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BACKGROUND AND AIMS: Granular mixed laterally spreading tumors (GM-LSTs) have an intermediate level of risk for submucosal invasive cancer (SMICs) without clear signs of invasion (covert); the optimal resection method is uncertain. We aimed to determine the risk of covert SMIC in GM-LSTs based on clinical and endoscopic factors. METHODS: We collected data from 693 patients (50.6% male; median age, 69 years) with colorectal GM-LSTs, without signs of invasion, who underwent endoscopic resection (74.2%) or endoscopic submucosal dissection (25.2%) at 7 centers in Italy from 2016 through 2019. We performed multivariate and univariate analyses to identify demographic and endoscopic factors associated with risk of SMIC. We developed a multivariate model to calculate the number needed to treat (NNT) to detect 1 SMIC. RESULTS: Based on pathology analysis, 66 patients (9.5%) had covert SMIC. In multivariate analyses, increased risk of covert SMIC were independently associated with increasing lesion size (odds ratio per mm increase, 1.02, 95% CI, 1.01-1.03; P = .003) and rectal location (odds ratio, 3.08; 95% CI, 1.62-5.83; P = .004). A logistic regression model based on lesion size (with a cutoff of 40 mm) and rectal location identified patients with covert SMIC with 47.0% sensitivity, 82.6% specificity, and an area under the curve of 0.69. The NNT to identify 1 patient with a nonrectal SMIC smaller than 4 cm was 20; the NNT to identify 1 patient with a rectal SMIC of 4 cm or more was 5. CONCLUSIONS: In an analysis of data from 693 patients, we found the risk of covert SMIC in patients with GM-LSTs to be approximately 10%. GM-LSTs of 4 cm or more and a rectal location are high risk and should be treated by en-bloc resection. ClinicalTrials.gov, Number: NCT03836131.
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Neoplasias Colorrectales , Resección Endoscópica de la Mucosa , Anciano , Colonoscopía , Neoplasias Colorrectales/epidemiología , Endoscopía , Femenino , Humanos , Mucosa Intestinal , Masculino , Recto , Estudios RetrospectivosRESUMEN
BACKGROUND AND AIMS: Clinical management after complete endoscopic resection of pT1 colorectal cancers (CRCs) is still under debate. Follow-up data are heterogeneous and poorly reported, resulting in variable clinical management. Our aim was to meta-analyze recurrence and cancer-specific mortality (CSM) occurring after endoscopic resection of low- and high-risk pT1 CRCs undergoing conservative (nonsurgical) management. METHODS: Literature was systematically searched until February 2019 for studies describing patients with pT1 CRCs, histologically classifiable as low or high risk, endoscopically resected without complementary surgery and with ≥12 months of follow-up. Pooled cumulative incidence (and incidence rate when specific follow-up intervals were available) of recurrence and CSM were calculated separately for low- and high-risk pT1 CRCs. Quality, publication bias, and heterogeneity were explored. RESULTS: Pooled cumulative incidences of recurrence and CSM among high-risk lesions (5 studies, 571 patients) were, respectively, 9.5% (95% confidence interval [CI], 6.7%-13.3%; I2 = 38.4%) and 3.8% (95% CI, 2.4%-5.8%; I2 = 0%), whereas among low-risk lesions (7 studies, 650 patients) they were, respectively, 1.2% (95% CI, .6%-2.5%; I2 = 0%) and .6% (95% CI, .2%-1.7%; I2 = 0%). Pooled incidence rates of recurrence and CSM among high-risk lesions (3 cohorts, 237 patients) were, respectively, 11 (95% CI, 2-20; I2 = 43.3%) and 4 (95% CI, 1-7; I2 = 0%) per 1000 patient-years, whereas among low-risk lesions (3 cohorts, 229 patients) they were 3 (95% CI, 0-6; I2 = 0%) and 2 (95% CI, 0-4; I2 = 0%) per 1000 patient-years, respectively. No publication bias or significant heterogeneity was found. CONCLUSIONS: Pooled estimates of adverse events after endoscopic resection of pT1 CRCs suggest a conservative approach for low-risk lesions. In high-risk lesions, increased surgical risk might justify a conservative management, whereas fitness for surgery makes surgical completion appropriate.
