 Diagram of the stomach, colon, and rectum Colorectal cancer, also called colon cancer or bowel cancer, includes cancerous growths in the colon, rectum and appendix. It is the third most common form of cancer and the second leading cause of death among cancers in the Western world. Many colorectal cancers are thought to arise from adenomatous polyps in the colon. These mushroom-like growths are usually benign, but some may develop into cancer over time. Diagnosis is by colonoscopy. Therapy is usually through surgery, with many cases also requiring chemotherapy. Diagram of the stomach, colon and rectum from public domain source at http://www. ...
Diagram of the stomach, colon and rectum from public domain source at http://www. ...
When normal cells are damaged or old they undergo apoptosis; cancer cells, however, avoid apoptosis. ...
In anatomy of the digestive system, the colon or large intestine is the part of the intestine from the cecum to the rectum. ...
The posterior aspect of the rectum exposed by removing the lower part of the sacrum and the coccyx. ...
In human anatomy, the vermiform appendix (or appendix) is a blind ended tube connected to the cecum. ...
Adenoma refers to a collection of growths (-oma) of glandular origin. ...
Polyp of sigmoid colon as revealed by colonoscopy. ...
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Colonoscopy is the minimally invasive endoscopic examination of the large colon and the distal part of the small bowel with a fiber optic camera on a flexible tube passed through the anus. ...
Chemotherapy is the use of chemical substances to treat disease. ...
Symptoms Symptoms of colorectal cancer include: Often, the symptoms are much less specific: In medicine, melaena or melena is the passage of black tarry motions per rectum. ...
Hematochezia is the passage of bright red blood from the rectum, with or without feces. ...
Bowel obstruction is mechanical blockage of the intestines, preventing the normal transit of the products of digestion. ...
It is also possible that there will be no symptoms at all. This is one reason why some recommend periodical screening for the disease. Anemia (American English) or anaemia (Commonwealth English), which literally means without blood, is a lack of red blood cells and/or hemoglobin. ...
Hepatomegaly is an enlargement of the liver (swelling). ...
The liver is an organ in vertebrates, including humans. ...
Metastasis (Greek: change of the state) is the spread of cancer from its primary site to other places in the body. ...
Risk factors The lifetime risk of developing colon cancer in the United States is about 7%. Certain factors increase a person's risk of developing the disease. These include: - Age. The risk of developing colorectal cancer increases with age. Most cases occur in the 60s and 70s, while cases before age 50 are uncommon unless a family history of early colon cancer is present.
- History of cancer. Women who have had cancer of the ovary, uterus, or breast are at higher risk of developing colorectal cancer.
- Heredity:
- Family history of colon cancer, especially in a close relative before the age of 55 or multiple relatives
- Familial adenomatous polyposis (FAP) carries a near 100% risk of developing colorectal cancer by the age of 40 if untreated
- Hereditary nonpolyposis colorectal cancer (HNPCC) or Lynch syndrome
- Long-standing ulcerative colitis or Crohn's disease of the colon, approximately 30% after 25 years if the entire colon is involved
- Smoking. Smokers are more likely to die of colorectal cancer than non-smokers
- Diet. Studies show that a diet high in red meat (Chao et al 2005) and low in fresh fruit, vegetables, poultry and fish increases the risk of colorectal cancer. In June 2005, a study by the European Prospective Investigation into Cancer and Nutrition suggested that diets high in red and processed meat, as well as those low in fiber, are associated with an increased risk of colorectal cancer. Individuals who frequently ate fish showed a decreased risk.[1] However, other studies have cast doubt on the claim that diets high in fiber decrease the risk of colorectal cancer.[2] The nature of the relationship between dietary fiber and risk of colorectal cancer remains controversial.
- Physical inactivity. People who are physically active are at lower risk of developing colorectal cancer.
- Virus. Exposure to some viruses (such as particular strains of human papilloma virus) may be associated with colorectal cancer.
Familial adenomatous polyposis (FAP) is an inherited condition in which numerous polyps to form in the epithelium of the large intestine. ...
Hereditary nonpolypsis colorectal cancer (HNPCC) is characterized by an increased risk of colon cancer and other cancers such as endometrium, ovary, stomach, small intestine, hepatobiliary tract, upper urinary tract, brain, and skin. ...
Diagram of the Human Intestine Crohns disease is a chronic inflammatory disease of the digestive tract and it can involve any part of it - from the mouth to the anus. ...
