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Effect of epidermal growth factor administration on intestinal cell proliferation, crypt fission and polyp formation in multiple intestinal neoplasia (Min) mice.

Recombinant epidermal growth factor (EGF) may be useful to treat severe ulcerative gastrointestinal injury. There is concern, however, that systemic use of this potent mitogen might increase tumour development and/or progression in susceptible subjects. We therefore examined the effect of chronic administration of systemic EGF to multiple intestinal neoplasia (Min ) mice, who have a genetic defect in the adenomatous polyposis coli (APC) gene, leading to increased polyp development. Min mice (n =26) and wild-type littermates (n =26) received saline or EGF (223 microg of EGF/kg per day) for 4 weeks using subcutaneous osmotic mini-pumps. Cell proliferation and crypt fission were analysed using microdissection techniques and the number and size of polyps in the small and large intestines were determined. EGF increased wet weight and crypt cell proliferation rate by approx. 20% (all P <0.01 compared with the relevant control) in the small intestine and colon of both control and Min mice. In both groups, EGF reduced the colonic fission index by approx. 40% (P <0.01), but did not affect crypt fission in the small intestine. In Min mice, administration of EGF did not increase numbers of polyps or degree of dysplasia, but resulted in a 40% increase in the polyp size in the proximal intestine (P <0.02), but not in the remainder of the small intestine or colon. No polyps were found in control mice given EGF. EGF did not initiate polyp formation in control or Min mice. However, as polyp size is an important determinant for subsequent risk of malignant change in human colon cancer, further studies appear justified.

Adenomatous Polyposis Coli↗

Colon polyp registries and colorectal cancer control.

This cohort of 252 subjects in the Roger Williams Hospital Polyp Registry who had adenomatous polyps removed in 1990, was followed for 6 years. Thirty subjects died during that period. Follow-up rate for the 222 living patients (88.1% of total) was 85%. New adenomatous polyps were found in 59% of the endoscoped subjects. Risk factors for new polyps included family history of colorectal carcinoma (p = 0.00079), right-sided location (p = 0.0108), and (probably) prior adenomatous polyps (p = 0.0595). In addition, three colorectal carcinomas, two of which were Dukes stage A, were found 1, 1, and 6 years after index polypectomy. If, as is common practice, the two first-year cancers are excluded, the observed incidence of metachronous colorectal cancer was 0.8/1000 patient years, which is substantially less than the expected incidence of such carcinomas in reference populations. Compared to the 1984 and 1987 cohorts in the polyp registry, colonoscopy was used more frequently and sigmoidoscopy less so for surveillance. Within the sigmoidoscopy group, the flexible instrument continued to rise in popularity as compared with rigid sigmoidoscopy. In addition to helping reduce the incidence of metachronous colorectal carcinomas, the polyp registry also serves the educational function of sensitizing physicians and their patients to the need to detect and treat these premalignant lesions. Enrollees in the registry also provide a source for studies designed to evaluate possible inhibitory effects of dietary, chemopreventive, and other agents on colorectal neoplasias.

Adenomatous Polyposis Coli↗

Familial juvenile polyposis. Study of a kindred: evolution of polyps and relationship to gastrointestinal carcinoma.

Familial juvenile polyposis is a rare intestinal polyposis that has recently been associated with gastric and colonic adenocarcinoma. The authors report a kindred of 41 members, 11 of whom have familial juvenile polyposis. In these patients, random sections of otherwise grossly normal-appearing colonic mucosa showed a dense population of mixed inflammatory cell infiltrates in the superficial third of the lamina propria. Fine nodular mucosa was noted focally and diffusely in six of eight colons resected. These consisted of foci of dense inflammatory cell infiltrates in the mucosa with slight crypt architectural abnormalities. The majority of lesions were typical juvenile polyps. Dysplastic changes were noted in the polyps that were 1-2.9 cm or larger. The largest polyps contained foci of villous adenoma and juvenile polyp. A focus of adenocarcinoma of the colon was noted at the base of the villous adenoma portion of the largest polyp. The gastric polyps were histologically identical to hyperplastic polyps of the stomach. This report represents the largest number of patients (eight) in a single family with familial juvenile polyposis studied histologically. This is also the first time that the changes in the nonpolypoid colonic and gastric mucosa have been reported. The pattern of inheritance in this family suggests that the trait for familial juvenile polyposis segregates as an autosomal dominant.

