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1. Farraye FA, Wallace M: Clinical significance of small polyps found during screening with flexible sigmoidoscopy. Gastrointest Endosc Clin N Am; 2002 Jan;12(1):41-51
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  • [Source] The source of this record is MEDLINE®, a database of the U.S. National Library of Medicine.
  • In deciding how to interpret the significance and management of small distal adenomatous polyps found on FS, one must first decide on the goal of a screening program.
  • If the goal is maximal reduction of CRC risk, regardless of cost, there is little argument that screening colonoscopy is the most effective approach.
  • Unfortunately cost and cost-effectiveness are important considerations when administering a screening program with a fixed budget.
  • Other authors using assumptions including low compliance rates for regular FOBT or FS have determined that colonoscopy every 10 years is the most cost-effective approach.
  • Multiple studies support the recommendation that villous polyps regardless of size and adenomatous polyps greater than 1 cm found on FS are important markers for the presence of advanced polyps and cancer in the proximal colon.
  • If one assumes that a sigmoidoscopy-based approach is reasonable, and accepts that such an approach always misses a small number of proximal lesions, how should one manage patients with a small adenomatous polyp on FS?
  • In aggregate, the studies discussed previously suggest that patients with no distal polyps, distal hyperplastic polyps, or a single small distal tubular adenoma have a similar and low risk of advanced proximal adenomas of the colon.
  • There are some studies, however, that do not support this.
  • With the exception of the study by Read et al, these studies included patients at elevated risk of CRC because of a family history, or inclusion of patients with positive FOBT (or not tested).
  • The study by Read et al also included patients with distal villous adenomas in their low-risk group.
  • Because a sigmoidoscopy-based strategy typically excludes patients at elevated risk, these results may not be applicable to low-risk patients undergoing sigmoidoscopy.
  • Given these caveats, what can one conclude about the predictive value of a small tubular adenoma found on FS?
  • These studies suggest that the risk of proximal advanced polyps is similar or slightly increased in patients with a distal adenoma than those with a negative FS.
  • The risk of finding an advanced adenoma seems to be 0% to 4% regardless of the findings of no polyps, hyperplastic polyps, or small tubular adenomatous polyps on FS in low-risk patients.
  • A small portion of patients with hyperplastic polyps found on FS have advanced proximal adenomas.
  • If a hyperplastic polyp on FS is not an indication for colonoscopy and the risk of proximal advanced adenomas is similar in patients with only a small distal adenoma, it is inconsistent to recommend colonoscopy for a small distal tubular adenoma and not a hyperplastic polyp.
  • Based on the studies of asymptomatic patients with no family history and negative FOBT, the authors believe it is reasonable to defer colonoscopy if no polyp, a hyperplastic, or a small tubular adenoma is found at sigmoidoscopy in low-risk patients.
  • If the patient or physician is unwilling to accept a small (0% to 4%) chance of missing an advanced proximal lesion, then a sigmoidoscopy-based approach (regardless of the threshold to go on to colonoscopy) is not appropriate.
  • It remains to be seen if the increase in costs and risks justifies the improved detection rate of colonic polyps.
  • Given manpower issues that face us today, and examining the question from a population perspective, reserving colonoscopy for only those patients with an advanced distal polyp on FS gives the biggest yield.