Human papillomavirus (HPV) is a virus which affects humans. ...
Diagnosis, screening and monitoring
Identification of malignancy Colorectal cancer can take many years to develop and early detection of colorectal cancer greatly improves the chances of a cure. Therefore, screening for the disease is recommended in individuals who are at increased risk. There are several different tests available for this purpose. - Digital rectal exam (DRE): The doctor inserts a lubricated, gloved finger into the rectum to feel for abnormal areas. It only detects tumors large enough to be felt in the distal part of the rectum and is not really a screening test.
- Fecal occult blood test (FOBT): a test for blood in the stool.
- Endoscopy:
- Sigmoidoscopy: A lighted probe (sigmoidoscope) is inserted into the rectum and lower colon to check for polyps and other abnormalities.
- Colonoscopy: A lighted probe called a colonoscope is inserted into the rectum and the entire colon to look for polyps and other abnormalities that may be caused by cancer. A colonoscopy has the advantage that if polyps are found during the procedure they can be immediately removed. Tissue can also be taken for biopsy.
- Double contrast barium enema (DCBE): First, an overnight preparation is taken to cleanse the colon. An enema containing barium sulfate is administered, then air is insufflated into the colon, distending it. The result is a thin layer of barium over the inner lining of the colon which is visible on X-ray films. A cancer or a precancerous polyp can be detected this way. This technique can miss the (less common) flat polyp.
- Virtual colonoscopy replaces X-ray films in the double contrast barium enema (above) with a special computed tomography scan and requires special workstation software in order for the radiologist to interpret. This technique is approaching colonoscopy in sensitivity for polyps. However, any polyps found must still be removed by standard colonoscopy.
- Standard computed axial tomography is an x-ray method that can be used to determine the degree of spread of cancer, but is not sensitive enough to use for screening. Some cancers are found in CAT scans performed for other reasons.
- Blood tests: Measurement of the patient's blood for elevated levels of certain proteins can give an indication of tumor load. In particular, high levels of carcinoembryonic antigen CEA in the blood can indicate metastasis of adenocarcinoma. These tests are frequently false positive or false negative, and are not recommended for screening.
- Genetic counseling and genetic testing for families who may have a heriditary form of colon cancer, such as hereditary nonpolyposis colorectal cancer (HNPCC) or familial adenomatous polyposis (FAP).
- Positron emission tomography (PET) is a 3-dimensional scanning technology where a radioactive sugar is injected into the patient, the sugar collects in tissues with high metabolic activity, and an image is formed by measuring the emission of radiation from the sugar. Because cancer cells often have very high metabolic rate, this can be used to differentiate benign and malignant tumors. PET is not used for screening and does not (yet) have a place in routine workup of colorectal cancer cases.
A rectal examination or rectal exam is an internal examination of the rectum by a physician. ...
Fecal occult blood is a term for blood present in the feces that is not visibly apparent. ...
Endoscopy means looking inside and refers to looking inside the human body for medical reasons. ...
Sigmoidoscopy is the minimally invasive medical examination of the large intestine from the rectum through the last part of the colon. ...
Colonoscopy is the minimally invasive endoscopic examination of the large colon and the distal part of the small bowel with a fiber optic camera on a flexible tube passed through the anus. ...
In zoology, a polyp is one of two forms of individuals found in many species of cnidarians. ...
A biopsy (in Greek: bios = life and opsy = look/appearance) is a medical test involving the removal of cells or tissues for examination. ...
This rectal bulb syringe may be used to administer small enemas. ...
Barium sulfate (or barium sulphate), chemical formula BaSO4, is an ionic compound and is essentially insoluble in water. ...
Virtual colonoscopy (VC) is a Medical imaging procedure which uses x-rays and computers to produce two- and three-dimensional images of the colon (large intestine) from the lowest part, the rectum, all the way to the lower end of the small intestine and display them on a screen. ...
CT apparatus in a hospital Computed tomography (CT), also known as computed axial tomography or computer-assisted tomography (CAT) and body section roentgenography, is a medical imaging method employing tomography where digital processing is used to generate a three-dimensional image of the internals of an object from a large...
Radiology is the branch of medical science dealing with the medical use of x-ray machines or other such radiation devices. ...
Colonoscopy is the minimally invasive endoscopic examination of the large colon and the distal part of the small bowel with a fiber optic camera on a flexible tube passed through the anus. ...
