Interval Colorectal Cancer 전임의 남지혁

Comparison of the Observed Incidence of Colorectal Cancer in the National Polyp Study Cohort with That Expected on the Basis of Data from the Three Reference Groups Winawer SJ et al. N Engl J Med 1993;329:

Clinical Gastroenterology and Hepatology Vol. 12, No. 1 Incidence/mortality of CRC and screening uptake rates over time. CRC incidence/mortality reported as rates among adults age 50 years or older (Surveillance, Epidemiology and End Results database) to reflect the screening population.

Korean J Gastroenterol, Vol. 59 No. 2, February 2012 대장내시경검사 (1)50 세 이상 평균위험군에서 대장암 선별과 대장샘종 진단검사로 대장내시경검 사를 우선적으로 권고한다. (2) 50 세 이상 평균위험군에서 첫 선별대장내시경검사가 일정 질 수준 이상으로 이루어졌다면 대장암이나 대장샘종이발견되지 않은 경우 5 년 이후 추적대장 내시경검사를 권고한다. 단, 대장암 경고증상이 새롭게 발생한 환자를 포함하 여추적기간 내 중간암의 우려가 있다고 의사가 판단하는 경우 5 년 이내라도 추적검사를 시행할 수 있다

일정한 자격을 갖춘 대장내시경의사가 양호한 대장정결상태에서 양질의 기준대 장내시경검사를 시행하였음을 전제로 기준대장내시경검사 소견이 폴립절제 후 진행신생물 발생의 고위험군에 해당되지 않는 경우, 추적대장내시경검사 를폴립절제 후 5 년에 시행할 것을 권고한다. 일정한 자격을 갖춘 대장내시경의사가 양호한 대장정결상태에서 양질의 기준대 장내시경검사를 시행하였음을 전제로 기준대장내시경검사 소견이 폴립절제 후 진행신생물 발생의 고위험군에 해당하는 경우는 추적대장내시경검사를 폴 립절제 후 3 년에 시행할 것을 권고한다. Korean J Gastroenterol 2012;59:99-117

대장 내시경은 대장암 사망률을 감소 시키는가 ? AuthorYearNCRC motalitiy reduction Bxter200910,292(case) 51,460(control) 67% (Lt) 1% (Rt) Singh201054,80329%, 47%(Lt),0%(Rt) Ranbeneck20102,412,0473% decrease/ 1% increase in colonoscopy Zauber20122,60253%

Interval Colorectal Cancer Interval Colorectal Cancer  Postcolonoscopy CRC after colonoscopy(0 - 5 yr) = Interval cnacer  Interval advanced adenoma > 1 CM villous high grade dysplasia

Interval cancer 의 빈도와 호발 위치  Clinical Gastroenterology and Hepatology Vol. 12, No. 1

Interval between last colonoscopy and index admission April 1997 ~ Mar Pt with new right colon cancer 2654 patients had at least 1 colonoscopy with 3 yrs 158 (7%)

중간암이 근위부 대장에 흔한 이유는 ? 중간암이 근위부 대장에 흔한 이유는 ? In the proximal colon  Worse bowel prepration  More incomplete colonoscopies  More difficult to examine ( esp. proximal to the IC valve, hepatic flexure or folds)  Flat lesions are more common

Interval cancer 의 위험인자 Clinical Gastroenterology and Hepatology Vol. 12, No. 1

Patient factor Age: every 10 year increase : OR 1.18(1.08 ~ 1.28) Female(2.28) Diverticulosis(OR 6.0) Positive FOBT (OR 2.93) Prior index colonoscopy Advanced adenoma, villous adenoma, high grade dysplasia Polypectomy (OR4.33), biopsy (2.97) Incomplete colonoscopy (OR 7.24) Endoscopist –related factor Lower polypetomy rate Lower adenoma detection rate Nongastroenterologist/nonsurgeon (OR 1.88, 1.67) Family medicine(OR 1.59) Nonhospital setting(OR 1.88) Rural hospital (OR 2.11) > Urban hospital

Why do Interval cancer occur ?  Why Colorectal Cancers Appear in the Period Shortly After Clearing Colonoscopy Am J Gastroenterol 2006;101:2866–2877

