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Key Topics in Gastroenterology. Edited Registrar Consider It, Although You Should by Anderson SHC, Davies G, Dalton HR

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Key Topics in Gastroenterology. Edited Registrar Consider It, Although You Should by Anderson SHC, Davies G, Dalton HR 440 Gut 2000;46:440–442 ing and subsequent regular surveillance 15 Orme SM, McNally RJ, Cartwright RA, et al. above that of the normal population cannot Mortality and cancer incidence in acromegaly: a retrospective cohort study. United Kingdom LETTERS TO be supported by the evidence currently avail- Acromegaly Study Group. J Clin Endocrinol able. Metab 1998;83:2730–4. Gut: first published as 10.1136/gut.46.3.440d on 1 March 2000. Downloaded from THE EDITOR A G RENEHAN STO’DWYER Reply Department of Surgery, Christie Hospital NHS Trust, Wilmslow Road, Withington, EDITOR,—Our conclusion that acromegaly Colorectal neoplasia in acromegaly: the Manchester M20 4BX, UK may be a high risk condition for the develop- ment of colorectal cancer is based not only on reported increased prevalence is S M SHALET our own data (we have now discovered 10 overestimated Department of Endocrinology, Christie Hospital NHS Trust patients with cancer from approximately 210 patients who have had a colonoscopy), but EDITOR,—We read with interest a recent also on those of several other studies. In the paper by Jenkins et al (Gut 1999;44:585– 1 Jenkins PJ, Fairclough PD, Richards T, et al. prospective studies by Archambeaud- 587). However, we are concerned with their Acromegaly, colonic polyps and carcinoma. Mouveroux and colleagues1 and Ituarte ,2 assertion that acromegaly is a high risk Clin Endocrinol (Oxf) 1997;47:17–22. et al 1a Atkin WS, Morson BC, Cuzick J. Long-term cancers were discovered in 12.5% and 20% condition for colorectal neoplasia, and their risk of colorectal cancer after excision of respectively of patients with acromegaly. Ret- recommended advice on colonoscopic rectosigmoid adenomas. N Engl J Med 1992; rospective epidemiological surveys may have screening and surveillance. Jenkins and col- 326:700–2. 2 Correa P, Strong JP, Reif A, . The epidemi- failed to show an increased risk of cancer leagues had found that 33 (26%) of 129 et al ology of colorectal polyps: prevalence in New because of diVerences in methodology—for patients (updated to 155), treated for ac- Orleans and international comparisons. Cancer example, in one study case ascertainment romegaly at St Bartholomew’s Hospital, had 1977;39:2258–64. 3 Eide TJ, Stalsberg H. Polyps of the large depended upon death certificate entries and at least one adenoma and six (5%) had intestine in Northern Norway. 1978; : 1 Cancer 42 cancer registrations which may have been adenocarcinomas. 2839–48. incomplete.3 Furthermore, these studies did 4 Williams AR, Balasooriya BA, Day DW. Polyps We feel that the choice of controls in this not discuss the relevance of the age of the study was inappropriate because although and cancer of the large bowel: a necropsy study in Liverpool. Gut 1982;23:835–42. patients. The mean and range of age during there is no ideal control population, the 5 Blatt LJ. Polyps of the colon and rectum: follow up were not stated,3 and in another authors used comparative data on the inci- incidence in northern Norway. Dis Colon study the mean age of the patients at diagno- dence of adenomatous polyps from only two Rectum 1961;4:277–82. 6 Arminski TC, McLean DW. Incidence and dis- sis of acromegaly was 52 years old and that at cohorts: a published study of left sided tribution of adenomatous polyps of the colon 4 1a follow up was only 61 years old. Our results adenomas, and colonoscopic records of all and rectum based on 1000 autopsy examina- clearly show that colorectal cancer is a late patients without acromegaly that had been tions. Dis Colon Rectum 1964;7:249–61. 7 Stemmermann GN, Yatani R. Diverticulosis complication of acromegaly, as the mean age examined by one of the authors. Matched for and polyps of the large intestine. A necropsy of our aVected patients was 67 years old. age (and side), the relative risk of adenomas study of Hawaii Japanese. Cancer 1973;31: The situation for adenomas is less clear and was higher in patients with acromegaly when 1260–70. 8 Rickert RR, Auerbach O, Garfinkel L, et al. we agree that there is a lack of proper control compared with data from the first study, but Adenomatous lesions of the large bowel: an groups. However, many of the prevalence fig- not when compared with data from the autopsy survey. Cancer 1979;43:1847–57. ures given by Renehan and colleagues were second. 9 Vatn MH, Stalsberg H. The prevalence of obtained from necropsy studies and therefore In an attempt to estimate more appropri- polyps of the large intestine in Oslo: an autopsy study. Cancer 1982;49:819–25. cannot provide a valid comparison because ately the prevalence of adenomas in the nor- 10 Jass JR, Young PJ, Robinson EM. Predictors of the resected bowel was thoroughly washed on mal population, we have carried out a presence, multiplicity, size and dysplasia of up to three occasions, repeatedly examined http://gut.bmj.com/ comprehensive review of the literature on colorectal adenomas. A necropsy study in New under magnification in optimal lighting, and adenoma prevalence per decade of life from Zealand. Gut 1992;33:1508–14. 