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PubMed2006

[Expression of vascular permeability factor in human vocal cord polyps].

OBJECTIVE: This study aimed to analyse the expression of vascular permeability factor (VPF) in human vocal fold polyps. Meanwhile, we studied the pathogenesis of vocal cord polyp further. METHOD: The expression of VPF were detected with immunohistochemical staining in the 37 cases with vocal cord polyps and 11 healthy vocal folds tissues (SP method). Meanwhile,the positive results were contrasted. RESULT: The percent of positive expression of VPF was 51.35 in vocal cord polyps. This expression tended not to be increased greatly compared with the percent of positive expression of VPF (18.18%) in healthy vocal fold (P > 0.05). But,the percent of positive vascular counts of VPF in the vocal cord polyps (56.66 +/- 25.48) %was higher than that in the healthy vocal fold tissues (37.11 +/- 29.52)% (P < 0.05). In the vocal cord polyps , there was no significant difference in the expression of VPF between the male and female( P > 0.05). CONCLUSION: The VPF may play a key role in the formation of heavy edema of vocal cord polyps. The VPF may be involved in the formation and development of vocal cord polyps . If we can control the produce of VPF in the vocal cord polyps, we may find a new way to treat it.

Adult↗
PubMed2006

[Clinical usefulness of fecal occult blood test as a screening method for asymptomatic patients with colon polyps].

BACKGROUND/AIMS: Detection of asymptomatic benign colon polyp is increasing because colonoscopy is widely used as a screening and diagnostic method. Fecal occult blood test is usually performed for the selection of patients requiring colonoscopy as well as mass screening for colon cancer. The aim of this study was to investigate the usefulness of fecal occult blood test performed prior to colonoscopy as a screening method of benign colon polyps. METHODS: Clinical characteristics of patients with polyps were evaluated according to the fecal occult blood test results in patients who underwent one-day fecal occult blood test and colonoscopic polypectomies from May 2003 to October 2004, retrospectively. RESULTS: A total of 942 colonoscopic polypectomies in 288 patients were evaluated. Fecal occult blood tests were positive only in 32 patients (11.1%). In univariate analysis, there was a significant difference in polyp size (p=0.02) and location (p=0.03) according to the presence of positive fecal occult blood tests. In addition, age of the patient (p=0.046), polyp size (mean, p=0.04; largest, p<0.01) and the number of polyps (p=0.045) were significantly different. However, in multivariate analysis, only polyp size larger than 20 mm was significantly related with positive fecal occult blood test with estimated odds ratio of 4.71. CONCLUSIONS: Fecal occult blood test has limitations as a screening test in asymptomatic patients with colon polyps, except for colon polyps larger than 20 mm in size.

Colonic Neoplasms↗
PubMed2006

[Rates and histological characteristics of rectal polyps in childhood].

AIM OF STUDY: To determine a single centre incidence, rate of early and late complications and sequelae and histological characteristics of solitary rectosigmoideal polyps in children. METHODS: Retrospective analysis of hospital charts and histological characteristics of patients operated for rectosigmoideal polyps between January 1995 and December 2005. There were 23 children operated on, the study group consists of 20 patients (3 patients were excluded because of insufficient documentation). Demographics, symptomatology, season of first manifestation, localization, histology, postoperative complications and recurrence rate were evaluated. RESULTS: There were 7 boys and 13 girls in the study group (1:1.9), age at manifestation was 2-17 years (average 5.6 y.). The presenting symptom was bleeding in 14 pts, anal prolaps once and combination of both symptoms 5 times. The polyps were localized 3-15 cm from anocutaneous border, on the posterior intestinal wall. Histological examination showed a juvenile polyp in 15 (75%) patients, atypical juvenile polyp and inflammatory polyp in 2 patients each and lymphoid polyp in one case. One patient suffered from a mild bleeding postoperatively. No recurrence was noted. CONCLUSION: Polyps in children are rare, surgical removal of polyps is a relatively easy operation with minimum complications. Long term follow-up is not necessary. The seasonal occurrence of first symptoms predominantly in autumn and winter months (19 pts) has not been to our knowledge previously published.

Adolescent↗
PubMed1989

Adequacy of "hot biopsy" for the treatment of diminutive polyps: a prospective randomized trial.

Patients with diminutive polyps in the rectum or sigmoid colon were randomized to "hot biopsy" treatment for either 1) electrocautery for 2 s (fixed duration cautery) or 2) cautery until visible necrosis of the polyp base was evident (variable duration cautery). Sigmoidoscopy was performed 4 wk after treatment to determine the adequacy of polyp eradication. In the fixed duration cautery group, 11 of 21 polyps (52%) were eradicated, compared with 12 of 14 polyps (86%) in the variable duration cautery group (p = 0.04). When analyzed according to whether or not visible necrosis was achieved (some of the polyps in the fixed duration cautery group showed necrosis with 2 s cautery), 19 of 23 polyps (83%) were eradicated when necrosis was evident, compared to 5 of 12 (42%) without necrosis (p = 0.004). We conclude that hot biopsy treatment for diminutive polyps is significantly more effective when visible necrosis is achieved during cautery. Furthermore, even with visible necrosis, there is a 17% failure rate of polyp eradication.

Adenoma↗
PubMed1988

Selenium status and the polyp-cancer sequence: a colonoscopically controlled study.

Diminished blood selenium levels have been associated with increased risk of gastrointestinal cancers in man, while dietary selenium supplementation reduces the incidence of experimental colon cancer in rats. However, no previously published data are available concerning selenium and the evolution of colon cancer from benign neoplastic colonic polyps through localized and metastatic cancer. To assess any influence of selenium on this polyp to cancer sequence, we measured plasma and erythrocyte selenium levels in colonoscopically and histologically evaluated patients with adenomatous polyps (group I), locally resectable colon cancer (group II), metastatic colon cancer (group III), and selected colonoscopy negative controls (group IV). We found no difference in selenium levels between groups IV versus groups I or II. Likewise, within group I, no difference in selenium was present for different polyp histologies or numbers of polyps. However, selenium levels did drop progressively (p = 0.028, ANOVA) from polyp (group I) to local cancer (group II, p = NS vs group I) to metastatic cancer (group III, p less than 0.05 vs group I or group II). Parallel changes were seen in both plasma and erythrocyte levels, suggesting that these selenium abnormalities are of long duration, reflecting tissue stores, and therefore capable of influencing cancer risk. We conclude that selenium stores may not be an important factor in the de novo formation of benign neoplastic colonic polyps. Although these data suggest that selenium does not affect the polyp-cancer sequence, it is possible that a subset of patients with polyps and the lowest selenium levels are at higher risk for malignant transformation. However, these human data do not support a significant role for selenium in colon carcinogenesis.

Aged↗
PubMed1986

Differential expression of difucosyl type 2 chain (LeY) defined by monoclonal antibody AH6 in different locations of colonic epithelia, various histological types of colonic polyps, and adenocarcinomas.

The expression of LeY (Fuc alpha 1----2Gal beta 1----4 [Fuc alpha 1----3]GlcNAc beta 1----R) (in which Fuc is fucose, Gal is galactose, and GlcNAc is N-acetylglucosamine) defined by monoclonal antibody AH6 in various locations of human colonic epithelia, colonic polyps, and adenocarcinomas has been studied. In normal colonic mucosa, strong staining by AH6 was observed in the proximal regions such as the terminal ileum and cecum. The staining was, however, greatly reduced in the epithelia of the ascending colon and became very weak in the epithelia of transverse, descending, and sigmoidal colon as well as the rectum. Of 481 crypts in 40 biopsy samples of the epithelia of normal sigmoidal colon, 421 crypts did not show any staining, and only a weak staining of the lowest crypt area was observed in 60 crypts (12%); of 474 crypts in 40 biopsy samples of normal rectal epithelia, 110 crypts (26%) showed a weak staining. At the fetal stage, the LeY staining was much more intense in all locations of the colon than in corresponding locations of adult epithelia, and staining was observed in the epithelia of the sigmoidal colon and rectum. A strong staining was observed in 24 of 25 cases of colorectal adenocarcinomas, irrespective of their original location. The expression of LeY in polyps was correlated with histological type as well as the degree of dysplasia of the polyps. Of various adenomas examined, tubular adenomas, many of which showed mild or moderate dysplasia and less malignant potentials, displayed the least LeY expression. Tubulovillous and villous adenomas, which have higher malignant potential and showed a higher incidence of severe dysplasia, showed a greater area and intensity of LeY expression. No LeY was detectable in juvenile polyps, and only a very weak staining was observed in the dysplastic area of hyperplastic polyps. The extent and intensity of staining in various adenocarcinomas and adenomas could not be correlated with blood group ABO status of the hosts nor with location of the tumors. These results suggest that LeY in colonic adenocarcinomas and polyps at the distal region of the colon and rectum is a typical oncofetal antigen and is a useful marker for diagnosis of colonic cancer. Its expression in colonic polyps can be correlated with the degree of dysplasia and may indicate the degree of malignant potential of the polyp. Thus, LeY expression in polyps may have prognostic value.

