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Abstract Cancer colon pathology A tenth of patients with involuntary weight loss IWL have gastrointestinal cancer.
Ferritin is the first parameter to be modified during the process leading to iron deficiency anaemia, therefore it should be the most sensitive. The aim of this study was to assess the ability of ferritin to rule out gastrointestinal cancer in patients with involuntary weight loss.
Methods All consecutive patients with IWL admitted in a secondary care university hospital were prospectively studied. Ferritin, haemoglobin with erythrocyte indices and serum iron were recorded for all patients.
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Results cancer colon pathology were included, a quarter had cancer, of which 22 7. Ferritin had the best area under the curve AUCboth for gastrointestinal cancer 0. There were three false negative patients, two with gastric cancer, and one with rectal cancer.
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For this reason, gastrointestinal endoscopy is recommended in the diagnosis of IWL, after the initial investigations consisting in history and physical examination, chest radiography, cancer colon pathology ultrasonography and proprietățile viermilor laboratory tests [ 25 ]. As it is known, iron deficiency anaemia appears in gastrointestinal cancer due to occult blood loss.
In the succession of events that leads to iron deficiency anaemia, ferritin diminution appears early, immediately after the waning of the iron stores in the bone marrow, and before occurrence of all the other changes in iron deficiency anaemia: decrease in transferrin saturation, serum iron, red cell volume and haemoglobin [ 9 ], and this allows us to hope that ferritin would have a higher sensitivity for the diagnosis cancer colon pathology gastrointestinal cancer.
In fact, ferritinaemia is the test with the highest accuracy in the diagnosis of iron deficiency anaemia compared to the above-mentioned parameters [ 10 — 12 ].
Serum ferritin was assessed in a cancer colon pathology, retrospective studies for the diagnosis of gastrointestinal cancer, and the results showed that it has no value as a screening test [ 13 ], probably because it lowers only when the tumour has grown enough [ 14 ], condition that might be satisfied in the case of IWL [ 15 ]. However, in a retrospective study on consecutive elderly inpatients referred to colonoscopy because of symptoms suggesting colorectal cancer, ferritin was not useful in the diagnosis [ 19 ].
To the date, no studies were done in patients with IWL. Methods Setting and patients We prospectively studied adult patients referred for IWL without evident origin after clinical assessmentadmitted as inpatients or referred to the day hospital in the Departments of Internal Medicine of a secondary care university hospital.
The second criterion was applied only for the selection of patients for whom there was no baseline weight documentation, and the amount of weight loss could not be computed in order to fulfil the first criterion; for these patients, the existence of the weight loss had to be confirmed by a relative, or by changes in clothes or belt size.
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The patients with voluntary weight loss or with a known malignancy were not included in the study. The study was conducted according to the Declaration of Helsinki, the protocol was approved by the ethics committee of Colentina University Hospital and all patients agreed to participate in the study and signed the informed consent before enrolling.
In order to avoid misclassification concerning the final diagnosis gastrointestinal cancer or not for patients who did not have endoscopic studies, after leaving the hospital all the patients were followed up for six months, verifying the final diagnosis, survival, state of health and further weight change. All patients had blood collected at admission. As one of the objectives of the research project was the validation of several simple clinical and biological parameters, found as diagnostic for cancer in IWL patients in three previous studies [ 20 — 22 ], all patients had a complete blood cell count including MCV and RDW and determination of blood erythrocyte sedimentation rate ESRserum C reactive protein CRPiron, albumin, alkaline phosphatase Cancer colon pathology aminotranspherase ALAT and lactate dehydrogenase LDH levels, cancer colon pathology in the hospital laboratory.
All variables were first recorded by every physician in a preformed questionnaire, and then registered by one of the authors into the database.
ESR was measured by Westergreen method. Throughout the study, the quality of results was validated by regular internal quality control procedures and participation in an external quality assessment scheme.
Results were expressed as frequencies for categorical cancer colon pathology, and median and extremes for non normal continuous variables. Stata 11 StataCorp, College Station, Texas, USA was used for the database construction and data analysis area under the curve calculation with confidence intervals, and logistic regression.
EBM calculator 1. Results Patients: inclusion, work-up and follow-up consecutive patients with IWL were admitted from January to September flow diagram presented in Figure 1. Two patients refused to participate, therefore patients were included in the present study — fulfilled the first inclusion criterion baseline weight was known, so the amount of weight loss could be computedwhile the other 62 fulfilled the second criterion.
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Figure 1 Full size image All admitted patients had hospital work-up and determination of ferritin. The eight patients diagnosed with gastric cancer had only upper endoscopy, considering this cancer as the cause of their weight loss, therefore the colonoscopy was not performed; of these patients, 6 were followed-up for six months. The characteristics of the patients, together with the results of the haematological and inflammation tests including ferritin are provided in Table 1.
As seen in Table 2ferritin had the best area under the curve AUCboth for gastrointestinal cancer 0. The parameters were lower when gastrointestinal cancer was considered instead of colorectal cancer. On the other hand, ferritin should be more sensitive in the diagnosis of iron deficiency states, therefore in the diagnosis of gastrointestinal cancer as the cause of weight cancer colon pathology.
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Upon this results, one could speculate that cancer colon pathology might be very sensitive only for colon cancer, whose main feature is iron deficiency anaemia, and not for the extremities of the digestive tract stomach and rectumwhich are, anyway, easier to explore by upper endoscopy and cancer colon pathology Additional file 2. Ferritin as a diagnostic test performed much better than haemoglobin both in terms of AUC and sensitivity.
Using ferritin in place of haemoglobin, cancer colon pathology additional patients without anaemia were diagnosed with cancer 1 with caecum cancer, 2 with stomach cancer, 2 with rectal cancer, and one with sigmoid cancer Table 6.
This finding could be explained, in our opinion, by the low statistical power only 7 and 5 patients without anaemia had gastrointestinal and colon cancer, respectivelyand by the fact that, in this population with IWL, ferritin was more homogenous in patients without anaemia, who generally did not have an organic disease, while being more frequently elevated in patients with anaemia of chronic disease, or low in patients with iron deficiency anaemia due to gastrointestinal cancer [ 24 ].
As it is known, ferritin increases in inflammation and alcohol consumption, which means that, if adjusted for inflammation, this test could have become even better as sensitivity with fewer false negativesand therefore for ruling out the disease.
Because IWL can have multiple causes, it is difficult, expansive and frequently useless to settle a standardized investigation protocol [ 2 ]. We decided to let the investigators decide the diagnostic approach in every patient, depending on clinical and biological diagnostic clues.
In order to avoid misclassification concerning the final diagnosis gastrointestinal cancer or not for cancer colon pathology who did not have both upper and lower digestive endoscopy, after leaving the hospital the patients were followed up for six months, therefore our diagnostic study had a valuable reference standard.
Only 11 3. All patients had ferritin measured.
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Florin Zaharie - Google Scholar Citations
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