Interdisciplinary Spanish consensus on a watch-and-wait approach for rectal cancer / Consenso español interdisciplinar sobre un enfoque de vigilancia y espera en el cáncer de recto

Watch-and-wait has emerged as a new strategy for the management of rectal cancer when a complete clinical response is achieved after neoadjuvant therapy. In an attempt to standardize this new clinical approach, initiated by the Spanish Cooperative Group for the Treatment of Digestive Tumors (TTD), and with the participation of the Spanish Association of Coloproctology (AECP), the Spanish Society of Pathology (SEAP), the Spanish Society of Gastrointestinal Endoscopy (SEED), the Spanish Society of Radiation Oncology (SEOR), and the Spanish Society of Medical Radiology (SERAM), we present herein a consensus on a watch-and-wait approach for the management of rectal cancer. We have focused on patient selection, the treatment schemes evaluated, the optimal timing for evaluating the clinical complete response, the oncologic outcomes after the implementation of this strategy, and a protocol for surveillance of these patients.(AU)

Effect of the SARS-CoV-2 pandemic on colorectal cancer diagnosis and prognosis.

BACKGROUND AND STUDY AIMS: Our aim was to determine the impact of the SARS-CoV-2 pandemic on the diagnosis and prognosis of colorectal cancer (CRC). PATIENTS AND METHODS: This prospective cohort study included individuals diagnosed with CRC between March 13, 2019 and June 20, 2021 across 21 Spanish hospitals. Two time periods were compared: prepandemic (from March 13, 2019 to March 13, 2020) and pandemic (from March 14, 2020 to June 20, 2021, lockdown period and 1 year after lockdown). RESULTS: We observed a 46.9% decrease in the number of CRC diagnoses (95% confidence interval (CI): 45.1%-48.7%) during the lockdown and 29.7% decrease (95% CI: 28.1%-31.4%) in the year after the lockdown. The proportion of patients diagnosed at stage I significantly decreased during the pandemic (21.7% vs. 19.0%; p = 0.025). Centers that applied universal preprocedure SARS-CoV-2 PCR testing experienced a higher reduction in the number of colonoscopies performed during the pandemic post-lockdown (34.0% reduction; 95% CI: 33.6%-34.4% vs. 13.7; 95% CI: 13.4%-13.9%) and in the number of CRCs diagnosed (34.1% reduction; 95% CI: 31.4%-36.8% vs. 26.7%; 95% CI: 24.6%-28.8%). Curative treatment was received by 87.5% of patients diagnosed with rectal cancer prepandemic and 80.7% of patients during the pandemic post-lockdown period (p = 0.002). CONCLUSIONS: The COVID-19 pandemic has led to a decrease in the number of diagnosed CRC cases and in the proportion of stage I CRC. The reduction in the number of colonoscopies and CRC diagnoses was higher in centers that applied universal SARS-CoV-2 PCR screening before colonoscopy. In addition, the COVID-19 pandemic has affected curative treatment of rectal cancers.

Interdisciplinary Spanish consensus on a watch-and-wait approach for rectal cancer.

Watch-and-wait has emerged as a new strategy for the management of rectal cancer when a complete clinical response is achieved after neoadjuvant therapy. In an attempt to standardize this new clinical approach, initiated by the Spanish Cooperative Group for the Treatment of Digestive Tumors (TTD), and with the participation of the Spanish Association of Coloproctology (AECP), the Spanish Society of Pathology (SEAP), the Spanish Society of Gastrointestinal Endoscopy (SEED), the Spanish Society of Radiation Oncology (SEOR), and the Spanish Society of Medical Radiology (SERAM), we present herein a consensus on a watch-and-wait approach for the management of rectal cancer. We have focused on patient selection, the treatment schemes evaluated, the optimal timing for evaluating the clinical complete response, the oncologic outcomes after the implementation of this strategy, and a protocol for surveillance of these patients.

Diagnosis of non-Hodgkin's lymphoma due to a tiny polyp in the cecum.

Endoscopic findings in primary or secondary intestinal lymphoma are non-specific, which can lead to finding a polyp, an ulcer or a completely normal mucosa. As a matter of fact, this makes having a high clinical suspicion with only the endoscopic technique, quite difficult. Due to this reason, we believe that either taking random biopsies or biopsies from visible lesions of affected sections in another imaging tests, should be indicated in order to increase the diagnostic capacity of the endoscopic technique.

Early colorectal cancer diagnosed after endoscopic resection: Conservative treatment is safe in most of the cases. Proposal for a risk-based management.