Adenocarcinoma↗

Peutz-Jeghers syndrome with osseous metaplasia of the intestinal polyps.

A case of Peutz-Jeghers syndrome (PJS) with osseous metaplasia in three of 15 hamartomatous polyps of the small intestine is reported. At 35 years of age, the patient was diagnosed as having PJS by cutaneous pigmentation around the mouth and polyposis of the stomach, duodenum and intestine. Fifty-two polys of the large intestine were resected, which were characteristic of those of PJS. Three of them showed adenomatous and carcinomatous changes, but there was no osseous metaplasia in any of the resected polyps. At age 40, he had surgery under the diagnosis of intestinal obstruction. There were 15 polyps in the resected jejunum. These polyps were also characteristic of those of PJS. Additionally, three of these polyps were accompanied by osseous metaplasia. Histologically, mature bone formation and calcification were found close to the hyperplastic glands in the submucosa or in the propriate muscle. Malignant transformation was not observed. Osseous metaplasia is extremely rare in benign polyps, and it has not been reported in hamartomatous polyps of PJS to date. The knowledge of this association may be helpful in the clinical diagnosis of this benign lesion in PJS.

Adult↗

Distribution of cancer and adenomatous polyps in the colorectum: study in an Iranian population.

OBJECTIVE: There is consensus that the majority of colorectal carcinomas (CRCs) arise from adenomatous polyps. Therefore, for management of colorectal cancer, diagnosis and endoscopic resection of adenomas is advised. If the same etiologic factors are operating for polyps and cancers their anatomical distributions should be the same. The present study was conducted to determine whether the distribution of adenomas is consistent with that of CRCs and for comparison with other studies, especially in Western populations. MATERIALS AND METHODS: We reviewed, retrospectively , endoscopically reported anatomic sites of all adenomatous polyps and CRCs which were histologically confirmed from Jan 1992 to Dec 2005 in Tabriz, the North-west of Iran. One hundred and forty-three CRC's and 180 adenomatous polyps (in 145 patients) were found. Patients with polyposis syndromes were excluded the analysis. Age and sex of patients, size and anatomic sites of polyps and cancers were studied. RESULTS: The average ages of patients with adenomas and cancers were 46.3(SD 14.7) and 53.9(SD 13.3)years, with 55.5% and 62.2% in males, respectively. In both cancer and adenoma cases the most common presenting symptoms were rectal bleeding and bloody diarrhea ( 52.4% , 16.9% and 39.2% , 15.8% for cancers and adenomas, respectively) without any significant difference(0>05). The vast majority of adenomas (85%) and cancers (81.7%) were left sided (p>0.05). The propensity for polyps to be found in the descending colon was of borderline significance (p=0.07). The cecal segment uniquely demonstrated cancers(p=0.01) without any polyps. CONCLUSION: A similar anatomic distribution pattern and left shift of colorectal adenomas and cancers in this Iranian population is compatible with most other Asian countries. However, because of the occurrence of the neoplasms in the right colon total colonoscopy should still be considered for screening purposes.

Adenocarcinoma↗

Colorectal adenomatous polyps and carcinoma in Ashkenazi and non-Ashkenazi Jews in Israel.

