Introduction

Queen Elizabeth Hospital (QEH) Gateshead and County Durham and Darlington NHS Foundation Trust (CDDFT) have collaborated since 2018 on a Complex Rectal Lesion (CRL) Multidisciplinary Team Meeting (MDT). The aim is to offer optimal individualised treatment for each patient: conservative management for those who choose or who are more likely to do badly with interventional treatment; organ sparing local resection for all benign and T1 Cancers; and full bowel resection for T2 or greater cancers. Discussing uncertainty and risk with patients is challenging and the CRL MDT values the input of the specialist nurse assigned to each patient to assess fitness and to support patients through the decision-making process. Given the known cancer risk of complex polyps, patients opting for local resection are recommended en bloc resection either with trans-anal surgery or Endoscopic Submucosal Dissection (ESD). We reviewed the outcomes for all patients discussed over a 3-year period.

Aims & Methods

Retrospective case note review of 318 new consecutive CRL MDT patients identified between January 2020 and December 2022 with complex rectal polyps or presumed early rectal cancer. We included patients with either adenoma or adenocarcinoma at final histology and excluded rectal cancer that appeared advanced or deeply invasive endoscopically or on imaging, as these were discussed at the colorectal cancer MDT and local resection was not an option. 305 patients (110 QEH patients and 195 CDDFT) met the inclusion criteria.

Results

Median patient age was 69 years (18 – 91 years). 292 patients were diagnosed at endoscopy, 7 at CT scan, 5 at CT colonography, and 1 at MRI (prostate). Median time between diagnosis and treatment was 75.5 days (interquartile range 70 days). Optimal endoscopic and radiological assessment of rectal lesions is essential to risk stratify these lesions. Prior to first treatment modality the MDT recommended and arranged repeat radiological imaging in 31 patients (10%) and repeat endoscopy in 65 patients (21%). 33 patients (11%) preferred or were recommended conservative treatment. 85 patients (28%) had rectal cancers at final outcome. 15 patients were referred to oncology due to deeply invasive disease on imaging and positive cancer biopsy. The remaining cancer stage post intervention was 50 T1, 15 T2, and 5 T3. 231 patients (76%) who were offered interventional treatment had organ sparing local resection. Major resection was offered to only 19 patients (6%). 3/19 of these were benign adenomas, 8 T1 cancers and 8 T2 or greater cancer at final histology. Table 1 shows breakdown of treatment modality, rate of cancer and T stage at first procedure.

Conclusion

Introduction

Colorectal Cancer (CRC) is the third most common cancer worldwide. Most CRCs arise from precursor adenomatous or serrated polyps. Various Screening programs to early detect and remove precancerous lesions before progression to malignancy results in significant decrease of colorectal cancer incidence in developed countries (1). Guidelines recommend regular screening for adenomatous polyps and colorectal cancer for individuals above the age of 50 (1). However, in 2018 the American Cancer Society prompted substantial controversy by lowering their recommended age to begin from age 50 to age 45 (2). According to recent studies, starting screening at age 40 or 45 can be cost effective.
According to international agency for research in cancer publication 2022 colorectal cancer is ranked the second between the top 3 cancers related deaths in United Arab Emirates.

Aims & Methods

The aim of this study to estimate the incidence of precancerous adenoma in average risk patients between 40 and 45 years of age.

Results

In this cohort of 703 individuals aged 40 to 45 years undergoing screening colonoscopy, adenomas were identified in 17.5% (n = 123) of patients. The mean age was similar between patients with and without adenomas (42.72 ± 1.84 vs. 42.53 ± 1.78 years; P = 0.293). Male sex was significantly associated with adenoma detection (51% vs. 39%; P = 0.014). No significant differences were observed between groups regarding BMI, alcohol use, diabetes, or family history of colorectal cancer. Smoking was significantly more prevalent among patients with adenomas (28% vs. 15%; P < 0.001) and remained an independent predictor on multivariate analysis (odds ratio [OR] 1.862; 95% confidence interval [CI], 1.078–3.217; P = 0.026). Other variables, including age, sex, BMI, alcohol intake, diabetes, and family history, were not independently associated with adenoma presence. The number needed to scope (NNS) to detect one adenoma was estimated at 5.7.

Conclusion

In conclusion, suggesting a non-negligible burden of colorectal neoplasia in individuals younger than 45 years. Early screening strategies, particularly targeted at high-risk individuals, may be warranted. Further multicenter studies with larger sample sizes are needed to confirm these findings and inform guideline recommendations for screening initiation age.

References

1. Authors: Rebecca L. Siegel, MPH, Christopher Dennis Jakubowski, MD, Stacey A. Fedewa, PhD, Anjee Davis, MPPA, and Nilofer S. Azad, MD nazad2@jhmi.eduAUTHORS INFO & AFFILIATIONS

Introduction

The incidence of rectal neuroendocrine tumors (rNETs) has risen over the past two decades, largely due to the increased use of endoscopic procedures. These tumors are typically small, well-differentiated, and associated with a favorable prognosis. However, up to 82% may be misdiagnosed, leading to inadequate treatment. Accurate staging and appropriate management are essential for achieving long-term, progression-free survival (PFS) [1-2].

