MALIGNANT OBSTRUCTIVE JAUNDICE

MINICORSO
Come migliorare
l’adenoma detection rate
Teresa Staiano
Gianluca Rotondano
Napoli, 19 marzo 2014
NATIONAL COLORECTAL CANCER AWARENESS MONTH, 2014
NOW, THEREFORE, I, BARACK OBAMA, President of the United States of America, by virtue of the
authority vested in me by the Constitution and the laws of the United States,
do hereby proclaim March 2014 as National Colorectal Cancer Awareness Month.
I encourage all citizens, government agencies, private businesses, non-profit organizations, and other
groups to join in activities that will increase awareness and prevention of colorectal cancer.
28 February 2014
BARACK OBAMA
Prevention of CRC: double impact of colonoscopy
1. early detection and removal of precancerous lesions
(polypectomy)  reduced incidence
2. diagnosis and treatment of colorectal cancer at early
stage  reduced mortality
Lambert R, Gastrointest Endosc 2009;70:1182-99
National Polyp Study
Study on mortality from colorectal cancer
2602 patients had adenomas removed
After a median of 15.8 years
SIR-mortality 0.47 [0.26 - 0.80] = 53% reduction in mortality
Zauber AG, N Engl J Med 2012;366:687-96
Association of colonoscopy with CRC incidence and mortality
Author
Country
Overall CRC
[95% CI]
Left-sided CRC
[95% CI]
Right-sided CRC
[95% CI]
Baxter
2009
Canada
OR 0.63 [0.570.69]
0.33 [0.28-0.39]
0.99 [0.86-1.14]
Mulder
2010
Netherlands
OR 0.56 [0.330.94]
0.36 [0.17-0.76]
0.98 [0.42-2.25]
Brenner
2010
Germany
PR 0.52 [0.370.73]
0.33 [0.21-0.53]
1.05 [0.63-1.76]
Canada
SMR 0.71 [0.610.82]
0.53 [0.42-0.67]
0.94 [0.77-1.17]
Brenner
2011
Germany
OR 0.23 [0.190.27]
0.16 [0.12-0.20]
0.44 [0.35-0.55]
Baxter
2012
US
OR 0.40 [0.370.43]
0.24 [0.21-0.27]
0.58 [0.53-0.64]
Singh
2010
Kahi CJ, Gastrointest Endosc 2013;77:335-50
Colonoscopy has long been considered
a nearly infallible test, but…
“Interval” cancers
1.8-14.4%
Brenner H, Gut 2012;61:1576-82
Adenoma miss rate
15-27%
Cooper GS, Cancer 2012;118:3044-52
1. Cosa è l’adenoma detection rate
2. Perché è così importante
3. Quali sono i fattori che determinano l’ADR
4. Come si può migliorare l’ADR
ADENOMA DETECTION RATE (ADR)
(N. pts with a least 1 adenoma / total N. pts)
 The most important outcome quality indicator for colonoscopy
 Independent predictor of interval colorectal cancer
In screening colonoscopies
≥25% in man
≥15% in women
Adler A, Gut 2013;62:236-41
Hazewinkel Y, Nat Rev Gastroenterol Hepatol 2011;8:554-64
NHS Bowel Cancer Screening Programme
Lee TJW, Gut 2012 ;61: 1050-7
Factors potentially associated with ADR
Patient
Endoscopist
Technology
Age > 65
Experience (knowledge of lesions &
HD scopes
technical competency)
Male gender
Sedation & spasmolytics
Image enhancement - NBI
Bowel cleansing
High quality colonoscopy
Special devices (3rd eye)
Full spectrum endoscopy
Lee TJW, Endoscopy 2014;46:203-11
• high-definition white light colonoscopy
• adequate luminal distension
• adequate cleanup of stool, mucus and bubbles (wash colon
surface)
• “working the folds” (careful inspection behind folds)
• cap-fitted colonoscopy
• recognition of subtle flat polyps (color, surface shape and contour,
loss of vascular pattern)
• recognition of serrated lesions (mucus cap)
• examine the right colon twice…
• adequate time !
Bourke MJ & Rex DK, Am J Gastroenterol 2012;107:1467-72
Modifiable endoscopic factors to improve ADR
Intervention
Colonoscopy withdrawal time > 8-10 minutes
Cecal intubation (> 95%)
Split bowel preparation and runway time less than 6-10 hrs
CME courses
Use of intravenous spasmolytics
Earlier procedure start time within a session
Greater colonoscopist experience
Jover R, GIE 2013;77:381-9
Butterly L, Am J Gastroenterol 2014;109:417-26
Lee TJ, Endoscopy 2013;45:20-6
Endoscopic innovations to improve ADR during colonoscopy
Intervention
Increased ADR
HD WLE
Limited increase in diagnostic yield
NBI
Better recognition of flat and small lesions
AFI
Lower adenoma miss rate (ARR 20%) – no routine
Water immersion
No – reduces pain scores and need for sedation
Water exchange
10% higher ADR – time consuming
Cap-assisted
10% higher ADR – can assist during EMR
Retroflexion
No – may facilitate removal of large polyps
Third-eye retroscope
15-25% higher ADR – reduces suction, not practical for polypectomy
FUSE
Considerably lower miss rate – requires little training
Dik VK, World J Gastroenterol 2014; 20: 2200-11
Advanced endoscopic
imaging
improves ADR ?
Overall detection of adenomas
6 studies;
n=2,284;
OR: 1.01 [0.74-1.37]
N. patients with polyps
6 studies;
n=2,275;
OR: 1.15 [0.80-1.64]
N. patients with adenomas
4 studies;
n=2,177;
OR: 1.0 [ 0.83-1.20]
Detection <10 mm adenomas
5 studies;
n=1,618;
OR: 1.32 [0.92-1.88]
Flat adenomas
5 studies;
n=1,675;
OR: 1.26 [0.62-2.57]
Compared with HD-WLE, HD-NBI does not increase the yield of
colon polyps, adenomas, or flat adenomas, nor does it decrease the
miss rate of colon polyps or adenomas
Pasha SF, Am J Gastroenterol 2012;107:363-70
Full-spectrum Endoscopy (FUSE)
N.pts randomised
Adenoma miss rate
Standard 170°
forward-viewing
first
FUSE
330°
first
88
97
40.8%
7.5%
P value
0.0001
FUSE represents a technology advancement for colonoscopy
and could improve the efficacy of colorectal cancer screening
and surveillance
Gralnek IM, Lancet Oncol 2014;15:353-60
Full-spectrum Endoscopy (FUSE)
Unità Operativa di Gastroenterologia, Torre del Greco
“Colorectal cancer screening is an American public health success story because
through colonoscopy fewer people are developing or dying from the disease”
Harry Sarles, President, American College of Gastroenterology
http://valueofcolonoscopy.org

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