2011 Debate on Chromoendoscopy for IBD colitis surveillance

2,764 views

Published on

Chromoendoscopy and other advanced endoscopic imaging techniques are becoming the standard of care in the surveillance of dysplasia. At the 2011 Australian Gastroenterology Week, the use of advanced imaging techniques was compared against four quadrant random biopsies at a breakfast debate.

Published in: Health & Medicine, Business
0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
2,764
On SlideShare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
92
Comments
0
Likes
2
Embeds 0
No embeds

No notes for slide
  • Therefore, random biopsies need to be taken throughout the bowel previously exposed to inflammation. It’s been calculated that taking at least 33 quadrantic random biopsies at 10cm intervals are required to yield a 90% confidence of picking up a dysplastic lesion if present. However, only 2% of gastroenterologists take >20 biopsies, let alone 33 biopsies; 50% only take 6 – 10 biopsies. Even when surveillance colonoscopies occur, a significant number of patients still present with symptomatic bowel cancer. Routine colonoscopy and random biopsies may not be adequate to pick up cancers and this review was from St Mark’s hospital, one of the leaders in IBD.
  • However, finding dysplasia in IBD poses a major challenges to endoscopists. Because dysplasia in IBD develops in flat mucosa which is difficult to see in comparison to sporadic polyps.
  • What new endoscopic technologies offer include: - improved resolution of tissue imaging plus magnification to increase the sensitivity of finding lesions - the use of special light properties that interact with tissue to differentiate lesions, - and technologies that allow for immediate in situ histology.
  • CE is low in cost, requires no special equipment apart from a spray catheter and a wide variety of contrast agents can be used. In IBD surveillance they tend to be methylene blue or indigo carmine.
  • Prospective randomised study
  • Take home points: - despite protocol 4 quadrant random biopsies, on average only 29 biopsies per person - random biopsies are rarely positive - pre-dye targeted biopsies are good; 4.6% yield (15 – 20mm lesions) - yield in dye targeted = an additional 7 cases or a 3.5 fold increase in detection, smaller dysplastic lesions
  • In another prospective study from the UK recruiting 350 patients into a conventional colonoscopy arm and another 350
  • In another prospective study from the UK recruiting 350 patients into a conventional colonoscopy arm and another 350
  • Although you may be in the minority of gastroenterologists in Australia that do not use advanced imaging techniques, this debate emphasises on what you SHOULD be doing. Based on that, ladies and gentleman, I hope that you would all agree that
  • Although you may be in the minority of gastroenterologists in Australia that do not use advanced imaging techniques, this debate emphasises on what you SHOULD be doing. Based on that, ladies and gentleman, I hope that you would all agree that
  • So how is CE performed? 1. Strict patient selection: symptoms in remission and or optimised medical therapy to induce remission whenever possible. 2. Unmasking the mucosa with an excellent bowel prep, removing mucus and using washes. 3. IV buscopan or glucagon can be used to reduce peristalsis. Air insufflation is required. 4. Full length staining refers to pan-chromoendoscopy of the whole colon, starting at the caecum. 5. Add dye in a segmental fashion every 20 – 30cm. On average 60 – 100ml of solution is required. 6. Crypt pattern is detected using magnifying colonoscopy 7. Endoscopic targeting of lesions is required
  • 2011 Debate on Chromoendoscopy for IBD colitis surveillance

