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Missed Adenomas during Colonoscopic Surveillance in Individuals with Lynch Syndrome (Hereditary Nonpolyposis Colorectal Cancer)

Authors' Affiliations: ¹ Brigham and Women's Hospital/Dana-Farber Harvard Cancer Institute, Boston, Massachusetts; ² University of Michigan Medical Center, ³ Biostatistics Unit, University of Michigan Comprehensive Cancer Center, ⁴ Department of Radiation Oncology, University of Michigan Medical School, Ann Arbor, Michigan; ⁵ M. D. Anderson Cancer Center, Houston, Texas; ⁶ The Wellesley Site-Saint Michael's Hospital, Toronto, Ontario; and ⁷ Dartmouth Medical School, Lebanon, New Hampshire

Requests for reprints: Elena M. Stoffel, Division of Gastroenterology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115. Phone: 617-632-5335; Fax: 617-632-4088; E-mail: estoffel{at}partners.org.

Background and Aims: Lynch syndrome (also known as hereditary nonpolyposis colon cancer) is associated with an increased risk for colorectal cancer, which can arise despite frequent colonoscopic exams. We evaluated the adenoma miss rate of conventional colonoscopy in patients with Lynch syndrome, and compared the sensitivity of chromoendoscopy versus intensive inspection for detecting polyps missed by conventional colonoscopy.

Methods: Fifty-four subjects with Lynch syndrome underwent tandem colonoscopies at four centers of the Great Lakes-New England Clinical Epidemiology and Validation Center of the Early Detection Research Network. All participants first had a conventional colonoscopy with removal of all visualized polyps. The second endoscopy was randomly assigned as either pancolonic indigo carmine chromoendoscopy or standard colonoscopy with intensive inspection lasting >20 minutes. Size, histology, and number of polyps detected on each exam were recorded.

Results: After undergoing standard colonoscopy, 28 individuals were randomized to a second exam with chromoendoscopy and 26 underwent intensive inspection. The mean interval since last colonoscopy was 17.5 months. Seventeen polyps (10 adenomas and 7 hyperplastic polyps) were identified on the first standard colonoscopies. Twenty-three additional polyps (12 adenomas and 11 hyperplastic polyps) were found on the second exams, yielding an adenoma miss rate of 55%. Fifteen polyps (5 adenomas and 10 hyperplastic polyps) were found in subjects who had chromoendoscopy and 8 polyps (7 adenomas and 1 hyperplastic polyp) in those who had intensive inspection. Chromoendoscopy was associated with more normal tissue biopsies (11 versus 5) and longer procedure times compared with intensive inspection (29.8 ± 9.5 versus 25.3 ± 5.8 minutes; P = 0.04). Controlling for age, number of previous colonoscopies, procedure time, and prior colonic resection, chromoendoscopy detected more polyps (P = 0.04), but adenoma detection was not significantly different compared with intensive inspection (P = 0.27).

Conclusions: Small adenomas are frequently missed in patients with Lynch syndrome. Although chromoendoscopy did not detect more missed adenomas than intensive inspection in this pilot study, larger trials are needed to determine optimal surveillance techniques in this high-risk population.

Key Words: Chromoendoscopy • Lynch syndrome