2015-07-13 18:34:49 UTC

Chromoendoscopy: This is What Progress Looks Like

July 20, 2015

Our guidelines and recommendations for detecting and managing dysplasia in colitis are based upon an outdated literature using outmoded detection techniques.

James F. Marion, MD

James F. Marion, MD

Professor of Medicine, Icahn School of Medicine at Mount Sinai, NY

Read the other half of this AGA Perspectives point-counterpoint debate: Chromoendoscopy: Still Not Ready for Prime Time

Most questions I hear from patients with longstanding colitis having surveillance for colon cancer remain pertinent and practical: Do I have dysplasia? Where was it? What did you do about it? Will I get cancer? Do I need surgery? How often do I need to have a colonoscopy? The questions from gastroenterologists are similarly pragmatic: Do I still need to do random biopsies? The colon looks so normal. Do I still need to scope them as often? Our current guidelines leave many of these questions unaddressed.1

The SCENIC consensus group is correct; our guidelines and recommendations for detecting and managing dysplasia in colitis are based upon an outdated literature using outmoded detection techniques.2

For years, we have trudged like Marley’s ghost “captive, bound and double-ironed” to the long, heavy chains of an unwieldy and antiquated random biopsy evidence base despite strong evidence over the last decade showing chromoendoscopy with targeted examination to be a more effective means for detecting dysplasia when it develops.3,4 Investigators continue to ignore the robust, prospective evidence base for chromoendoscopy and continue to add weak, retrospective links to the random biopsy rationale chain.5 Patients and gastroenterologists are confused, and we have only ourselves to blame.

The controversy surrounding chromoendoscopy and SCENIC is a welcome and necessary, but long overdue, chapter in the progress toward better detection for these patients. One must revisit the transition from contrast radiography, specifically barium enema, to colonoscopy for polyps or colorectal cancer screening to find a similarly messy, contentious but necessary process.6 The emergence of colonoscopy as the procedure of choice was not based on consensus as much as an appreciation of the practical advantages of reliably identifying a polyp and plucking it out. Still, it has been a decades-long and agonizing defeat for our radiologic colleagues who have continued this battle under the new flag of CT colography sometimes resorting to aromatherapy and soothing music to distract us from the impracticality of the method.7,8 The SCENIC group aimed for consensus and practicality.

The SCENIC recommendations should encourage gastroenterologists to more clearly characterize dysplasia at screening in this population and be a springboard for further study. What else has improved aside from our scope resolution since Blackstone’s work in the 1980s? 9 We have developed a far more sophisticated set of tools to crack the code of cancer in IBD. We can track dysplasia more closely and apply our best translational, genomic, microbiomic and digital resources to capture the full natural history, from stem cells to metastases of dysplasia in IBD.

Advances in clinical electronic data collection and medical record mining greatly increase our ability to collaborate across medical centers, and even across continents. Finally, each year, we are graduating a new class of fellows with endoscopic skills far more sophisticated than mine were upon graduation to meet the endoscopic challenges these newly identified dysplasias will create. Continuing to randomly poke around our patient’s colonic mucosa will get us nowhere. We have an evidence base and consensus that chromo finds more dysplasia than any other technique we are doing now, but is detecting dysplasia enough?10–14 Not all dysplasias carry the same prognosis. The majority of the dysplasias detected in these referral populations were manageable endoscopically. The question of long-term management of these patients remains a glaring gap in the SCENIC recommendations.


Investigators continue to ignore the robust, prospective evidence base for chromoendoscopy.


Avoiding cancer remains an admirable goal, but other goals such as protecting patients from too onerous surveillance schedules, unnecessary colectomies or even surprises after colectomy, must be accomplished as well. The Barrett’s model, using endoscopic resection and ablation to preserve the esophagus, may be a good model to replicate. Now we have to roll up our sleeves and map the natural history, determine which dysplasias in which patients can become dangerous and communicate this in a clear and practical fashion to our patients. We must capitalize on the advantages of this technique to clarify our understanding of the natural history of dysplasia in our patients to the point where we can stratify them safely according to their risk. Our target is polyps that are smaller, flatter, rarer and less likely to result in a catastrophic outcome for most patients.15

Image of a colitis patient with inflammatory polyps and dysplasia detected through chromoendoscopy.

We need to reach across the aisle to our colleagues in the breast and prostate cancer prevention communities as they formulate their guideline recommendations. This will require multi-center collaboration and funding to execute a prospective study of the practical efficacy of these techniques. Dysplasia detection rates are not enough, a strategy to identify those patients truly at risk and improve outcomes must be the goal. The SCENIC group was silent on several practical issues such as random biopsy. The same prospective, endoscopic trials that demonstrated the superiority of chromoendoscopy also showed the startling futility of random biopsy to detect dysplasia. This has led some to recommend abandoning the practice altogether and adopt targeted techniques.16

Endoscopy centers of excellence compare adenoma detection rates among endoscopists and we must take the same results-oriented approach to our patients when we are doing chromoendoscopy. To completely free ourselves from the chains of our outdated evidence base, we must build the foundation for a new one and SCENIC is the cornerstone. This latest chapter in our evolving management of dysplasia in colitis is being encouraged and watched by our patients.17 Patient advocacy has become the norm in our modern medical culture, but in this instance has been met with some resistance by the gastroenterology community. Patients with IBD bear the brunt of our lack of understanding of these diseases and the resultant controversies. Their practical concerns bring a refreshing perspective to the table. Further, our current surveillance approach has performed poorly when put to the same level of scrutiny as chromoendoscopy and our patients pick up on our disillusionment.18,19

We need to be clear with our patients about what chromoendoscopy in this setting can and cannot do. We have a new and effective technique to answer many of our patients (and our own) questions about what dysplasia in colitis might portend. Now we have to get to work to establish long-term strategies. There is still work to be done to justify our surveillance strategies for the gastroenterology community, and most importantly, our patients. This work will involve diluting up some blue dye, stepping on the foot pedal, covering the mucosa with dye and finding a dysplasia in your patient when it’s there, or not when it’s not. Next, tracking the incidence of dysplasia in this population of patients over time with the goal of being able to predict the patient’s risk of developing colon cancer. This is what progress looks like.