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Adenocarcinoma/cirugía , Colonoscopía/métodos , Neoplasias Colorrectales/cirugía , Recurrencia Local de Neoplasia/epidemiología , Adenocarcinoma/mortalidad , Adenocarcinoma/patología , Neoplasias Colorrectales/mortalidad , Neoplasias Colorrectales/patología , Humanos , Incidencia , Márgenes de Escisión , Invasividad Neoplásica , Estadificación de NeoplasiasRESUMEN
BACKGROUND: Random biopsies are recommended to identify individuals at risk of gastric adenocarcinoma. Cumulative evidence suggests that narrow-band imaging (NBI) can be used to grade gastric intestinal metaplasia (GIM). We aimed to externally validate a classification of endoscopic grading of gastric intestinal metaplasia (EGGIM). METHODS: Consecutive patients in two centers were submitted to high resolution white-light gastroscopy followed by NBI to estimate EGGIM - a score (0â-â10) resulting from the sum of endoscopic assessments of GIM, scored as 0, 1, or 2 for no GIM, ≤â30â%, or >â30â% of the mucosa, respectively, in five areas (lesser and greater curvature of both antrum and corpus, and incisura). If GIM was endoscopically suspected, targeted biopsies were performed; if GIM was not noticeable, random biopsies were performed according to the Sydney system to estimate the operative link on gastric intestinal metaplasia (OLGIM; the gold standard). RESULTS: 250 patients (62â% female; median age 55 years) were included. GIM was staged as OLGIM 0, I, II, III, IV in 136 (54â%), 15 (6â%), 52 (21â%), 34 (14â%), and 13 (5â%) patients, respectively. All patients with GIM except three were identifiable with targeted biopsies. For the diagnosis of OLGIM III/IV, the area under the ROC curve was 0.96 (95â% confidence interval [CI] 0.93â-â0.98) and by using the cutoff >â4, sensitivity, specificity, and positive likelihood ratio were 89â%, 95â%, and 16.5, respectively; results were similar (91â%, 95â%, and 18.1) when excluding patients with foveolar hyperplasia. CONCLUSIONS: For the first time, an endoscopic approach was externally validated to determine the risk of gastric cancer without the need for biopsies. This can be used to simplify and individualize the management of patients with gastric precancerous conditions.
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Endoscopía Gastrointestinal , Enfermedades Intestinales/patología , Lesiones Precancerosas/patología , Adenocarcinoma/patología , Anciano , Biopsia , Femenino , Humanos , Neoplasias Intestinales/patología , Italia , Masculino , Metaplasia , Persona de Mediana Edad , Portugal , Estudios Prospectivos , Medición de RiesgoRESUMEN
In patients with colonic diverticulosis, the prevalence of segmental colitis associated with diverticulosis (SCAD) is debated. The aim of this study was to assess the prevalence of SCAD in consecutive patients with diverticulosis in a single tertiary center. Over a six-month period, consecutive adult patients with colonic diverticulosis were included. Patients with endoscopic signs of interdiverticular mucosal inflammation (erythema, friability, and ulcerations) were considered suspected SCAD and underwent multiple biopsy samplings to confirm diagnosis. Clinical features were collected from diverticulosis and suspected SCAD patients. In total, 367 (26.5%) of 1383 patients who underwent colonoscopy presented diverticulosis. Among diverticulosis patients, 4.3% (n = 16) presented macroscopic signs of interdiverticular mucosal inflammation and were identified as suspected SCAD. Compared to that of patients with diverticulosis, the age of suspected SCAD patients was significantly lower (60 ± 12.9 years (41.0-86.0) vs. 70 ± 10.6 years (38.0-93.0)) (p = 0.047). Among patients with suspected SCAD, one patient received a new diagnosis of Crohn's disease, one had spirochetosis infection, and one presented drug-induced colitis. The remaining patients with suspected SCAD (n = 13) were not confirmed by histology. This observational study suggests that SCAD diagnosis is a challenge in clinical practice due to the heterogeneity of endoscopic findings and lack of stated histological criteria.
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We describe a case of severe acute hepatitis B developing in a patient with Hodgkin's lymphoma after chemotherapy and before radiotherapy. Entecavir was administered leading to virological and biochemical response, which allowed the scheduled treatment to be completed. The patient had complete haematological remission and made a complete recovery from hepatitis B.
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Antivirales/administración & dosificación , Guanina/análogos & derivados , Hepatitis B/diagnóstico , Hepatitis B/tratamiento farmacológico , Enfermedad de Hodgkin/complicaciones , Adulto , Alanina Transaminasa/sangre , Antineoplásicos/administración & dosificación , Bilirrubina/sangre , ADN Viral/sangre , Quimioterapia/métodos , Femenino , Guanina/administración & dosificación , Enfermedad de Hodgkin/tratamiento farmacológico , Humanos , Resultado del TratamientoRESUMEN
OBJECTIVES: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is highly contagious; gastrointestinal endoscopies are considered risky procedures for the endoscopy staff. Data on the SARS-CoV-2-exposure/infection rate of gastrointestinal endoscopy staff is scarce. This study aimed to assess the SARS-CoV-2-exposure/infection rate among gastrointestinal endoscopists/nurses performing gastrointestinal endoscopies before and after the adoption of specific prevention measures. PATIENTS AND METHODS: Cross-sectional study in a teaching hospital (Rome, Central Italy) on retrospective data (9 March-15 April 2020) of consecutive gastrointestinal endoscopies, characteristics of procedures, patients and endoscopy staff, SARS-CoV-2-exposure/positivity of patients and staff before and after adoption of prevention measures. Exposed staff tested for SARS-CoV-2 by nasopharyngeal swabs(RNA-PCR) and serology. RESULTS: A total of 130 gastrointestinal endoscopies were performed in 130 patients (age 66 ± 14 years, 51% women, 51% inpatients, 56.9% lower). A total of 12 (9.2%) patients were SARS-CoV-2-positive and 14(10.8%) had a high risk of potential infection. Of the endoscopy staff (n = 16, 5 endoscopists, 8 nurses and 3 residents), 14 (87.5%) were exposed to SARS-CoV-2-infected and 16 (100%) to potentially infected patients. 3/5 and 5/5 endoscopists were exposed to actual and potential, 1/3 and 3/3 residents to actual and potential and 8/8 nurses to actual and potential infection, respectively. None of the staff was found to be infected with SARS-CoV-2. None experienced fever or any other suspicious symptoms of coronavirus disease 2019. Before the adoption of prevention measures, more endoscopists/nurses were in the endoscopy room than after (3.5 ± 0.6 vs. 2.1 ± 0.3, P < 0.0001). CONCLUSIONS: Despite supposed high infection risk, gastrointestinal endoscopies may be safe for the endoscopy staff during the SARS-CoV-2 pandemic.
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COVID-19 , Anciano , Anciano de 80 o más Años , Estudios Transversales , Endoscopía Gastrointestinal , Femenino , Humanos , Italia/epidemiología , Masculino , Persona de Mediana Edad , Pandemias , Estudios Retrospectivos , SARS-CoV-2RESUMEN
BACKGROUND: Although evidence suggests frequent gastrointestinal (GI) involvement during coronavirus disease 2019 (COVID-19), endoscopic findings are scarcely reported. AIMS: We aimed at registering endoscopic abnormalities and potentially associated risk factors among patients with COVID-19. METHODS: All consecutive patients with COVID-19 undergoing endoscopy in 16 institutions from high-prevalence regions were enrolled. Mann-Whitney U, χ2 or Fisher's exact test were used to compare patients with major abnormalities to those with negative procedures, and multivariate logistic regression to identify independent predictors. RESULTS: Between February and May 2020, during the first pandemic outbreak with severely restricted endoscopy activity, 114 endoscopies on 106 patients with COVID-19 were performed in 16 institutions (men=70.8%, median age=68 (58-74); 33% admitted in intensive care unit; 44.4% reporting GI symptoms). 66.7% endoscopies were urgent, mainly for overt GI bleeding. 52 (45.6%) patients had major abnormalities, whereas 13 bled from previous conditions. The most prevalent upper GI abnormalities were ulcers (25.3%), erosive/ulcerative gastro-duodenopathy (16.1%) and petechial/haemorrhagic gastropathy (9.2%). Among lower GI endoscopies, 33.3% showed an ischaemic-like colitis.Receiver operating curve analysis identified D-dimers >1850 ng/mL as predicting major abnormalities. Only D-dimers >1850 ng/mL (OR=12.12 (1.69-86.87)) and presence of GI symptoms (OR=6.17 (1.13-33.67)) were independently associated with major abnormalities at multivariate analysis. CONCLUSION: In this highly selected cohort of hospitalised patients with COVID-19 requiring endoscopy, almost half showed acute mucosal injuries and more than one-third of lower GI endoscopies had features of ischaemic colitis. Among the hospitalisation-related and patient-related variables evaluated in this study, D-dimers above 1850 ng/mL was the most useful at predicting major mucosal abnormalities at endoscopy. TRIAL REGISTRATION NUMBER: ClinicalTrial.gov (ID: NCT04318366).
