René Lambert

Time trends incidence of both major histologic types of esophageal carcinomas in selected countries, 1973–1995

The purpose of our study was to examine the incidence patterns of 2 major histologic types of esophageal cancer, in selected countries world‐wide and to identify components of birth cohort, period and age as determinants of observed time trends using regression modeling. The roles of temporal changes in specification of histology of tumors and of classification of cancers at the gastroesophageal junction as esophageal or gastric in origin were taken into consideration. In all, 56,426 esophageal cancer cases were included. The results indicate that the incidence rate of squamous cell carcinoma of the esophagus has been relatively stable in most of the countries analyzed, although increasing trends were observed in Denmark and the Netherlands (Eindhoven) among men and in Canada, Scotland and Switzerland among women. There was a significant increase in the incidence of esophageal adenocarcinomas in both sexes in the United States (among whites and blacks), Canada and South Australia and in 6 European countries (Scotland, Denmark, Iceland, Finland, Sweden and Norway). In France the increase was limited to men and in Switzerland the increase was observed only in women. Modeling was unable to distinguish which trends were the results of changes in risk between generations (as cohort effects), or changes in all age groups simultaneously (as a period effect).

Contribution of endoscopy to diagnosis and treatment of tumors of the ampulla of Vater

In a series of 52 patients presenting with tumors of the ampulla of Vater, endoscopic procedures, especially endoscopic sphincterotomy and snare biopsies, permitted histologic classifications as follows: adenocarcinoma: 50%, adenoma: 35%, and adenoma with cancer: 15%. In 37% of cases, the papilla was normal endoscopically and the tumor was detected only after sphincterotomy. Destruction of adenomas by snare resection, laser photoradiation, or both after sphincterotomy was attempted in 11 patients. Subsequent biopsies revealed persistence or recurrence of adenomatous tissue in only one case and complete destruction of adenomas, with a mean duration of follow‐up of 39 months, in the 10 other cases. Palliative treatment by endoscopic procedures was performed in 21 patients and was effective for a mean of 45 months for adenomas and for a mean of 6 months for adenocarcinomas, with a mortality of 10%. To avoid repeated sphincterotomy in patients requiring palliative treatment, the data support the early use of endobiliary prostheses. Endoscopic palliative treatment is not indicated, however, for infiltrative tumors that can induce rapid duodenal obstruction.

Incidence and mortality from stomach cancer in Japan, Slovenia and the USA

The mortality and incidence from stomach cancer were compared in Japan (a country with a high incidence where there was full application of mass screening during this period) and 2 countries with no screening policy: the USA (with a very low incidence) and Slovenia (with an intermediate rate). The registered cases of stomach cancer were from the Osaka Cancer Registry, the Slovenian National Cancer Registry and the Surveillance, Epidemiology, and End Results (SEER) registries in the USA. In the period 1975–95, the age‐adjusted incidence rate (/100,000) of stomach cancer declined in the 3 countries, as follows: Japan, from 76.0 to 53.0 in men and 38.4 to 21.3 in women; Slovenia, from 40.2 to 24.1 in men and 16.6 to 10.8 in women; and the USA, from 9.5 to 6.9 in men and 4.3 to 2.9 in women. During the same period, the age‐adjusted mortality rate declined, as follows: Japan, from 60.2 to 34.2 in men and 30.5 to 14.1 in women; Slovenia, from 37.7 to 21.2 in men and 13.8 to 9.0 in women; the USA, from 5.6 to 4.7 in men and 2.5 to 2.3 in women. In the period studied, specific trends on incidence and mortality with a cohort effect occurred only in Japan: analysis by the age period‐cohort model confirmed that the decline has occurred since the generations born in 1910. The trend therefore corresponds to unplanned prevention through changes in environmental factors occurring since the early 20th century. The study of stage‐specific incidence rates confirmed the declining trend for regional cancer, whereas there was an increase in the incidence of localized cancer, associated with a period effect in 1975–95. This is attributed to the policy of early detection of stomach cancer, with the inclusion of intramucosal lesions of favorable prognosis and explains why mortality decreased faster than incidence during the period.

Prospective evaluation of transnasal esophagogastroduodenoscopy: feasibility and study on performance and tolerance.

BACKGROUND With a pediatric endoscope, esophagogastroduodenoscopy (EGD) can be performed via a nasal route in adults. To evaluate this new procedure, we conducted a randomized comparative study of the feasibility of diagnostic transnasal EGD and assessed the factors influencing its quality and tolerance (endoscope diameter or route). METHODS Transnasal EGD was attempted in 100 patients to assess its feasibility. For the analysis of quality and tolerance, 150 patients were randomized as follows into 3 groups according to the route of examinations: (1) oral route with 9.8 mm diameter standard videoendoscope; (2) oral route with 6.0 mm diameter pediatric videoendoscope; (3) transnasal route with 6.0 mm diameter pediatric videoendoscope. The operator assessed the quality of examination by standard scores. Patients quantified pain intensity, nausea, and choking sensation. RESULTS Transnasal EGD was feasible in 82% of patients. The quality of the examination was significantly lower with pediatric endoscope. No difference was noted concerning pain intensity, but nausea and choking sensation were significantly reduced when the nasal route was used. CONCLUSIONS Transnasal EGD is feasible in the routine practice of diagnostic EGD. The nasal route, and not endoscope diameter (6.0 mm vs 9.8 mm diameter), is the determining factor that explains increased patient tolerance during transnasal EGD. Technical improvements in pediatric videoendoscopes are required.

