Effect of optical diagnosis training on recognition and treatment of submucosal invasive colorectal cancer in community hospitals: a prospective multicenter intervention study

Abstract

Background Recognition of submucosal invasive colorectal cancer (T1 CRC) is difficult, with sensitivities of 35 %–60 % in Western countries. We evaluated the real-life effects of training in the OPTICAL model, a recently developed structured and validated prediction model, in Dutch community hospitals.

Methods In this prospective multicenter study (OPTICAL II), 383 endoscopists from 40 hospitals were invited to follow an e-learning program on the OPTICAL model, to increase sensitivity in detecting T1 CRC in nonpedunculated polyps. Real-life recognition of T1 CRC was then evaluated in 25 hospitals. Endoscopic and pathologic reports of T1 CRCs detected during the next year were collected retrospectively, with endoscopists unaware of this evaluation. Sensitivity for T1 CRC recognition, R0 resection rate, and treatment modality were compared for trained vs. untrained endoscopists.

Results 1 year after e-learning, 528 nonpedunculated T1 CRCs were recorded for endoscopies performed by 251 endoscopists (118 [47 %] trained). Median T1 CRC size was 20 mm. Lesions were mainly located in the distal colorectum (66 %). Trained endoscopists recognized T1 CRCs more frequently than untrained endoscopists (sensitivity 74 % vs. 62 %; mixed model analysis odds ratio [OR] 2.90, 95 %CI 1.54–5.45). R0 resection rate was higher for T1 CRCs detected by trained endoscopists (69 % vs. 56 %; OR 1.73, 95 %CI 1.03–2.91).

Conclusion Training in optical recognition of T1 CRCs in community hospitals was associated with increased recognition of T1 CRCs, leading to higher en bloc and R0 resection rates. This may be an important step toward more organ-preserving strategies.