중간암의 원인 분석 Robertson DJ, et al. Gut 2014;63:949–956

중간암의 원인 분석 Interval cancer/ Total participants Missed lesion Incomplete ressection New lesion Failed biopsy Robertson /9,16752% ( 30 )19% ( 11 )24% ( 14 )5% ( 3 ) Huang /1,79436% ( 5 )50% ( 7 )14% ( 2) Pabby /2,07923% ( 3 )30.7% ( 4 )23% ( 3 ) Total85/13, % (38)25,9% (22)22.4% (19)7.0%( 6 )

Characteristics of missed polyp Endoscopy 2008; 40: 284 ± 290

Polyp Miss Rate Determined by Tandem Colonoscopy: A Systematic Review The American Journal of Gastroenterology (2006) 101, 343–350

Adenoma miss rate by size [Biliary cystadenocarcinoma of the liver: the need for complete resection, Eur J Cancer Nov; 34(12): ]

Screening Colonoscopies and Detection Rates  6681 screening colonoscopies,15 gastroenterologists, over a 10-year period  11,049 polyps (adenomas(51%) serrated polyps(36%) proximal serrated polyps (11% ) CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2011;9:42–46

Rates of Detection of Lesions According to Mean Withdrawal Time N Engl J Med 2006;355: Colonoscopies(2053 screening), 12 experienced gastroenterologists, 15-month

Risk of the Patients with Missed Polyp, Adenoma or Advanced Adenoma by Bowel Preparation Status Clin Endosc 2012;45:

Adenoma 발견률이 높으면 ? 186 endoscopist 45,026 patients 42 interval cancers N Engl J Med 2010; 362:

Complete colonoscopy 와 interval cancer 와 상관 관계 GASTROENTEROLOGY 2011;140:65– ~2005, 14,064 CRC patients 6.8% distal / 12.4% proximal interval cancer Complete colonoscopy : to cecum, to termonal ileum

Missed polyp / cancer Contribute to 44.7% (23-54%) of interval cancer Technical limitations : hidden mucosa, flat lesion Endoscopist – dependent Suboptimal observation techniques/ withdrawal time Incomplete bowel preparation Incomplete colonoscopy ]

폴립의 불완전 절제

중간암의 원인 분석 Interval cancer/ Total participants Missed lesion Incomplete ressection New lesion Failed biopsy Robertson /9,16752% ( 30 )19% ( 11 )24% ( 14 )5% ( 3 ) Huang /1,79436% ( 5 )50% ( 7 )14% ( 2) Pabby /2,07923% ( 3 )30.7% ( 4 )23% ( 3 ) Total85/13, % (38)25,9% (22)22.4% (19)7.0%( 6 )

Pathologically incomplete resection rate : 10.1% (determined by the presence of neoplastic tissues on postpolypectomy biopsy)

Characteristics of incompletely resected polyps Characteristics of incompletely resected polyps

Polyp recurrence after endoscopic mucosal resection of sessile and flat colonic adenomas Dig Dis Sci 2011 Aug;56(8): ] 105 patients 121 flat or sessile adenomas (> 10mm) EMR : 67 piecemeal, 54 En –block Recurrence rate (piecemeal vs En bloc) : 9.9% vs 1.7%

Risk of incomplete resection for individual endoscopist

Incomplete resection of polyp Contribute to 25.9% (19-50%) of interval cancer Large, sessile polyp Piecemeal resection Endoscopist – dependent ]

중간암의 원인 분석 Interval cancer/ Total participants Missed lesion Incomplete ressection New lesion Failed biopsy Robertson /9,16752% ( 30 )19% ( 11 )24% ( 14 )5% ( 3 ) Huang /1,79436% ( 5 )50% ( 7 )14% ( 2) Pabby /2,07923% ( 3 )30.7% ( 4 )23% ( 3 ) Total85/13, % (38)25,9% (22)22.4% (19)7.0%( 6 )

Tumorigenesis of colorectal cancer

Molecular, clinical and morphological features of colorectal cancer

Molecular characteristics Interval CRC vs Noninterval CRC 감사합니다 Dig Dis Sci (2012) 57:913–917

빠르게 성장하는 종양 빠르게 성장하는 종양 Contribute to 22.4% (13-24%) of interval cancer May have different molecular profiles than non interval CRC Rapid growth Molecular diffenrnces Difficult to detect the lesions ] Interval cancer