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COVID-19/patología , Endoscopía Gastrointestinal , Mucosa Gástrica/patología , Anciano , COVID-19/complicaciones , Colitis Isquémica/etiología , Colitis Isquémica/patología , Estudios Transversales , Duodeno/patología , Femenino , Hemorragia Gastrointestinal/etiología , Hemorragia Gastrointestinal/patología , Humanos , Masculino , Persona de Mediana Edad , Pandemias , Estudios Prospectivos , Factores de Riesgo , SARS-CoV-2 , Úlcera Gástrica/etiología , Úlcera Gástrica/patologíaRESUMEN
BACKGROUND: Use of herbal remedies (HR) has increased in the general population, particularly among patients with chronic diseases. Marketing of HR is usually regulated by imperfect standards, and the reporting of HR-related adverse reactions has increased. Studies assessing prevalence of HR use among patients with liver/biliary tract disorders are limited and no data are available in Italy. Aims of this study were to assess the prevalence of HR use, the clinical and demographic variables of HR users, and to evaluate their safety perception about HR. STUDY: From October 1, 2007 to April 30, 2008, 231 consecutive patients attending the Liver Disease Unit clinic at Sant'Andrea Hospital, II Faculty of Medicine "La Sapienza" Rome, were interviewed using an ad hoc developed questionnaire. The questionnaire addressed the following items: demographic and clinical characteristics, use of conventional therapy, use of HR and safety perception. Data were expressed as mean (+/-SD) or number/total, and evaluated by student t and chi2 tests; univariate analysis and multivariate logistic regression (MLR) were conducted. RESULTS: Prevalence of HR use was 35.5%. HR use was more common among women (P=0.01), and in patients attending sports activity (P=0.03). 72% of patients using HR had never considered potentially harmful HR-side effects or interactions. Sixty-seven percent used HR in addition to conventional therapy. CONCLUSIONS: More than a third of patients attending Liver/Biliary Disorders Clinic uses HR. Misconceptions about HR safety is common.
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Enfermedades de las Vías Biliares/tratamiento farmacológico , Fármacos Gastrointestinales/uso terapéutico , Hepatopatías/tratamiento farmacológico , Preparaciones de Plantas/uso terapéutico , Adulto , Anciano , Distribución de Chi-Cuadrado , Femenino , Fármacos Gastrointestinales/efectos adversos , Encuestas de Atención de la Salud , Conocimientos, Actitudes y Práctica en Salud , Humanos , Italia , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Servicio Ambulatorio en Hospital , Percepción , Preparaciones de Plantas/efectos adversos , Medición de Riesgo , Encuestas y Cuestionarios , Malentendido Terapéutico , Resultado del TratamientoRESUMEN
INTRODUCTION: Gastric polypoid lesions (GPL) are endoscopic findings whose histological nature is difficult to determine with white-light endoscopy. Hyperplastic polyps (HP), type-1 gastric carcinoids (T1-GC) and adenomas are the most frequent GPL needing different management. Narrow-band imaging (NBI) has high accuracy for gastric malignant lesions but few studies assessed whether GPL display specific NBI characteristics. We aimed to investigate the endoscopic NBI appearances of GPL. MATERIALS AND METHODS: During gastroscopies, images of GPL were recorded, and lesions were removed for histological evaluation. Two endoscopists blindly reviewed the digital images and registered the endoscopic NBI appearances on a specific check-list. GPL were categorized in HP, adenomas and T1-GC using histology as gold standard. RESULTS: Overall 52 GPL, observed in 40 patients [F55%; age 63 (36-85) years], were included: 29 (55.8%) HP; 18 (34.6%) T1-GC; 5 (9.6%) adenomas. The median size was seven (2-35) mm. A regular circular mucosal pattern was more frequently observed in HP and T1-GC compared to adenomas (P < 0.001). T1-GC showed a central erosion in 77.8% (P < 0.001 versus HP) with a clear demarcation line in 33.3%. Adenomas had tubule-villous mucosal pattern in 80% (P = 0.01 versus other lesions). CONCLUSION: NBI analysis of the mucosal pattern seems to be effective to endoscopically discriminate between adenomas and HP while the main characteristic of T1-GC seems to be the presence of a central erosion, sometimes with demarcation line. The endoscopic NBI characterization of GPL may contribute to optimize the management of these lesions.
