The “diagnose and leave in” strategy for diminutive rectosigmoid polyps in Lynch syndrome: a post hoc analysis from a randomized controlled trial

Abstract

Background and study aim: The ‘diagnose-and-leave-in’ policy has been established to reduce risks and costs related to unnecessary polypectomies in the average-risk population. In Lynch syndrome individuals, due to accelerated carcinogenesis, the general recommendation is to remove all polyps, irrespective of size, location and appearance. We evaluated the feasibility and safety of the ‘diagnose-and-leave-in’ strategy in Lynch syndrome individuals. Patients and methods: We performed a post-hoc analysis based on per-polyp data from a randomized, clinical trial conducted by 24 dedicated colonoscopists at 14 academic centres, in which 256 individuals with confirmed Lynch syndrome underwent surveillance colonoscopy from July 2016 to January 2018. In vivo optical diagnosis with the level of confidence of all detected lesions were obtained before polypectomy using virtual chromoendoscopy alone or with dye-based chromoendoscopy. Our primary outcome was the negative predictive value (NPV) for neoplasia of high-confidence optical diagnosis among diminutive (≤ 5 mm) rectosigmoid lesions. Histology was the reference standard. Results: Of 147 rectosigmoid lesions, 128 were diminutive. In 103 of the 128 lesions (81%) , the optical diagnostic confidence was high, showing a NPV of 96.0% (95% confidence interval, [88.9%–98.6%]) and accuracy of 89.3% (95% confidence interval, [81.9%–93.9%]). By following the ‘diagnose-and-leave-in” policy, we would have avoided 59% (75/128) unnecessary polypectomies at expenses of 2 diminutive low-grade dysplasia adenomas and 1 diminutive sessile serrated lesion that would have been left in situ. Conclusion: In Lynch syndrome patients, the “diagnose-and-leave-in strategy” for diminutive rectosigmoid polyps would be feasible and safe.

Real-time diagnostic accuracy of blue light imaging, linked color imaging and white-light endoscopy for colorectal polyp characterization

“…This "under-detection" could have artificially increased the proportion of adenomas and SSLs among diminutive rectosigmoid lesions in our study (53 %), which is higher ▶ Table 3 Outcomes of multilevel logistic regression analysis to find predictors for accurate endoscopic prediction of histology. than the prevalence found in another large cohort of patients with Lynch syndrome (23 %) [28]. If all polyps would have been included leaving no polyps in situ, the results might have been better.…”

The Role of Colonoscopy in the Management of Individuals with Lynch Syndrome: A Narrative Review

“…Out of one hundred and twenty-eight diminutive (≤5 mm) rectosigmoid lesions diagnosed in vivo by real-time optical diagnosis, with virtual chromoendoscopy alone or with dye-based chromo-endoscopy, only three neoplastic lesions were wrongly classified as hyperplastic polyps and eight non-adenomatous lesions were misdiagnosed as neoplastic. Thus, the use of NPV for neoplastic histology among diminutive rectosigmoid lesions exceeded the benchmark of 90%, indicating both the feasibility and the safety of the "diagnose-and-leave-in" strategy for the surveillance of individuals with LS [19]. The results of this study suggest the possibility that enhanced endoscopy may improve the characterization of colorectal lesions in the LS population.…”

“…A recent randomized controlled trial resumed the discussion about the unnecessary overtreatment of irrelevant lesions detected during the surveillance colonoscopies of individuals with LS [19]. According to the ASGE-PIVI's first statement regarding the "diagnose and leave in" strategy for diminutive rectosigmoid polyps, the negative predictive value (NPV) for adenomatous histology must not be inferior to 90% when used with a high level of confidence to introduce new strategies into current clinical practice [20].…”