression, 62.5% patients accepted chemotherapy instantly while 33.3% accepted subsequently. Only 1.3% cases reported very bad and 1.3% bad tolerability. CONCLUSION: In those units in which the problem of the elderly is actually recognised, CRC treatment is adequate, not influenced by age discrimination but inhomogeneous. In the future, standardizing treatment in different oncology units could prove to be beneficial to this population.