New Paradigms for Colonoscopic Management of Diminutive Colorectal Polyps: Predict, Resect, and Discard or Do Not Resect?

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Abstract

The possibility to predict in vivo the histology of colorectal polyps by advanced endoscopic imaging has resulted in the implementation of a more conservative management for diminutive lesions detected at colonoscopy. In detail, a predict-and-do-not-resect strategy has been proposed for diminutive lesions located in the rectosigmoid tract, whilst a predict-resect-and-discard policy has been advocated for nonrectosigmoid diminutive polyps. Recently, the American Society for Gastrointestinal Endoscopy set required thresholds to be met, before allowing the adoption of these policies in the clinical field. The ability of current endoscopic imaging in reaching these thresholds would depend on a complex interaction among the accuracy of advanced endoscopic imaging in differentiating between adenomatous and hyperplastic lesions, the prevalence of (advanced) neoplasia within diminutive lesions, and the type of surveillance intervals recommended. Aim of this review is to summarize the data supporting the application of both a predict-and-do-not-resect and a predict-resect-and-discard policies, also addressing the potential pitfalls associated with these strategies.

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Most cited references 58

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Validation of a simple classification system for endoscopic diagnosis of small colorectal polyps using narrow-band imaging.

David G. Hewett, Tonya Kaltenbach, Yasushi Sano … (2012)

Almost all colorectal polyps ≤ 5 mm are benign, yet current practice requires costly pathologic analysis. We aimed to develop and evaluate the validity of a simple narrow-band imaging (NBI)-based classification system for differentiating hyperplastic from adenomatous polyps. The study was conducted in 4 phases: (1) evaluation of accuracy and reliability of histologic prediction by NBI-experienced colonoscopists; (2) development of a classification based on color, vessels, and surface pattern criteria, using a modified Delphi method; (3) validation of the component criteria by people not experienced in endoscopy or NBI analysis (25 medical students, 19 gastroenterology fellows) using 118 high-definition colorectal polyp images of known histology; and (4) validation of the classification system by NBI-trained gastroenterology fellows, using still images. We performed a pilot evaluation during real-time colonoscopy. We developed a classification system for the endoscopic diagnosis of colorectal polyp histology and established its predictive validity. When all 3 criteria were used, the specificity ranged from 94.9% to 100% and the combined sensitivity ranged from 8.5% to 61.0%. The specificities of the individual criteria were lower although the sensitivities were higher. During real-time colonoscopy, endoscopists made diagnoses with high confidence for 75% of consecutive small colorectal polyps, with 89% accuracy, 98% sensitivity, and 95% negative predictive values. We developed and established the validity of an NBI classification system that can be used to diagnose colorectal polyps. In preliminary real-time evaluation, the system allowed endoscopic diagnoses of colorectal polyp histology. Copyright © 2012 AGA Institute. Published by Elsevier Inc. All rights reserved.

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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.

Douglas Rex, Charles Kahi, Michael V O'brien … (2011)

The PIVI (Preservation and Incorporation of Valuable endoscopic Innovations) initiative is an ASGE program whose objectives are to identify important clinical questions related to endoscopy and to establish a priori diagnostic and/or therapeutic thresholds for endoscopic technologies designed to resolve these clinical questions. Additionally, PIVIs may also outline the data and or the research study design required for proving an established threshold is met. Once endoscopic technologies meet an established PIVI threshold, those technologies are appropriate to incorporate into clinical practice presuming the appropriate training in that endoscopic technology has been achieved. The ASGE encourages and supports the appropriate use of technologies that meet its established PIVI thresholds. The PIVI initiative was developed primarily to direct endoscopic technology development toward resolving important clinical issues in endoscopy. The PIVI initiative is also designed to minimize the possibility that potentially valuable innovations are prematurely abandoned due to lack of utilization and to avoid widespread use of an endoscopic technology before clinical studies documenting their effectiveness have been performed. The following document, or PIVI, is one of a series of statements defining the diagnostic or therapeutic threshold that must be met for a technique or device to become considered appropriate for incorporation into clinical practice. It is also meant to serve as a guide for researchers or those seeking to develop technologies that are designed to improve digestive health outcomes. An ad hoc committee under the auspices of the existing ASGE Technology and Standards of Practice Committees Chairs develops PIVIs. An expert in the subject area chairs the PIVI, with additional committee members chosen for their individual expertise. In preparing this document, evidence-based methodology was employed, using a MEDLINE and PubMed literature search to identify pertinent clinical studies on the topic. PIVIs are ultimately submitted to the ASGE Governing Board for approval, as is done for all Technology and Standards of Practice documents. This document is provided solely for educational and informational purposes and to support incorporating these endoscopic technologies into clinical practice. It should not be construed as establishing a legal standard of care. Copyright © 2011. Published by Mosby, Inc.

