Clinical Case Summary

Esophageal papillomas are benign lesions of unknown cause. some evidence suggests that it could be secondary to chronic inflammatory process (1,2) and other evidence suggests that human papilloma virus has a role in the formation of papillomas (3). animal studies have shown that papillomas can be induced by caustic mucosal irritation with benzopyrene and nitrosamines (4). Here we present the case of a 25-year-old man who presented to the Gastroenterology Clinic with a one-month history of localized epigastric pain occurring after meals, accompanied by burping and abdominal bloating. He reported regular bowel movements of 2-3 times per. He denied any other gastrointestinal symptoms but mentioned a history of loose motions worsened by stress and associated with mucus. The patient denied taking any medication, and the examination was unremarkable. Laboratory tests, including anti-gliadin IgG antibodies, TTG IgA&IgG, CBC, ESR, CRP, and abdominal ultrasound and DEXA scan were normal.

Gastroscopy revealed patchy erythematous mucosa in the entire stomach with a few nonbleeding superficial duodenal ulcers and distal esophageal nodule which was not present on a previous endoscopy done back in 2022. Biopsies taken from the duodenal showed villous shortening and mild atrophy with crypt hyperplasia, intraepithelial lymphocytosis, and increased lymphocytic inflammation in the lamina propria, consistent with celiac disease, Esophageal biopsy revealed squamous cell papilloma and stomach biopsies showed H. pylori-associated mild-to-moderate chronic active gastritis. The patient received a levofloxacin-based H. pylori eradication regimen, scheduled him for follow-up endoscopy in one year and he was referred to the Infectious Diseases Clinic for evaluation, where human papillomavirus infection and human immunodeficiency virus were excluded. Our case highlights esophageal squamous cell papilloma since this entity is rare and there are no clear guidelines available for treatment.

References

1. Carr NJ, Monihan JM, Sobin LH. Squamous cell papilloma of the esophagus: a clinicopathologic and follow-up study of 25 cases. Am J Gastroenterol. 1994 Feb;89(2):245-8. PMID: 8304311.
2. Fernández-Rodríguez CM, Badia-Figuerola N, Ruiz del Arbol L, Fernández-Seara J, Dominguez F, Avilés-Ruiz JF. Squamous papilloma of the esophagus: report of six cases with long-term follow-up in four patients. Am J Gastroenterol. 1986 Nov;81(11):1059-62. PMID: 3776954
3. Nakamura T, Matsuyama M, Kishimoto H. Tumors of the esophagus and duodenum induced in mice by oral administration of N-ethyl-N'-nitro-N-nitrosoguanidine. J Natl Cancer Inst. 1974 Feb;52(2):519-22. doi: 10.1093/jnci/52.2.519. PMID: 4816007.
4. Dunham LJ, Sheets RH. Effects of esophageal constriction on benzo(alpha)pyrene carcinogenesis in hamster esophagus and forestomach. J Natl Cancer Inst. 1974 Sep;53(3):875-81. doi: 10.1093/jnci/53.3.875. PMID: 4413133.

Introduction

Basic science results suggest that abnormalities of the endocrine pancreas in cystic fibrosis (CF) occur earlier than hitherto estimated (1). All stages of the abnormal glucose tolerance (AGT) spectrum are associated with declining pulmonary function and increased mortality which could be reduced by early recognition and treatment (2-4). Despite, screening for AGT is recommended only from 10 years of age (yoa) according to the current guidelines (5,6). Accurate knowledge of the prevalence of AGT and its subtypes is essential to develop a better screening strategy, therefore we conducted a systematic review and meta-analysis in the topic.

Aims & Methods

Our systematic review and meta-analysis (PROSPERO number: CRD42021282516) was conducted on studies that reported data on the prevalence of AGT or its subtypes in CF populations. Literature search was conducted in MEDLINE (via PubMed), Embase and Cochrane Register of Controlled Trials (CENTRAL). General and superselected populations (e.g.: pancreas exocrine insufficient, ΔF508 homozygous) were separately analyzed. Pooled proportions, risk and odds ratios with 95% confidence intervals (CI) were calculated in at least three age subgroups (pediatric, adult, mixed/unknown). One-stage dose-response random effect meta-analysis was used to assess the effect of age on CF- related diabetes (CFRD).

Results

The quantitative analysis included 457 studies and data from 520,544 patients. More than one third of children with CF (chwCF) were affected by AGT (0.31 [95% CI 0.25-0.37]), even under 10 yoa 0.33 [95% CI 0.23-0.44], and half of the adults with CF (awCF) had AGT (0.51 [95% CI 0.45-0.57]). The prevalence of prediabetes remained unchanged (impaired glucose tolerance in chwCF: 0.14 [95% CI 0.10-0.18]) vs. awCF: 0.19 [95% CI 0.14-0.25]), while the proportion of CFRD increased by age (<5 yoa: 0.005 [95% CI 0.0001-0.15]; 5-10 yoa: 0.05 [95% CI 0.01-0.27]; 10-18 yoa: 0.11 [95% CI 0.08-0.14]; >18 yoa: 0.27 [95% CI 0.24-0.30]).

Conclusion

CF-related AGT is common under 10 years of age. Reconsideration of the current guidelines and better awareness are needed for screening and treating AGT in CF, especially under 10 yoa, to delay the disease progression and maintain a better life quality.