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Imagen de Banda Estrecha , Pólipos , Gastropatías , Adenoma/diagnóstico , Adenoma/diagnóstico por imagen , Gastroscopía , Humanos , Hiperplasia , Persona de Mediana Edad , Imagen de Banda Estrecha/métodos , Proyectos Piloto , Pólipos/diagnóstico , Pólipos/diagnóstico por imagen , Estudios Prospectivos , Gastropatías/diagnóstico , Gastropatías/diagnóstico por imagen , Neoplasias Gástricas/diagnóstico , Neoplasias Gástricas/diagnóstico por imagenRESUMEN
[This corrects the article DOI: 10.1055/a-1220-6261.].
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Background and study aims Outcomes of endoscopic assessment and management of large colorectal (CR) non-pedunculated lesions (LNPLs) are still under evaluation, especially in Western settings. We analyzed the clinical impact of changes in LNPL management over the last decade in a European center. Patients and methods All consecutive LNPLsâ≥â20âmm endoscopically assessed (2008-2019) were retrospectively included. Lesion, patient, and resection characteristics were compared among clinically relevant subgroups. Multivariate logistic regression (for predictors of submucosal invasion [SMI] and recurrence), Kaplan-Meier curves and ROC curves (for temporal cut-offs in trends analyses) were used. Results A total of 395 LNPLs were included (30âmm [range 20-40]; SMIâ=â9.6â%; primary endoscopic resection [ER]â=â88.4â%). Pseudo-depression and JNET classification independently predicted SMI beyond single morphologies/location. After complete ER, involvement of ileocecal valve/dentate line, piece-meal resection and high-grade dysplasia independently predicted recurrence. Rates of 5-year recurrence-free, surgery-free and cancer-free survival were 77.5â%, 98.6â% and 100â%, respectively, with 93.8â% recurrences endoscopically managed and no death attributable to ER or CR cancer (versus 3.4â% primary surgery mortality). ROC curves identified the period ≥â2015 (following Endoscopic Submucosal Dissection [ESD] introduction and education on pre-resective lesion assessment) as associated with improved lesions' characterization, increased en-bloc resection of SMI lesions (87.5â% vs 37.5â%; pâ=â0.0455), reduced primary surgery (7.5â% vs 16.7â%; pâ=â0.0072), surgical referral of benign lesions (5.1â% vs 14.8â%; pâ=â0.0019), and recurrences. Conclusions ESD introduction and educational interventions allowed ER of more complex lesions, offset by increased complementary surgery for complications or intrinsic histological risk. Nevertheless, overall, they have reduced surgery demand and increased appropriateness and safety of LNPL management in our center.
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Endoscopic submucosal dissection (ESD) allows removing neoplastic lesions on gastric mucosa, including early gastric cancer (EGC) and dysplasia. Data on ESD from Western countries are still scanty. We report results of ESD procedures performed in Italy. Data of consecutive patients who underwent ESD for gastric neoplastic removal were analyzed. The en bloc resection rate and the R0 resection rates for all neoplastic lesions were calculated, as well as the curative rate (i.e., no need for surgical treatment) for EGC. The incidence of complications, the one-month mortality, and the recurrence rate at one-year follow-up were computed. A total of 296 patients with 299 gastric lesions (80 EGC) were treated. The en bloc resection was successful for 292 (97.6%) and the R0 was achieved in 266 (89%) out of all lesions. In the EGC group, the ESD was eventually curative in 72.5% (58/80) following procedure. A complication occurred in 30 (10.1%) patients. Endoscopic treatment was successful in all 3 perforations, whereas it failed in 2 out of 27 bleeding patients who were treated with radiological embolization (1 case) or surgery (1 case). No procedure-related deaths at one-month follow-up were observed. Lesion recurrence occurred in 16 (6.2%) patients (6 EGC and 10 dysplasia). In conclusion, the rate of both en bloc and R0 gastric lesions removal was very high in Italy. However, the curative rate for EGC needs to be improved. Complications were acceptably low and amenable at endoscopy.
