1. Jasper Vleugels PhD-student AMC
Workshop
Jasper Vleugels
PhD-student AMC

2. Program
Introduction
Training differentiation
Test

3. Program
Introduction
Training differentiation
Test

4. Introduction Benign Malignant TP53 18q21 (DCC, SMAD-2/4) TGF-ßRII
K-RAS
TP q21 (DCC, SMAD-2/4) TGF-ßRII
Normal epithelium
Aberrant crypt focus (ACF)
Adenoma
Adenocarcinoma
APC mutation
Benign Malignant
Adapted from from Fearon and Vogelstein et al. Cell 1990, Wilson et al. Gastroenterology 2004

5. Introduction Benign Malignant TP53 18q21 (DCC, SMAD-2/4) TGF-ßRII
K-RAS
TP q21 (DCC, SMAD-2/4) TGF-ßRII
Normal epithelium
Aberrant crypt focus (ACF)
Adenoma
Adenocarcinoma
APC mutation
Benign Malignant
Adapted from from Fearon and Vogelstein et al. Cell 1990, Wilson et al. Gastroenterology 2004

6. Background Polyp subtypes: Malignant polyp (contains focus of CRC)
Potential harmfull polyp (neoplastic):
Adenoma
Sessile serrated polyp
Harmless polyp (non-neoplastic):
Hyperplastic polyp

7. Background Lifetime risk CRC approximately 5%1
Colonoscopy with polypectomy reduces incidence and mortality of CRC2
Recently Dutch nationwide population screening has started with FIT3
1 Edwards et al. Cancer 2010
2 Zauber et al. New England Journal of Medicine 2014 3

8. Background

9. Background

10. Background

11. Background

12. Background
> 90% of polyps detected at screening colonoscopy are small (6-9mm) or diminutive (≤5 mm)1-3
These lesions rarely contain cancer – 0-0.2% for adenomas 6-9mm and 0-0.1% for those <5mm1,3
1Lieberman et al. Gastroenterology 2008
2Chen et al. Am J Gastroenterol 2007
3Rex et al. Am J Gastroenterol 2009

13. Background
Current practice to resect and collect all lesions and send them for histopathology (outcome determines surveillance interval)
<5% of tubular adenomas with LGD progress to CRC1
Considerable burden for endoscopist, endoscopy- nurses and pathologist
Prolongs procedural time, time to advice surveillance interval and costs
1 Muto et al. Cancer 1975

14. Optical diagnosis
Expert endoscopists accurate endoscopic differentiation in 93-94% between neoplastic and non-neoplastic lesions using NBI1,2
1Rex et al. Gastroenterology 2009
2Ignjatovic et al. Lancet Oncology 2009

15. Narrow band imaging

16. Background

17. Background

18. Consequences of optical diagnosis
Adenomas would be resected but would not need to be retrieved and sent for histopathology, saving time. In addition, patients could be given a surveillance interval immediately following the colonoscopy (again leading to savings in time and cost)1,2
Hyperplastic polyps in the rectum and sigmoid, which have no malignant potential could be left in situ (reducing the risks associated with polypectomy)1,2
1 Rex et al. ASGE PIVI guideline. Gastrointestinal Endoscopy 2012
2 Hassan et al. ESGE advanced endoscopic imaging guideline. Endoscopy 2014

19. Background
Not all lesions can be assessed endoscopically

20. Background
Not all lesions can be assessed endoscopically

21. Potential effect of optical diagnosis
Disadvantages:
Slight chance of missing submucosal-invasion (carcinoma) in a small polyp
Untill now, optical diagnosis is only reliable when performed by experts

22. DISCOUNT1
1 Kuiper et al. Clinical Gastroenterology and Hepatology 2012

23. DISCOUNT1
1 Kuiper et al. Clinical Gastroenterology and Hepatology 2012

24. Program
Introduction
Training differentiation
Test