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Do all colorectal carcinomas arise in preexisting adenomas?

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Abstract

In this article, the underlying nature of the adenoma is defined and evidence in support of the adenoma-carcinoma sequence is presented. Emphasis is placed on recent findings from the field of molecular biology which fortify the concept of the adenoma as a step in the evolution of large bowel cancer. Despite the considerable body of indirect evidence in support of the adenoma-carcinoma sequence, the de novo theory still has some support. Although differences between the de novo and adenoma-carcinoma concept are largely semantic, the fact that infiltrating carcinoma can arise within small, flat foci of severely dysplastic epithelium (indistinguishable from carcinoma in situ) may be of considerable clinical importance. Other routes of morphogenesis exist also, but these make a relatively small contribution to the overall incidence of colorectal cancer. Even if it is accepted that the majority of colorectal cancers develop in a preexisting adenoma, the systematic removal of adenomas would pose a number of practical difficulties. First, adenomas are extremely common, particularly in populations at high risk of colorectal cancer. A second factor is the recently recognized existence of flat or depressed adenomas which may be small and difficult to visualize endoscopically. A simple screening program based on our knowledge of the evolution of colorectal cancer is outlined.

Résumé

La nature et le potentiel de croissance des adénomes et notablement l'évidence en faveur de la séquence adénome-cancer sont présentés. En particulier, des données récentes en biologie moléculaire semblent renforcer la conception de la progression adénome-cancer du côlon. Malgré ce, l'hypothèse du développement de novo des cancers intestinaux garde ses partisans. En fait les différences entre les deux théories semblent être essentiellement sémantiques: un cancer infiltrant peut se développer à partir de petits foyers aplatis au sein d'un épithélium dysplasique (ce qui ne peut être distingué d'un cancer in situ) et ce fait peut avoir une importance clinique. D'autres modes de morphogenèse sont possibles, mais ne seraient responsables que d'une petite proportion de cancers colorectaux. Même si on accepte le principe que la majorité des cancers se développent à partir des adénomes pré-existants, l'ablation systématique de tous les adénomes pose un certain nombre de problèmes difficiles. Tout d'abord, l'adénome est d'une extrême fréquence, particulièrement dans les populations à haut risque de cancer colorectal. Deuxièmement, il y a la notion d'acquisition plus récente de l'existence d'adénomes plats ou mêmes déprimés et de petite taille et de ce fait de reconnaissance endoscopiquement difficile. Un programme simple de dépistage, basé sur nos connaissances actuelles sur l'évolution du cancer colorectal est schématisé.

Resumen

En este artículo se define la naturaleza del adenoma colorrectal y se resume la evidencia sobre la secuencia tejido normaladenoma-carcinoma. Se hace énfasis sobre los hallazgos recientes en el campo de la biología molecular que fortalecen el concepto del adenoma como una fase en la evolución del cáncer del intestino grueso. A pesar de un cuerpo considerable de evidencia en soporte de la secuencia adenoma-carcinoma, la teoría del carcinoma de novo todavía posée apoyo. Aunque las diferencias entre el concepto del carcinoma de novo y el concepto de la secuencia adenoma-carcinoma son principalmente semánticas, el hecho de que un carcinoma infiltrante pueda originarse en focos pequeños y planos de epitelio severamente displásicos (indistinguible del carcinoma in situ), puede ser de importancia clínica considerable. También pueden existir otras rutas de morfogénesis, pero éstas representan una contribución relativamente pequeña a la incidencia global del cáncer colorrectal. Aún si se acepta que la mayoría de los cánceres colorrectales se desarrollan en adenomas preexistentes, la remoción sistemática de los adenomas presentaría un número de dificultades prácticas. En primer lugar, los adenomas son extremadamente comunes, particularmente en poblaciones con alto riesgo de cáncer colorrectal. Un segundo factor es la recientemente reconocida existencia de adenomas planos o deprimidos, los cuales pueden ser muy pequeños y difíciles de visualizar a la endoscopia. Se delinea un sencillo programa de tamizaje fundamentado en nuestro conocimiento sobre la evolution del cáncer colorrectal.

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  1. Department of Pathology, St. Mark's Hospital, London, England, UK

    Jeremy R. Jass B.Sc, M.D., M.R.C.Path.

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  1. Jeremy R. Jass B.Sc, M.D., M.R.C.Path.
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Jass, J.R. Do all colorectal carcinomas arise in preexisting adenomas?. World J. Surg. 13, 45–51 (1989). https://doi.org/10.1007/BF01671153

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