Adenocarcinoma↗
PubMed1986

Changing concepts of colonic polyps: clinical and radiographic implications.

The relationship of colonic polyps to carcinoma of the colon provides a basis for their importance. Recent advances in the detection of colonic polyps, including double contrast barium examination and colonoscopy, have provided a method for more extensive study of colonic polyps. Studies using these newer techniques indicate that many traditional concepts of colonic polyps were inaccurate. The relationships of polyp size to histology, polyp location to age, and the phenomenon of colon polyp clustering are important to both the immediate treatment of the polyp and to the long-term follow-up of the patient. The use of hemoccult stool screening as a technique for screening for colonic pathology is also of significance to the radiologist. The changing relationships of various parameters of colon polyps bring into question the utility of many of the currently recommended screening procedures for colon pathology. Undoubtedly, this will impact on the practice of radiology.

Aged↗
PubMed1987

Malignant transformation of gastric hyperplastic polyps.

Four hundred and seventy-seven hyperplastic polyps, removed by endoscopic polypectomy, were reviewed with special reference to the appearance of dysplastic foci and their malignant transformation. Focal carcinomas were found in 10 hyperplastic polyps, which corresponded to 2.1% of the total of 477 hyperplastic polyps. The location of cancer was at the head or at the surface of the polyp, and was intramucosal. Dysplastic foci equivalent in the degree of histological atypia to adenoma were found adjacent to the cancerous foci in these 10 polyps. Dysplastic foci were also found in 19 hyperplastic polyps without cancerous foci, which corresponded to 4.0% of the total hyperplastic polyps. In connection with the histogenesis of malignant transformation of hyperplastic polyps, the results of clinicopathological examination and immunohistochemical stains strongly suggested that cancer cells arose from the dysplastic area in hyperplastic polyps, rather than directly from nondysplastic hyperplastic epithelium.

Adenocarcinoma↗
PubMed1986

Treatment of colonic polyps--practical considerations.

The adenomatous colonic polyp, a neoplastic lesion, is the precursor of most if not all carcinomas of the colon and rectum. Confirmatory evidence is derived from epidemiological, histological and clinical data demonstrating a close parallelism between adenomas and cancer of the colon. Based on current knowledge, all colonic polyps should be removed to prevent the development of colonic cancer. However, since the risk of malignancy within an adenoma is related to its size, histology and the degree of dysplasia, practical considerations dictate that all polyps 1 cm in diameter or larger should be removed upon their detection by barium enema or colonoscopy since such adenomas are the ones most likely to contain malignancy. The endoscopic removal of colon polyps can be efficiently and safely accomplished when established principles of colonoscopy and electrosurgery are followed. This technique requires the proper equipment, a skilled endoscopy assistant, and an experienced endoscopist with the ability to adeptly perform colonoscopy, an understanding of the basic concepts of electrocautery and knowledge of the various structural configurations of colonic polyps. Colonoscopic polypectomy will avoid the need for surgical resection in most instances. Management of the malignant colonic polyp remains controversial. The patient with a sessile or pseudo-pedunculated polyp containing invasive cancer should undergo colonic resection. Surgery is not necessary for the majority of patients whose pedunculated adenomas contain invasive cancer, unless the malignancy is poorly differentiated, the cancer invades lymphatics or vascular channels, or tumour is seen at or near the resection margin. Surveillance colonoscopy after endoscopic polypectomy should be performed in most instances within one year to look for recurrent tumour, missed polyps or a metachronous adenoma. Subsequently, colonoscopy should be performed every two years in patients with multiple index polyps, and every three years after removal of a single index adenoma.

Adenoma↗
PubMed1995

Distribution of adenomatous polyps in African-Americans.

OBJECTIVES: Previous research has suggested that polyps and colon cancer occur more commonly in the right colon in African-Americans compared with the general population. The purpose of this study is to determine the pattern of distribution of colonic polyps in African-Americans. METHODS: We retrospectively evaluated 141 colonoscopies in which 179 polypectomies were done. The polyps were described on the basis of anatomical distribution, gross description, size, and histology. Sixty-nine males and 72 females had colonoscopic polypectomies. The mean age was 67 yr (range, 43-91 yr). RESULTS: Seventy-seven (43%) were classified as left sided, and 102 (57%) were right sided. Left-sided polyps were more likely to be pedunculated than right-sided polyps (p < 0.01). Larger polyps were more common on the left side than the right side (p < 0.01), but villous histology was almost as high on the right side as on the left side. Polyps that had the highest malignant potential were found almost as commonly on the right side as on the left side. CONCLUSIONS: This study supports previous work that suggests that there is a significant shift to the right in the anatomical distribution of polyps in African-Americans. It also shows that the malignant potential is as high for right-sided polyps as it is for those on the left. Current screening recommendations may not be effective enough for preventing colon cancer in this population.

Adult↗
PubMed1995

Diminutive colonic polyps: histopathology, spatial distribution, concomitant significant lesions, and treatment complications.

OBJECTIVES: Our objectives in this study were to determine diminutive colonic polyp histology, distribution, frequency of significant synchronous neoplastic lesions, and treatment complications. METHODS: We evaluated consecutive colonoscopic examinations in which one or more diminutive polyps were detected over a 36-month period; these examinations had been entered into an endoscopy database at the time of colonoscopy. RESULTS: A total of 1964 diminutive polyps were found and removed in 753 colonoscopies; 1525 were removed by hot biopsy, 436 were removed by cold biopsy, and three were removed by snare. Of the diminutive polyps, 40.7% were adenomatous, 37.2% were hyperplastic, 17.9% were mucosal tags or lymphoid aggregates, and 4.3% were mixed; 0.26% contained atypia, and none were cancerous. In the right colon and transverse colon, diminutive polyps were more likely to be neoplastic (p < 0.0001), but in the left colon they were more likely to be nonneoplastic (p < 0.0001). The prevalence of synchronous neoplastic lesions was 21.5%. No perforations were seen; however, significant hemorrhages occurred in six cases in which hot biopsy was used. The risk of a significant hemorrhage from hot biopsy of diminutive polyps was 0.39%. The risk of hot biopsy-induced hemorrhage was significantly higher in the right colon than in the transverse colon and left colon (p < 0.05). The risk in the cecum was 1.33%; in the ascending colon it was 1.03%, and for the remainder of the colon it was 0.24%. CONCLUSIONS: Most diminutive polyps proximal to the left colon are neoplastic. The decision to use the hot biopsy or cold biopsy technique to eradicate diminutive polyps should take into account the location of the polyp because of the significantly increased risk of hemorrhage with hot biopsies in the right colon.

Adenoma↗
PubMed1997

Morphological and molecular processes of polyp formation in Apc(delta716) knockout mice.

Mutations in the human adenomatous polyposis coli (APC) gene are responsible for not only familial adenomatous polyposis but also many sporadic cancers of the digestive tract. Using homologous recombination in embryonic stem cells, we recently constructed Apc gene knockout mice that contained a truncation mutation at codon 716 (Apc(delta716)). The heterozygous mice developed numerous intestinal polyps. All microadenomas dissected from nascent polyps had already lost the wild-type allele, indicating the loss of heterozygosity (M. Oshima et al., Proc. Natl. Acad. Sci. USA, 92: 4482-4486, 1995). We also demonstrated that cyclooxygenase 2 is induced in the polyps at an early stage and plays a key role in polyp development (M. Oshima et al., Cell 87: 803-809, 1996). We have analyzed the process of polyp development in these mice both at morphological and molecular levels. A small intestinal microadenoma is initiated as an outpocketing pouch in a single crypt and develops into the inner (lacteal) side of a neighboring villus forming a double-layer nascent polyp. The microadenoma then enlarges and gets folded inside the villus. When it fills the intravillous space, it expands downward and extends into adjoining villi, rather than rupturing into the intestinal lumen. During this course of development, the basement membrane remains intact, and the labeling index of the microadenoma cells is similar to that of the normal crypt epithelium. As in the crypt cells, neither transforming growth factor beta1 nor its receptor type II is expressed in the microadenoma cells. No hot spot mutations in the K-ras gene are found in the microadenoma tissue during these early stages of polyp development. Essentially, the same results have been obtained for the colonic polyps as well. These results suggest that early adenomas in the Apc(delta716) polyps are very similar to the normal proliferating cells of the crypt except for the lack of directed migration along the crypt-villus axis.

