Colon Polyps: Detection, Inspection and Characteristics

Transcription

1 Colon Polyps: Detection, Inspection and Characteristics Stephen Kim, M.D. Assistant Professor of Medicine Interventional Endoscopy Services UCLA Division of Digestive Diseases September 29,

2 Disclosures Boston Scientific, consultant ARIES, consultant 2

3 Colon Polyps Detection Inspection Characteristics 3

4 Adenoma Detection Rate 4

5 Adenoma Detection Rate Adenoma Detection Rate (ADR) = # of colonoscopies with 1 adenoma total # of colonoscopies Rex et al. Quality Indicators for Colonoscopy. Gastrointest Endosc

6 Adenoma Detection Rate 2002: Multi-Society Task Force % of persons age 50 with 1 adenoma Benchmarks: 25% men, 15% women 2006: modified by ACG/ASGE Task Force % of first time screening colonoscopies in persons age 50 with 1 adenoma Benchmarks: unchanged 2015: ACG/ASGE Task Force on Quality Benchmarks: 30% men, 20% women Rex et al. Gastrointest Endosc

7 Adenoma Detection Rate ADR Benchmarks For asymptomatic men and women 50 years of age undergoing screening colonoscopy: Men: ADR 30% Women: ADR 20% Rex et al. Gastrointest Endosc

8 Interval Cancer Baseline Colonoscopy Recommended Surveillance Interval (years) No polyps Interval Cancer 1-2 tubular adenomas Interval Cancer High-risk adenoma(s) Interval Cancer Lieberman et al. Gastroenterology

9 Interval Cancer 58 (0.6%) interval cancers found in 9,167 patients Martinez et al. Gastroenterology

10 Adenoma Detection Rate Polish Database Hazard Ratios p=0.02 Kaminski et al. NEJM

11 Adenoma Detection Rate Each 1% increase in ADR 3% decrease in incidence of interval colorectal cancer 5% decrease in incidence of fatal colorectal cancer Increasing ADR is cost-effective Higher cost of more colonoscopies is outweighed by reduction in cost of colorectal cancer care Corley et al. NEJM Meester et al. JAMA

12 Why Do We Miss Polyps? 12

13 Why Do We Miss Polyps? Patient Poor bowel prep Polyp Flat, sessile polyps Small polyps Difficult location Physician Poor technique Folds/turns Residual debris Inadequate distension Rapid withdrawal time Fatigue Physicians are human 13

14 How Can We Do Better? Patient Split dose bowel prep Equipment High definition WL Chromoendoscopy Devices Cap Endocuff / Endoring Third eye Physician Proper technique Training in lesion recognition Public reporting Videorecording Withdrawal time Reposition patient Second look in right colon Retroflexion in right colon 14

15 Tips for Polyp Detection 1. Second look in right colon 2. Retroflexion in right colon Rex D. Am J Gastroenterol

16 RCT of Right Colon 850 patients with clearance of right colon At least one more adenoma detected p= nd Forward View 10.5% Retroflexed View 7.5% Kushnir et al. Am J Gastroenterol

17 Right Colon Examine the right colon twice First exam of right colon shows polyps Older age Male patients Lynch syndrome Second view of right colon Forward view = retroflexion Rex D. ACG

18 Tips for Polyp Detection 1. Second look in right colon 2. Retroflexion in right colon 3. Cap 18

19 Cap Attached to the distal end of the colonoscope Flattens mucosal folds Improves visibility of proximal side of folds Can aid in resection of flat colon polyps 19

20 Cap Multiple meta-analyses show improved ADR with cap-assisted colonoscopy vs. standard Proximal colon ADR Flat adenomas Sessile serrated adenomas Desai M et al. Gastrointest Endosc Ng SC et al. Am J Gastroenterol

21 Tips for Polyp Detection 1. Second look in right colon 2. Retroflexion in right colon 3. Cap 21

22 Inspection 22

23 Polyp Inspection Size small vs. large Shape pedunculated vs. flat Location IC valve vs. rectum Orientation easy to snare vs. difficult location 23

24 Polyp Inspection 1. Is the polyp benign or malignant? Adenoma Hyperproliferation Small High-grade dysplasia Cancer Large BENIGN MALIGNANT 24

25 Polyp Inspection 1. Is the polyp benign or malignant? 25

26 Polyp Inspection 1. Is the polyp benign or malignant? High-definition white light Ulcerated or depressed Non-granular 26

27 Polyp Inspection 1. Is the polyp benign or malignant? High-definition white light Ulcerated or depressed Non-granular Virtual chromoendoscopy Delineate border Disrupted or missing vessels 27

28 Polyp Inspection 1. Is the polyp benign or malignant? High-definition white light Ulcerated or depressed Non-granular Virtual chromoendoscopy Delineate border Disrupted or missing vessels Submucosal injection 28

29 Example 29

30 Example 30

31 Polyp Inspection 1. Is the polyp benign or malignant? High-definition white light Ulcerated or depressed Non-granular Virtual chromoendoscopy Delineate border Disrupted or missing vessels Submucosal injection 31

32 Polyp Inspection 1. Is the polyp benign or malignant? High-definition white light Ulcerated or depressed Non-granular Virtual chromoendoscopy Delineate border Disrupted or missing vessels Submucosal injection Biopsy* 32

33 Polyp Inspection 1. Is the polyp benign or malignant? 2. Can I remove the polyp or should I send it to someone else? 33

34 Characteristics 34

35 Characteristics of the Polyp Description of polyp Size Shape Location Orientation Surface morphology Polyp classification systems 35

36 Polyp Classifications Paris NICE JNET LST Kudo 36

37 Polyp Classifications Determine if benign vs. malignant Characterize/describe polyp Shape Surface morphology Risk of submucosal invasion 37

38 Paris Classification Holt BA and Bourke MJ. Clin Gastroenterol and Hepatol

39 NICE Classification Narrow-Band Imaging International Colorectal Endoscopic (NICE) Designed for polyps <10 mm in size Criteria Color Vessels Surface pattern Types 1-3 Hewett et al. Gastrenterology

40 NICE Classification Type 1 Type 2 Type 3 Color Vessels Same or lighter than background None Surface Pattern Most likely pathology Dark uniform spots or homogeneous Hyperplastic 40

41 NICE Classification Type 1 Type 2 Type 3 Color Vessels Surface Pattern Most likely pathology Same or lighter than background None Dark uniform spots or homogeneous Hyperplastic Brown relative to background Brown vessels surrounding white structures Oval, tubular or branched white structure surrounded by brown vessels Adenoma 41

42 NICE Classification Type 1 Type 2 Type 3 Color Same or lighter than background Brown relative to background Brown to dark brown relative to background Vessels None Brown vessels surrounding white structures Disrupted or missing vessels Surface Pattern Dark uniform spots or homogeneous Oval, tubular or branched white structure surrounded by brown vessels Amorphous or absent surface pattern Most likely pathology Hyperplastic Adenoma Deep submucosal invasive cancer 42

43 Conclusions ADR is an independent predictor of the risk of interval colorectal cancer. Tips to improve colon polyp detection: Examine the right colon twice: forward or retroflexed Consider a clear cap on the end of the colonoscope Tips to improve colon polyp inspection: Use HD, virtual chromoendoscopy, submucosal injection Tips to improve colon polyp classification: Become familiar with the Paris or NICE classification 43

44 Thank you! 44

45 Stephen Kim, MD Contact Information Location: UCLA Division of Digestive Diseases Le Conte Ave, Suite 2114 Los Angeles, CA Referral Line: Referral Fax: