Introduction

Patients deemed to remain at increased risk of colorectal cancer (CRC) following detection and removal of colorectal polyps are recommended to undergo surveillance by colonoscopy. Risk stratification to inform recommendations for the first surveillance colonoscopy, according to characteristics of baseline polyps, is well established. However, the UK, European, and US post-polypectomy surveillance guidelines highlight the paucity of data to inform ongoing surveillance beyond the first surveillance colonoscopy.

Aims & Methods

Our aim was to identify which patient groups, defined by combinations of polyp findings at baseline and first surveillance, need ongoing surveillance and how many surveillance colonoscopies they might need. We performed a retrospective analysis of patients who underwent baseline colonoscopy with polypectomy at 17 UK hospitals, mostly from 2000 to 2010, and had ≥1 surveillance examinations. Cancer registration and death certificate data were collected through 2017. We examined patients in four groups defined by combinations of polyp findings at baseline and first surveillance: group 1 (low-risk findings at both baseline and first surveillance), group 2 (low-risk findings at baseline and high-risk findings at first surveillance), group 3 (high-risk findings at baseline and low-risk findings at first surveillance), and group 4 (high-risk findings at both baseline and first surveillance). High-risk findings included 2 premalignant polyps (PMPs: adenomas or serrated polyps) of which ≥1 was ‘advanced’ (adenoma ≥10mm or with high-grade dysplasia, or serrated polyp ≥10mm or with any dysplasia), ≥5 PMPs, or ≥1 non-pedunculated polyp ≥20mm, while all other findings were included as low-risk findings, as per the UK post-polypectomy surveillance guidelines. We examined CRC incidence after first surveillance, in the presence of a single surveillance examination, and after second surveillance, in the presence of ≥2 examinations. We compared incidence to that in the general population of England in 2007 using standardised incidence ratios (SIRs).

Results

After exclusions, 10,832 patients were available for analysis, of whom 6,746 (62%), 248 (2%), 3,437 (32%), and 401 (4%) were classified into group 1, 2, 3, and 4, respectively. Among each respective group, 3,581 (53%), 84 (34%), 1,478 (43%), and 119 (30%) had a single surveillance examination; remaining patients had ≥2 surveillance examinations. The median time from first surveillance to end of follow-up was 10.9 years, during which 158 patients were diagnosed with CRC. Compared to the general population, CRC incidence after first surveillance, with a single surveillance examination, was lower in group 1 (SIR 0.51, 95%CI 0.36-0.71), non-significantly different in group 2 (SIR 2.51, 95%CI 0.81-5.85) and group 3 (SIR 1.22, 95%CI 0.90-1.63), but higher in group 4 (SIR 2.84, 95%CI 1.30-5.39). After second surveillance, CRC incidence in group 4 was no longer higher than that in the general population (SIR 1.86, 95%CI 0.89-3.42).

Conclusion

In our cohort of patients undergoing post-polypectomy surveillance, high-risk polyp findings were uncommon at first surveillance, even among those with high-risk findings at baseline. Only those with high-risk findings at both baseline and first surveillance appear to have needed ongoing surveillance, with the second surveillance examination appearing sufficient to eliminate the excess CRC risk in these patients.

Introduction

Post endoscopy upper gastrointestinal cancers (PEUGIC) are often missed opportunities to diagnose earlier or even prevent cancer. A national process for identifying all PEUGIC in the English National Health Service (NHS) and performing root cause analysis was developed. In parallel, a survey of NHS endoscopy providers diagnostic and surveillance UGI endoscopy practices was undertaken to investigate organisational factors which may contribute to endoscopy quality and PEUGIC.

Aims & Methods

PEUGIC occurring 3-36 months after an index endoscopy without a cancer diagnosis between 2017 and 2023 were identified from National Cancer Registration and Hospital Episode Statistics datasets. Data from local root cause analysis were uploaded onto a secure portal for national analysis. Endoscopy providers taking part in the project were asked to complete an online organisational survey, covering diagnostic and surveillance endoscopic practices, equipment and the management of dysplasia and early cancer.

Results

3151 PEUGIC were examined by local reviewers in 144 hospitals in England. 635 (20%) were excluded on local review. Data were available for 2516 PEUGIC. 1897 PEUGIC (75.4%) were following diagnostic endoscopy and 618 (24.6%) were undergoing surveillance. 80% of endoscopy providers responded to the survey.
For diagnostic PEUGIC, less than 20 minutes being allocated to UGI endoscopy was associated with no abnormalities detected in the PEUGIC segment at index endoscopy OR 1.25 (95% CI 1.04-1.50). Oesophageal squamous cell PEUGIC were associated with less time allocated per endoscopy OR 1.28 (95% CI 1.03-1.59). Endoscopy providers with lower number of procedures during an endoscopy session were associated more frequently with adequate management of lesions OR 2.6 (95% CI 1.03-6.87). Patient harm and adverse treatment outcomes were associated with an inadequate index endoscopy OR 1.56 (95% CI 1.28-1.91). The most common reason for inadequate endoscopy was inadequate management of lesions identified, which were most likely to be cancer associated lesions OR 1.43 (95% CI 1.11-1.69), specifically oesophageal strictures (24%) and gastric ulcers (23%).
For surveillance PEUGIC, organisational factors associated with increased detection of stage 1 (success of surveillance) PEUGIC compared with stage ≥2 were: dedicated surveillance sessions OR 2.08 (95% CI 1.46-2.98), >20 minutes allocated per endoscopy OR 2.05 (95% CI 1.48-2.84) and surveillance in an endoscopic resection centre OR 3.50 (95% CI 1.99-6.13).
Booking delays and errors were noted in 12% of PEUGIC, patient factors (e.g. non-attendance) were noted in 11% and clinical error in 11.7% (inappropriate decision 7.5% and histology not actioned in 4.2%). Surveillance was delayed in 27% of PEUGIC and associated with adverse treatment outcomes OR 1.79 (95%CI 1.72-2.73).

Conclusion

A survey of endoscopy providers’ organisational structure has revealed factors which contribute to PEUGIC not captured during individual root cause analysis. Less time allocated for endoscopy was associated with no abnormalities being found during endoscopies that lead to PEUGIC. Surveillance outcomes were better in patients who had their endoscopies in dedicated surveillance sessions, with more time allocated and undertaken in endoscopic resection centres. Surveillance delays are common and associated with worse outcomes.

Introduction

Accurate endoscopic diagnosis of colorectal polyps is essential for determining appropriate treatment strategies. The Japan NBI Expert Team (JNET) classification and pit pattern diagnosis are used for diagnosis, but their comparative diagnostic performance in real-world clinical settings remains unclear, particularly between experts and non-experts.

Aims & Methods

This post-hoc analysis aimed to evaluate the diagnostic accuracy of both classification across different levels of expertise using data from a prospective multicenter trial. We conducted a post-hoc analysis of the deTXIon trial¹ , a randomized controlled trial conducted at eight Japanese institutions between March and October 2023. From the per-protocol set, we analyzed colorectal lesions that had both JNET classification and pit pattern diagnosis with confirmed histopathology. JNET classification categorizes lesions into Type 1 (corresponding to hyperplastic polyps [HPs] and sessile serrated lesions [SSLs]), Type 2A (low-grade adenomas), Type 2B (high-grade adenomas or superficial submucosal invasive cancer), and Type 3 (deep submucosal invasive cancer). Pit pattern classification included Type II ( HPs/SSLs ), Type III_S/III_L/IV (low-grade adenomas), Type V_I low-grade (high-grade adenoma), and Type V_I high-grade/V_N (submucosal invasive cancer). We calculated sensitivity (Sen), specificity (Spe), positive predictive value (PPV), and negative predictive value (NPV) for each classification stratified by endoscopist expertise and lesion size.

Results

A total of 1,617 colorectal lesions with a median size (IQR) of 2(1-4) mm were included in this analysis. Histopathological examination revealed that 71.5% (1,156/1,617) were low-grade adenomas, 1.0% (16/1,617) were high-grade adenomas or cancer, 19.3% were HPs (312/1,617), and 8.2% (133/1,617) were SSLs. For JNET Type 1 lesions, diagnostic accuracy was comparable between experts (Sen: 82.8%, Spe: 95.9%, PPV: 88.3%, NPV: 93.7%) and non-experts (Sen: 81.7%, Spe: 93.4%, PPV: 83.1%, NPV: 92.8%). Similarly, for JNET Type 2A, both groups showed high diagnostic performance (experts: Sen 93.8%, Spe 81.0%, PPV: 92.6%, NPV: 83.8%; non-experts: Sen 91.5%, Spe 78.3%, PPV: 90.3%, NPV: 80.6%).
In contrast, pit pattern diagnosis experts showed higher performances, particularly for Type II (experts: Sen 80.9%, Spe 96.3%, PPV: 89.0%, NPV: 93.1%; non-experts: Sen 57.9%, Spe 92.8%, PPV: 76.0%, NPV: 84.8%). The diagnostic performance for small lesions (≤5mm) was consistently high with JNET classification (Type 1: Sen 79.5%, Spe 94.3%; Type 2A: Sen 93.7%, Spe 79.2%), while pit pattern diagnosis showed lower performance (Type II: Sen 70.8%, Spe 94.5%; Type III_S/III_L/IV: Sen 93.6%, Spe 79.5%), for these lesions among non-experts.

