High Levels Of Triglycerides And Apolipoprotein B Increase The Risk Of Colorectal Polyp Recurrence After Endoscopic Resection

doi:10.21203/rs.3.rs-1434188/v1

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High Levels Of Triglycerides And Apolipoprotein B Increase The Risk Of Colorectal Polyp Recurrence After Endoscopic Resection

https://doi.org/10.21203/rs.3.rs-1434188/v1

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Purpose: Rates of colorectal polyp incidence and recurrence are high, so this study investigated risk factors of colorectal polyp recurrence after endoscopic surgery.

Methods: This retrospective study analyzed various blood lipid indices for 357 patients at our hospital who underwent intestinal polypectomy from January 1, 2018, to June 1, 2020, 161 of them recurred during a follow-up of about 1 year. Potential associations between blood indices and risk of recurrence were analyzed.

Results: Levels of triglycerides and apolipoprotein B were significantly higher among patients who experienced recurrence than among those who did not. Binary logistic regression identified three independent risk factors for recurrence: triglycerides (odds ratio 1.763, 95% confidence interval 1.003-3.098, P = 0.049), apolipoprotein B (5.438, 1.411-20.961, P = 0.014) and the number of polyps (2.54, 1.649-3.911, P < 0.001).

Conclusion: High levels of triglycerides and apolipoprotein B in the blood are independent risk factors for colorectal polyp recurrence.

Colorectal Polyps

Hyperlipidemia

Hypertriglyceridemia

Dyslipidemia

Apolipoprotein B.

Colorectal cancer (CRC) kills nearly 900,000 people every year, making it the world’s fourth most deadly cancer, after lung, liver, and gastric cancers¹. Diagnosing and treating CRC earlier can substantially improve 5-year survival rates². The National Polyp Study demonstrated the incidence of CRC was reduced 76–90% after the colon was cleared by colonoscopy³. Even better is early detection and removal of colorectal polyps, which can reduce the risk of CRC⁴. However, polyps can recur after endoscopic removal in 22–69% of patients^5–8. The risk of recurrence has been associated with several factors, such as sex, age, obesity index, use of tobacco and alcohol, polyp characteristics, and diet⁹. For example, recurrence risk is higher among patients who are obese¹⁰, who have been smoking longer than 35 years [odds ratio (OR) 2.88, 95% confidence interval (CI) 2.06–4.01, P = 0.001]¹¹, or who drink alcohol¹².

Identifying non-invasive markers of polyp recurrence risk could help identify at-risk patients. Elevated triglyceride levels in serum are an independent risk factor for polyp recurrence in patients with advanced adenomas¹³. Long-term lipid stimulation suppresses anti-tumor immune responses, facilitating colorectal tumorigenesis and distant metastasis, and suppresses immune infiltrating cell function in the tumor microenvironment, thereby accelerating tumor progression¹⁴. On the other hand, several studies have suggested no association or negative correlation between lipid levels in blood and risk of colorectal polyps or CRC^15–20.

To help clarify these discrepancies, we retrospectively analyzed data from 357 patients at our hospital who underwent endoscopic resection of colorectal polyps in order to identify independent risk factors for colorectal polyp recurrence, including lipid levels in the blood.

Patients

For this retrospective study, we screened for inclusion all 2,738 patients who underwent intestinal polypectomy for the first time between January 1, 2019 and June 1, 2020 in the Department of Gastroenterology at Sichuan Provincial People's Hospital. To be enrolled, patients had to be 65 years or younger, they had to undergo at least one colonoscopic follow-up after polypectomy, and baseline clinicodemographic and laboratory test data had to be available.

Patients were excluded if they were found to have high-grade intraepithelial neoplasia or carcinoma based on histopathology; if they had hypertension, diabetes, thyroid disease, or severe cardiac or pulmonary dysfunction; or if they had a history of familial adenomatous polyposis, inflammatory bowel disease, or a malignant tumor at any site. They were also excluded if they took hypolipidemic drugs before or during follow-up.

Surgical procedure

All patients were placed on a liquid diet 24 hours before surgery, and bowel washing medication was taken to clean the bowel. The patient underwent general anesthesia enteroscopy surgery after fasting for 4 hours. The procedures were performed by physicians experienced in digestive endoscopy centers. Surgical modalities collectively include high-frequency electrocoagulation, argon plasma coagulation(APC), endoscopic mucosal resection(EMR), and endoscopic submucosal dissection(ESD). Finally, biopsy specimens were performed under the microscope by experienced pathologists.

Polyp classification and definition of polyp recurrence

Pathology type report from hospital pathology department. According to the World Health Organization (WHO) classification, polyps can be classified into four types: adenomatous polyps, inflammatory polyps, hyperplastic polyps, and hamartomatous polyps²¹. High-grade intraepithelial neoplasia and carcinoma were excluded. Polyp recurrence was defined as the detection of one or more polyps at any time after polypectomy, irrespective of site²².