Dr. Marion has no conflicts to disclose.

References

1. Kornbluth A, Sachar DB, Practice Parameters Committee of the American College of Gastroenterology. Ulcerative colitis practice guidelines in adults: American college of gastroenterology, practice parameters committee. Am J Gastroenterol. 2010;105(3):501-23; quiz 524. doi: 10.1038/ajg.2009.727 [doi].

2. Laine L, Kaltenbach T, Barkun A, et al. SCENIC international consensus statement on surveillance and management of dysplasia in inflammatory bowel disease. Gastrointest Endosc. 2015;81(3):489-501. e26. doi: 10.1016/j.gie.2014.12.009 [doi].

3. Dickens C. A christmas carol. London: Chapman and Hall; 1843.

4. Wu L, Li P, Wu J, Cao Y, Gao F. The diagnostic accuracy of chromoendoscopy for dysplasia in ulcerative colitis: Meta-analysis of six randomized controlled trials. Colorectal Dis. 2012;14(4):416-420. doi: 10.1111/j.1463-1318.2010.02505.x [doi].

5. Mooiweer E, van der Meulen-de Jong AE, Ponsioen CY, et al. Chromoendoscopy for surveillance in inflammatory bowel disease does not increase neoplasia detection compared with conventional colonoscopy with random biopsies: Results from a large retrospective study. Am J Gastroenterol. 2015. doi: 10.1038/ajg.2015.63 [doi].

6. Myren J, Eie H, Serck-Hanssen A. The diagnosis of colitis by colonoscopy with biopsy and X-ray examination. A blind comparative study. Scand J Gastroenterol. 1976;11(2):141-144.

7. de Haan MC, Pickhardt PJ, Stoker J. CT colonography: Accuracy, acceptance, safety and position in organised population screening. Gut. 2015;64(2):342- 350. doi: 10.1136/gutjnl-2014-308696 [doi].

8. Nagata K, Iida N, Kanazawa H, et al. Effect of listening to music and essential oil inhalation on patients undergoing screening CT colonography: A randomized controlled trial. Eur J Radiol. 2014;83(12):2172-2176. doi: S0720-048X(14)00459-8 [pii].

9. Blackstone MO, Riddell RH, Rogers BH, Levin B. Dysplasia-associated lesion or mass (DALM) detected by colonoscopy in long-standing ulcerative colitis: An indication for colectomy. Gastroenterology. 1981;80(2):366-374. doi: S0016508581000449 [pii].

10. Kiesslich R, Fritsch J, Holtmann M, et. al. Methylene blue aided chromoendoscopy for the detection of intraepithelial neoplasia and colon cancer in ulcerative colitis. Gastroenterology 2003;124:880-888

11. Rutter MD, Saunders BP, Schofield G et al. Pancolonic indigo carmine dye spray for the detection of dysplasia in ulcerative colitis. Gut 2004;53:256-260.

12. Matsumoto T, Nakamura S, Jo Y, et al. Chromoscopy might improve diagnostic accuracy in cancer surveillance for ulcerative colitis. Am J Gastroenterol 2003;98:1827-1833

13. Hurlstone DP, McAlindon ME, Sanders DS. et al. Further validation of high-magnification chromoscopic colonoscopy for the detection of intraepithelial neoplasia and colon cancer in ulcerative colitis. Gastroenterology 2004;126:376-378 1

14. Subramanian V, Mannath J, Ragunath K, Hawkey C. Meta-analysis: the diagnostic yield of chromoendoscopy for detecting dysplasia in patients with colonic inflammatory bowel disease. Aliment Pharmacol Ther. 2011 Feb;33(3):304-12.

15. Jess T, Simonsen J, Jorgensen KT, Pedersen BV, Nielsen NM, Frisch M. Decreasing risk of colorectal cancer in patients with inflammatory bowel disease over 30 years. Gastroenterology. 2012;143(2):375-81.e1; quiz e13-4. doi: 10.1053/j. gastro.2012.04.016 [doi].

16. Cairns SR, Scholefield JH, Steele RJ, et al. Guidelines for colorectal cancer screening and surveillance in moderate and high risk groups (update from 2002). Gut. 2010;59(5):666-689. doi: 10.1136/gut.2009.179804 [doi].

17. Zarrow R, Zarrow A, Zarrow H. “That was me” A patient’s perspective on flat lesion in inflammatory bowel disease. Gastrointest Endosc Clin N Am. 2014;24(3):349-351. doi: http://dx.doi. org/10.1016/j.giec.2014.03.007.

18. Bernstein CN, Shanahan F, Weinstein WM. Are we telling patients the truth about surveillance colonoscopy in ulcerative colitis? Lancet. 1994;343(8889):71-74. doi: S0140-6736(94)90813-3 [pii].

19. Lynch DA, Lobo AJ, Sobala GM, Dixon MF, Axon AT. Failure of colonoscopic surveillance in ulcerative colitis. Gut. 1993;34(8):1075-1080

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