The “diagnose and leave in” strategy for diminutive rectosigmoid polyps in Lynch syndrome: a post hoc analysis from a randomized controlled trial

Abstract

Background The “diagnose-and-leave-in” policy has been established to reduce the risks and costs related to unnecessary polypectomies in the average-risk population. In individuals with Lynch syndrome, owing to accelerated carcinogenesis, the general recommendation is to remove all polyps, irrespective of size, location, and appearance. We evaluated the feasibility and safety of the diagnose-and-leave-in strategy in individuals with Lynch syndrome.

Methods We performed a post hoc analysis based on per-polyp data from a randomized, clinical trial conducted by 24 dedicated colonoscopists at 14 academic centers, in which 256 patients with confirmed Lynch syndrome underwent surveillance colonoscopy from July 2016 to January 2018. In vivo optical diagnosis with confidence level for all detected lesions was obtained before polypectomy using virtual chromoendoscopy alone or with dye-based chromoendoscopy. Primary outcome was the negative predictive value (NPV) for neoplasia of high-confidence optical diagnosis among diminutive (≤ 5 mm) rectosigmoid lesions. Histology was the reference standard.

Results Of 147 rectosigmoid lesions, 128 were diminutive. In 103 of the 128 lesions (81 %), the optical diagnostic confidence was high and showed an NPV of 96.0 % (95 % confidence interval [CI] 88.9 %–98.6 %) and accuracy of 89.3 % (95 %CI 81.9 %–93.9 %). By following the diagnose-and-leave-in policy, we would have avoided 59 % (75/128) of polypectomies at the expense of two diminutive low grade dysplastic adenomas and one diminutive sessile serrated lesion that would have been left in situ.

Conclusion In patients with Lynch syndrome, the diagnose-and-leave-in strategy for diminutive rectosigmoid polyps would be feasible and safe.

^* These authors contributed equally to this work.

Publication History

Received: 19 March 2020

Accepted after revision: 03 December 2020

Accepted Manuscript online:
03 December 2020

Article published online:
11 February 2021

• References

• 1 Moreira L, Balaguer F, Lindor N. et al. Identification of Lynch syndrome among patients with colorectal cancer. JAMA 2012; 308: 1555-1565
• 2 Vasen HFA, Boland CR. Progress in genetic testing, classification, and identification of Lynch syndrome. JAMA 2005; 293: 2028-2030
• 3 Ahadova A, Gallon R, Gebert J. et al. Three molecular pathways model colorectal carcinogenesis in Lynch syndrome. Int J Cancer 2018; 143: 139-150
• 4 Jenkins MA, Hayashi S, O’Shea A-M. et al. Pathology features in Bethesda guidelines predict colorectal cancer microsatellite instability: a population-based study. Gastroenterology 2007; 133: 48-56
• 5 Edelstein DL, Axilbund J, Baxter M. et al. Rapid development of colorectal neoplasia in patients with Lynch syndrome. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc 2011; 9: 340-343
• 6 Rijcken FEM, Hollema H, Kleibeuker JH. Proximal adenomas in hereditary non-polyposis colorectal cancer are prone to rapid malignant transformation. Gut 2002; 50: 382-386
• 7 Rondagh EJA, Gulikers S, Gómez-García EB. et al. Nonpolypoid colorectal neoplasms: a challenge in endoscopic surveillance of patients with Lynch syndrome. Endoscopy 2013; 45: 257-264
• 8 van Leerdam ME, Roos VH, van Hooft JE. et al. Endoscopic management of Lynch syndrome and of familial risk of colorectal cancer: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2019; 51: 1082-1093
• 9 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
• 10 Abu Dayyeh BK, Thosani N. ASGE Technology Committee. 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.e1-502.e16
• 11 Hazewinkel Y, López-Cerón M, East JE. et al. Endoscopic features of sessile serrated adenomas: validation by international experts using high-resolution white-light endoscopy and narrow-band imaging. Gastrointest Endosc 2013; 77: 916-924
• 12 Puig I, López-Cerón 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
• 13 Kudo S, Hirota S, Nakajima T. et al. Colorectal tumours and pit pattern. J Clin Pathol 1994; 47: 880-885
• 14 Hewett DG, Kaltenbach T, Sano Y. et al. Validation of a simple classification system for endoscopic diagnosis of small colorectal polyps using narrow-band imaging. Gastroenterology 2012; 143: 599-607
• 15 Rivero-Sánchez L, Arnau-Collell C, Herrero J. et al. White-light endoscopy is adequate for Lynch syndrome surveillance in a randomized and noninferiority study. Gastroenterology 2020; 158: 895-904
• 16 Harris PA, Taylor R, Thielke R. et al. Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42: 377-381
• 17 IJspeert JEG, Bastiaansen BAJ, 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
• 18 Nanda KS, Tutticci N, Burgess N. et al. Caught in the act: endoscopic characterization of sessile serrated adenomas with dysplasia. Gastrointest Endosc 2014; 79: 864-870
• 19 Tate DJ, Jayanna M, Awadie H. et al. A standardized imaging protocol for the endoscopic prediction of dysplasia within sessile serrated polyps (with video). Gastrointest Endosc 2018; 87: 222-231
• 20 Gastrointest Endosc. The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. 2003; 58: S3-43
• 21 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
• 22 Dixon MF. Gastrointestinal epithelial neoplasia: Vienna revisited. Gut 2002; 51: 130-131
• 23 Nagtegaal ID, Odze RD, Klimstra D. et al. The 2019 WHO classification of tumours of the digestive system. Histopathology 2020; 76: 182-188
• 24 Kaltenbach T, Rastogi A, Rouse RV. et al. Real-time optical diagnosis for diminutive colorectal polyps using narrow-band imaging: the VALID randomised clinical trial. Gut 2015; 64: 1569-1577
• 25 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
• 26 Bustamante-Balén M, Satorres C, Puchades L. et al. Non-guided self-learning program for high-proficiency optical diagnosis of diminutive and small colorectal lesions: a single-endoscopist pilot study. World J Gastroenterol 2019; 25: 1278-1288
• 27 IJspeert JEG, Bastiaansen BAJ, 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
• 28 Wong NACS, Hunt LP, Novelli MR. et al. Observer agreement in the diagnosis of serrated polyps of the large bowel. Histopathology 2009; 55: 63-66
• 29 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
• 30 Vleugels JLA, Sahin H, Hazewinkel Y. et al. Endoscopic detection rate of sessile serrated lesions in Lynch syndrome patients is comparable with an age- and gender-matched control population: case-control study with expert pathology review. Gastrointest Endosc 2018; 87: 1289-1296
• 31 Vleugels JLA, van Neerven SM, van Leerdam ME. et al. CD31-positive microvessel density within adenomas of Lynch Syndrome patients is similar compared to adenomas of non-Lynch patients. Endosc Int Open 2019; 7: E701-E707
• 32 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