Activin Receptors, Type I↗
PubMed1997

Risk factors for gallbladder polyps in the Chinese population.

OBJECTIVES: To assess the prevalence of and risk factors for gallbladder (GB) polyps in the Chinese population. METHODS: A prospective ultrasonographic study of GB polyps was conducted in 3647 Chinese subjects who received a paid physical checkup at this hospital. Their demographic characteristics and biochemical parameters were recorded. Ultrasonographic diagnosis revealed a normal GB in 2946 subjects (1838 men, 1108 women), polyps in 243 (174 men, 69 women), gallstones in 286 (196 men, 90 women), a history of cholecystectomy in 100 (56 men, 44 women), mixed gallstones/GB polyps in 17 (10 men, seven women), and miscellaneous results in 35. RESULTS: Excluding subjects with cholecystectomy and mixed gallstones/GB polyps, the overall prevalence of GB polyps in the study group was 6.9%. The studied risk factors manifesting an increased odds ratio (OR) for the development of GB polyps were glucose intolerance (OR 1.506, p < 0.05) and male gender (OR 1.723, p < 0.05) in multivariate analysis. Other demographic characteristics and biochemical parameters, such as age, body mass index, cigarette smoking, alcohol consumption, blood pressure, lipid profile, hepatitis B virus carrier, liver function, and parity, did not exhibit any correlation to GB polyps. CONCLUSIONS: Among Chinese of higher socioeconomic status, men and individuals with glucose intolerance tend to have a high risk for developing GB polyps.

Adult↗
PubMed2005

Gallbladder Polyps.

Most small gallbladder polyps are benign and do not change significantly over time. They are usually incidental findings on ultrasound. Therefore, these polyps should be checked periodically with routine percutaneous ultrasonography. In the asymptomatic patient, gallbladder polyps that are greater than 1 cm in diameter should be treated with cholecystectomy. The size of the polyp and the patient greater than 50 years are important risk factors for malignant potential. Patients who have biliary pain and small gallbladder polyps without gallstones present a difficult management decision for the clinician. If the physician is confident that the polyps are the source of the pain, patients should be referred for cholecystectomy. Endoscopic ultrasound and positron emission tomography may prove to be useful in assessing the malignant potential of large gallbladder polyps. Laparoscopic cholecystectomy is the treatment of choice for most gallbladder polyps. If a malignant polyp is suspected, patients should undergo an open cholecystectomy.

Journal Article↗
PubMed2006

Laparoscopic-assisted double-balloon enteroscopy for small-bowel polyp surveillance and treatment in patients with Peutz-Jeghers syndrome.

BACKGROUND: Surveillance and treatment of small-bowel polyps in patients with Peutz-Jeghers syndrome (PJS) can be challenging and may require intraoperative enteroscopy. While initial reports that used double-balloon enteroscopy (DBE) for the resection of small-bowel polyps in patients with PJS appear promising, complete enteroscopy when using this technique may require multiple procedures or may not be possible at all. OBJECTIVE: To develop a single-procedure approach to the surveillance and the treatment of small-bowel polyps in patients with PJS. DESIGN: Retrospective review. SETTING: Single, North American tertiary-care center. PATIENTS: Individuals with PJS and small-bowel polyps identified by other modalities. INTERVENTIONS: DBE was combined with laparoscopy as a single-procedure surveillance and therapeutic strategy for small-bowel PJS polyps. MAIN OUTCOME MEASUREMENTS: Completion of enteroscopy, number of polyps resected, procedure duration, complications. RESULTS: Three patients with a history of PJS and known small-bowel polyps underwent laparoscopic-assisted DBE (LADBE). Complete enteroscopy was performed, and all polyps larger than 0.5 cm were resected endoscopically. No cases of cancer or dysplasia were noted; procedure times lasted from 1 to 4 hours. Postoperative complications included ileus in 2 patients. LIMITATIONS: Small sample size, single-center experience. CONCLUSIONS: LADBE holds promise as a new technique that can be used as both a surveillance and a therapeutic tool for small-bowel polyps in patients with PJS.

