Adenomas and Carcinomas Missed in Routine Colonoscopy: A Prospective Study in Resected Colon Segments

Abstract

Colonoscopy is the standard technique in the diagnosis and treatment of colorectal neoplasia, but small adenomas and even advanced lesions can be missed during the procedure. With large scale screening colonoscopy programs installed, information on quality of colonoscopy in primary care is essential, but scarcely available. Over a period of 45 months, we prospectively included all those patients in our study, who underwent major colonic surgery at our institution and who had undergone a colonoscopy within 42 days prior to the operation. 89 men and 100 women, median age 71 years, were included. The majority of these operations were performed for colorectal carcinoma (125), other malignant tumors (4), suspected malignancies (6) or large adenomas (14). The pathologist inspected the resected colonic segment, and we compared his findings with the colonoscopy report. Colonoscopies had been performed by 22 doctors in 13 institutions. Median length of the resected colonic segments was 20 cm (range 3 to 135 cm), total length was 41,21 metres. In 14 segments the pathologist identified 28 neoplastic lesions not described in the endoscopy report. Colonoscopy had missed 2 carcinomas, both in the right colon, and a 12 mm tubulo-villous adenoma with high-grade dysplasia. Another 25 tubular adenomas had been missed, 2 measuring 10 mm, 7 between 5 and 9 mm and 16 smaller than 5 mm. We conclude that primary care colonoscopy misses neoplastic lesions in a significant number of procedures. Most of the missed lesions in our high risk group of patients would have been of little clinical consequence. In a small, but clinically important number of cases, however, advanced adenomas and even colorectal carcinomas were missed by endoscopy.

Zusammenfassung

Die Koloskopie ist die Standardtechnik in der Diagnostik und Therapie kolorektaler Neoplasien, auch wenn kleine Adenome und größere Läsionen übersehen werden können. Da die Koloskopie als Instrument der Vorsorge akzeptiert ist, sind Untersuchungen zur Qualität der Koloskopie in der klinischen Routine erforderlich, aber derzeit kaum verfügbar. Über einen Zeitraum von 45 Monaten wurden in unserem Krankenhaus prospektiv alle Patienten erfasst, bei denen innerhalb von 42 Tagen nach einer Koloskopie ein Dickdarmsegment entfernt wurde. 89 Männer und 100 Frauen mit einem medianen Alter von 71 Jahren wurden in die Studie eingeschlossen. Die Mehrzahl der Operationen erfolgte wegen eines kolorektalen Karzinoms (125), aufgrund anderer maligner Tumoren (4), unter dem Verdacht auf einen Tumor (6) oder wegen großer Adenome (14). Der Pathologe arbeitete das Kolonresektat auf, und wir glichen dies mit dem Koloskopiebefund ab. Die Koloskopien wurden von 22 Ärzten in 13 Institutionen durchgeführt. Die mediane Länge des Resektats lag bei 20 cm (Spanne von 3 bis 135 cm). Insgesamt wurden 41,21 Meter Dickdarm vom Pathologen untersucht. In 14 Resektaten fand der Pathologe insgesamt 28 neoplastische Läsionen, die der Endoskopiker nicht beschrieben hatte: zwei Karzinome im rechten Kolon und ein 12 mm großes tubulovillöses Adenom mit hochgradigen Dysplasien sowie 25 tubuläre Adenome, von denen 2 10 mm maßen, 7 zwischen 5 und 9 mm und 16 < 5 mm waren. Somit werden in der endoskopischen Routine neoplastische Läsionen regelmäßig übersehen. Der Mehrzahl der übersehenen Neoplasien in der hier untersuchten Hochrisikogruppe dürfte klinisch keine wesentliche Bedeutung zukommen, aber auch signifikante Adenome und sogar Karzinome wurden übersehen.

Schlüsselwörter

kolorektales Adenom - kolorektales Karzinom - Koloskopie

Key words

colorectal adenoma - colorectal carcinoma - colonoscopy

• References

• 1 Rockey DC, Niezwiecki D, Davis W et al. Analysis of air contrast barium enema, computed tomographic colonography and colonoscopy. Lancet 2005; 365: 305-311
• 2 Rex DK, Rahmani AY, Haseman JH et al. Relative sensitivity of colonoscopy and barium enema for detection of colorectal cancer in clinical practice. Gastroenterology 1997; 112: 17-23
• 3 Haseman JH, Lemmel GT, Rahmani EY et al. Failure of colonoscopy to detect colorectal cancer: evaluation of 47 cases in 20 hospitals. Gastrointest Endosc 1997; 45: 451-455
• 4 van Rijn JC, Reitsma JB, Stoker J et al. Polyp miss rate determined by tandem colonoscopy: a systematic review. Am J Gastroenterol 2006; 101: 343-350
• 5 von Schönfeld J, Hinzmann S. Missed colonic adenomas in routine primary cae endoscopy: a prospective tandem colonoscopy study. Z Gastroenterol 2010; 48: 1207-1210
• 6 Leaper M, Johnston MJ, Barclay M et al. Reasons for failure to diagnose colorectal carcinoma at colonoscopy. Endoscopy 2004; 36: 499-503
• 7 Robertson DJ, Greenberg ER, Beach M et al. Colorectal cancer in patients under close colonoscopic surveillance. Gastroenterology 2005; 129: 34-41
• 8 Hosokawa O, Shirasaki S, Kaizaki Y et al. Invasive colorectal cancer detected up to 3 years after a colonoscopy negative for cancer. Endoscopy 2003; 35: 506-510
• 9 Kaminski MF, Regula J, Kraszewska E et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med 2010; 362: 1795-1803
• 10 Bressler B, Paszat LF, Vinden C et al. Colonoscopic miss rates for right-sided colon cancer: a population-based analysis. Gastroenterology 2004; 127: 452-456
• 11 Baxter NN, Goldwasser MA, Paszat LF et al. Association of colonoscopy and death from colorectal cancer: a population-based, case-control study. Ann Int Med 2009; 150: 1-8
• 12 Postic G, Lewin D, Bickerstaff C et al. Colonoscopic miss rates determined by direct comparison with colon resection specimen. Am J Gastroenterol 2002; 97: 3182-3185
• 13 Harewood GC, Sharma VK, de Garmo P. Impact of colonoscopy preparation quality on detection of suspected colonic neoplasia. Gastrointest Endosc 2003; 58: 76-79
• 14 Chen CC, Rex DK. Endoscopist can be more powerful than age and male gender in predicting adenoma detection at colonoscopy. Am J Gastroenterol 2007; 102: 856-861
• 15 Rex DK. Colonoscopic withdrawal technique is associated with adenoma miss rates. Gastrointest Endosc 2000; 51: 33-36
• 16 Sanchez W, Harewood GC, Petersen BT. Evaluation of polyp detection in relation to procedure time of screening or surveillance colonoscopy. Am J Gastroenterol 2004; 99: 1941-1945
• 17 Barclay RL, Vicari JJ, Doughty AS et al. Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. N Engl J Med 2006; 355: 2533-2541