Blood lipid analysis

Fasting peripheral venous blood was analyzed within 24 hours after admission for triglycerides, cholesterol, high-density lipoprotein, low-density lipoprotein, apolipoprotein A1 (apoA1), and apolipoprotein B (apo B). Patients were diagnosed with dyslipidemia if levels of cholesterol were ≥ 5.2 mmol/L; triglycerides, ≥ 1.7 mmol/L; high-density lipoprotein-cholesterol, < 1.03 mmol/L; low-density lipoprotein cholesterol, ≥ 3.3 mmol/L; apoA1, < 1.05 g/L; and apoB, ≥ 1.4 g/L .

Data collection

The following baseline data were collected for all patients: sex, age, body mass index, history of smoking and alcohol consumption, as well as polyp size, number, and histopathological type.

Statistical analysis

All analyses were performed using SPSS 26.0 (IBM, Armonk, NY, USA). Normally distributed data were expressed as mean (standard deviation), otherwise, as median (interquartile range). Inter-group differences in continuous data (such as age, follow-up time, body mass index, and blood lipid levels) were assessed for significance using the Student’s t-test, analysis of variance, or the Kruskal – Wallis test as appropriate. Differences in categorical data were assessed using the chi-squared test. Binary logistic regression was used to identify independent risk factors for polyp recurrence. Differences associated with P < 0.05 were considered significant.

Of the 2,738 patients screened, 1,212 were excluded because no follow-up enteroscopy data were available, 437 were lost to follow-up, and 732 met exclusion criteria. In the end, 357 patients were included in the study, of whom 225 (63%) were men and 161 (45%) experienced recurrence during follow-up, which lasted a mean of 12 months (Fig. 1). Relatively small percentages of patients reported smoking (22%) or drinking (21%).

Patients who experienced recurrence or not were similar in sex distribution, mean age, mean body mass index, and smoking or alcohol consumption (Table 1). Similarly, the two groups of patients did not differ significantly in the size or histopathological type of polyps (Table 2).

Table 1. Characteristics of patients with colorectal polyps, stratified by whether they experienced polyp recurrence during follow-up

Characteristic

Recurrence

(n=161)

No recurrence

(n=196)

P *

Sex

Male

Female

Age, yr

Follow-up, mo.

History of smoking

History of drinking

Body mass index, kg/m²

109

50.2 (12)

12 (3)

23.1 (4)

116

48.8 (12)

12 (0.75)

23 (3.9)

0.097

0.121

0.411

0.103

0.479

0.946

Values are n, mean (standard deviation), or median (interquartile range), unless otherwise noted.

* Based on Student’s t-test or the Mann-Whitney test (continuous variables) or Fisher’s exact test (categorical variables)

n, number; BMI, body mass index;

Table 2. Comparison of polyp characteristics between patients who experienced polyp recurrence or not

Characteristic

Recurrence

(n=161)

No recurrence

(n=196)

P *

Polyp type

Hyperplastic

Inflammatory

Tubular adenoma

Hamartomatous

N/A

Polyp size, mm

≤ 10

10-19

≥ 20

N/A

Polyp number

≥ 3

N/A

126

157

0.081

0.793

* Based on Student’s t-test or the Mann-Whitney test (continuous variables) or Fisher’s exact test (categorical variables)

n, number; N/A, unclear;

In contrast, patients who experienced recurrence had a significantly greater number of polyps.

In addition, patients who experienced recurrence showed significantly higher levels of triglycerides and apoB (Table 3). The two groups of patients did not differ significantly in levels of cholesterol, high- or low-density lipoprotein cholesterol, or apoA1.

Table 3

Lipid levels in the blood of patients who experienced polyp recurrence or not
Lipid species	Recurrence (n = 161)	No recurrence (n = 196)	P *
Triglycerides, mmol/L Cholesterol, mmol/L HDL-C, mmol/L LDL-C, mmol/L Apolipoprotein A1, g/L Apolipoprotein B, g/L	1.54 (0.95) 4.97 (0.96) 1.27 (0.42) 2.3 (0.97) 1.33 (0.35) 0.87 (0.26)	1.25 (1.01) 4.6 (1.00) 1.29 (0.44) 2.17 (0.78) 1.32 (0.32) 0.79 (0.16)	0.036 0.895 0.762 0.146 0.741 0.001
Values are n, mean (standard deviation), or median (interquartile range), unless otherwise noted. * Based on Student’s t-test or the Mann-Whitney test (continuous variables) or Fisher’s exact test (categorical variables) n, number; HDL-C, High-density lipoprotein cholesterol; LDL-C, Low-density lipoprotein cholesterol.

Binary logistic regression identified the following independent risk factors for polyp recurrence (Table 4): high triglycerides (OR 1.763, 95% CI 1.003–3.098, P = 0.049), high apoB (5.438, 1.411–20.961, P = 0.014) and the presence of at least three polyps (2.54, 95% CI 1.649–3.911, P < 0.001).