Adult↗
PubMed2006

Video capsule endoscopy in peutz-jeghers syndrome: a blinded comparison with barium follow-through for detection of small-bowel polyps.

BACKGROUND AND STUDY AIMS: Video capsule endoscopy has shown promise for the surveillance of significant small-bowel polyps in patients with Peutz-Jeghers syndrome. In this study the yield of significant small-bowel polyps by capsule endoscopy was compared to the yield of these polyps by barium follow-through in adults with Peutz-Jeghers syndrome. PATIENTS AND METHODS: A total of 19 adults with Peutz-Jeghers syndrome who were undergoing surveillance underwent both capsule endoscopy and barium follow-through examinations, and the number of small-bowel polyps of at least 1 cm in diameter that were detected was recorded for each method. The two methods were assessed in terms of comfort and convenience for the patients and their preferred future surveillance method, using a questionnaire. RESULTS: Capsule endoscopy detected a median of four significant small-bowel polyps while barium follow-through detected a median of one (P = 0.008). There was a trend towards more participants having at least one significant small-bowel polyp detected by capsule endoscopy than was the case with barium follow-through, though capsule endoscopy seemed to be less reliable for accurate sizing of polyps that were at the limit of clinical significance. Most participants expressed a preference for capsule endoscopy for future surveillance. CONCLUSIONS: Capsule endoscopy should replace barium follow-through for the surveillance of small-bowel polyps in adults with Peutz-Jeghers syndrome, but the findings of this study should be interpreted with caution until a more reliable means of sizing polyps by capsule endoscopy is available.

Administration, Oral↗
PubMedDate not supplied

Characterization of colonic polyps by two-dimensional gel electrophoresis.

To identify proteins that may specifically characterize colonic polyps we have investigated the abundance of numerous proteins in epithelial cells from 15 normal colon specimens and 13 colonic polyps, using two-dimensional gel analysis to detect possible differences in expression. Silver-stained digitized images of the gels were analyzed with Melanie II 2.1 software. We consistently detected more than 700 protein spots on each gel, and found that the intensity of 59 of them was significantly altered in polyp specimens (Wilcoxon test assuming P< or =0.05). Immunostaining, microsequencing and mass spectrometry (matrix-assisted laser desorption/ionization - time of flight; MALDI-TOF) techniques were used to identify these proteins and selected others that did not show differential regulation. The expression of numatrin (nucleophosphine/B23), hsp 70, and hsp60 was increased in polyps; levels of fatty acid binding protein (L-FABP), 14-3-3 sigma, citokeratin 20, cytochrome c oxidase polypeptide Va, Rho GDP-dissociation inhibitor (Rho GDI), and beta- and gamma-actins were decreased. Although the levels of expression of a given protein often varied among polyp specimens, it generally held true that the direction of variation (up or down) remained constant across the panel. We concluded that proteins showing constant differential regulation across all or most of the polyp specimens represent the most characteristic regulatory pathways in colon polyps, while more sporadic variations reflect characteristics of individual polyps.

Adenomatous Polyps↗
PubMed2001

Hyperplastic polyps of the colorectum-innocent or guilty?

Hyperplastic polyps have traditionally been regarded as nonneoplastic polyps lacking malignant potential. The demonstration of genetic alterations within these lesions indicates an underlying neoplastic cause. There is evidence that hyperplastic polyps are heterogeneous. Most are innocuous, but subsets may have malignant potential. Risk factors for neoplastic progression include multiple, large, and proximally located polyps. Aberrant methylation resulting in the silencing of cancer genes may be an important underlying mechanism, particularly in pathways progressing to tumors with DNA microsatellite instability. Lesions intermediate between hyperplastic polyp and cancer include admixed polyps and serrated adenomas. Currently, pathologists have different thresholds for diagnosing serrated adenomas, including the distinction from large hyperplastic polyps. Reasons for over looking this pathway in the past may include rapid tumor progression and the fact that proximally located hyperplastic polyps may be flat and not especially numerous. Management of the serrated pathway of colorectal neoplasia may require novel approaches to screening, early detection, and prevention.

Colon↗