Linked-color imaging versus high definition white-light endoscopy for evaluation of post-polypectomy scars of nonpedunculated lesions: LCI-Scar study

Abstract

Background Detection and treatment of recurrence after piecemeal endoscopic mucosal resection of nonpedunculated colorectal polyps are crucial for avoidance of post-colonoscopy cancer. Linked-color imaging (LCI) has demonstrated improved polyp detection but has never been assessed for evaluation of post-polypectomy scars. Our aim was to compare sensitivity and negative predictive value (NPV) between LCI and white-light endoscopy (WLE) for detection of post-polypectomy recurrence.

Methods Patients undergoing surveillance colonoscopy after resection of lesions ≥15 mm were included in this prospective, single-center, randomized, crossover study. Each post-polypectomy scar underwent two examinations, one with LCI and the other with WLE, performed by two blinded endoscopists. Blue-light imaging (BLI) was then applied. A diagnosis of recurrence with a level of confidence was made for each modality and histopathology was the gold standard.

Results 129 patients with 173 scars were included. Baseline patient, lesion, and procedural characteristics were similar in both arms. Recurrence was detected in 56/173 (32.4%), with 27/56 (48.2%) adenomas and 29/56 (51.8%) serrated lesions. LCI had greater sensitivity (96.4% [95%CI 87.8%–99.5%]) versus WLE (89.3% [95%CI 78.1%–95.9%]) and greater NPV (98.1% [95%CI 93.4%–99.8%] versus 94.6% [95%CI 88.7%–98.0%]). Paired concordance between modalities was 96.0%. In discordant cases, LCI identified four true-positive cases not detected by WLE and reclassified one false-positive of WLE. WLE reclassified two false positives of LCI without any increase in recurrence detection.

Conclusions LCI was highly accurate and had greater ability than WLE to rule out recurrence on post-polypectomy scars after resection of large polyps.