CT apparatus in a hospital Computed axial tomography (CAT), computer-assisted tomography, computed tomography, CT, or body section roentgenography is the process of using digital processing to generate a three-dimensional image of the internals of an object from a large series of two-dimensional X-ray images taken around...
Blood tests are laboratory tests done on blood to gain an appreciation of disease states and the function of organs. ...
A representation of the 3D structure of myoglobin, showing coloured alpha helices. ...
CEA is an abbreviation the may refer to the following: Carcinoembryonic antigen - a tumour marker for colorectal cancer. ...
Metastasis (Greek: change of the state) is the spread of cancer from its primary site to other places in the body. ...
In medicine, carcinoma is any cancer that arises from epithelial cells. ...
A false positive, also called false alarm, exists when a test reports, incorrectly, that it has found a signal where none exists in reality. ...
A false negative, also called a miss, exists when a test reports, incorrectly, that a signal was not detected when, in fact, was present. ...
Genetic counseling generally refers to prenatal counseling done when a genetic condition is suspected in a pregnancy. ...
Genetic testing allows the genetic diagnosis of vulnerabilities to inherited diseases, and can also be used to determine a persons ancestry. ...
Hereditary nonpolypsis colorectal cancer (HNPCC) is characterized by an increased risk of colon cancer and other cancers such as endometrium, ovary, stomach, small intestine, hepatobiliary tract, upper urinary tract, brain, and skin. ...
Familial adenomatous polyposis (FAP) is an inherited condition in which numerous polyps to form in the epithelium of the large intestine. ...
Positron emission tomography (PET) is a nuclear medicine medical imaging technique which produces a three dimensional image or map of functional processes in the body. ...
Pathology The pathology of the tumor is usually reported from the analysis of tissue taken from a biopsy or surgery. A pathology report will usually contain a description of cell type and grade. The most common colon cancer cell type is adenocarcinoma which accounts for 95% of cases. Other, rarer types include lymphoma and squamous cell carcinoma. Pathology (in ancient Greek pathos = feeling, pain, suffering and logos = discourse or treatise, i. ...
Histology is the study of tissue sectioned as a thin slice, using a microscope. ...
In medicine, carcinoma is any cancer that arises from epithelial cells. ...
Lymphoma is a general term for localized malignancies that develop in the lymphatic or reticuloendothelial system. ...
In medicine, squamous cell carcinoma is a form of carcinoma cancer that occurs in many different organs, including the skin, the esophagus, the lungs, and the cervix. ...
Cancers on the right side (ascending colon and caecum) tend to be exophytic, that is the tumour grows outwards from one location in the bowel wall. This very rarely causes obstruction of feces, and present with symptoms such as anemia. Left-sided tumours tend to be circumferential, and can obstruct the bowel much like a napkin ring. In anatomy of the digestive system, the cecum or caecum is a pouch connected to the large intestine between the ileum and the colon. ...
Rabbit feces are usually 0. ...
Anemia (American English) or anaemia (Commonwealth English), which literally means without blood, is a lack of red blood cells and/or hemoglobin. ...
Histopathology: Adenocarcinoma is a malignant epithelial tumor, originating from glandular epithelium of the colorectal mucosa. It invades the wall, infiltrating the muscularis mucosae, the submucosa and thence the muscularis propria. Tumor cells describe irregular tubular structures, harboring pluristratification, multiple lumens, reduced stroma ("back to back" aspect). Sometimes, tumor cells are discohesive and secrete mucus which invades the interstitium producing large pools of mucus/colloid (optically "empty" spaces) - mucinous (colloid) adenocarcinoma, poorly differentiated. If the mucus remains inside the tumor cell, it pushes the nucleus at the periphery - "signet-ring cell". Depending on glandular architecture, cellular pleomorphism and mucosecretion of the predominant pattern, adenocarcinoma may present 3 degrees of differentiation: well, moderate and poorly differentiate. 1
Staging
TNM or Duke's Colon cancer staging is an estimate of the condition of a particular cancer for diagnostic and research purposes. The systems for staging colorectal cancers largely depend on the extent of local invasion, the degree of lymph node involvement and whether there is distant metastasis. Metastasis (Greek: change of the state) is the spread of cancer from its primary site to other places in the body. ...