11 DiSario JA, Foutch PG, Mai HD, et al. lesions as small as l mm were classified as which two groups of studies emerged. The Prevalence and malignant potential of colorec- adenomas. This gives an increased prevalence first group comprised six necropsy studies tal polyps in asymptomatic, average-risk men. of the disease compared with incidences of (n=2914), and the second comprised three Am J Gastroenterol 1991;86:941–5. 12 Lieberman DA, Smith FW. Screening for colon neoplasia revealed by colonoscopic screen- screening colonoscopy studies of asympto- malignancy with colonoscopy. Am J Gastroen- ing. Furthermore, these studies were of matic average risk volunteers (n=720, table terol 1991;86:946–51. populations with very diVerent demographic, 2–13 1). With the exception of those patients 13 Rex DK, Lehman GA, Ulbright TM, et al. socioeconomic and dietary influences, which Colonic neoplasia in asymptomatic persons on September 30, 2021 by guest. Protected copyright. between 50–59 years old, the prevalence rates with negative fecal occult blood tests: influence are factors known to influence the incidence of adenomas in patients with acromegaly are of age, gender, and family history. Am J Gastro- and prevalence of colonic adenomas. By con- remarkably similar to those for individuals in enterol 1993;88:825–31. trast, our control groups were taken from screening colonoscopy studies, and less than 14 Ron E, Gridley G, Hrubec Z, et al. Acromegaly and gastrointestinal cancer. Cancer 1991;68: similar populations to the patients with those from necropsy studies. We find no evi- 1673–7. acromegaly, and in one group, the colono- dence that patients with acromegaly are at increased risk of developing adenomas. For colorectal cancer, Jenkins and Table 1 Prevalence (%) of adenomatous polyps by decade of life colleagues1 used comparative data from a regional cancer registry and estimated in- Age group (years) creased relative risks of 13–90. These figures n <40 40–49 50–59 60–69 70+ Total are exaggerated in comparison with studies using standardised age and sex adjusted Autopsy studies2–4* population data. Ron and colleagues14 re- Blatt5 446 0 21 34 34 44 39 ported 13 colonic cancers in 1041 male Arminski and McLean6 1000 20 19 27 35 46 33 7 veteran acromegalics (standardised incidence Stemmermann and Yatani 202 43 – 72 59 63 62 Rickert and colleagues8 518 – 17 35 56 58 47 ratio (SIR) 3.1; 95% CI 1.7 to 5.1) and, using Vatn and Stalsberg9 445 – 6 23 31 46 33 uniform methods of ascertainment of cases Jass and colleagues10 303 3 11 33 30 36 24 and comparison groups, Orme and 15 Colonoscopy studies in screened populations colleagues found 12 cases of colonic cancer DiSario and colleagues11 119 – – 21 45 53 41 in a larger study of 1362 patients with Lieberman and Smith12 105 – – 28 41 58 41 acromegaly (SIR 1.68; p=0.06). Rex and colleagues13 496 – – 20 33† 31‡ 26 There are approximately 1500 patients Weighted averages with acromegaly in the United Kingdom, and Necropsy studies 2914 9 15 31 40 48 37 it would seem sensible for strategies for large Screening studies 720 – – 20 38 37 31 bowel screening to be evidence based. The v 1 data given above suggest that the reported Acromegalics (Jenkins and colleagues ) 129 8 12 29 36 39 26 increased prevalence of colorectal neoplasia *Three other autopsy studies (Correa and colleagues2; Eide and colleagues3; Williams and colleagues4) were in patients with acromegaly is overestimated considered but not included as the age bands in these studies did not correspond with those used by Jenkins and thus, the recommendations given by et al.1 these authors for early colonoscopic screen- †Patients aged 60–64; ‡patients aged 65–75. Letters, Book reviews, Notes 441 scopies were performed by the same operator. stump appeared mildly inflamed. Biopsy and/or measurement of the portocaval pres- A comparison between these groups showed samples of the rectal stump were consistent sure gradient, together with imaging of the a significant increase in the relative risk of with active colitis and a putative diagnosis of portal venous system in order to exclude por- adenomas in patients with acromegaly, al- diversion colitis was made. Treatment with tal or splenic vein thrombosis. The Gut: first published as 10.1136/gut.46.3.440d on 1 March 2000. Downloaded from though we accept that this risk is not as high steroid enemas was eVective. Six months later importance of this is illustrated by the series as that for cancer, and this raises intriguing the patient developed bleeding and mucus of patients with GAVE after bone marrow questions about the causes of colorectal can- discharge through the colostomy for the first transplantation, cited by Spahr et al.2 In this cer in patients with acromegaly.
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