• References

• 1 Zauber AG, Winawer SJ, O’Brien MJ. et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012; 366: 687-696
• 2 Robertson DJ, Lieberman DA, Winawer SJ. et al. Colorectal cancers soon after colonoscopy: a pooled multicohort analysis. Gut 2014; 63: 949-956
• 3 Rutter MD, Beintaris I, Valori R. et al. World Endoscopy Organization Consensus Statements on post-colonoscopy and post-imaging colorectal cancer. Gastroenterology 2018; 155: 909-925.e3
• 4 le Clercq CMC, Bouwens MWE, Rondagh EJA. et al. Postcolonoscopy colorectal cancers are preventable: a population-based study. Gut 2014; 63: 957-963
• 5 Pohl H, Srivastava A, Bensen SP. et al. Incomplete polyp resection during colonoscopy – results of the Complete Adenoma Resection (CARE) study. Gastroenterology 2013; 144: 74-80.e1
• 6 Moss A, Williams SJ, Hourigan LF. et al. Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study. Gut 2015; 64: 57-65
• 7 Desomer L, Tutticci N, Tate DJ. et al. A standardized imaging protocol is accurate in detecting recurrence after EMR. Gastrointest Endosc 2017; 85: 518-526
• 8 Pohl H, Anderson JC, Aguilera-Fish A. et al. Recurrence of colorectal neoplastic polyps after incomplete resection. Ann Intern Med 2021; 174: 1377-1384
• 9 Kandel P, Brand EC, Pelt J. et al. Endoscopic scar assessment after colorectal endoscopic mucosal resection scars: when is biopsy necessary (EMR Scar Assessment Project for Endoscope (ESCAPE) trial). Gut 2019; 68: 1633-1641
• 10 Riu Pons F, Andreu M, Naranjo D. et al. Narrow-band imaging and high-definition white-light endoscopy in patients with serrated lesions not fulfilling criteria for serrated polyposis syndrome: a randomized controlled trial with tandem colonoscopy. BMC Gastroenterol 2020; 20: 111
• 11 Bisschops R, East JE, Hassan C. et al. Advanced imaging for detection and differentiation of colorectal neoplasia: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2019. Endoscopy 2019; 51: 1155-1179
• 12 Oliveira dos Santos CE, Malaman D, Pereira-Lima JC. et al. Impact of linked-color imaging on colorectal adenoma detection. Gastrointest Endosc 2019; 90: 826-834
• 13 Paggi S, Mogavero G, Amato A. et al. Linked color imaging reduces the miss rate of neoplastic lesions in the right colon: a randomized tandem colonoscopy study. Endoscopy 2018; 50: 396-402
• 14 Houwen BBSL, Hazewinkel Y, Pellisé M. et al. Linked colour imaging for the detection of polyps in patients with Lynch syndrome: a multicentre, parallel randomised controlled trial. Gut 2022; 71: 553-560
• 15 Bossuyt PM, Reitsma JB, Bruns DE. et al. STARD 2015: an updated list of essential items for reporting diagnostic accuracy studies. BMJ 2015; 351: h5527
• 16 Higaki S, Hashimoto S, Harada K. et al. Long-term follow-up of large flat colorectal tumors resected endoscopically. Endoscopy 2003; 10: 845-849
• 17 Dixon MF. Gastrointestinal epithelial neoplasia: Vienna revisited. Gut 2002; 51: 130-131
• 18 Schlemper RJ, Riddell RH, Kato Y. et al. The Vienna classification of gastrointestinal epithelial neoplasia. Gut 2000; 47: 251-255
• 19 Saito S, Tajiri H, Ikegami M. Serrated polyps of the colon and rectum: endoscopic features including image enhanced endoscopy. World J Gastrointest Endosc 2015; 7: 860
• 20 Caraguel CGB, Vanderstichel R. The two-step Fagan’s nomogram: ad hoc interpretation of a diagnostic test result without calculation. Evid Based Med 2013; 18: 125-128
• 21 Ranganathan P, Aggarwal R. Understanding the properties of diagnostic tests – Part 2: Likelihood ratios. Perspect Clin Res 2018; 9: 99
• 22 Belderbos TDG, Leenders M, Moons LMG. et al. Local recurrence after endoscopic mucosal resection of nonpedunculated colorectal lesions: systematic review and meta-analysis. Endoscopy 2014; 46: 388-400
• 23 Newcombe RG. Two-sided confidence intervals for the single proportion: comparison of seven methods. Stat Med 1998; 17: 857-872
• 24 Hajian-Tilaki K. Sample size estimation in diagnostic test studies of biomedical informatics. J Biomed Inform 2014; 48: 193-204
• 25 Tate DJ, Desomer L, Klein A. et al. Adenoma recurrence after piecemeal colonic EMR is predictable: the Sydney EMR recurrence tool. Gastrointest Endosc 2017; 85: 647-656.e6
• 26 Higurashi T, Ashikari K, Tamura S. et al. Comparison of the diagnostic performance of NBI, laser-BLI and LED-BLI: a randomized controlled noninferiority trial. Surg Endosc 2022; 36: 7577-7587
• 27 Andreu M, Beltran JG, Álvarez-Gonzalez MA. et al. Narrow band imaging and white light endoscopy in the characterization of a polypectomy scar: a single-blind observational study. World J Gastroenterol 2018; 24: 5179-5188
• 28 Pellise M, Burgess NG, Tutticci N. et al. Endoscopic mucosal resection for large serrated lesions in comparison with adenomas: a prospective multicentre study of 2000 lesions. Gut 2017; 66: 644-653
• 29 Pellisé M, Desomer L, Burgess NG. et al. The influence of clips on scars after EMR: clip artifact. Gastrointest Endosc 2016; 83: 608-616
• 30 East JE, Vleugels JL, Roelandt P. et al. Advanced endoscopic imaging: European Society of Gastrointestinal Endoscopy (ESGE) Technology Review. Endoscopy 2016; 48: 1029-1045