The most common currently used system for staging is the TNM system, though many doctors still use the older Duke's system. The TNM system assigns a number: TNM Classification of Malignant Tumours (TNM) is the system developed and maintained by the International Union Against Cancer (UICC) to maintain consensus on one globally recognised standard for categorising cancer. ...
TNM Classification of Malignant Tumours (TNM) is the system developed and maintained by the International Union Against Cancer (UICC) to maintain consensus on one globally recognised standard for categorising cancer. ...
- T - The degree of invasion of the intestinal wall
- T0 - no evidence of tumor
- Tis- cancer in situ (tumor present, but no invasion)
- T1 - tumor present but minimal invasion
- T2 - invasion into the submucosa
- T3 - invasion into the muscularis propria
- N - the degree of lymphatic node involvement
- N0 - no lymph nodes involved
- N1 - one to three nodes involved
- N2 - four or more nodes involved
- M - the degree of metastasis
- M0 - no metastasis
- M1 - metastasis present
In mammals including humans, the lymphatic vessels (or lymphatics) are a network of thin tubes that branch, like blood vessels, into tissues throughout the body. ...
Structure of the lymph node. ...
Metastasis (Greek: change of the state) is the spread of cancer from its primary site to other places in the body. ...
AJCC stage groupings The stage of a cancer is usually quoted as a number I,II,III,IV derived from the TNM value grouped by prognosis; a higher number indicates a more advanced cancer and a likely worse outcome. - Stage 0
- Stage I
- Stage IIA
- Stage IIB
- Stage IIIA
- Stage IIIB
- Stage IIIC
- Stage IV
Pathogenesis Colorectal cancer is a disease originating from the epithelial cells lining the gastrointestinal tract. Mutations in specific DNA (particularly the FAP, KRAS and p53 genes) lead to unrestricted cell division. Various causes for these mutations are inborn genetic aberrations, tobacco smoking, environmental, and possibly viral causes. The exact reason why a diet high in fiber prevents colorectal cancer remains uncertain. Chronic inflammation, as in inflammatory bowel disease, may predispose patients to malignancy. In zootomy, epithelium is a tissue composed of a layer of cells. ...
The gastrointestinal or digestive tract, also referred to as the GI tract or the alimentary canal or the gut, is the system of organs within multicellular animals which takes in food, digests it to extract energy and nutrients, and expels the remaining waste. ...
Mutations are permanent, sometimes transmissible (if the change is to a germ cell) changes to the genetic material (usually DNA or RNA) of a cell. ...
DNA - Wikipedia, the free encyclopedia /**/ @import /skins-1. ...
Human p53 protein bound to a short DNA fragment. ...
This stylistic schematic diagram shows a gene in relation to the double helix structure of DNA and to a chromosome (right). ...
Three types of viruses: a bacterial virus, otherwise called a bacteriophage (left center); an animal virus (top right); and a retrovirus (bottom right). ...
In medicine, inflammatory bowel disease (IBD) is a group of inflammatory conditions of the large intestine and, in some cases, the small intestine. ...
Treatment The treatment depends on the staging of the cancer. When colorectal cancer is caught at early stages (with little spread) it can be curable. However when it is detected at later stages (when distant metastases are present) it is less likely to be curable. Metastasis (Greek: change of the state) is the spread of cancer from its primary site to other places in the body. ...
Surgery remains the primary treatment while chemotherapy and/or radiotherapy may be recommended depending on the individual patient's staging and other medical factors.
Surgery Surgical treatment is by far the most likely to result in a cure of colon cancer if the tumor is localized. Very early cancer that develops within a polyp can often be cured by removing the polyp at the time of colonoscopy. More advanced cancers typically require surgical removal of the section of colon containing the tumor leaving sufficient margins to reduce likelihood of re-growth. If possible, the remaining parts of colon are anastomosed together to create a functioning colon. In cases when anastomosis is not possible, a stoma (artificial orifice) is created. While surgery is not usually offered if significant metastasis is present, surgical removal of isolated liver metastases is common. Improved chemotherapy has increased the number of patients who are offered surgical removal of isolated liver metastases. A typical modern surgery operation For other meanings of the word, see Surgery (disambiguation) Surgery (from the Greek cheirourgia - lit. ...
Colonoscopy is the minimally invasive endoscopic examination of the large colon and the distal part of the small bowel with a fiber optic camera on a flexible tube passed through the anus. ...
An anastomosis(plural anastomoses) is an connection between two structures, organs or spaces. ...