Aims & Methods

This study evaluates the clinical outcomes of patients with rNETs ≤1 cm who underwent local excision.
This retrospective, dual-center study included patients with rNETs measuring ≤10 mm who underwent local excision. The primary endpoint was PFS. Resection techniques were categorized into two groups based on guideline recommendations: recommended (m-EMR, ESD, EFTR, and TAMIS/TEMS) or not recommended (biopsy forceps and hot/cold snare polypectomy). Statistical analyses were performed using MedCalc software, with significance set at p < 0.05.

Results

Among 101 patients initially evaluated, 91 were included after excluding 10 due to incomplete endoscopic follow-up. The cohort consisted of 51 men (56%) and 40 women (44%), with a median age of 53 years. The median tumor size was 5 mm (range: 1–10 mm). Tumor grading was G1 in 93.4% of cases and G2 in 6.6%, with a median Ki-67 index of 2%.
Recommended resection techniques were used in 34 patients (37.4%), while 57 patients (62.6%) underwent non-recommended methods. Positive R1 resection margins were found in 27 cases (29.7%), and lymphovascular invasion was detected in two cases. Tumor progression (defined as recurrence, increase in residual tumor following R1 resection, or development of metastasis) occurred in 15 patients (16.5%), with only one case progressing to lymph node metastasis (median time to progression: 14 months [1–108 months]). Two deaths were recorded, neither related to the tumor. The median progression-free survival was 28 months (range: 1–170 months).
Univariate analysis showed that the use of recommended resection techniques significantly improved prognosis (HR 0.12, p = 0.04).

Conclusion

Although rNETs measuring ≤10 mm can recur, their risk of metastatic progression remains low, confirming their indolent behavior. However, early detection and the choice of appropriate resection techniques are essential for optimizing patient outcomes. Guideline-recommended resection methods are linked to a lower risk of progression and should be the preferred approach in clinical practice.

References

1. Rinke A, Ambrosini V, Dromain C, Garcia-Carbonero R, Haji A, Koumarianou A, van Dijkum EN, O'Toole D, Rindi G, Scoazec JY, Ramage J. European Neuroendocrine Tumor Society (ENETS) 2023 guidance paper for colorectal neuroendocrine tumours. J Neuroendocrinol. 2023 Jun;35(6):e13309.
2. Fine C, Roquin G, Terrebonne E, Lecomte T, Coriat R, Do Cao C, de Mestier L, Coffin E, Cadiot G, Nicolli P, Lepiliez V, Hautefeuille V, Ramos J, Girot P, Dominguez S, Céphise FV, Forestier J, Hervieu V, Pioche M, Walter T. Endoscopic management of 345 small rectal neuroendocrine tumours: A national study from the French group of endocrine tumours (GTE). United European Gastroenterol J. 2019 Oct;7(8):1102- 1112.

Introduction

Colorectal endoscopic submucosal dissection (ESD) is now widely performed and has become a standard procedure even at core hospitals throughout regional areas. As a minimally invasive treatment, it is frequently applied to elderly patients; however, it is crucial to determine whether such treatment can be achieved safely and effectively across an entire region, especially considering the presence of comorbidities or frailty and the risks associated with limited life expectancy.

Aims & Methods

This study aimed to evaluate the safety and efficacy of colorectal ESD for elderly patients in the Hiroshima region. We used a prospective registry of all colorectal ESD cases performed between August 2013 and December 2018 at 11 core hospitals in the Hiroshima area. Patients were categorized into an elderly group (≥75 years) and a non-elderly group (<75 years). Short- and long-term outcomes were compared between the two groups. Patients with advanced colorectal cancer, inflammatory bowel disease, familial adenomatous polyposis, or missing data were excluded.

Results

A total of 2,226 patients with 2,332 lesions were included: 684 patients with 716 lesions in the elderly group and 1,542 patients with 1,616 lesions in the non-elderly group. Baseline characteristics (elderly/non-elderly) were as follows: proportion of male patients was 56%/61% (P=0.024), median age was 79/66 years (P<0.001), and prevalence of comorbidities was 54.4%/35.7% (P<0.001), including cardiovascular disease (17%/7%), cerebrovascular disease (10%/5%), diabetes (17%/13%), pulmonary disease (9%/4%), hepatic disease (5%/3%), and other organ cancers (18%/12%). Antithrombotic drug use was 26%/11% (P<0.001). Regarding lesion characteristics, lesion location (right colon/left colon/rectum) was 52%/21%/28% vs. 53%/21%/27% (P=0.858), and median lesion size was 30 mm vs. 25 mm (P=0.066). Procedural outcomes were as follows: en bloc/piecemeal/interrupted resection rates were 96%/3%/1% vs. 96%/3%/1% (P=0.998), median procedure time was 65 min vs. 60 min (P=0.025), intraoperative perforation occurred in 3%/3% (P=0.594), delayed bleeding in 2%/2% (P=0.816), delayed perforation in 0.3%/0.4% (P=0.903), and emergency surgery in 0.6%/0.4% (P=0.523). Histopathological diagnoses were adenoma/pTis/pT1a/pT1b in 36%/46%/7%/11% vs. 38%/44%/7%/11% (P=0.830), with poorly differentiated histology of 0.1%/0.2% (P=0.652), lymphovascular invasion 6%/7% (P=0.543), tumor budding 3%/3% (P=0.765), positive vertical margin 8%/7% (P=0.161), and curative resection 81%/83% (P=0.484). Among non-curatively resected lesions, additional surgical resection was performed in 42% (56/134) vs. 64% (181/283) (P<0.001), and lymph node metastasis was detected in 10% (6/56) vs. 12% (22/181). During a median follow-up of 62 vs. 64 months, disease-specific death occurred in 3 vs. 2 patients, and death due to other causes occurred in 93 vs. 69 patients. The 5-year overall survival rate was 87.3% vs. 96.1% (P<0.001), and the 5-year disease-specific survival rate was 99.6% vs. 99.9% (P=0.114). Recurrence (local/distant) occurred in 1.3% (0.7%/0.6%) vs. 0.4% (0.2%/0.2%) (P=0.014), and the 5-year recurrence-free survival rate was 98.5% vs. 99.6% (P=0.010).

Conclusion

Although elderly patients had a higher baseline risk due to comorbidities and use of antithrombotic agents, colorectal ESD achieved favorable short- and long-term outcomes comparable to those in non-elderly patients. This study demonstrates that colorectal ESD was safely and effectively implemented throughout the Hiroshima region.

Introduction

Quantitative faecal immunochemical testing (FIT) is used in primary care to triage symptomatic patients for two-week-wait (TWW) colorectal cancer (CRC) referral, advised for use in all symptoms by specialty associations. FIT may effectively rule out CRC in FIT negative patients with rectal bleeding, with the potential to reduce endoscopy demand for patients with very low risk of CRC. Nottingham incorporated FIT (OC Sensor) into the TWW CRC diagnosis pathways for patients with rectal bleeding in November 2021. General Practitioners were advised to complete TWW referral for FIT ≥10 µgHb/g faeces (≥4 in the presence of anaemia or thrombocytosis).

Aims & Methods

Evaluate the demographics, investigations and early outcomes of the patients completing a FIT for rectal bleeding and compare to a reference group of TWW patients with rectal bleeding prior to the implementation of FIT.
Patients with rectal bleeding undertaking FIT after its introduction in this pathway (November 2021 to July 2022) had data collected in the Trust Enterprise Data Warehouse, allowing the formation of aggregate data (FIT group). Demographic, endoscopy, and cancer diagnosis was recorded with linkage to trust endoscopy and histology databases. A database of patients with rectal bleeding referred on a TWW pathway prior to the introduction of FIT (November 2017 to August 2019) was used as a comparison (pre-FIT group). In the pre-FIT group, investigation/outcome data was entered directly into the database by the nursing team managing referrals.

Results

2490 patients undertook a FIT for rectal bleeding after its introduction into the pathway, with 1497 patients in the reference pre-FIT group. There were more females in the FIT group than pre-FIT group (52.6% vs 48.9% respectively). The median age was lower in the FIT group (58 years vs 63.2 years). 75% of patients with rectal bleeding undertaking FIT had a negative (<10 µgHb/g faeces) FIT, 4% a value 10-19.9 µgHb/g faeces, 8% 20-99.9 µgHb/g faeces and 12.4% ≥100 µgHb/g faeces.
65.6% of patients with a FIT ≥ 10 µgHb/g faeces underwent endoscopy, compared to 81.2% in the pre-FIT group. The proportion of patients having endoscopy increased with rising FIT result (50% at a result 10-19.9µgHb/g faeces, 74.2% ≥100 µgHb/g faeces). 13.3% of patients with a FIT <10 µgHb/g faeces underwent endoscopy.
24 (3.9%) of patients with a FIT ≥10 µgHb/g faeces had histological diagnosis of CRC. There were no diagnoses of CRC in FIT <10 µgHb/g faeces. 10 extra-colonic cancers were diagnosed in the FIT group (0.4%), all FIT <10 µgHb/g faeces. 93 (6.2%) of the pre-FIT group had a histological diagnosis of CRC, 9 (0.6%) had a diagnosis of extra-colonic cancer.

Conclusion

FIT’s role in rectal bleeding remains unclear. In the limited follow-up of this study FIT appears to rule out CRC – 75% of patients returned a result <10 µgHb/g faeces and no CRC was found in these patients. However, CRC detection rates were almost 60% higher pre-FIT than in the FIT positive group; this may be explained by FIT being used for lower risk patients or the limited follow-up. Even in rectal bleeding a negative FIT may signpost towards extracolonic cancer, all found in FIT <10, suggesting appropriate investigations are required for these patients with low risk of CRC. Longer-term follow-up is required to assess whether any CRCs have been missed in “FIT-negative” patients to gauge the effectiveness of FIT for rectal bleeding and impact on endoscopy demand.