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  • (PMID = 11916160.001).
  • [ISSN] 1052-5157
  • [Journal-full-title] Gastrointestinal endoscopy clinics of North America
  • [ISO-abbreviation] Gastrointest. Endosc. Clin. N. Am.
  • [Language] eng
  • [Publication-type] Journal Article; Review
  • [Publication-country] United States
  • [Number-of-references] 45
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2. Riojas MA, Guo M, Glöckner SC, Machida EO, Baylin SB, Ahuja N: Methylation-induced silencing of ASC/TMS1, a pro-apoptotic gene, is a late-stage event in colorectal cancer. Cancer Biol Ther; 2007 Nov;6(11):1710-6
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  • [Source] The source of this record is MEDLINE®, a database of the U.S. National Library of Medicine.
  • [Title] Methylation-induced silencing of ASC/TMS1, a pro-apoptotic gene, is a late-stage event in colorectal cancer.
  • The hypermethylation of tumor-suppressor gene promoter regions has been shown to result in the epigenetic inactivation of many genes.
  • ASC/TMS1 is a pro-apoptotic gene that has been shown to be methylated in many different human neoplasms.
  • The methylation status of ASC/TMS1 was analyzed in a series of colorectal cancer (CRC) cell lines, adenomas and primary colorectal cancers and normal colorectal tissue samples using methylation-specific PCR (MSP).
  • Methylation analysis showed complete methylation of ASC/TMS1 in 5 of 7 (71%) CRC cell lines.
  • RT-PCR showed absence of mRNA expression in these same cell lines, and expression was restored after treatment with the demethylating drug 5-aza-2'-deoxyazacytidine.
  • The two unmethylated cell lines showed ASC/TMS1 mRNA expression both before and after treatment with 5-aza-2'-deoxyazacytidine.
  • Methylation was seen in 20 of 115 (17%) of primary colorectal cancer specimens, but no methylation was seen in 30 colorectal adenomas and 11 normal colorectal tissue samples.
  • Methylation status of ASC/TMS1 was correlated with a series of clinicopathological variables using multivariate analysis.
  • Methylation of ASC/TMS1 was more common in right-sided tumors (p = 0.02), concordant with hMLH1 methylation (p = 0.03) and is a late stage event, occurring in 0 of 18 tubular adenomas, 0 of 12 villous adenomas, 2 of 44 (5%) Stage 1 cancers, 8 of 31 (26%) Stage 2 cancers, 8 of 21 (38%) Stage 3 cancers and 2 of 19 (11%) Stage 4 cancers.
  • Methylation of ASC/TMS1 appears to be a late-stage event in colorectal carcinogenesis associated with invasive carcinomas but not with normal colorectal tissue or colorectal adenomas.
  • [MeSH-major] Colorectal Neoplasms / genetics. Cytoskeletal Proteins / genetics. DNA Methylation
  • [MeSH-minor] Adult. Aged. Cell Line, Tumor. Female. Gene Silencing. Humans. Male. Middle Aged. Neoplasm Staging. RNA, Messenger / analysis. Reverse Transcriptase Polymerase Chain Reaction. Tumor Necrosis Factor-alpha / pharmacology

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  • (PMID = 17986858.001).
  • [ISSN] 1555-8576
  • [Journal-full-title] Cancer biology & therapy
  • [ISO-abbreviation] Cancer Biol. Ther.
  • [Language] eng
  • [Publication-type] Journal Article; Research Support, Non-U.S. Gov't
  • [Publication-country] United States
  • [Chemical-registry-number] 0 / Cytoskeletal Proteins; 0 / PYCARD protein, human; 0 / RNA, Messenger; 0 / Tumor Necrosis Factor-alpha
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3. Reichart M, Busch OR, Bruno MJ, Van Lanschot JJ: Black esophagus: a view in the dark. Dis Esophagus; 2000;13(4):311-3
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  • A 73-year-old man had a low anterior resection for a villous adenoma in the rectosigmoid.
  • On the 4th day after surgery, he suddenly developed severe interscapular pain.
  • With conservative treatment, including proton pump inhibition, he recovered completely.
  • We hypothesize that a transient gastric outlet obstruction and massive gastroesophageal reflux played a significant role in the etiology of this rare and alarming, but, in this case, completely reversible, syndrome.

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  • (PMID = 11284980.001).
  • [ISSN] 1120-8694
  • [Journal-full-title] Diseases of the esophagus : official journal of the International Society for Diseases of the Esophagus
  • [ISO-abbreviation] Dis. Esophagus
  • [Language] ENG
  • [Publication-type] Case Reports; Journal Article
  • [Publication-country] United States
  • [Chemical-registry-number] 0 / Anti-Ulcer Agents; 0 / Proton Pump Inhibitors; 54182-58-0 / Sucralfate; KG60484QX9 / Omeprazole
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4. Cruz-Correa M, Hylind LM, Romans KE, Booker SV, Giardiello FM: Long-term treatment with sulindac in familial adenomatous polyposis: a prospective cohort study. Gastroenterology; 2002 Mar;122(3):641-5
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  • [Source] The source of this record is MEDLINE®, a database of the U.S. National Library of Medicine.
  • [Title] Long-term treatment with sulindac in familial adenomatous polyposis: a prospective cohort study.
  • Sulindac, a nonsteroidal anti-inflammatory drug, causes regression of colorectal adenomas in the retained rectal segment of FAP patients, although long-term use of this therapy has not been studied.
  • We evaluated the long-term effectiveness and toxicity of sulindac in attempting to maintain retained rectal segments free of adenomas.
  • METHODS: Twelve FAP patients (5 women), mean age 37.1 years, with IRA received sulindac (mean dosage, 158 mg/day) for a mean period of 63.4 +/- 31.3 months (range, 14-98 months).
  • Number, size, and histologic grade of polyps, side effects, and medication compliance were assessed every 4 months.
  • Prevention of recurrence of higher-grade adenomas (tubulovillous, villous adenomas) was also observed (P = 0.004).
  • At 35 months of follow-up, 1 patient developed stage III cancer in the rectal stump.
  • CONCLUSIONS: Long-term use of sulindac seems to be effective in reducing polyp number and preventing recurrence of higher-grade adenomas in the retained rectal segment of most FAP patients.
  • [MeSH-major] Adenomatous Polyposis Coli / drug therapy. Anti-Inflammatory Agents, Non-Steroidal / administration & dosage. Sulindac / administration & dosage
  • [MeSH-minor] Adult. Disease-Free Survival. Female. Follow-Up Studies. Humans. Male. Middle Aged. Neoplasm Recurrence, Local / prevention & control. Prospective Studies. Rectum / pathology

