Dye chromoendoscopy leads to a higher adenoma detection in the duodenum and stomach in patients with familial adenomatous polyposis

Abstract

Backround and study aims Duodenal cancer is the cancer most often seen in patients with familial adenomatous polyposis (FAP) who have undergone risk-reducing colonic surgery. Almost all patients with FAP eventually develop duodenal adenomas and risk for duodenal cancer is up to 12 % with poor prognosis. In addition, there is a rising concern regarding increased gastric cancer risk in patients with FAP. Our aim was to enhance polyp detection by using CE (CE) with the application of indigo carmine dye. Patient and methods We conducted a prospective, blinded study of patients with FAP undergoing endoscopic examination of the upper gastrointestinal tract. First, a standard white-light examination (WLE) was done followed by an examination performed by an endoscopist who was blinded to the previous examination, using chromoendoscopy (CE) (0.4 % indigo carmine dye). Results Fifty patients were included in the study. Using WLE, a median number of 13 adenomas (range 0–90) was detected compared to 23 adenomas/patient (range 0–150; P < 0.0001) detected after staining, leading to a higher Spigelman stage in 16 patients (32 %; P = 0.0003). CE detected significantly more larger adenomas (> 10 mm) than WLE (12 vs. 19; P = 0.0391). In the gastric antral region, a median number of 0 adenomas (range 0–6) before and 0.5 adenomas (range 0–7) after staining (P = 0.0025) were detected. Conclusion This prospective endoscopic trial, to our knowledge the largest in patients with FAP, showed a significant impact of CE on adenoma detection and therapeutic management in the upper gastrointestinal tract. This leads to more intensive surveillance intervals.

Personalized endoscopic surveillance and intervention protocols for patients with familial adenomatous polyposis: the European FAP Consortium strategy

“…We decided to advice to use high-definition WLE, and leave the use of advanced imaging techniques for the rectum, pouch, stomach and duodenum to the discretion of the endoscopist. Using chromoendoscopy may lead to better detection of small adenomas in the rectum, pouch and duodenum 9 38 39 40 41 . Detecting more tiny adenomas may not be clinically relevant in a condition like FAP.…”

“…Detecting more tiny adenomas may not be clinically relevant in a condition like FAP. However, in a recent study, dye-based chromoendoscopy resulted in higher detection rates of duodenal adenomas > 10 mm compared to WLE [39]. The additive value of virtual chromoendoscopy (such as NBI, TXI, BLI and LCI), which might be a suitable less time-consuming alternative to dye-based chromoendoscopy, was not evaluated in this study.…”

The Approach to Performance of Quality Upper Endoscopy in Lynch Syndrome (QUELS)

“…Surface features of gastric polyps under HD-WLE and virtual chromoendoscopy that may aid in distinguishing gastric neoplasms from low-risk polyps have been described and may be utilized to identify neoplastic epithelial polyps which should be completely resected. 37,38 Given the risk of advanced neoplasia associated with polyp size ≥ 10 mm, regardless of polyp histology, we recommend all gastric polyps ≥10 mm, and those with a neoplastic appearance should undergo complete resection. [39][40][41] If a lesion morphologically appears to contain invasive cancer, biopsies targeted to the pit pattern that seems to demonstrate the most advanced histology should be taken.…”

“…[4][5][6][7][8]10 Endoscopic Evaluation HD-WLE and virtual chromoendoscopy have both been shown to help identify duodenal adenomas; however, the optimal imaging modality for duodenal adenoma detection remains to be defined. 37,49,50 The size, number, location, and morphology (according to the Paris classification) of duodenal lesions should be reported and photodocumented. Visualization and photodocumentation of the ampulla, if normal, are not required in LS.…”

“…The size, number, location, and morphology (according to the Paris classification) of gastric lesions should be documented. Surface features of gastric polyps under HD-WLE and virtual chromoendoscopy that may aid in distinguishing gastric neoplasms from low-risk polyps have been described and may be utilized to identify neoplastic epithelial polyps which should be completely resected 37,38. Given the risk of advanced neoplasia associated with polyp size ≥10 mm, regardless of polyp histology, we recommend all gastric polyps ≥10 mm, and those with a neoplastic appearance should undergo complete resection 39–41.…”