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BACKGROUND AND AIMS: Most of the evidence supporting endoscopic submucosal dissection (ESD) comes from Asia. European data are primarily reported by specialized referral centers and thus may not be representative of common European ESD practice. The aim of this study is to understand the current state of ESD practice across Italian endoscopy centers. METHODS: All Italian endoscopists who were known to perform ESD were invited to complete a structured questionnaire including: operator features and competencies, ESD training details and clinical outcomes over a 2-year period. RESULTS: Twenty-nine operators from 23 centers (69% response rate) completed the questionnaire: 18 (62%) were <50 years old; 7 (24%) were female; 16 (70%) were located in Northern Italy. Overall ESD volume was <40 cases in 9 (31%) operators, 40-80 in 8 (27.5%), 80-150 in 4 (13.8%) and >150 in 8 (27.5%). Colorectal ESD was predominant for operators with an experience >80 cases. En-bloc resection rates ranged from 77.2 to 97.2% depending on the anatomic location with an R0 resection rate range of 75.3-93.6%. ESD perforation rates in the colon and rectum were significantly lower when experience was >150 compared to 80-150 cases (pâ¯<â¯0.0001 and pâ¯=â¯0.006 for colon and rectum, respectively). CONCLUSION: ESD in Italy is performed by a significant number of operators. Overall, Italian endoscopists performing ESD have achieved a good competence level. However, there is much variability in training protocols, initial supervision of procedures, practice settings, case mix and procedural volume/year that are likely responsible for some of the suboptimal resectional outcomes and increased perforation risk, mainly in the colon. Standardized training programs, practice parameters and auditing of outcomes are required.
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Competencia Clínica , Colonoscopía/métodos , Disección/métodos , Mucosa Gástrica/cirugía , Gastroscopía/métodos , Mucosa Intestinal/cirugía , Anciano , Colon/cirugía , Colonoscopía/efectos adversos , Colonoscopía/educación , Disección/efectos adversos , Disección/educación , Educación de Postgrado en Medicina , Femenino , Humanos , Italia , Curva de Aprendizaje , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/prevención & control , Recto/cirugía , Estudios Retrospectivos , Encuestas y Cuestionarios , Resultado del TratamientoRESUMEN
We retrospectively collected a series of 82 endoscopically removed early colorectal cancers. Histological specimens were revised by two gastrointestinal pathologists, performing a re-evaluation of all risk factors for lymph node metastasis. The comparison between second opinion and first pathological report revealed that lymphovascular invasion and tumor grading showed a lower level of concordance than other parameters. Our results demonstrated that second opinion modified risk assessment in about 10% of cases. It was mainly due to a lack in reporting of some parameters at the first diagnosis and a different evaluation in second opinion for updated guidelines. Considering the subgroup of patients with modified risk assessment, clinical data revealed that tumors, re-classified as low risk, did not develop lymph node metastasis that, conversely, occurred in patients identified as high risk by second opinion. In conclusion, second opinion significantly alters risk perception of endoscopically removed early colorectal carcinomas representing a valuable tool for their appropriate clinical management.
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Carcinoma/diagnóstico , Neoplasias Colorrectales/diagnóstico , Anciano , Anciano de 80 o más Años , Carcinoma/patología , Neoplasias Colorrectales/patología , Endoscopía , Femenino , Humanos , Metástasis Linfática , Masculino , Persona de Mediana Edad , Clasificación del Tumor , Patólogos , Pronóstico , Derivación y Consulta , Estudios Retrospectivos , Medición de Riesgo , Factores de RiesgoRESUMEN
Background Implementation of colorectal cancer (CRC) screening programs increases endoscopic resection of polyps with early invasive CRC (pT1). Risk of lymph node metastasis often leads to additional surgery, but despite guidelines, correct management remains unclear. Our aim was to assess the factors affecting the decision-making process in endoscopically resected pT1-CRCs in an academic center. Methods We retrospectively reviewed patients undergoing endoscopic resection of pT1 CRC from 2006 to 2016. Clinical, endoscopic, surgical treatment, and follow-up data were collected and analyzed. Lesions were categorized according to endoscopic/histological risk-factors into low and high risk groups. Comorbidities were classified according to the Charlson comorbidity index (CCI). Surgical referral for each group was computed, and dissociation from current European CRC screening guidelines recorded. Multivariate analysis for factors affecting the post-endoscopic surgery referral was performed. Results Seventy-two patients with endoscopically resected pT1-CRC were included. Overall, 20 (27.7â%) and 52 (72.3â%) were classified as low and high risk, respectively. In the low risk group, 11 (55â%) were referred to surgery, representing over-treatment compared with current guidelines. In the high risk group, nonsurgical endoscopic surveillance was performed in 20 (38.5â%) cases, representing potential under-treatment. After a median follow-up of 30 (6â-â130) months, no patients developed tumor recurrence. At multivariate analysis, age (OR 1.21, 95â%CI 1.02â-â1.42; P =â0.02) and CCI (OR 1.67, 95â%CI 1.12â-â3.14; P â=â0.04) were independent predictors for subsequent surgery. Conclusions A substantial rate of inappropriate post-endoscopic treatment of pT1-CRC was observed when compared with current guidelines. This was apparently related to an overestimation of patient-related factors rather than endoscopically or histologically related factors.