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  • (PMID = 11874996.001).
  • [ISSN] 0016-5085
  • [Journal-full-title] Gastroenterology
  • [ISO-abbreviation] Gastroenterology
  • [Language] eng
  • [Publication-type] Clinical Trial; Journal Article
  • [Publication-country] United States
  • [Chemical-registry-number] 0 / Anti-Inflammatory Agents, Non-Steroidal; 184SNS8VUH / Sulindac
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5. Lin OS, Schembre DB, McCormick SE, Gluck M, Patterson DJ, Jiranek GC, Soon MS, Kozarek RA: Risk of proximal colorectal neoplasia among asymptomatic patients with distal hyperplastic polyps. Am J Med; 2005 Oct;118(10):1113-9
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  • [Source] The source of this record is MEDLINE®, a database of the U.S. National Library of Medicine.
  • [Title] Risk of proximal colorectal neoplasia among asymptomatic patients with distal hyperplastic polyps.
  • PURPOSE: Many guidelines on colorectal cancer screening do not consider distal hyperplastic polyps to be a marker for proximal neoplasia.
  • However, 11 of 17 published studies have shown an increased risk of proximal neoplasia in patients with distal hyperplastic polyps.
  • Our goal is to assess the risk of proximal neoplasia in asymptomatic patients with distal hyperplastic polyps, compared to those with distal tubular adenomas or no distal polyps.
  • METHODS: We assessed proximal (cecum, ascending, transverse colon and splenic flexure) and distal polyps in patients undergoing screening colonoscopy, classifying them into 3 groups: distal hyperplastic polyps only; distal adenomas with or without hyperplastic polyps; no distal polyps.
  • The prevalence of proximal neoplasia and advanced neoplasia (polyps > or =1 cm, villous adenomas, or cancer) was compared among these groups.
  • Proximal neoplasia occurred in 175 (9%) of 1896 patients with no distal polyps, compared with 28 (12%) of 237 with distal hyperplastic polyps (P = 0.20) and 64 (29%) of 224 with distal adenomas (P <0.0001).
  • Proximal advanced neoplasia occurred in 39 (2%) patients with no distal polyps, compared with 4 (2%) with distal hyperplastic polyps (P = 0.70) and 9 (4%) with distal adenomas (P = 0.13).
  • CONCLUSIONS: Patients with distal hyperplastic polyps, unlike those with distal adenomas, do not exhibit an increased risk for proximal neoplasia or proximal advanced neoplasia compared to those with no distal polyps.
  • The discovery of hyperplastic polyps on screening sigmoidoscopy should not prompt colonoscopy.
  • [MeSH-major] Adenoma / epidemiology. Colon / pathology. Colorectal Neoplasms / epidemiology. Intestinal Polyps / epidemiology. Precancerous Conditions / epidemiology. Rectum / pathology
  • [MeSH-minor] Age Factors. Colonoscopy. Female. Humans. Hyperplasia / epidemiology. Logistic Models. Male. Mass Screening. Middle Aged. Multivariate Analysis. Risk. Sex Factors. Washington / epidemiology

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  • (PMID = 16194642.001).
  • [ISSN] 0002-9343
  • [Journal-full-title] The American journal of medicine
  • [ISO-abbreviation] Am. J. Med.
  • [Language] eng
  • [Publication-type] Journal Article; Research Support, Non-U.S. Gov't
  • [Publication-country] United States
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