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Optical diagnosis of diminutive polyps in the Dutch Bowel Cancer Screening Program: Are we ready to start?
submitted 05 August 2019
accepted after revision 18 November 2019
21 February 2020 (online)
Background and study aims Implementation of optical diagnosis of diminutive polyps may potentially increase the efficacy and cost-effectiveness of colonoscopies. To adopt such strategy in clinical practice, the Preservation and Incorporation of Valuable endoscopic Innovations (PIVI) thresholds provide the basis to be met: ≥ 90 % negative predictive value (NPV) for diagnosis of adenomatous histology and ≥ 90 % agreement on surveillance intervals. We evaluated this within the Dutch Bowel Cancer Screening Program (BCSP).
Patients and methods Endoscopic and histological data were collected from participants of the national bowel cancer screening program with an unfavorable fecal immunochemical test referred for colonoscopy between February 2014 and August 2015 at four endoscopy centers. The “resect and discard” scenario was studied, resecting diminutive polyps without histological evaluation. Agreement between optical diagnosis and histological diagnosis was measured for surveillance intervals according to Dutch, European and American post-polypectomy surveillance guideline.
Results Fifteen certified endoscopists participated in this study and included 3028 diminutive polyps. In 2,330 patients both optical and histological diagnosis were available. Optical diagnosis of diminutive polyps showed NPV of 84 % (95 % CI 80–87) for adenomatous histology in the rectosigmoid. Applying the ‘resect and discard’ strategy resulted in 90.6 %, 91.2 %, 90.9 % agreement on surveillance intervals for the Dutch, European and American guideline respectively.
Conclusion Our data representing current clinical practice in the Dutch BCSP practice on optical diagnosis of diminutive polyps showed that accuracy of predicting histology remains challenging, and risk of incorrect optical diagnosis is still significant. Therefore, it is too early to safely implement these strategies.
* These authors contributed equally.
- 1 Edwards BK, Ward E, Kohler BA. et al. Annual report to the nation on the status of cancer, 1975-2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates. Cancer 2010; 116: 544-573
- 2 Lieberman DA, Rex DK, Winawer SJ. et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2012; 143: 844-857
- 3 von Karsa L, Patnick J. European Colorectal Cancer Screening Guidelines Working Group. et al. European guidelines for quality assurance in colorectal cancer screening and diagnosis: overview and introduction to the full supplement publication. Endoscopy 2013; 45: 51-59
- 4 Shaukat A, Mongin SJ, Geisser MS. et al. Long-term mortality after screening for colorectal cancer. N Engl J Med 2013; 369: 1106-1114
- 5 Toes-Zoutendijk E, van Leerdam ME, Dekker E. et al. Real-time monitoring of results during first year of dutch colorectal cancer screening program and optimization by altering fecal immunochemical test cut-off levels. Gastroenterology 2017; 152: 767-775 e762
- 6 Hassan C, Pickhardt PJ, Rex DK. A resect and discard strategy would improve cost-effectiveness of colorectal cancer screening. Clin Gastroenterol Hepatol 2010; 8: 865-869, 869 e861-863
- 7 ASGE Technology Committee. Abu Dayyeh BK, Thosani N. et al. ASGE Technology Committee systematic review and meta-analysis assessing the ASGE PIVI thresholds for adopting real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc 2015; 81: 502 e501-502 e516
- 8 Rex DK, Kahi C, OʼBrien M. et al. The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc 2011; 73: 419-422
- 9 le Clercq CM, Bouwens MW, Rondagh EJ. et al. Postcolonoscopy colorectal cancers are preventable: a population-based study. Gut 2014; 63: 957-963
- 10 Rondagh EJ, Bouwens MW, Riedl RG. et al. Endoscopic appearance of proximal colorectal neoplasms and potential implications for colonoscopy in cancer prevention. Gastrointest Endosc 2012; 75: 1218-1225
- 11 (RIVM) RvVeM. Protocol voor de toelating en auditing van coloscopiecentra en endoscopisten – Bevolkingsonderzoek Darmkanker. 2012 https://www.rivm.nl/documenten/protocol-toelating-en-auditing-coloscopiecentra-endoscopisten
- 12 Bronzwaer MES, Depla A, van Lelyveld N. et al. Quality assurance of colonoscopy within the Dutch national colorectal cancer screening program. Gastrointest Endosc 2019; 89: 1-13
- 13 Calderwood AH, Schroy 3rd PC, Lieberman DA. et al. Boston Bowel Preparation Scale scores provide a standardized definition of adequate for describing bowel cleanliness. Gastrointest Endosc 2014; 80: 269-276
- 14 Schlemper RJ, Riddell RH, Kato Y. et al. The Vienna classification of gastrointestinal epithelial neoplasia. Gut 2000; 47: 251-255
- NVMDL (Dutch Association of Gastroenterology) – Dutch Guideline Colonoscopy Surveillance 2013.