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Anticuerpos Monoclonales/uso terapéutico , Hepatitis B Crónica/complicaciones , Linfoma de Células B/tratamiento farmacológico , Anticuerpos Monoclonales/efectos adversos , Anticuerpos Monoclonales de Origen Murino , Antivirales/uso terapéutico , Hepatitis B Crónica/tratamiento farmacológico , Humanos , Inmunoterapia , RituximabRESUMEN
Recent-years technological innovation has achieved two important objectives: 1) to develop advanced diagnostic tools able to determine with a fair degree of accuracy the nature of a lesion by means of the simple endoscopic observation; 2) to improve the therapeutic approach to lesions, by extending the least-invasive endoscopic treatment also to lesions that in the past were referred to surgery. Advanced diagnostic methodologies have been achieved thanks to the introduction of high definition endoscopes and virtual chromo-endoscopy. Therapeutic innovation is represented by endoscopic sub-mucosal dissection (ESD) that enables the "en bloc" resection of the lesions, thus ensuring a more accurate histological evaluation of their level of infiltration and of the radicality of the resection. These diagnostic and therapeutic methodologies have been applied intensively in Barrett's esophagus, in the early gastric cancer and in the neoplastic lesions of colon-rectum. Concerning the screening of colon-rectum cancer, recent-years literature concentrated on defining the minimal necessary requirements to perform an effective and safe colonoscopy, the so-called "quality endoscopy", for which reference indicators and standards have been set.
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Endoscopía Gastrointestinal , Esófago de Barrett , Colonoscopía , Disección , Humanos , Neoplasias GástricasRESUMEN
OBJECTIVE: Narrow-band imaging (NBI) has been associated with high accuracy for the identification of gastric malignant lesions. This study aimed to investigate for the first time the endoscopic NBI appearances of type 1 gastric carcinoids in a consecutive series of patients with atrophic gastritis. METHODS: Seven consecutive patients (five women, median age 61 years) with atrophic gastritis and polypoid type 1 gastric carcinoids were included. After white-light examination, gastric antrum and body were examined by NBI for the examination of polyps and lesions. Digital images of polyps from recorded videos were extracted and reviewed for NBI features. RESULTS: Fifteen polypoid type 1 gastric microcarcinoids (median size 3 mm) were detected in the seven patients; four patients had synchronous lesions. Nine (60%) lesions showed a tubulovillous and six lesions (40%) showed an irregular mucosal pattern; a regular circular pattern was never observed. A light-blue crest was observed on six (40%) lesions. The vascular pattern was irregular in eight (53.3%) microcarcinoids. All six type 1 gastric carcinoids with an irregular mucosal pattern showed an irregular vascular pattern without light-blue crest. Of the nine carcinoids with a tubulovillous mucosal pattern, two had an irregular and seven had a regular vascular pattern. CONCLUSION: Polypoid type 1 gastric microcarcinoids always show an abnormal NBI mucosal surface pattern, but no specific features to distinguish them from other intraepithelial lesions such as intestinal metaplasia, adenomas, or low-grade and high-grade dysplasia are observed. Thus, target biopsies to diagnose the pathological nature of the lesion are advocated.
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Tumor Carcinoide/patología , Mucosa Gástrica/patología , Gastroscopía/métodos , Imagen de Banda Estrecha , Pólipos/patología , Derivación y Consulta , Neoplasias Gástricas/patología , Adulto , Anciano , Anciano de 80 o más Años , Tumor Carcinoide/etiología , Diagnóstico Diferencial , Femenino , Gastritis Atrófica/complicaciones , Gastritis Atrófica/patología , Humanos , Masculino , Persona de Mediana Edad , Clasificación del Tumor , Variaciones Dependientes del Observador , Pólipos/etiología , Valor Predictivo de las Pruebas , Reproducibilidad de los Resultados , Ciudad de Roma , Neoplasias Gástricas/etiología , Carga Tumoral , Grabación en VideoRESUMEN
BACKGROUND: Large colorectal superficial neoplastic lesions are challenging to remove. This study aimed to assess the outcomes of routine endoscopic resection of large (≥2 cm and <3 cm) and giant (≥3 cm) lesions. METHODS: From 4587 endoscopic resections, 265 (5.7%) large and giant lesions were removed in 249 patients. We retrospectively analyzed 125 patients (141 endoscopic mucosal resection, 73 large and 68 giant lesions) with a follow-up of 6-12 months. Rate of en bloc and piecemeal resection, recurrence and risk factors were analyzed. RESULTS: En bloc was performed in 92 cases (65.2%) and piecemeal resection in 49 (34.8%). A complete endoscopic resection was achieved in 139 cases (98.5%) with radical resection in 84/139 cases (60.4%). Argon plasma coagulation was applied in 18/141 lesions (12.8%). A recurrence occurred in 16/139 lesions (11.5%). The risk of recurrence at one year was significantly higher for giant than large lesions (p=0.03). The recurrence risk was higher in treated than in non-argon plasma coagulation treated lesions (p=0.01). CONCLUSIONS: endoscopic mucosal resection is a safe and effective routine treatment for large superficial neoplastic lesions. The risk factors for recurrence include giant size, non-protruding morphology, piecemeal technique and argon plasma coagulation.
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Pólipos del Colon/patología , Neoplasias Colorrectales/patología , Mucosa Intestinal/patología , Recurrencia Local de Neoplasia/epidemiología , Adulto , Anciano , Anciano de 80 o más Años , Coagulación con Plasma de Argón , Pólipos del Colon/cirugía , Colonoscopía , Neoplasias Colorrectales/cirugía , Femenino , Estudios de Seguimiento , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
Since gastro-entero-pancreatic endocrine tumors are rare and heterogeneous diseases, their prognosis and long-term survival are not well known. This study aimed at identifying prognostic factors and assessing long-term survival in gastro-entero-pancreatic endocrine tumors. A total of 156 patients enrolled. Prognostic factors were determined by univariate/multivariate analysis; survival rates were assessed by the Kaplan-Meier method. The tumors were non-functioning in 59.6% of patients, and originated from the pancreas in 42.9%. At diagnosis, 64.3% of patients had metastases. The tumors were well differentiated in 89.6% of patients. Ki67 was >2% in 39.6% of patients. Primary tumor size was >3 cm in 49.6% of cases studied. For the univariate analysis, the negative prognostic factors were: pancreatic origin (rate ratio 4.64, P = 0.0002), poorly differentiated tumor (rate ratio 7.70, P = 0.0001), primary tumor size >3 cm (rate ratio 4.26, P = 0.0009), presence of distant metastases (liver: rate ratio 5.88, P = 0.01; distant extra-hepatic: rate ratio 13.41, P = 0.0008). The pancreatic site, the poor degree of differentiation and the distant metastases were confirmed as negative prognostic factors at multivariate analysis. Overall 5-year survival rate was 77.5%. Survival rates differed according to: primary tumor site (62% for pancreatic vs 89.9% for gastrointestinal tract, P = 0.0001) and size (65.7% for >3 cm vs 88.8% for < or = 3 cm, P = 0.0003), degree of differentiation (22% for poor vs 86.8% for good, P < 0.0001), Ki67 (53.5% for > 2% vs 90.1% for < or = 2%, P = 0.003), metastases (96.1, 77, 73.3 and 50.1% for absent, local, liver and distant extra-hepatic metastases respectively), age at diagnosis (85.3% for < or = 50 years vs 70.3% for > 50 years, P = 0.03). Although 64.3% of gastro-entero-pancreatic endocrine tumors present metastases at diagnosis, the 5-year survival rate is 77.5%. Pancreatic site, a poor degree of tumor cell differentiation and distant extra-hepatic metastases are the major negative prognostic factors.