INTRODUCTION: Endoscopic resection offers advantages over surgical resection for early colorectal cancer (ECC). However, there might be a presumed risk of recurrence. We aimed to determine the risk of recurrence after endoscopic removal of ECC. METHODS: A single-centre series of endoscopic resections for ECC. Patients were stratified according to four risk factors: positive resection margins, Haggitt 4, lymphatic/vascular invasion and tumour budding. RESULTS: We included 127 patients. Haggitt classification was grade 4 in 54.0%. Positive margins were found in 43 (33.9%), 16 (12.6%) had lymphatic or vascular invasion, and 5 (4.0%) had high grade budding. In 82 (64.5%) endoscopic excision was the definitive treatment, 45 (35.4%) underwent surgery. Six patients (13.3%) had residual tumour on specimen and/or node metastases. Postoperative complications occurred in ten (22.2%). At a median follow-up of 63 months, none of the 82 patients treated with endoscopic resection alone had recurrence. After stratifying patients according to risk factors, those who had residual tumour also had ≥2 risk factors. CONCLUSIONS: Endoscopic follow up might be a valid option for patients with ECC. A risk-adjusted management seems prudent.

Impact of the European Society of Gastrointestinal Endoscopy 2020 guidelines on the number of scheduled post-polypectomy surveillance colonoscopies: Meeting presentations: Partial results of this research were published in abstract form at ESGE Days 2020.

Background and study aims In contrast with the European Society of Gastrointestinal Endoscopy (ESGE) 2013 and the US Multi-society Task Force (USMSTF) 2020 guidelines, the ESGE 2020 guideline considers patients with three to four adenomas < 10 mm or an adenoma with villous histology as low risk. The aim of this study was to quantify the influence of the application of the new ESGE 2020 guidelines, as opposed to the ESGE 2013 and USMSTF 2020 guidelines, on the number of scheduled colonoscopies, and to describe the main causes for changes in the surveillance intervals. Patients and methods A retrospective evaluation was conducted of a prospectively maintained fecal immunochemical test (FIT)-based regional colorectal cancer screening program database. Surveillance regimens following ESGE 2020, ESGE 2013, and USMSTF 2020 guidelines were compared. Results Overall, 1284 individuals with a positive FIT and undergoing colonoscopy were consecutively included. When applying the ESGE 2020 guidelines, 10.8 % of patients changed to a "no-surveillance" group (relative reduction in colonoscopies of 82.5 %). The main reason for these changes was considering three to four adenomas as low risk. The proportion of patients from the "3-year surveillance" group who moved to the "no-surveillance" group was lower when a sessile serrated lesion (SSL) was present (ESGE 2013, 32.0% vs 16.3 %; USMSTF 2020 17.2 % vs 6.8 %). Analyzing the 41 patients with SSLs who remained unchanged in the "no-surveillance" group, only in 15 (36.6 %) the cause was the presence of an SSL. Conclusions applying the new ESGE 2020 guidelines could reduce by 11 % the proportion of individuals being offered surveillance. SLLs have not a major influence on the change of surveillance intervals.

Development of knowledge-based clinical decision support system for patients included in colorectal screening program / Desarrollo de un sistema de soporte a la decisión médica basado en el conocimiento para los pacientes incluidos en el programa de cribado del cáncer colorrectal

Background & aims: Colorectal (CRC) screening programs represent a large volume of procedures that need a follow-up endoscopy. A knowledge-based clinical decision support system (K-CDSS) is a technology which contains clinical rules and associations of compiled data that assist with clinical decision-making tasks. We develop a K-CDSS for management of patients included in CRC screening and surveillance of colorectal polyps. Methods: We collected information on 48 variables from hospital colonoscopy records. Using DILEMMA Solutions Platform © (https://www.dilemasolution.com) we designed a prototype K-CDSS (PoliCare CDSS), to provide tailored recommendations by combining patients data and current guidelines recommendations. The accuracy of rules was verified using four scenarios (normal colonoscopy, lesions different than polyps, non-advanced adenomas and advanced adenomas). We studied the degree of agreement between the clinical assessments made by expert doctors and nurses equipped with PoliCare CDSS. Two experts confirmed a correlation between guidelines and PoliCare recommendations. Results: 56 consecutive endoscopy cases from colorectal screening program were included (62.8 years; range 53-71). Colonoscopy results were: absence of colon lesions (n=7, 12.5%), lesions in the colon that are not polyps (n=3, 5.4%) and resected colonic polyps (n=46, 82.1%; 100% R0 resection). Patients with resected polyps presented non-advanced adenoma (n=21, 45.6%) or advanced lesions (n=25, 54.4%). There were no differences in erroneous orders with PoliCare CDSS (Kappa value 1.0). Conclusions: PoliCare CDSS can easily be integrated into the workflow for improving the overall efficiency and better adherence to evidence-based guidelines.(AU)