    1. 1. Rupert WL Leong Director of Endoscopy Senior Staff Specialist Gastroenterologist Concord & Bankstown Hospitals Conjoint Associate Professor UNSW AIBDA Symposium Colorectal Cancer Surveillance What should we be doing?  New endoscopy techniques and targeted biopsies are now the standard of care
    2. 2. <ul><li>standard white light & random biopsies FAIL to identify treatable flat dysplasia </li></ul><ul><li>newer imaging techniques improves yield 3-10X </li></ul><ul><li>newer techniques recommended by guidelines </li></ul><ul><li>newer techniques are already utilized locally & overseas </li></ul>
    3. 3. Definitions <ul><li>“ new” </li></ul><ul><ul><li>chromoendoscopy (1977+, colitis 2003+) </li></ul></ul><ul><ul><li>high definition, zoom endoscopy (2003+) </li></ul></ul><ul><ul><li>NBI (2006+) </li></ul></ul><ul><ul><li>+ targeted biopsies </li></ul></ul><ul><li>“ old” </li></ul><ul><ul><li>4 quadrant biopsies every 10cm </li></ul></ul><ul><ul><li>PLUS biopsies of any lesions </li></ul></ul>
    4. 4. <ul><ul><li>2000cm 2 colon SA vs 1.32cm 2 random SA </li></ul></ul><ul><ul><li>33 random biopsies sample <0.1% of the bowel </li></ul></ul>
    5. 5. Why newer endoscopic techniques are required? <ul><li>Surveillance colonoscopy in IBD </li></ul><ul><ul><li>>33 random colonic biopsies </li></ul></ul><ul><ul><li>interval colorectal cancers (white light) </li></ul></ul><ul><ul><li>2% of gastroenterologists take >20 biopsies </li></ul></ul><ul><ul><li>>33 biopsies samples only a v small part of the colon </li></ul></ul>Eaden et al . GI Endosc 2000 Connell et al . Gastroenterol 1994 Rubin et al . Gastroenterol 1992 Kandiel et al .  Visible Human J Endosc.  2008
    6. 6. What is being done? Australia <ul><li>online survey </li></ul><ul><ul><li>57% use NBI or chromoendoscopy </li></ul></ul><ul><ul><ul><li>others HD, zoom scopes </li></ul></ul></ul><ul><ul><li>37% perform recommended biopsies </li></ul></ul><ul><li>expert opinion promotes CE </li></ul>Fok I, et al . J Gastroenterol Hepatol 2010 (Abst) Majority of GE already use newer endoscopic techniques Efthymiou, Taylor, Kamm, et al. Inflamm Bowel Dis . 2011
    7. 7. What is Being Done? Overseas <ul><li>Academic Medical Centre, Amsterdam: </li></ul><ul><ul><li>Profs Paul Fockens, Evelien Dekker </li></ul></ul><ul><li></li></ul>Centres of excellence use newer techniques
    8. 8. Why newer endoscopic techniques are required? Sporadic Cancer Normal Colon Aberrant crypt foci Adenoma Carcinoma Normal Colon Inflammation Flat Dysplasia Carcinoma IBD Cancer
    9. 9. How newer techniques identify flat dysplasia? <ul><li>improved resolution, magnification </li></ul><ul><ul><li>increases sensitivity, delineates extent </li></ul></ul><ul><li>differential light or dye interaction </li></ul><ul><ul><li>improve the yield of dysplasia </li></ul></ul>Tada et al . Endosc . 1977;8:70–74.
    10. 10. Chromoendoscopy
    11. 11. Is chromoendoscopy difficult? No <ul><li>reusable catheter </li></ul><ul><li>2 vials </li></ul><ul><ul><li>1. methylene blue 0.1% absorptive (vital) </li></ul></ul><ul><ul><li>2. indigo carmine 0.1-0.5% topography </li></ul></ul><ul><ul><li>1ml dye + 9ml N Saline </li></ul></ul>
    12. 12. Is it difficult? No <ul><ul><li>don’t need to learn Kudo classification </li></ul></ul><ul><ul><li>don’t need to describe pit pattern </li></ul></ul><ul><li>most evidence at present remains chromoendoscopy </li></ul><ul><li>NBI : vascular network, lesion-mucosa interface </li></ul>