Publication History

Received: 07 April 2023

Accepted: 24 April 2024

Accepted Manuscript online:
24 April 2024

Article published online:
11 June 2024

• References

• 1 Bahin FF, Heitman SJ, Rasouli KN. et al. Wide-field endoscopic mucosal resection versus endoscopic submucosal dissection for laterally spreading colorectal lesions: a cost-effectiveness analysis. Gut 2018; 67: 1965-1973
• 2 Vleugels JLA, Koens L, Dijkgraaf MGW. et al. Suboptimal endoscopic cancer recognition in colorectal lesions in a national bowel screening programme. Gut 2020; 69: 977-980
• 3 Meulen LWT, van de Wetering AJP, Debeuf MPH. et al. Optical diagnosis of T1 CRCs and treatment consequences in the Dutch CRC screening programme. Gut 2020; 69: 2049-2051
• 4 Denis B, Gendre I, Perrin P. et al. Management of large polyps in a colorectal cancer screening program with fecal immunochemical test: a community- and population-based observational study. Endosc Int Open 2021; 9: E1649-E1657
• 5 Puig I, Lopez-Ceron M, Arnau A. et al. Accuracy of the Narrow-Band Imaging International Colorectal Endoscopic classification system in identification of deep invasion in colorectal polyps. Gastroenterology 2019; 156: 75-87
• 6 Backes Y, Moss A, Reitsma JB. et al. Narrow band imaging, magnifying chromoendoscopy, and gross morphological features for the optical diagnosis of T1 colorectal cancer and deep submucosal invasion: a systematic review and meta-analysis. Am J Gastroenterol 2017; 112: 54-64
• 7 Zhang QW, Teng LM, Zhang XT. et al. Narrow-band imaging in the diagnosis of deep submucosal colorectal cancers: a systematic review and meta-analysis. Endoscopy 2017; 49: 564-580
• 8 Burgess NG, Hourigan LF, Zanati SA. et al. Risk stratification for covert invasive cancer among patients referred for colonic endoscopic mucosal resection: a large multicenter cohort. Gastroenterology 2017; 153: 732-742.e731
• 9 D’Amico F, Amato A, Iannone A. et al. Risk of covert submucosal cancer in patients with granular mixed laterally spreading tumors. Clin Gastroenterol Hepatol 2021; 19: 1395-1401
• 10 Vosko S, Shahidi N, Sidhu M. et al. Optical evaluation for predicting cancer in large nonpedunculated colorectal polyps is accurate for flat lesions. Clin Gastroenterol Hepatol 2021; 19: 2425-2434.e2424
• 11 Bonniaud P, Jacques J, Lambin T. et al. Endoscopic characterization of colorectal neoplasia with different published classifications: comparative study involving CONECCT classification. Endosc Int Open 2022; 10: E145-E153
• 12 Backes Y, Schwartz MP, Ter Borg F. et al. Multicentre prospective evaluation of real-time optical diagnosis of T1 colorectal cancer in large non-pedunculated colorectal polyps using narrow band imaging (the OPTICAL study). Gut 2019; 68: 271-279
• 13 Fabritius M, Gonzalez JM, Becq A. et al. A simplified table using validated diagnostic criteria is effective to improve characterization of colorectal polyps: the CONECCT teaching program. Endosc Int Open 2019; 7: E1197-E1206
• 14 Brule C, Pioche M, Albouys J. et al. The COlorectal NEoplasia Endoscopic Classification to Choose the Treatment classification for identification of large laterally spreading lesions lacking submucosal carcinomas: a prospective study of 663 lesions. United European Gastroenterol J 2022; 10: 80-92
• 15 Hirata D, Kashida H, Iwatate M. et al. Effective use of the Japan Narrow Band Imaging Expert Team classification based on diagnostic performance and confidence level. World J Clin Cases 2019; 7: 2658-2665
• 16 Hosotani K, Imai K, Hotta K. et al. Diagnostic performance for T1 cancer in colorectal lesions ≥ 10 mm by optical characterization using magnifying narrow-band imaging combined with magnifying chromoendoscopy; implications for optimized stratification by Japan Narrow-band Imaging Expert Team classification. Dig Endosc 2021; 33: 425-432
• 17 Komeda Y, Kashida H, Sakurai T. et al. Magnifying narrow band imaging (NBI) for the diagnosis of localized colorectal lesions using the Japan NBI Expert Team (JNET) classification. Oncology 2017; 93 (Suppl. 01) 49-54
• 18 Iwatate M, Sano Y, Tanaka S. et al. Validation study for development of the Japan NBI Expert Team classification of colorectal lesions. Dig Endosc 2018; 30: 642-651
• 19 Casparie M, Tiebosch AT, Burger G. et al. Pathology databanking and biobanking in The Netherlands, a central role for PALGA, the nationwide histopathology and cytopathology data network and archive. Cell Oncol 2007; 29: 19-24
• 20 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
• 21 Heidari S, Babor TF, De Castro P. et al. Sex and gender equity in research: rationale for the SAGER guidelines and recommended use. Res Integr Peer Rev 2016; 1: 2
• 22 van Oostendorp SE, Smits LJH, Vroom Y. et al. Local recurrence after local excision of early rectal cancer: a meta-analysis of completion TME, adjuvant (chemo)radiation, or no additional treatment. Br J Surg 2020; 107: 1719-1730
• 23 Fukuda H, Takeuchi Y, Shoji A. et al. Curative value of underwater endoscopic mucosal resection for submucosally invasive colorectal cancer. J Gastroenterol Hepatol 2021; 36: 2471-2478
• 24 Zwager LW, Bastiaansen BAJ, Montazeri NSM. et al. Deep submucosal invasion is not an independent risk factor for lymph node metastasis in T1 colorectal cancer: a meta-analysis. Gastroenterology 2022; 163: 174-189
• 25 Didden P, van Eijck van Heslinga RAH, Schwartz MP. et al. Relevance of polyp size for primary endoscopic full-thickness resection of suspected T1 colorectal cancers. Endoscopy 2022; 54: 1062-1070
• 26 Leicher LW, Huisman JF, van Grevenstein WMU. et al. Colonoscopic-assisted laparoscopic wedge resection for colonic lesions: a prospective multicenter cohort study (LIMERIC-Study). Ann Surg 2022; 275: 933-939
• 27 Moons LMG, Bastiaansen BAJ, Richir MC. et al. Endoscopic intermuscular dissection for deep submucosal invasive cancer in the rectum: a new endoscopic approach. Endoscopy 2022; 54: 993-998