BACKGROUNDFor colorectal cancer screening, the predictive value of distal findings in the ascertainment of proximal lesions is not fully established. The aims of this study were to assess distal findings as predictors of advanced proximal neoplasia and to compare the predictive value of endoscopy alone vs. combined endoscopic and histopathologic data. METHODSPrimary colonoscopy screening was performed in 2210 consecutive, average-risk adults. Age, gender, endoscopic (size, number of polyps), and histopathologic distal findings were used as potential predictors of advanced proximal neoplasms (i.e., any adenoma ≥1 cm in size, and/or with villous histology, and/or with severe dysplasia or invasive cancer). Polyps were defined as distal if located in the descending colon, the sigmoid colon, or the rectum. Those in other locations were designated proximal. RESULTSNeoplastic lesions, including 11 invasive cancers, were found in 617 (27.9%) patients. Advanced proximal neoplasms without any distal adenoma were present in 1.3% of patients. Of the advanced proximal lesions, 39% were not associated with any distal polyp. Older age, male gender, and distal adenoma were independent predictors of advanced proximal neoplasms. The predictive ability of a model with endoscopic data alone did not improve after inclusion of histopathologic data. In multivariate logistic regression analysis, the predictive ability of models that use age, gender, and any combination of distal findings was relatively low. The proportion of advanced proximal neoplasms identified if any distal polyp was an indication for colonoscopy was only 62%. CONCLUSIONSA strategy in which colonoscopy is performed solely in patients with distal colonic findings is not effective screening for the detection of advanced proximal neoplasms in an average-risk population.Reprint requests: Maite Betés Ibáñez, MD, PhD, Departamento de Digestivo, Clínica Universitaria de Navarra, 31080 Pamplona, Spain. INTRODUCTIONMost colorectal cancers (CRC) develop from adenomas, 1-3 which have a long, asymptomatic phase during which they are detectable and curable. Excision of colorectal adenomas reduces the incidence and the mortality of CRC. 2,4-11 Therefore, CRC fulfills the criteria for benefit from screening. 12 In 1996, the United States Preventive Services Task Force recommended screening of asymptomatic adults over 50 years of age with either flexible sigmoidoscopy (FS) or fecal occult blood tests (FOBT). 13 These recommendations now are endorsed by the American Cancer Society, 14 the World Health Organization, 15 and by virtually all medical and surgical professional societies concerned with digestive diseases. 16,17 A positive FS or FOBT result is an indication for colonoscopy. The continuing high mortality rates for patients with CRC, together with two large studies that demonstrate that FS fails to identify a substantial proportion of proximal lesions, 18,19 have led many specialists to regard reliance on FS or FOBT alone as screening tests would be as wrong as mammography o...

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INTRODUCCIÓNEl carcinoma colo-rectal sigue manteniendo unas elevadas tasas de mortalidad (1), por lo que constituye en nuestro medio la segunda causa en cuanto a número de fallecimientos por cáncer (2). La Organización Mundial de la Salud ha estimado una tasa de 945.000 casos diagnosticados anualmente en el mundo, de los que 492.000 fallecerán (1). El pronóstico del cáncer colo-rectal se ha relacionado con numerosos factores, probablemente interdependientes (1,3-9).La multiplicidad de lesiones neoplásicas en forma de adenomas y carcinomas sincrónicos es frecuente en el cáncer de colon y recto (3), por lo que tras su diagnóstico es necesario efectuar un estudio completo del mismo para poder asegurar la resección endoscópico-quirúrgica de todas las lesiones (10). La causa de la multicentricidad tumoral no es bien conocida, postulándose que sea debida a la interacción de múlti-ples factores, aumentándose así la probabilidad de desarrollar neoplasias en diferentes puntos del colon (3).La posible influencia de la multicentricidad lesional sobre el [0212-7199 (2008) RESUMENObjetivo: Analizar la relación entre la presencia de lesiones sincró-nicas en el cáncer colo-rectal y su pronóstico.Método: Revisamos 369 cánceres colo-rectales resecados. Comparamos el porcentaje de cirugía aparentemente curativa, la progresión y recidiva tumoral, aparición posterior de cáncer extra-colónico y mortalidad entre los cánceres sincrónicos y el resto. Analizamos los cánceres con adenomas sincrónicos frente al resto de casos. Repetimos el estudio estratificando los casos según su estadio pTNM: estadios 0-I-II versus III-IV.Resultados: Registramos un 7,6% de cánceres sincrónicos y un 54,7% de adenomas sincrónicos. El seguimiento entre los grupos con y sin cáncer sincrónico fue de 70,8 ± 22,9 vs 67,2 ± 24,5 meses (p = 0,55). Los cánceres sincrónicos mostraron mayor mortalidad: 35,7% vs. 14,4%: p = 0,006; OR = 3,31 (1,33-8,13), mayor progresión tumoral: 39,3 vs. 19,1%: p = 0,011; OR = 2,75 (1,14-6,56) y mayor recidiva: 10,7 vs. 3,5%: p = 0,096. Al estratificar según el estadio, los pacientes con estadio 0-I-II y cáncer sincrónico mantuvieron peor pronóstico: mortalidad = 27,7 vs. 8,1% p = 0,019; OR = 4,45 (1,20-15,10), progresión tumoral = 27,8 vs. 8,5% p = 0,02; OR = 4,12 (1,14-14,19), cáncer extra-colónico = 16,7 vs. 6,4% p = 0,095. No encontramos diferencias entre los casos con y sin adenomas sincrónicos.Conclusiones: Los cánceres sincrónicos muestran peor pronóstico tras la resección, con mayor tasa de progresión tumoral y mortalidad. Esta diferencia se centra en los casos diagnosticados en estadios 0-I-II, perdiéndose en los estadios III-IV. En nuestra serie, la presencia de adenomas sincrónicos no influye en el pronóstico. were: 70.8 ± 22.9 and 67.2 ± 24.5 months (p = 0.55) respectivelly. Synchronous cancers showed higher mortality: 35.7 vs. 14.4%: p = 0.006; higher tumoral progression : 39.3 vs. 19.1%: p = 0.011; prognosis: mortality = 27.7 vs. 8.1%, p = 0.019; tumoral progression = 27.8 vs. 8.5%, p = 0.02;