Antecedentes & objetivos: Los programas de cribado de cáncer colorrectal (CCR) generan un gran número de colonoscopias de seguimiento. Un sistema de soporte a la decisión clínica basado en el conocimiento (K-CDSS) es una tecnología que contiene reglas clínicas y asociaciones de datos que ayudan en la tarea de toma de decisiones clínicas. El objetivo fue desarrollar un K-CDSS para el manejo de los pacientes de cribado de CCR, y evaluar su eficacia. Métodos: Recolectamos información de 48 variables de registros de colonoscopia. Mediante el software DILEMMA (https://www.dilemasolution.com) diseñamos un prototipo de K-CDSS (PoliCare CDSS), para proporcionar recomendaciones personalizadas, combinando los datos de los pacientes y las recomendaciones de las guías actuales. La exactitud de las reglas se verificó mediante cuatro escenarios (colonoscopia normal, lesiones diferentes a pólipos, adenomas no avanzados y adenomas avanzados). Se estudió el grado de concordancia entre las valoraciones clínicas realizadas por médicos expertos y enfermeros equipados con PoliCare CDSS. Dos expertos confirmaron una correlación entre las pautas y las recomendaciones de PoliCare. Resultados: Se incluyeron 56 casos consecutivos del programa de cribado (62,8 años; rango 53-71). Los resultados de la colonoscopia fueron: ausencia de lesiones de colon (n = 7, 12,5%), lesiones en el colon que no son pólipos (n = 3, 5,4%) y pólipos de colon resecados (n = 46, 82,1%; resección R0 del 100%). Los pacientes con pólipos resecados presentaron adenoma no avanzado (n = 21, 45,6%) o lesiones avanzadas (n = 25, 54,4%). No hubo diferencias en recomendaciones erróneas con PoliCare CDSS (valor Kappa 1.0). Conclusiones: PoliCare CDSS se puede integrar fácilmente en el flujo de trabajo de una unidad de endoscopia digestiva.(AU)

Cold loop polypectomy perforation of a tiny colon polyp.

We report the case of a 61-year-old woman having corticoid treatment with corticosteroids for polyarthralgia, who underwent a post-polypectomy surveillance colonoscopy, identifying a 5-mm diameter, flat-elevated polyp in the proximal transverse colon (Paris 0-IIa).

Development of knowledge-based clinical decision support system for patients included in colorectal screening program.

BACKGROUND & AIMS: Colorectal (CRC) screening programs represent a large volume of procedures that need a follow-up endoscopy. A knowledge-based clinical decision support system (K-CDSS) is a technology which contains clinical rules and associations of compiled data that assist with clinical decision-making tasks. We develop a K-CDSS for management of patients included in CRC screening and surveillance of colorectal polyps. METHODS: We collected information on 48 variables from hospital colonoscopy records. Using DILEMMA Solutions Platform © (https://www.dilemasolution.com) we designed a prototype K-CDSS (PoliCare CDSS), to provide tailored recommendations by combining patients data and current guidelines recommendations. The accuracy of rules was verified using four scenarios (normal colonoscopy, lesions different than polyps, non-advanced adenomas and advanced adenomas). We studied the degree of agreement between the clinical assessments made by expert doctors and nurses equipped with PoliCare CDSS. Two experts confirmed a correlation between guidelines and PoliCare recommendations. RESULTS: 56 consecutive endoscopy cases from colorectal screening program were included (62.8 years; range 53-71). Colonoscopy results were: absence of colon lesions (n=7, 12.5%), lesions in the colon that are not polyps (n=3, 5.4%) and resected colonic polyps (n=46, 82.1%; 100% R0 resection). Patients with resected polyps presented non-advanced adenoma (n=21, 45.6%) or advanced lesions (n=25, 54.4%). There were no differences in erroneous orders with PoliCare CDSS (Kappa value 1.0). CONCLUSIONS: PoliCare CDSS can easily be integrated into the workflow for improving the overall efficiency and better adherence to evidence-based guidelines.

Definition of competence standards for optical diagnosis of diminutive colorectal polyps: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement.