In Israel, the incidence of colorectal cancer among European-American-born Jews is approximately 2.5 times that of African-Asian-born Jews. To determine the risk of all colorectal tumors for the two ethnic groups, 335 patients with colorectal adenomatous polyps and 295 with colorectal cancer, diagnosed between 1980-1984 at the Sheba Medical Center, were compared to the 35,094 persons attending the outpatient clinics at the same hospital, during September and October 1984. Ashkenazi patients (European-American-born) had a 2.5-fold risk (95% confidence interval 1.9-3.3) of colorectal polyps compared to non-Ashkenazi patients (African-Asian-born). The risk was similar for males (odds ratios [OR] = 2.3) and females (OR = 2.8). Ashkenazis also had a significantly enhanced risk of carcinoma: OR = 3.1; 95% confidence interval 2.2-4.3. The risk ratio was slightly higher for males (OR = 3.5) than females (OR = 2.7). Age-specific analyses demonstrated an elevated risk of both malignant and benign neoplasms among Ashkenazi patients at all ages at diagnosis. Among the polyp patients, the highest risk ratio was for patients between 30 and 49 years old, while among the cancer patients the risk was highest in the group of 60-69-year-olds. The distribution by size of polyps, number of polyps, as well as polyp subsite, was similar for Ashkenazi and non-Ashkenazi patients; however non-Ashkenazis tended to have slightly more right-sided colon cancer.

Adult↗

Tissue CEA detection by immunoperoxidase (PAP) test in colorectal polyps: correlations with the degree of dysplasia.

We study the presence of Carcinoembryonic antigen (CEA) on 39 colorectal polyps by the immunoperoxidase technique. The histological examination demonstrated 15 tubular adenomas, one villous adenoma, two tubulo-villous adenomas, six tubular adenomas with slight dysplasia, one tubular adenoma with moderate dysplasia, four tubular adenomas with severe dysplasia, three tubulo-villous adenomas with severe dysplasia, five tubular adenomas with neoplastic degeneration, and two tubulo-villous adenomas with neoplastic degeneration. Twenty-eight of thirty-nine polyps (71.79%) showed a positive staining reaction for CEA. Regarding the intensity of the reaction (classified as absent or negative [-], slightly positive [+], and markedly positive [+ +]), 11/39 polyps presented a negative reaction (28.21%), 19/39 (48.71%) presented a slight reaction, and 10/39 polyps (25.64%) presented a marked reaction. Results demonstrated a higher intensity of the staining reaction in severely dysplastic polyps and in neoplastic degeneration. In conclusion, it is possible that the presence of CEA can be useful to show an initial cellular restlessness of certain polyps.

Adenoma↗

Other gastrointestinal polyps.

Gastrointestinal polyp is a descriptive concept--observation of an elevated broad-based or stalked lesion which can be defined exactly only when examined histologically. Therefore, all polyps must, in principle, be snared or excised to achieve a final diagnosis. Nonneoplastic polyps or tumor-like lesions were formerly considered innocent findings with no malignant potential, while neoplastic adenomas with dysplasia are well-known premalignant lesions. This view of the totally harmless nature of nonneoplastic polyps is no longer true. At least the dominantly inherited juvenile polyposis and Peutz-Jeghers polyposis syndromes definitely have malignant potential through adenomatous change in the originally hamartomatous lesions. Consequently, juvenile polyposis is best treated with colectomy and ileorectal anastomosis, and repeated multiple polypectomies are now recommended in Peutz-Jeghers polyposis, in combination with laparotomy when feasible. In addition, hyperplastic gastric polyps may reflect an underlying atrophic gastritis implying increased risk of gastric carcinoid tumors and cancer. Furthermore, even colorectal hyperplastic polyps may undergo adenomatous change, and thus represent, theoretically, a reservoir from which adenomas arise.

Humans↗

The fate of patients following polypectomy alone for polyps containing invasive carcinoma.