Conclusion

JNET classification demonstrates comparable diagnostic performance between expert and non-expert endoscopists, likely due to its standardized and intuitive visual criteria. Pit pattern diagnosis shows experience-dependent performance differences, suggesting that NBI-based assessment may be more suitable for routine clinical practice, especially for diminutive lesions.

References

1. Toyoshima N, Mizuguchi Y, Takamaru H,et al. The Efficacy of Texture and Color Enhancement Imaging Observation in the Detection of Colorectal Lesions: A Multicenter, Randomized Controlled Trial (deTXIon Study). Gastroenterology. 2025 in press

Disclosure

These authors disclose the following: Yutaka Saito, Masashi Misawa, Shin-ei Kudo, and Toshio Uraoka have received lecture fees from Olympus
Corporation. The remaining authors disclose no conflicts.

Introduction

The incidence of oesophago-gastric cancer has an age-dependent male predominance mirroring physiological changes in sex hormonal levels. Some previous studies suggest that menopausal hormone therapy (MHT) counteracts the occurrence of these tumours, but larger studies with longer follow-up and adjustment for confounders are needed, which prompted the present study.

Aims & Methods

To investigate the hypothesis that MHT decreases the risk of developing oesophago-gastric cancer, especially oesophageal adenocarcinoma.
This population-based case-control study included women aged ≥45 years in all five Nordic countries (Denmark, Finland, Iceland, Norway, Sweden) between 1995-2020. Prospectively collected data came from national complete registries for medications, cancer, diagnoses, total populations, and death. The study included 19,518 case patients with oesophago-gastric cancer and 195,094 randomly identified control participants matched for age, country and calendar year. The participants were categorised into three equal-sized groups (tertiles) of defined daily doses (DDD) of MHT, with non-users as the reference group. MHT was also categorized as systemic or local, and oestrogen only or oestrogen combined with progesterone MHT. Oesophago-gastric cancer was divided into oesophageal or cardia adenocarcinoma, oesophageal squamous cell carcinoma, and gastric non-cardia adenocarcinoma as separate outcomes. Conditional logistic regression provided odds ratios (OR) with 95% confidence intervals (CI), adjusted for age, calendar year, country, obesity, gastroesophageal reflux disease, smoking, alcohol, Helicobacter pylori eradication, use of statins and non-steroidal anti-inflammatory drugs.

Results

​Compared to non-users of MHT, the adjusted ORs of oesophageal or cardia adenocarcinoma were 0.74 (95% CI 0.67-0.81) for low MHT-use (<158 DDDs), 0.68 (95% CI 0.61-0.75) for intermediate MHT-use (158-848 DDDs), and 0.68 (95% CI 0.61-0.75) for high MHT-use (>848 DDDs). The corresponding ORs were 0.69 (95% CI 0.62-0.77), 0.70 (95% CI 0.62-0.77), and 0.71 (95% CI 0.64-0.79) for oesophageal squamous cell carcinoma, and 0.90 (95% CI 0.84-0.96), 0.85 (95% CI 0.79-0.91), and 0.80 (95% CI 0.74-0.86) for gastric non-cardia adenocarcinoma.

Table. Odds ratios (OR) and 95% confidence intervals (CI) of oesophago-gastric cancer by tertiles of defined daily doses (DDD) of menopausal hormone therapy (MHT), MHT hormonal constitution and administration of MHT.

Conclusion

This study provides support for the hypothesis of an inverse association between MHT and risk of developing oesophago-gastric cancer, and particularly for oesophageal adenocarcinoma where the association was seemingly dose-dependent and stronger for combined oestrogen and progesterone MHT and for systemic MHT. A limitation to the study was the inability to adjust for socioeconomic factors as confounders.