1. Optical Diagnosis for Colorectal Polyps? Steve Schrock, MD, FAAFP November 5, 2015

2. History 1993 National Polyp Study in NEJM – removal of all visible polyps via polypectomy reduced colon cancer Standard of Care Costs Recently – the “Optical Biopsy” Hyperplastic polyps recognized and discarded without pathology evaluation Decreased cost Should not decrease standards for patient care

3. Potential Problems Accuracy of Optical Biopsies Potential Liability Issues Reimbursement Limitations Institutional Policies Regarding Discarding Tissue ADR – adenoma detection rates

4. NICE – Narrow Band Imaging (NBI) International Colorectal Endoscopic Classification System Color Vessels Surface Pattern Most Likely Pathology

5. Type 1 Color – Same or lighter than background Vessels - None or isolated lacey vessels may be present coursing across the lesion Surface Pattern - Dark spots surrounded by white Most Likely Pathology - Hyperplastic

6. Type 2 Color – Browner Relative to Background (Verify color arise from vessels) Vessels – Thick brown vessels surrounding white structures Surface Pattern – Oval, tubular, or branched structures surrounded by brown vessels Most Likely Pathology - Adenoma

7. Type 3 Color – Brown to dark brown relative to background; sometimes patchy whiter areas Vessels – Has area(s) with markedly distorted or missing vessels Surface Pattern – Distortion or absence of pattern Most Likely Pathology – Deep submucosal invasive cancer

8. Type 1, Type 2, or Type 3….Why…Color, Vessels, and Surface Pattern

9. Methods to Become a High Performer in Characterization of Colorectal Polyp Histology Shreyas Saligram, MD Amit Rastogi, MD Best Practice and Research Clinical Gastroenterology 29 (2015) 651- 662

10. Optical Diagnosis of Small Colorectal Polyps during Colonoscopy: When to Resect and Discard? Ana Wilson, MD Best Practice and Research Clinical Gastroenterology 29 (2015) 639- 649

11. Proposal for a new “resect and discard” strategy using magnifying narrow band imaging: Pilot study of diagnostic accuracy Yoji Takeuchi Digestive Endoscopy 2014; 26(Supplement 2): 90-97.

12. Narrow Band Imaging of Colorectal Lesions Using NICE Classification to Avoid Discarding Significant Lesions Santa Hattori World Journal of Gastrointestinal Endoscopy 2014 December 16; 6(12): 600-605.

13. Implementation of Optical Diagnosis for Colorectal Polyps: Standardization of Studies is Needed Tonya Kaltenbach, MD Douglas K. Rex, MD Et al Clinical Gastroenterology and Hepatology 2015;13:6-10

14. Do You Send Every Polyp? What do you do individually? How will the technology continue to develop? Testing Human vs Computer pattern recognition Will the AAPCE have a role in educating and documenting competence?