Eighty-two patients with colon and rectal polyps containing invasive adenocarcinoma treated by polypectomy alone were studied. Seven of 34 patients (21 percent) with sessile lesions had an adverse outcome, including five local recurrences and two distant metastases. They occurred from 4 to 68 months after the polypectomy. Forty-seven pedunculated polyps with invasion to the head (Level 1) or to the stalk (Level 3) and one polyp to the base of the stalk (Level 4) had no evidence of local recurrence or signs of metastasis. Twenty-eight percent of patients were found to have adenomatous polyps, and 4 percent had malignant polyps during the follow-up examinations (range, 3-119 months; mean, 53 months). The findings suggested that pedunculated polyps with invasion to the head (Level 1), neck (Level 2), or stalk (Level 3) can be safely treated with a complete polypectomy provided that the carcinoma is not undifferentiated. Sessile lesions as well as Level 4 pedunculated lesions should be treated aggressively. If resection is not performed, a long-term follow-up in these patients is essential.

Adenocarcinoma↗

Accuracy of colonoscopy for the detection of colorectal polyps.

The findings at colonoscopy were compared with the pathologic findings of the surgical specimen in 235 patients who underwent a colon resection for a primary colorectal neoplasm from January 1980 to December 1987 at Roswell Park Cancer Institute. Seven patients (3 percent) were found to have synchronous primary colon carcinomas, and 100 patients (43 percent) were found to have synchronous adenomatous polyps identified by colonoscopy and/or pathology. In patients with polyps 10 mm or greater in diameter, the findings on colonoscopy agreed with the pathology report 96 percent of the time. When polyps of all sizes were included, with many less than 5 mm in diameter, colonoscopy agreed with the pathology in 89 percent of patients. When only the area of the colon resected was used to determine the ability of colonoscopy to locate polyps, 58 percent of polyps of all sizes were located. The majority of the missed polyps were adjacent to a carcinoma. One cecal carcinoma was not seen by colonoscopy because of technical inabilities to reach the cecum. A second carcinoma (20 mm x 17 mm) was not seen at the splenic flexure.

Colectomy↗

Histologic risk factors and clinical outcome in colorectal malignant polyp: a pooled-data analysis.

PURPOSE: The malignant polyp carries a significant risk of lymphohematic metastasis and mortality. Clinical usefulness of histologic risk factors is still controversial. The study was designed to compute the association between the main histologic risk factors and the occurrence of unfavorable outcomes in patients with malignant polyps. METHODS: A MEDLINE search regarding malignant polyps was performed. Three histologic risk factors (positive resection margin, poor differentiation of carcinoma, vascular invasion) and five (residual disease, recurrent disease, lymph node metastasis, hematogenous metastasis, mortality) unfavorable clinical outcomes were evaluated. Further analysis was performed by subgrouping polyps in high-risk and low-risk groups. RESULTS: Thirty-one studies enrolling 1,900 patients with malignant polyp were selected. Positivity of resection margin was significantly predictive of the presence of residual disease (odds ratio, 22; P < 0.0001), poorly differentiated carcinoma was associated with an increased mortality (odds ratio, 9.2; P < 0.05), and vascular invasion with a higher lymph node metastasis risk (odds ratio, 7; P < 0.05). Patients with high-risk polyps showed a significantly worse outcome than those with low-risk, especially for mortality (odds ratio, 11; P < 0.05). Surgical-related death was as low as 0.8 percent. CONCLUSIONS: All three histologic risk factors are significantly associated with the clinical outcome. Classification in low-risk and high-risk patients may be regarded as a meaningful staging procedure.

Carcinoma↗

Differential labeling by monoclonal antibodies Adnab-9 and anti-alpha-defensin 5 based on the distribution and adenomatous tissue content of colonic polyps.

We sought a correlation between site and morphology of colonic polyps by labeling with neoplastic and general Paneth cell markers, monoclonal antibodies Adnab-9 and anti-alpha-defensin 5, respectively. Proportions labeled by Adnab-9 and anti-alpha-defensin 5 were, respectively, 42 and 85% for adenomas, 39 and 63% for early tubular adenomas, 41 and 44% for serrated, 34 and 20% for mixed, and 11 versus 2.7% for hyperplastic polyps. Compared with hyperplastic polyps, the proportion of other polyps labeled by Adnab-9 or anti-alpha-defensin 5 was higher but this difference was more significant for distal (P = 0.008 for Adnab-9 and P = 0.0001 for anti-alpha-defensin 5) than proximal (P = 0.645 and P = 0.154, respectively) polyps. While increased labeling of all proximal polyps compared to distal ones mirrored the colonic distribution of Paneth cells, distal adenomas tended to have a higher proportion labeled by Adnab-9, suggesting that Adnab-9 labels Paneth cells associated with increased neoplastic potential.