    13. 13. <ul><li>CE is not required IF there is already visible cancer; which is TOO LATE! </li></ul><ul><li>how did it get there? </li></ul><ul><ul><li>poor surveillance technique! </li></ul></ul>
    14. 14. <ul><li>HGD </li></ul><ul><ul><li>no invasion </li></ul></ul><ul><ul><li>no LN metastasis </li></ul></ul>
    15. 15. Does it work? Yes
    16. 16. Which technique has a higher yield of dysplasia? <ul><li>New </li></ul>
    17. 17. CE in UC Surveillance <ul><li>Methylene-blue magnifying CE in UC ≥ 8yr </li></ul><ul><li>CE in predicting neoplasia: sensitivity 97%; specificity 93% </li></ul><ul><li>duration CE = 44 minutes, conventional 35 minutes (ns) </li></ul>Kiesslich et al . Gastroenterol 2003 Conventional (n = 81) Chromoendoscopy (n = 84) P Intra-epithelial neoplasias - low grade - high grade 8 2 24 8 <0.005 Cancer 1 3 (2 A’s, 1 B) ns Flat mucosa IN 4 (on random Bx) 24 <0.001
    18. 18. CE in UC Surveillance <ul><li>back-to-back conventional colonoscopy vs indigo carmine 0.1% CE </li></ul><ul><li>n=100; 46 neoplastic lesions in 19 patients </li></ul>Rutter et al . Gut 2004 Conventional (n = 100) CE (n = 100) P Dysplasia: - non-targeted - pre-dye target - dye targeted - 0/ 2,904 biopsies - 2/ 43 (15-20mm) - *+7/ 114 (2-6mm) 0.02 0.06 * Duration (median) 11min 10min ns
    19. 19. CE in UC Surveillance <ul><li>High magnification CE (indigo carmine 0.5%) vs conventional colonoscopy </li></ul><ul><li>n=738; UC ≥ 8 years </li></ul>Hurlstone et al . Endoscopy 2005 Conventional (n = 350) High Mag-CE (n = 350) P Intra-epith neoplasia - non-targeted - targeted 24 - 38/12,482 (0.14%) - 3/369 (1.6%) 69 - 20/12,850 (0.16%) - 49/644 (8%) <0.0001 Cancer 1 3 ns Duration (median) 13min 24min <0.02
    20. 20. CE in Colitis Surveillance <ul><li>CE (methylene blue 0.01%) vs WLE </li></ul><ul><li>n=102; UC or Crohns colitis </li></ul>Marion et al . Am J Gastroienterol 2008 0.09% 20.7% Conventional (n = 102) CE (n = 102) P <ul><li>Dysplasia </li></ul><ul><li>- non-targeted </li></ul><ul><li>targeted </li></ul>3/3264 Bx LGD 12/50 LGD 1/50 HGD 16/82 LGD 1/82 HGD 0.001 Duration (median) 15min 22min ns
    21. 21. Dysplasia Yield Conventional Chromoendoscopy P Kiesslich Gastro. 2003 (n = 163) 3X <0.005 35min 44min ns Rutter Gut 2004 (n = 100) 3.5X 0.02 11min 10min ns Hurlstone Endos. 2005 (n = 350) 10X <0.0001 13min 24min Marion AJG 2008 (n = 102) 230X <0.0002 15min 22min
    22. 22. NBI vs CE UC Surveillance <ul><li>high-res NBI vs high-res CE </li></ul><ul><li>n=60; randomised cross-over; colitis >8yr </li></ul><ul><li>BOTH: newer techniques – equivalent </li></ul>Pellise M, et al . Gastrointest Endosc 2011 NBI (n = 33/27) CE (n = 27/33) P Per-Pt true pos 11/16 12/16 0.727 Withdrawal time 15.7 26.9 <0.01
    23. 23. <ul><li>466 surveillance colonoscopies (167 pt) </li></ul><ul><li>11,772 biopsies </li></ul>van den Broek Am J Gastroenterol 2011 <ul><li>1 LGD = positive on random biopsies (all others were targeted biopsies) </li></ul>
    24. 24. Is it recommended? <ul><li>CCFA: endorses the incorporation of chromoendoscopy into surveillance colonoscopy… </li></ul>Itzkowitz, Present. Inflamm Bowel Dis 2005 BSG 2011 <ul><ul><li>chromoendoscopy should be the default technique </li></ul></ul>