The dimensions of the CRC problem

Colorectal cancer is a significant health problem, the importance of which will increase substantially in the coming years, both in more, as well as in less developed regions of the world. The present paper describes the dimensions of the problem from an epidemiologic viewpoint as well as from the perspective of policy makers and professionals seeking to control the disease. Currently, colorectal cancer is the third most common cancer and the fourth most common cause of cancer deaths worldwide, with 1.2 million estimated cases and 609,000 estimated deaths in 2008. Based on demographic trends, the annual incidence is expected to increase by nearly 80% to 2.2 million cases over the next two decades and most of this increase will occur in the less developed regions of the world (62%). These regions are ill equipped to deal with the rapidly increasing demand for cancer treatment resulting from population growth and higher life expectancy. Concerted efforts to control colorectal cancer are therefore of great importance worldwide. They will require allocation of additional resources and should be based on an appropriate balance between prevention, diagnosis and treatment.

Quality assurance in pathology in colorectal cancer screening and diagnosis—European recommendations.

In Europe, colorectal cancer is the most common newly diagnosed cancer and the second most common cause of cancer deaths, accounting for approximately 436,000 incident cases and 212,000 deaths in 2008. The potential of high-quality screening to improve control of the disease has been recognized by the Council of the European Union who issued a recommendation on cancer screening in 2003. Multidisciplinary, evidence-based European Guidelines for quality assurance in colorectal cancer screening and diagnosis have recently been developed by experts in a pan-European project coordinated by the International Agency for Research on Cancer. The full guideline document consists of ten chapters and an extensive evidence base. The content of the chapter dealing with pathology in colorectal cancer screening and diagnosis is presented here in order to promote international discussion and collaboration leading to improvements in colorectal cancer screening and diagnosis by making the principles and standards recommended in the new EU Guidelines known to a wider scientific community.

Pragmatic classification of superficial neoplastic colorectal lesions

Recently, the emerging role of nonpolypoid precursors of colorectal cancer has challenged the conventional polyp-cancer sequence. The impact of colonoscopy in cancer prevention depends on its reliability in the diagnosis of colorectal neoplasia when the lesion does not extend beyond the submucosa and is potentially curable. The estimation of the risk of progression is based on the prediction of histology from the morphological appearance of the lesion and includes (1) distinction between neoplastic and non-neoplastic lesions, (2) identification of different categories of non-serrated and serrated lesions, and (3) determination of the localization in the proximal or distal colon, which has an impact on the morphology and behavior of the lesion. The pragmatic classification Of superficial neoplastic lesions proposed in this text takes into account these changes and is based oil a 2-step strategy of endoscopic diagnosis with initial detection and characterization, followed by treatment implementation, Such as endoscopic resection, ablation, and Surgery

Mass screening for colorectal cancer is not justified in most developing countries.

Most developed countries insist on the prevention of colorectal cancer (CRC) and offer screening to the population. Mass screening is proposed to both sexes in the population aged 50 years or more. Colonoscopy is then offered to persons having a positive faecal occult blood test. This recommendation should not be diffused over the world without considering the distinct dimensions of the risk and resources in developed and developing countries. A national screening policy is legitimate in developed countries like Japan, South Korea, and in North America and Europe. On the other hand, a mass screening policy for CRC is not recommended in most developing countries. The limited amount of resources attributed to health care for cancer should concern other indications in the control of common cancers, particularly in the cervix or liver. Indeed the risk of CRC is very low in most regions of Africa, and in some countries of South America and Asia.

Annex to Quirke et al. Quality assurance in pathology in colorectal cancer screening and diagnosis: annotations of colorectal lesions

Multidisciplinary, evidence-based European Guidelines for quality assurance in colorectal cancer screening and diagnosis have recently been developed by experts in a pan-European project coordinated by the International Agency for Research on Cancer. The full guideline document includes a chapter on pathology with pan-European recommendations which take into account the diversity and heterogeneity of health care systems across the EU. The present paper is based on the annex to the pathology chapter which attempts to describe in greater depth some of the issues raised in the chapter in greater depth, particularly details of special interest to pathologists. It is presented here to make the relevant discussion known to a wider scientific audience.

Laterally spreading tumors in the colon and rectum.

The large and relatively flat colorectal neoplastic lesions called laterally spreading tumors are classified as nonpolypoid despite some mixed patterns with protruding nodules. Large hyperplastic polyps and sessile serrated lesions are non-neoplastic lesions that also have this morphology and may potentially progress to neoplasia. All these large and relatively flat lesions are more frequent in the proximal colon and less conspicuous than polypoid lesions. Their underdiagnosis is a major factor in the failure of colonoscopy to prevent cancer in the proximal colon. The treatment of laterally spreading tumors by endoscopic resection (endoscopic mucosal resection, piecemeal endoscopic mucosal resection, endoscopic submucosal dissection), or by surgery is based on a careful morphologic analysis, taking into account the size and surface with nodules or depression. The technique of endoscopic submucosal dissection should be diffused because it reduces the number of surgical indications.