Adenomatous Polyps↗

Cold snare excision of small colorectal polyps.

This study describes a new technique for excision of small colorectal polyps in a series of 210 consecutive patients, who had total colonoscopy, and in whom any clotting problems had been excluded. A total of 288 small polyps of 5 mm or less in diameter were transected by mechanical strangulation with a polypectomy snare, but without applying any electrical energy. All polyps were recovered whole and sent for histologic examination. No case of perforation, serious bleeding, or mortality was recorded, nor was there any need for blood transfusion because of sudden or delayed bleeding. Of the small polyps, 56% were adenomas, 43% hyperplastic, and 1% were other types. No invasive cancer was found, but in seven small adenomas severe dysplasia was observed. No correlation between the macroscopic appearance of small polyps at endoscopy and their nature at histology was found. Our data confirm that all visible polypoid lesions of the colon should be removed, and that cold snare excision of small polyps is a safe and effective alternative method of treatment in patients without clotting problems.

Colon↗

Cumulative risk of developing polyps or malignancy at the ileal pouch-anal anastomosis in patients with familial adenomatous polyposis.

Restorative proctocolectomy with an ileal pouch-anal anastomosis is performed in an increasing number of patients with familial adenomatous polyposis (FAP). Two techniques are currently used to construct an ileal pouch-anal anastomosis: (1) a double-stapled anastomosis between the pouch and the anal canal and (2) mucosectomy with a hand-sewn ileoanal anastomosis at the dentate line. Although this procedure is thought to abolish the risk of colorectal adenoma, an increasing number of case reports have been published concerning the development of adenoma at the anastomotic site. The purpose of this study was to evaluate the overall cumulative risk of developing adenomatous polyps after ileal pouch-anal anastomosis and to compare the cumulative risk after either anastomotic technique. A total of 126 consecutive FAP patients undergoing a restorative proctocolectomy were identified from polyposis registries in The Netherlands, Denmark, Italy, Germany, and New York. Life-table analysis was used to calculate the cumulative risk of developing polyps in 97 patients with at least 1 year of endoscopic follow-up (median 66 months, range 12 to 188 months). A double-stapled anastomosis was used in 35 patients, whereas in 62 patients a hand-sewn anastomosis with a mucosectomy was performed. In 13 patients polyps developed at the anastomotic site, four with severe and four with moderate dysplasia. None of the patients developed a carcinoma at the anastomotic site. The cumulative risk of developing a polyp at the anastomotic site was 8% (95% confidence interval 2% to 14%) at 3.5 years and 18% (95% confidence interval 8% to 28%) at 7 years, respectively. The risk of developing a polyp at the anastomotic site within 7 years was 31% for patients with a double-stapled vs. 10% for patients with a hand-sewn anastomosis with mucosectomy (P = 0.03 [log-rank test]). Because FAP patients undergoing a restorative proctocolectomy with either a double-stapled or hand-sewn anastomosis have a substantial risk of developing adenomatous polyps at the anastomotic site, lifelong endoscopic surveillance is mandatory in both groups.

Adenoma↗

Endoscopic snare excision of large pedunculated colorectal polyps: a new, safe, and effective technique.

