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PAOLA CESAROPAOLA CESAROPAOLA CESAROPAOLA CESARO
IL II LIVELLO DEL PROGRAMMA DI IL II LIVELLO DEL PROGRAMMA DI IL II LIVELLO DEL PROGRAMMA DI IL II LIVELLO DEL PROGRAMMA DI
SCREENING: SCREENING: SCREENING: SCREENING:
LA COLONSCOPIALA COLONSCOPIALA COLONSCOPIALA COLONSCOPIA
� Study cohort of 1418 patients who had a complete colonoscopyduring which one or more adenomas of the colon or rectum wereremoved
� The patients subsequently underwent periodic colonoscopy during anaverage follow-up of 5.9 years
� The incidence rate of colorectal cancer was compared with that inthree reference groups, including two cohorts in which colonic polypswere not removed and one general-population registry
76-90%
EXPECTED
OBSERVED
NO POLYP = NO CANCER
COLORECTAL CANCER SCREENING
“We now have clearer insight into the natural history of colorectal
cancer and clinical skills with which to intervene and make
difference for many people.
Colorectal cancer screening has come of age”.
Sidney J. Winawer, MD
2015(22 years later )
COLORECTAL CANCER IN EUROPE
(Ferlay, Parkin & Steliarova-Foucher 2010)
COMPLIANCE TO CRC SCREENING(ANY METHOD)
< 60% USA
< 30% Europe
COMPLIANCE TO COLONOSCOPY
�Some patients under close colonoscopicsurveillance still develop CRC at short intervals
INTERVAL COLORECTAL CANCERS
Robertson DJ. Gastroenterology 2005; 129: 34-41
� “Raccomandazioni sul laQual i tà del la esecuzionetecnica del la Colonscopia esul Processo di Migl ioramentoContinuo del la Qual i tà del laColonscopia”
� Scopo:
� Fornire Standards basati sullaEvidenza e sul Consenso perla esecuzione di Colonscopiedi elevata Qualità
� Permettere lo sviluppo diprogrammi di MiglioramentoContinuo della Qualità (CQI)
2002: Prime Raccomandazioni
Rex DK. Am J Gastroenterol, 2002
Segnan N., Atkin W., 2011
LINEE GUIDA E RACCOMANDAZIONI SULLA QUALITÀ DELLA COLONSCOPIA
INDICATORI DI QUALITA’ (Quality Indicators)
Risultati verificabili per i quali esiste una evidenza scientifica
RISULTATI VERIFICABILI (Auditable Outcomes)
Indicatori importanti per i quali non esiste però una chiara evidenza
INDICATORI DI PERFORMANCE
CRITERI DI QUALITY ASSURANCE (QA)PER LA COLONSCOPIA
INDICATORI DI QUALITA’ (QI) DELLA COLONSCOPIA (REX, 2006)
�PRE-PROCEDURALI� Appropriatezza della indicazione� Adesione ai corretti intervalli di sorveglianza� Corretti intervalli di sorveglianza per IBD� Consenso informato ottenuto correttamente� Preparazione intestinale
� INTRA-PROCEDURALI� Tasso di raggiungimento del cieco� Tasso di identificazione di adenomi in soggetti asintomatici� Durata dell’esame in retrazione, dal cieco all’ano � Biopsie eseguite in pazienti con diarrea cronica� Numero e sede delle biopsie in pazienti in sorveglianza per IBD� Polipi <2 cm non inviati alla chirurgia, se non evidenza di
infiltrazione
� POST-PROCEDURALI� Incidenza di perforazione intestinale � Incidenza di sanguinamento post-polipectomia� Sanguinamenti post-polipectomia inviati alla chirurgia
COLONOSCOPY PRACTICE IN ITALY
� 13.7% Screening colonoscopies
� 44.9% No Sedation
� 19.3% Cecum not reached
Need for Colonoscopy Retraining Program !
SCREENING COLONOSCOPY
Il Gold Standard nel futuro dello screening
del cancro colonrettalesarà ancora
una colonscopia tradizionale?
� Self-Propelled Endoscopes
� Colon Capsule Endoscopy
“ROBOTIC” AUTOMATIONOF COLONOSCOPY
�E-Worm
�Aer-O-Scope
� Invendoscope
�NeoGuide Systems
�Stryker Colonosight
SELF-PROPELLED (« EASIER ») ENDOSCOPES
�E-Worm
�Aer-O-Scope
� Invendoscope
�NeoGuide Systems
�Stryker Colonosight
SELF-PROPELLED (« EASIER ») ENDOSCOPES
�E-Worm
�Aer-O-Scope
� Invendoscope
�NeoGuide Systems
�Stryker Colonosight
SELF-PROPELLED (« EASIER ») ENDOSCOPES
�E-Worm
�Aer-O-Scope
� Invendoscope
�NeoGuide Systems
�Stryker Colonosight
SELF-PROPELLED (« EASIER ») ENDOSCOPES
�E-Worm
�Aer-O-Scope
� Invendoscope
�NeoGuide Systems
�Stryker Colonosight
SELF-PROPELLED (« EASIER ») ENDOSCOPES
COLON CAPSULE ENDOSCOPY
PILLCAM COLON IMAGES:ANATOMICAL SITES
ICV Ascending Transverse Descending Rectum
A noninvasive tool for visual examination of the colon has the potential to:
�Free capacity for therapeutic endoscopies
� Be an adjunct to incomplete colonoscopy
� Offer an alternative to patients who refuse standard colonoscopy
COLON CAPSULE ENDOSCOPY
EliakimEndoscopy 2009
9878%
(95% CI, 68-
86)
81%89%
(70-97%)
76% (72-78%)
SpadaGIE 2011
10985%
(95% CI, 73-
88)
81%84%
(74-95%)
64% (52-76%)
*within 8 hours post ingestion
** for polyps ≥ 6 mm
ACCURACY
EliakimEndoscopy 2009
9878%
(95% CI, 68-
86)
81%88%
(56-98%)
89% (86-90%)
SpadaGIE 2011
10985%
(95% CI, 73-
88)
81%88%
(76-99%)
95% (90-100%)
*within 8 hours post ingestion
** for polyps ≥ 10 mm
ACCURACY
10/10 CRC CCE-DETECTED
IN CCE-2 STUDIES
Eliakim 2009; Spada 2011;Leen 2012; Rex 2013; Adler 2013
CCE ready for primetime in CRC screening program?
The ORCA/CCANDY trialsnew perspectives on screening
� CRC screening program standard
� No evidence
� Hypothesis• CCE filter• Colonoscopy only therapeutic
� Costs (???)
CCE2 AND SCREENING
POpulation colon cancer sc Reening by CApsule endoscopyThe ORCA trialCo lon Capsu le for A denoma and Neoplas ia Diagnost ic Yie ldThe CCANDY tr ia l
CTC FALSE NEGATIVE
No
alternative techniques
ready for clinical use
TRADITIONAL COLONOSCOPY
� Chromoendoscopy� Magnification� High-Resolution� Narrow Band Imaging (NBI)� FICE� i-Scan� Confocal Laser Endomicroscopy� Autofluorescence� Optical Coherence Tomography (OCT)� Endocytoscopy
ENDOSCOPIC TECHNIQUES FOR DETECTION OF EARLY GI CANCER
PREDICTIVE FACTORS OF SUBMUCOSAL CANCERS
�Lateral Spreading Tumors Non Granular Type (LST-NGT)
Moss A. et al Gastroenterology 2011;140: 1907-18
�Lateral Spreading Tumors-Non Granular Type (LST-NGT)
�Lesions classified as Paris type:• IIc • IIc + IIa
Moss A. et al Gastroenterology 2011;140: 1907-18
PREDICTIVE FACTORS OF SUBMUCOSAL CANCERS
�Lateral Spreading Tumors-Non Granular Type (LST-NGT)
�Lesions classified as Paris type:• IIc • IIa + IIc
�Lesions with Pit Pattern type V (Kudo)
Moss A. et al Gastroenterology 2011;140: 1907-18
PREDICTIVE FACTORS OF SUBMUCOSAL CANCERS
DIAGNOSIS AND THERAPY