References

1. Olivier AK, Yi Y, Sun X, Sui H, Liang B, Hu S, et al. Abnormal endocrine pancreas function at birth in cystic fibrosis ferrets. J Clin Invest. 2012;122(10):3755-68.
2. Ode KL, Moran A. New insights into cystic fibrosis-related diabetes in children. Lancet Diabetes Endocrinol. 2013;1(1):52-8.
3. Lewis C, Blackman SM, Nelson A, Oberdorfer E, Wells D, Dunitz J, et al. Diabetes-related mortality in adults with cystic fibrosis. Role of genotype and sex. Am J Respir Crit Care Med. 2015;191(2):194-200.
4. Moran A, Pekow P, Grover P, Zorn M, Slovis B, Pilewski J, et al. Insulin therapy to improve BMI in cystic fibrosis-related diabetes without fasting hyperglycemia: results of the cystic fibrosis related diabetes therapy trial. Diabetes Care. 2009;32(10):1783-8.
5. Moran A, Brunzell C, Cohen RC, Katz M, Marshall BC, Onady G, et al. Clinical care guidelines for cystic fibrosis-related diabetes: a position statement of the American Diabetes Association and a clinical practice guideline of the Cystic Fibrosis Foundation, endorsed by the Pediatric Endocrine Society. Diabetes Care. 2010;33(12):2697-708.
6. Balfour-Lynn I. Clinical Guidelines: Care of Children with Cystic Fibrosis. UK: Royal Brompton and Harefield Hospital, NHS Trust Foundation; 2023.

Introduction

T1 colorectal cancer can be managed either by surgery or interventional endoscopy. High-risk features after endoscopic resection (G3, submucosal invasion >1000 µm, lympho-vascular invasion, tumour budding+, or R1 resection) increase the risk of lymphnode metastasis (10-15%), often requiring additional surgery. However, the benefits of surgery versus endoscopic resection alone remain unclear, particularly in elderly or frail patients.

Aims & Methods

The aim of the study is to assess recurrence rate and overall survival in patients underwent surgery, endoscopy or both. Secondary endpoints is to evaluate incidence of adverse events and length of hospital stay
All consecutive patients diagnosed with T1 colorectal cancer from 2018 to 2024 in our institution were enrolled in this retrospective study. We divided this cohort in 3 groups: endoscopic resection plus surgery (ER-S), upfront surgery (SR), or endoscopic resection alone (ER). Demographics data, mortality, cancer recurrence rate, disease free survival and AEs were recorded.

Results

One-hundred and thirty-three patients were enrolled in the study: 34 (72 years±10) in the SR group, 65 (65 years±11) in the ER-S group and 34 (77 years±11) in ER, respectively.
Lesions were similar (p-value 0.30) for dimension: 31±15 mm (ER) vs 23±12 mm (ER-S) vs 30±13 mm (ER) such as follow-up (23 vs 24 vs 21 months) for the three groups (p-value 0.428). Hospital stay after the procedure was significantly lower in the ER group (1 day median) vs SR (median 9 days;p-value 0.0001) and ER-S group (7 days median;p-value 0.003). Cumulative 30 days adverse events were higher in the SR group (62%; p-value 0.0001) and in the ER-S group (22%; p-value 0.001) compared to ER alone (12%). During the study period, no endoscopic/radiological recurrence occurred in the SR group whereas 1 patient in the ER-S group and 2 in the ER group showed recurrence non suitable for further treatments.
Five patients in SR group died after a median of 18 months (1 for early surgical complication); 2 died in the ER-S group after a median of 34 months and 3 died in the ER group after a median of 24 months (1 for rectal cancer progression) (p-value 0.365).
Overall survival was comparable among the three groups with no significant difference (p-value 0.718) with a median of 40 months (SR), 28 (ER-S) and 26 (ER) months.

Conclusion

Endoscopic resection alone appears to be a reasonable option for high-risk T1 CRC patients, especially those with increased surgical risk due to low rate of recurrence, low adverse events and a comparable overall survival in short-mid term.

References

1. Quénéhervé, L.; Pioche, M.; Jacques, J. Curative Criteria for Endoscopic Treatment of Colorectal Cancer. Best Pract. Res. Clin. Gastroenterol. 2024, 101883, doi:10.1016/j.bpg.2024.101883.
2. Chen, Y.; Jing, W.; Chen, M.; Wang, Z.; Wu, J.; Yang, J.; Yang, L.; Deng, K. Long-Term Outcomes of Local Resection versus Surgical Resection for High-Risk T1 Colorectal Cancer: A Systematic Review and Meta-Analysis. Gastrointest. Endosc. 2023, 97, 1016-1030.e14, doi:10.1016/j.gie.2023.02.027.
3. Spadaccini M, Bourke MJ, Maselli R, et al. Clinical outcome of non-curative endoscopic submucosal dissection for early colorectal cancer. Gut. Published online January 20, 2022. doi:10.1136/gutjnl-2020-323897
4. Corre, F.; Albouys, J.; Tran, V.-T.; Lepilliez, V.; Ratone, J.-P.; Coron, E.; Lambin, T.; Rahmi, G.; Karsenti, D.; Canard, J.-M.; et al. Impact of Surgery after Endoscopically Resected High-Risk T1 Colorectal Cancer: Results of an Emulated Target Trial. Gastrointest. Endosc. 2023, S0016-5107(23)02933-4, doi:10.1016/j.gie.2023.09.027.
5. UICC. TNM. Classification of malignant tumours. eighth ed. Wiley; 2016. p. 272

Disclosure

Giuseppe Grande is consultant for Olympus, Boston Scientific, ERBE, Fujifilm