    25. 25. Does it matter? <ul><li>long term outcomes chronic colitis in Australia </li></ul><ul><li>life-time colon cancer risk: 35% </li></ul>Selinger et al .  J Gastroenterol Hepatol.  2011(abst)
    26. 26. New Endoscopic Techniques <ul><li>cheap & easy </li></ul><ul><li>effective in finding more EARLY dysplasia </li></ul><ul><li>acceptable to doctors/ nurses/ pathologists </li></ul><ul><li>already performed & recommended </li></ul><ul><li>vs random biopsies </li></ul><ul><li>slow </li></ul><ul><li>difficult for doctors/ nurses/ pathologists </li></ul><ul><li>ineffective in finding dysplasia </li></ul>
    27. 27. <ul><li>IBD Colorectal Cancer Surveillance: What should we be doing? </li></ul><ul><li>purpose of surveillance: find treatable lesions not to miss them </li></ul><ul><li>we should use newer endoscopy techniques </li></ul>
    28. 28. Rupert WL Leong Director of Endoscopy Senior Staff Specialist Gastroenterologist Concord & Bankstown Hospitals Conjoint Associate Professor UNSW AIBDA Symposium Colorectal Cancer Surveillance What should we be doing?  New endoscopy techniques and targeted biopsies are now the standard of care
    29. 29. <ul><li>IBD Colorectal Cancer Surveillance: What should we be doing? </li></ul><ul><li>10cm 4 quadrant biopsies –negligible yield, samples only 0.01% of colon, expensive pathology, unpopular in Australia </li></ul><ul><li>purpose of surveillance: find early lesions not to miss them </li></ul>
    30. 30. Is it messy? <ul><li>A little bit </li></ul><ul><li>But far fewer histology bottles! </li></ul>
    31. 31. Costs <ul><li>chromoendoscopy = cheap </li></ul><ul><li>all new video endoscopes = higher resolutions </li></ul><ul><li>large-screen monitors </li></ul>
    32. 32. Is it difficult? No <ul><li>S trict patient selection: colitis; remission/ steroids </li></ul><ul><li>U nmask: bowel prep, wash, insufflation </li></ul><ul><li>R educe peristalsis: buscopan, glucagon </li></ul><ul><li>F ull segmental stain </li></ul><ul><li>A dd dye </li></ul><ul><li>C rypt/ surface irregularities </li></ul><ul><li>E ndoscopic targeted biopsies </li></ul>Kiesslich et al . Gastroenterol 2003
    33. 33. Procedure/ Withdrawal Times Conventional Chromoendoscopy P Kiesslich Gastro. 2003 (n = 163) 3X <0.005 35min 44min ns Rutter Gut 2004 (n = 100) 3.5X 0.02 11min 10min ns Hurlstone Endos. 2005 (n = 350) 10X <0.0001 13min 24min Marion AJG 2008 (n = 102) 230X <0.0002 15min 22min
    34. 34. Time Saving <ul><li>reduced numbers of normal and futile random biopsies </li></ul><ul><li>pathology cost savings </li></ul><ul><li>proper surveillance – may increase repeat colonoscopy interval time (to be validated) </li></ul>
    35. 35. What about training & safety? <ul><li>no accreditation recommendations </li></ul><ul><li>dyes are safe </li></ul><ul><ul><li>methylene blue: good experience </li></ul></ul><ul><ul><li>indigo carmine: inert </li></ul></ul><ul><li>can still perform random biopsies </li></ul><ul><ul><li>document disease activity </li></ul></ul>
    36. 36. New Endoscopic Techniques <ul><li>cheap & easy </li></ul><ul><li>effective in finding more EARLY dysplasia </li></ul><ul><li>acceptable to doctors/ nurses/ pathologists </li></ul><ul><li>already performed & recommended </li></ul><ul><li>vs random biopsies </li></ul><ul><li>slow </li></ul><ul><li>difficult for doctors/ nurses/ pathologists </li></ul><ul><li>ineffective in finding dysplasia </li></ul>

    ×