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A pooled analysis of advanced colorectal neoplasia diagnoses after colonoscopic polypectomy.

María Elena Martínez, John A Baron, David A Lieberman … (2009)

Limited data exist regarding the actual risk of developing advanced adenomas and cancer after polypectomy or the factors that determine risk. We pooled individual data from 8 prospective studies comprising 9167 men and women aged 22 to 80 with previously resected colorectal adenomas to quantify their risk of developing subsequent advanced adenoma or cancer as well as identify factors associated with the development of advanced colorectal neoplasms during surveillance. During a median follow-up period of 47.2 months, advanced colorectal neoplasia was diagnosed in 1082 (11.8%) of the patients, 58 of whom (0.6%) had invasive cancer. Risk of a metachronous advanced adenoma was higher among patients with 5 or more baseline adenomas (24.1%; standard error, 2.2) and those with an adenoma 20 mm in size or greater (19.3%; standard error, 1.5). Risk factor patterns were similar for advanced adenomas and invasive cancer. In multivariate analyses, older age (P < .0001 for trend) and male sex (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.19-1.65) were associated significantly with an increased risk for metachronous advanced neoplasia, as were the number and size of prior adenomas (P < .0001 for trend), the presence of villous features (OR, 1.28; 95% CI, 1.07-1.52), and proximal location (OR, 1.68; 95% CI, 1.43-1.98). High-grade dysplasia was not associated independently with metachronous advanced neoplasia after adjustment for other adenoma characteristics. Occurrence of advanced colorectal neoplasia is common after polypectomy. Factors that are associated most strongly with risk of advanced neoplasia are patient age and the number and size of prior adenomas.

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Author and article information

Journal

Journal ID (nlm-ta): Clin Endosc

Journal ID (iso-abbrev): Clin Endosc

Journal ID (publisher-id): CE

Title: Clinical Endoscopy

Publisher: The Korean Society of Gastrointestinal Endoscopy

ISSN (Print): 2234-2400

ISSN (Electronic): 2234-2443

Publication date (Print): March 2013

Publication date (Electronic): 31 March 2013

Volume: 46

Issue: 2

Pages: 130-137

Affiliations

[1 ]Digestive Endoscopy Unit, Istituto Clinico Humanitas, Milan, Italy.

[2 ]Division of Gastroenterology, University of Kansas Medical Center, Kansas City, KS, USA.

Author notes

Correspondence: Cesare Hassan. Division of Gastroenterology, Ospedale Nuovo Regina Margherita Hospital, Via E. Morosini 30, I-00153 Rome, Italy. Tel: +39-3387922296, Fax: +39-3387922296, cesareh@ 123456hotmail.com

Article

DOI: 10.5946/ce.2013.46.2.130

PMC ID: 3630306

PubMed ID: 23614122

SO-VID: feb7a06f-e25e-452d-bddb-95b3f4d8a0b8

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 28 January 2013

Date revision received : 13 February 2013

Date accepted : 13 February 2013

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New Paradigms for Colonoscopic Management of Diminutive Colorectal Polyps: Predict, Resect, and Discard or Do Not Resect?

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Most cited references 58

Validation of a simple classification system for endoscopic diagnosis of small colorectal polyps using narrow-band imaging.

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.

A pooled analysis of advanced colorectal neoplasia diagnoses after colonoscopic polypectomy.

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Cited by 3

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