Table 4. Multivariate analysis of risk factors associated with polyp recurrence (n = 357 patients)

Parameter

OR (95% CI) P-value

Sex

Age

Follow-up time

Smoking

Drinking

BMI ≥ 25 kg/m²

Polyp size ≥ 20 mm

Polyp number ≥ 3

Triglyceride (≥ 1.7 mmol/L)

Cholesterol (≥ 5.2 mmol/L)

HDL-C

LDL-C

Apolipoprotein A1

Apolipoprotein B

0.724 (0.446-1.175) 0.191

1.017 (0.994-1.042) 0.152

0.978 (0.925-1.033) 0.42

0.669 (0.329-1.363) 0.268

1.308 (0.642-2.664) 0.459

1.002 (0.631-1.59) 0.995

1.073 (0.404-2.848) 0.888

2.54 (1.649-3.911) 0.000

1.763 (1.003-3.098) 0.049

1.639 (0.923-2.908) 0.092

1.309 (0.577-2.971) 0.519

0.98 (0.926-1.037) 0.485

1.3 (0.382-4.432) 0.675

5.438 (1.411-20.961) 0.014

* Based on binary regression analysis.

OR, odd ratio; CI, confidence interval; BMI, body mass index; HDL-C, High-density lipoprotein cholesterol; LDL-C, Low-density lipoprotein cholesterol.

Here we provide evidence that hypertriglyceridemia and high apoB are independent risk factors for polyp recurrence. To our knowledge, this is the first report linking high apoB to polyp recurrence. Our findings are consistent with studies suggesting that hypertriglyceridemia promotes the formation of reactive oxygen species that damage DNA and thereby initiate CRC²³, and that this and other abnormalities of lipid metabolism suppress anti-tumor immune responses¹⁴.

Early polyp detection and removal are effective for preventing CRC. Adenomatous polyps can progress to malignancy via the adenoma-carcinoma pathway^{24, 25}, while hyperplastic polyps can progress to malignancy via the serrated or microsatellite instability pathway²⁶. A hamartoma adenoma-carcinoma sequence has also been suggested²⁷. Therefore, identifying patient characteristics associated with the risk of polyp recurrence may help reduce the risk of CRC.

Studies have explored potential correlations between blood lipid indices and risk of CRC, but they have been unable to separate potential associations from other dietary or metabolic confounders^{16, 28,29}. Similarly, studies have failed to unambiguously identify associations between dyslipidemia and the risk of colorectal polyps. ^30,31. Our study provides strong evidence linking hypertriglyceridemia to polyp recurrence. At least three mechanisms may underlie this association. One is that hypertriglyceridemia causes hyperinsulinemia and insulin resistance, which drives the proliferation of normal and cancer cells in the large intestine³². Another mechanism is that dyslipidemia creates a tumorigenic environment by increasing levels of interleukin-6, tumor necrosis factor-α, and other inflammatory cytokines³³. Finally, Boying Liu et al. suggested that TG may affect polyp recurrence by increasing the proliferative capacity of cancer stem cells or stimulating signaling pathways that promote cell invasion¹³.

Our data also link high levels of apoB to polyp recurrence. ApoB is a structural component of chylomicrons as well as lipoproteins of various densities³⁴, so it plays an important role in atherogenesis^{34, 35}. Given one study linking elevated low-density lipoprotein cholesterol to the formation of colorectal polyps³⁶, we suggest that apoB may influence polyp recurrence by affecting the metabolism of low-density lipoprotein. Elevated levels of low-density lipoprotein cholesterol have been linked to oxidative stress and inflammatory responses in the intestine^33,37. By reducing levels of low-density lipoprotein cholesterol in serum, statins may inhibit polyp formation ^38,39,40, which may help explain their ability to slow the growth of several types of colorectal tumors^41–44. Future studies should explore whether other hypolipidemic agents such as fibrates can inhibit polyp formation and CRC.

Our findings should be interpreted with caution given that our patient sample was relatively small and came from a single center. The numbers of polyps differed between patients who experienced recurrence or not, which may have confounded our analyses. Despite these limitations, our data suggest that administering hypolipidemic drugs to individuals with hyperlipidemia may help reduce the risk of polyp recurrence and thereby CRC.

Our retrospective, single-center study suggests that hypertriglyceridemia and high apoB are independent risk factors for colorectal polyp recurrence.

The authors have no competing interests to declare that are relevant to the content of this article.

This work was supported by Key Research and Development Projects of Sichuan Science and Technology Department [Grant No: 22ZDYF1691 and 2018FZ0062].

Author Contributions

Jia-yu Du and Gui-ying Huang were responsible for the main manuscript writing and data analysis, Yong-chun Xie , Nan-xi Li and Zhi-wei Lin were responsible for the data collection and graphic production, Li Zhang was responsible for the revision and guidance of the whole article, and all authors reviewed the manuscript.

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No competing interests reported.

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High Levels Of Triglycerides And Apolipoprotein B Increase The Risk Of Colorectal Polyp Recurrence After Endoscopic Resection

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Version 1

Abstract

Figures

Introduction

Methods

Patients

Surgical procedure

Polyp classification and definition of polyp recurrence

Blood lipid analysis

Data collection

Statistical analysis

Results

Discussion

Conclusions

Statements And Declarations

References

Additional Declarations

Status:

Version 1