BACKGROUND : The European Society of Gastrointestinal Endoscopy (ESGE) has developed a core curriculum for high quality optical diagnosis training for practice across Europe. The development of easy-to-measure competence standards for optical diagnosis can optimize clinical decision-making in endoscopy. This manuscript represents an official Position Statement of the ESGE aiming to define simple, safe, and easy-to-measure competence standards for endoscopists and artificial intelligence systems performing optical diagnosis of diminutive colorectal polyps (1 - 5 mm). METHODS : A panel of European experts in optical diagnosis participated in a modified Delphi process to reach consensus on Simple Optical Diagnosis Accuracy (SODA) competence standards for implementation of the optical diagnosis strategy for diminutive colorectal polyps. In order to assess the clinical benefits and harms of implementing optical diagnosis with different competence standards, a systematic literature search was performed. This was complemented with the results from a recently performed simulation study that provides guidance for setting alternative competence standards for optical diagnosis. Proposed competence standards were based on literature search and simulation study results. Competence standards were accepted if at least 80 % agreement was reached after a maximum of three voting rounds. RECOMMENDATION 1: In order to implement the leave-in-situ strategy for diminutive colorectal lesions (1-5 mm), it is clinically acceptable if, during real-time colonoscopy, at least 90 % sensitivity and 80 % specificity is achieved for high confidence endoscopic characterization of colorectal neoplasia of 1-5 mm in the rectosigmoid. Histopathology is used as the gold standard.Level of agreement 95 %. RECOMMENDATION 2: In order to implement the resect-and-discard strategy for diminutive colorectal lesions (1-5 mm), it is clinically acceptable if, during real-time colonoscopy, at least 80 % sensitivity and 80 % specificity is achieved for high confidence endoscopic characterization of colorectal neoplasia of 1-5 mm. Histopathology is used as the gold standard.Level of agreement 100 %. CONCLUSION : The developed SODA competence standards define diagnostic performance thresholds in relation to clinical consequences, for training and for use when auditing the optical diagnosis of diminutive colorectal polyps.

How to avoid overtreatment of benign colorectal lesions: Rationale for an evidence-based management.

Implementing population-based screening programs for colorectal cancer has led to an increase in the detection of large but benign histological lesions. Currently, endoscopic mucosal resection can be considered the standard technique for the removal of benign lesions of the colon due to its excellent safety profile and good clinical results. However, several studies from different geographic areas agree that many benign colon lesions are still referred for surgery. Moreover, the referral rate to surgery is not decreasing over the years, despite the theoretical improvement of endoscopic resection techniques. This article will review the leading causes for benign colorectal lesions to be referred for surgery and the influence of the endoscopist experience on the referral rate. It will also describe how to categorize a polyp as complex for resection and consider an endoscopist as an expert in endoscopic resection. And finally, we will propose a framework for the accurate and evidence-based treatment of complex benign colorectal lesions.

Compound Endoscopic Morphological Features for Identifying Non-Pedunculated Lesions ≥20 mm with Intramucosal Neoplasia.

BACKGROUND: The major limitation of piecemeal endoscopic mucosal resection (EMR) is the inaccurate histological assessment of the resected specimen, especially in cases of submucosal invasion. OBJECTIVE: To classify non-pedunculated lesions ≥20 mm based on endoscopic morphological features, in order to identify those that present intramucosal neoplasia (includes low-grade neoplasia and high-grade neoplasia) and are suitable for piecemeal EMR. DESIGN: A post-hoc analysis from an observational prospective multicentre study conducted by 58 endoscopists at 17 academic and community hospitals was performed. Unbiased conditional inference trees (CTREE) were fitted to analyse the association between intramucosal neoplasia and the lesions' endoscopic characteristics. RESULT: 542 lesions from 517 patients were included in the analysis. Intramucosal neoplasia was present in 484 of 542 (89.3%) lesions. A conditional inference tree including all lesions' characteristics assessed with white light imaging and narrow-band imaging (NBI) found that ulceration, pseudodepressed type and sessile morphology changed the accuracy for predicting intramucosal neoplasia. In ulcerated lesions, the probability of intramucosal neoplasia was 25% (95%CI: 8.3-52.6%; p < 0.001). In non-ulcerated lesions, its probability in lateral spreading lesions (LST) non-granular (NG) pseudodepressed-type lesions rose to 64.0% (95%CI: 42.6-81.3%; p < 0.001). Sessile morphology also raised the probability of intramucosal neoplasia to 86.3% (95%CI: 80.2-90.7%; p < 0.001). In the remaining 319 (58.9%) non-ulcerated lesions that were of the LST-granular (G) homogeneous type, LST-G nodular-mixed type, and LST-NG flat elevated morphology, the probability of intramucosal neoplasia was 96.2% (95%CI: 93.5-97.8%; p < 0.001). CONCLUSION: Non-ulcerated LST-G type and LST-NG flat elevated lesions are the most common non-pedunculated lesions ≥20 mm and are associated with a high probability of intramucosal neoplasia. This means that they are good candidates for piecemeal EMR. In the remaining lesions, further diagnostic techniques like magnification or diagnostic +/- therapeutic endoscopic submucosal dissection should be considered.