BACKGROUND AND STUDY AIMS: The endoscopic polypectomy of large pedunculated polyps can have serious complications, such as hemorrhage, which has an incidence of about 2 %. We describe here a new, safe, and effective technique of endoscopic polypectomy for the treatment of large pedunculated colorectal polyps using a standard detachable diathermic snare. PATIENTS AND METHODS: 35 patients (18 men, 12 women; mean age 67.3, range 35 - 82), with 43 pedunculated colorectal polyps, of benign appearance and of size 3 cm or larger (range 3 - 5 cm) on colonoscopy, were included in our study. The polypectomy was performed in two steps: a) we first placed a polypectomy snare round the middle of the stalk, as a prophylactic measure to prevent postpolypectomy bleeding, and we then took out the colonoscope without removing the snare after dismantling it and blocking with a clip; b) endoscopic polypectomy was done using a second polypectomy snare, and transecting the stalk of the polyps at 2 mm above the first snare. The first polypectomy snare was left in place, and the patients were discharged within 3 hours of endoscopic polypectomy. The first polypectomy snare sloughed off spontaneously and slipped down the anus, being evacuated within 4 days following the endoscopic polypectomy. RESULTS: The ensnared polyps were located in the rectosigmoid region (n = 27), and the descending (n = 13) and transverse colon (n = 3). Complete ensnarement of the head of the polyp with a single endoscopic treatment was obtained in all cases. In addition, no procedural or delayed bleeding was noted during a 6-month follow-up. CONCLUSIONS: Our technique allows us to overcome the risk of bleeding, since the use of a standard diathermic snare makes it easier to obtain optimal tightness. Moreover, this technique is cheaper than the use of the standard detachable snare currently available (the cost of the snares being $50.52 compared with $189.47).

Adult↗

[Endoscopic resection of colorectal polyps].

In 766 patients, 1413 polyps of the colon and the rectum were resected endoscopically. 79% of the polyps were located in the rectum and sigmoid colon. The histological examination revealed adenomatous polyps in 60%. 3.9% of the polyps showed a severe dysplasia in accordance with the WHO guidelines, and a further 3.1% already contained parts of an invasively growing carcinoma with involvement of the submucosa. Polyps in excess of 2 cm diameter had already undergone malignant transformation in 12%. However, the smallest malignant polyp was only 8 mm in size. Complications after endoscopic polypectomy occurred in 14 patients (1%); they could be controlled conservatively in 13 cases. Surgery was necessary in one case. No patient died.

Adult↗

The pathology of Cronkhite-Canada polyps. A comparison to juvenile polyposis.

We studied Cronkhite-Canada (CC) polyps from nine patients, and compared them to gastric and colonic juvenile and gastric hyperplastic polyps. The CC polyp is characterized by its broad sessile base, expanded edematous lamina propria, and cystic glands. Similar features are found in the lesions of juvenile polyposis and gastric hyperplastic polyps. The only reliable distinction between CC and colonic juvenile polyposis was the pedunculated growth of the latter; however, this feature did not hold for gastric lesions. Unlike CC polyps, juvenile polyps sometimes have areas of dysplasia, but this is not typical. Therefore the diagnosis of CC polps, especially when located in the stomach, requires the presence of the ectodermal changes characteristic of this syndrome.

Adenomatous Polyposis Coli↗

Dietary factors and colorectal polyps: a case-control study.

In the case-control study we compared dietary habits among 108 patients with small (< or = 5 mm, n = 26), medium (5-9 mm, n = 48) or large (> or = 10 mm, n = 34) colorectal polyps with 35 healthy age- and gender-matched controls. A food record by weighing during 5 consecutive days was performed. The intake of fat was significantly higher among the patients, in contrast to a significantly lower intake of carbohydrate, dietary fibre and iron, compared with controls. The intake of vitamin C and calcium was shown to be lower among the patients, but this was significant only for women. There was a tendency among the patients to consume a lower-antioxidant, fibre and cereal fibre diet, and a calcium-rich and more cholesterol-rich diet with increasing size of polyps. The patients with the smallest polyps tended to consume less starch. Our results are too preliminary to draw conclusions with regard to the influence of nutritional factors on the size and growth of polyps. However, our risk factors for the presence of polyps are in agreement with previous studies. Further studies taking into account the size of the polyp are needed to corroborate our findings.

Aged↗