- 16 Hassan C, Quintero E, Dumonceau JM. et al. Post-polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2013; 45: 842-851
- 17 Lieberman D, Moravec M, Holub J. et al. Polyp size and advanced histology in patients undergoing colonoscopy screening: implications for CT colonography. Gastroenterology 2008; 135: 1100-1105
- 18 Von Renteln D, Bouin M, Barkun AN. Current standards and new developments of colorectal polyp management and resection techniques. Expert Rev Gastroenterol Hepatol 2017; 11: 835-842
- 19 Vleugels JLA, Hassan C, Senore C. et al. Diminutive polyps with advanced histologic features do not increase risk for metachronous advanced colon neoplasia. Gastroenterology 2019; 156: 623-634 e623
- 20 Vleugels JLA, Dijkgraaf MGW, Hazewinkel Y. et al. Effects of training and feedback on accuracy of predicting rectosigmoid neoplastic lesions and selection of surveillance intervals by endoscopists performing optical diagnosis of diminutive polyps. Gastroenterology 2018; 154: 1682-1693
- 21 Ignjatovic A, East JE, Suzuki N. et al. Optical diagnosis of small colorectal polyps at routine colonoscopy (Detect InSpect ChAracterise Resect and Discard; DISCARD trial): a prospective cohort study. Lancet Oncol 2009; 10: 1171-1178
- 22 Ladabaum U, Fioritto A, Mitani A. et al. Real-time optical biopsy of colon polyps with narrow band imaging in community practice does not yet meet key thresholds for clinical decisions. Gastroenterology 2013; 144: 81-91
- 23 Rees CJ, Rajasekhar PT, Wilson A. et al. Narrow band imaging optical diagnosis of small colorectal polyps in routine clinical practice: the Detect Inspect Characterise Resect and Discard 2 (DISCARD 2) study. Gut 2017; 66: 887-895
- 24 Klare P, Haller B, Wormbt S. et al. Narrow-band imaging vs. high definition white light for optical diagnosis of small colorectal polyps: a randomized multicenter trial. Endoscopy 2016; 48: 909-915
- 25 Basford PJ, Longcroft-Wheaton G, Higgins B. et al. High-definition endoscopy with i-Scan for evaluation of small colon polyps: the HiSCOPE study. Gastrointestinal endoscopy 2014; 79: 111-118
- 26 Kuiper T, Marsman WA, Jansen JM. et al. Accuracy for optical diagnosis of small colorectal polyps in nonacademic settings. Clin Gastroenterol Hepatol 2012; 10: 1016-1020; quiz e1079
- 27 Repici A, Ciscato C, Correale L. et al. Narrow-band Imaging International Colorectal Endoscopic Classification to predict polyp histology: REDEFINE study (with videos). Gastrointest Endosc 2016; 84: 479-486 e473
- 28 JE IJ, Bastiaansen BA, van Leerdam ME. et al. Development and validation of the WASP classification system for optical diagnosis of adenomas, hyperplastic polyps and sessile serrated adenomas/polyps. Gut 2016; 65: 963-970
- 29 Schachschal G, Mayr M, Treszl A. et al. Endoscopic versus histological characterisation of polyps during screening colonoscopy. Gut 2014; 63: 458-465
- 30 Vleugels JLA, Greuter MJE, Hazewinkel Y. et al. Implementation of an optical diagnosis strategy saves costs and does not impair clinical outcomes of a fecal immunochemical test-based colorectal cancer screening program. Endosc Int Open 2017; 5: E1197-E1207
- 31 Kaltenbach T, Rex DK, Wilson A. et al. Implementation of optical diagnosis for colorectal polyps: standardization of studies is needed. Clin Gastroenterol Hepatol 2015; 13: 6-10 e11
- 32 Kaminski MF, Hassan C, Bisschops R. et al. Advanced imaging for detection and differentiation of colorectal neoplasia: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2014; 46: 435-449
- 33 Atkinson NS, East JE. Optical biopsy and sessile serrated polyps: Is DISCARD dead? Long live DISCARD-lite!. Gastrointest Endosc 2015; 82: 118-121
- 34 von Renteln D, Kaltenbach T, Rastogi A. et al. Simplifying resect and discard strategies for real-time assessment of diminutive colorectal polyps. Clin Gastroenterol Hepatol 2018; 16: 706-714
- 35 Mori Y, Kudo SE, Misawa M. et al. Real-time use of artificial intelligence in identification of diminutive polyps during colonoscopy: a prospective study. Ann Intern Med 2018; 169: 357-366
- 36 Byrne MF, Chapados N, Soudan F. et al. Real-time differentiation of adenomatous and hyperplastic diminutive colorectal polyps during analysis of unaltered videos of standard colonoscopy using a deep learning model. Gut 2017; DOI: 10.1136/gutjnl-2017-314547.
- 37 Chen PJ, Lin MC, Lai MJ. et al. Accurate Classification of diminutive colorectal polyps using computer-aided analysis. Gastroenterology 2018; 154: 568-575
- 38 Vinsard DG, Mori Y, Misawa M. et al. Quality assurance of computer-aided detection and diagnosis in colonoscopy. Gastrointest Endosc 2019; 90: 55-63