This is not about surgically created bowel openings; see stoma (medicine) In botany, a stoma (also stomate; plural stomata) is a tiny opening or pore, found mostly on the undersurface of a plant leaf, and used for gas exchange. ...
Laparoscopic assist resection of the colon for tumour can reduce the size of painful incision and minimize the risk of infection. Laparoscopic surgery, also called keyhole surgery (when natural body openings are not used), bandaid surgery, or minimally invasive surgery (MIS), is a surgical technique. ...
As with any surgical procedure, colorectal surgery can in rare cases result in complications. These may include infection, abscess, fistula or bowel obstruction. An infection is the detrimental colonization of a host organism by a foreign species. ...
An abscess is a collection of pus collected in a cavity formed by the tissue on the basis of an infectious process (usually caused by bacteria or parasites) or other foreign materials (e. ...
In medicine, a fistula (pl. ...
Bowel obstruction is mechanical blockage of the intestines, preventing the normal transit of the products of digestion. ...
Chemotherapy Chemotherapy is used to reduce the likelihood of metastasis developing, shrink tumor size, or slow tumor growth. Chemotherapy is often applied after surgery (adjuvant), before surgery (neo-adjuvant), or as the primary therapy if surgery is not indicated (palliative). The treatments listed here have been shown in clinical trials to improve survival and/or reduce mortality and have been approved for use by the US Food and Drug Administration. Chemotherapy is the use of chemical substances to treat disease. ...
In medicine, a clinical trial (synonyms: clinical studies, research protocols, medical research) is a research study. ...
The United States Food and Drug Administration is the government agency responsible for regulating food, dietary supplements, drugs, cosmetics, medical devices, biologics and blood products in the United States. ...
- Adjuvant(after surgery) chemotherapy
- Palliative Chemotherapy - Standard first-line therapy
- Alternate first line Chemotherapy
Fluorouracil (5-FU) is a drug that is used in the treatment of cancer. ...
Folinic acid, generally administered as calcium folinate, is an adjuvant used in cancer chemotherapy involving the drug methotrexate. ...
Oxaliplatin - Wikipedia /**/ @import /w/skins-1. ...
Capecitabine - Wikipedia /**/ @import /w/skins-1. ...
Fluorouracil (5-FU) is a drug that is used in the treatment of cancer. ...
Folinic acid, generally administered as calcium folinate, is an adjuvant used in cancer chemotherapy involving the drug methotrexate. ...
Capecitabine - Wikipedia /**/ @import /w/skins-1. ...
Oxaliplatin - Wikipedia /**/ @import /w/skins-1. ...
Bevacizumab is an anti-angiogenesis drug used in treatment of cancer. ...
Cetuximab (Erbitux®) is a chimeric monoclonal antibody given by intravenous injection for treatment of colorectal cancer. ...
Radiation therapy Radiation therapy is used to kill tumor tissue before or after surgery or when surgery is not indicated. Sometimes chemotherapy agents are used to increase the effectiveness of radiation by sensitizing tumor cells if present. Radiotherapy is not used routinely in colorectal cancer, as it could lead to radiation enteritis, and is difficult to target specific portions of the colon, but may be used on metastatic tumor deposits if they compress vital structures and/or cause pain. There may be a role for post-operative adjuvant radiation in the case where a tumor perforates the colon as judged by the surgeon or the pathologist. However, as the area of the prior tumor site can be difficult (if not impossible) to ascertain by imaging, surgical clips need to be left in the colon to direct the radiotherapist to the area of risk. Radiation therapy (or radiotherapy) is the medical use of ionizing radiation as part of cancer treatment to control malignant cells (not to be confused with radiology, the use of radiation in medical imaging and diagnosis). ...
Metastasis (Greek: change of the state) is the spread of cancer from its primary site to other places in the body. ...
Immunotherapy Bacillus Calmette-Guérin (BCG) is gaining prominence as a complementary theraputic agent in the treatment of colorectal cancer. A review of results from recent clinical trials is given in Mosolits et al. Bacillus of Calmette and Guérin (BCG) is a vaccine against tuberculosis that is prepared from a strain of the attenuated (weakened) live bovine tuberculosis bacillus, Mycobacterium bovis that has lost its virulence in humans by specially culturing in artificial medium for years. ...
Alternative therapies The agents listed here are not proven in clinical trials but may be considered to have anti-colon cancer properties in in-vitro studies, the popular press, folk medicine or other sources. In medicine, a clinical trial (synonyms: clinical studies, research protocols, medical research) is a research study. ...
- Ginger
- Curcumin (Turmeric anti-angiogenesis factor)
- Mistletoe extract (as solid tumor reducer)
- Acupuncture (symptom reduction)
Binomial name Curcuma longa Linnaeus Turmeric (Curcuma longa, also known as tumeric or curcumin) is a spice commonly used in curries and other south Asian cooking. ...
Support therapies Cancer diagnosis very often results in an enormous change in the patient's psychological wellbeing. Various support resources are available from, hospitals and other agencies which provide counseling, social service support, cancer support groups, and other services. These services help to mitigate some of the difficulties of integrating a patient's medical complications into other parts of their life. Psychotherapy is a set of techniques believed to cure or to help solve behavioral and other psychological problems in humans. ...
Cancer support groups provide a setting in which cancer patients can talk about living with cancer with others who may be having similar experiences. ...
Prevention Most colorectal cancers should be preventable, through increased surveillance, improved lifestyle, and, probably, the use of dietary chemopreventive agents. - Surveillance: most colorectal cancer arise from adenomatous polyps. These lesions can be detected and removed during colonoscopy. Studies show this procedure would decrease by > 80% the risk of cancer death, provided it is started by the age of 50, and repeated every 5 or 10 years (Winawer et al 1993).
- Lifestyle: The comparison of colorectal cancer incidence in various countries strongly suggests that sedentarity, overeating (= high caloric intake), and perhaps a diet high in meat (red or processed) could increase the risk of colorectal cancer. In contrast, physical exercise, and eating plenty of fruits and vegetables would decrease cancer risk, probably because they contain protective phytochemicals. Eating whole apples, including the skin, offers some anticancer benefits (Liu et al). Accordingly, lifestyle changes could decrease the risk of colorectal cancer as much as 60-80% (Cummings and Bingham 1998).
- Chemoprevention: More than 200 agents, including the above cited phytochemicals, and other food components like calcium or folic acid (a B vitamin), and NSAIDs like aspirin, are able to decrease carcinogenesis in preclinical models: Some studies show full inhibition of carcinogen-induced tumours in the colon of rats. Other studies show strong inhibition of spontaneous intestinal polyps in mutated mice (Min mice). Chemoprevention clinical trials in human volunteers have shown smaller prevention, but few intervention studies have been completed today. Calcium and aspirin supplements, given for 3 to 5 years after the removal of a polyp, modestly decreased the recurrence of polyps in volunteers (by 15-20%). The "chemoprevention database"[3] shows the results of all published scientific studies of chemopreventive agents, in people and in animals.
Non-steroidal anti-inflammatory drugs, usually abbreviated to NSAIDs, are drugs with analgesic, antipyretic and anti-inflammatory effects - they reduce pain, fever and inflammation. ...
References - Chao A, Thun MJ, Connell CJ, McCullough ML, Jacobs EJ, Flanders WD, Rodriguez C, Sinha R, Calle EE. Meat consumption and risk of colorectal cancer. JAMA 2005;293:172-82. PMID 15644544.
- Cummings JH, Bingham SA. Diet and the prevention of cancer. BMJ 1998;317:1636-40. Fulltext. PMID 9848907.
- Liu RH et al, Phytochemicals in apples are found to provide anticancer and anti-oxidant benefits. Link.
- Mosolits S, Nilsson B, Mellstedt H. Towards therapeutic vaccines for colorectal carcinoma: a review of clinical trials., Expert Rev. Vaccines, 2005;4:329-50. PMID 16026248
- Winawer SJ, Zauber AG, Ho MN, O'Brien MJ, Gottlieb LS, Sternberg SS, Waye JD, Schapiro M, Bond JH, Panish JF, Ackroyd F, Shike M, Kurtz RC, Hornsby-Lewis L, Gerdes H, Stewart ET, The National Polyp Study Workgroup. Prevention of colorectal cancer by colonoscopic polypectomy. N Engl J Med 1993;329:1977-81. PMID 8247072.
The British Medical Journal (BMJ) is a medical journal published weekly in the United Kingdom by the British Medical Association (BMA). ...
The New England Journal of Medicine (NEJM) is a peer-reviewed medical journal published by the Massachusetts Medical Society. ...
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