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Development of distal rectal cancer 5 years after a normal photograph of the distal rectum
Letters to the Editor
Matthew J. McKinley, MD,FACG ProHEALTHCare Associates New Hyde Park, New York
REFERENCE 1. Ooi BP, Hassan MR, Kiew KK, et al. Case report of a hemostatic clip being retained for 2 years after deployment. Gastrointest Endosc 2010;72: 1315– 6. doi:10.1016/j.gie.2011.05.036
Development of distal rectal cancer 5 years after a normal photograph of the distal rectum To the Editor: A 61-year-old male with no family history of colorectal cancer presented for a routine postpolypectomy surveillance colonoscopy. He was asymptomatic and scheduled the colonoscopy after receiving a routine reminder from our endoscopy unit. Ten years earlier, he had undergone his first colonoscopy for screening and had resection of two diminutive adenomas from the transverse colon. Five years earlier, he had undergone his second colonoscopy and had resection of two adenomas (3 and 4 mm in size) from the sigmoid colon. The preparation was excellent, and photographs documented cecal intubation, the polyps, and the retroflexion in the rectum (Fig. 1A). On the day of the third colonoscopy, digital rectal examination revealed a small, mobile mass. The colonoscopy result was normal except for a 2-cm mass on the dentate line (Fig. 1B). Biopsies revealed moderately differentiated adenocarcinoma. Results of CT scans of the chest, abdomen, and pelvis were normal. EUS of the rectum revealed a T2N0 tumor. The patient elected abdominoperineal resection. The pathologic stage was T2N1 (one lymph node positive). The patient underwent adjuvant chemotherapy and radiation. Although cancers that develop after colonoscopy are welldocumented, recent analyses suggest that most cancers arise from lesions that are missed.1 To my knowledge, there are no published previous cases in which an average-risk patient had a cancer arise in an area that was documented by photography as normal at a previous examination. Logically, the tumors in such cases would occur in areas that would be routinely photographed at colonoscopy, such as the cecal caput, ileocecal valve, and distal rectum. These areas also include anatomic landmarks that are fixed, namely the appendiceal orifice, ileocecal valve, and the dentate line, as seen on retroflexion in the rectum. It is possible that a lesion near the dentate line 5 years previously was hidden in retroflexion by the colonoscope. However, the endoscopist reports routinely rotating the instrument in retroflexion to see the full circumference of the 728 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 3 : 2011
Figure 1. A, Retroflexed view at a colonoscopy in January 2006. B, Retroflexed view in January 2011.
anorectal junction. Further, the endoscopist reports always deflecting the instrument tip, and rotating the instrument insertion tube in the same directions for every rectal retroflexion and further reports routinely taking the photograph as soon as the retroflexed view is achieved. This would seem to increase the chance that the instrument was in a very similar relationship to the anal canal and rectum in both photographs. This finding has several implications. First, interval cancers are at least sometimes not the result of a missed lesion. Second, the routine use of photography eliminated the possibility of operator error as the cause of an interval cancer. This suggests the value of routine photography as a means of reducing medical-legal risk. By extrapolation, routine use of videotaping2 also could reduce medicallegal risk when it documents a high-quality examination technique. Finally, although current recommendations for postpolypectomy surveillance3 are generally very protective against interval cancers when there is a high-quality examination performed, they should not be expected to be perfect. Documented events of this type (occurrence of a colorectal cancer 5 years later in an area that was documented to be normal) are exceedingly rare and should not, in my opinion, justify revision of recommendations or routine shortening of intervals by individual practitioners.4 www.giejournal.org
Letters to the Editor
Douglas K. Rex, MD Department of Medicine, Division of Gastroenterology Indiana University School of Medicine Indianapolis Indiana, USA
REFERENCES 1. Pohl H, Robertson DJ. Colorectalcancersdetectedaftercolonoscopyfrequently result from missed lesions. Clin Gastroenterol Hepatol 2010;8:858-64.
2. Rex DK, Hewett DG, Raghavendra M, et al. The impact of videorecording on the quality of colonoscopy performance: a pilot study. Am J Gastroenterol 2010;105:2312-7. 3. Winawer SJ, Zauber AG, Fletcher RH, et al. Guidelines for colonoscopy surveillance after polypectomy: a consensus update by the US MultiSociety Task Force on Colorectal Cancer and the American Cancer Society. Gastroenterology 2006;130:1872-85. 4. Bonelli L, Sciallero S, Senore C, et al. History of negative colorectal endoscopy and risk of rectosigmoid neoplasms at screening flexible sigmoidoscopy. Int J Colorectal Dis 2006;21:105-13. doi:10.1016/j.gie.2011.05.035
ERRATUM In the August 2011 Table of Contents, the author of “Training to competency in colonoscopy: assessing and defining competency standards” should be R. E. Sedlack (Gastrointest Endosc 2011;74:355-66).
www.giejournal.org
Volume 74, No. 3 : 2011 GASTROINTESTINAL ENDOSCOPY 729
Matthew J. McKinley, MD,FACG ProHEALTHCare Associates New Hyde Park, New York
REFERENCE 1. Ooi BP, Hassan MR, Kiew KK, et al. Case report of a hemostatic clip being retained for 2 years after deployment. Gastrointest Endosc 2010;72: 1315– 6. doi:10.1016/j.gie.2011.05.036
Development of distal rectal cancer 5 years after a normal photograph of the distal rectum To the Editor: A 61-year-old male with no family history of colorectal cancer presented for a routine postpolypectomy surveillance colonoscopy. He was asymptomatic and scheduled the colonoscopy after receiving a routine reminder from our endoscopy unit. Ten years earlier, he had undergone his first colonoscopy for screening and had resection of two diminutive adenomas from the transverse colon. Five years earlier, he had undergone his second colonoscopy and had resection of two adenomas (3 and 4 mm in size) from the sigmoid colon. The preparation was excellent, and photographs documented cecal intubation, the polyps, and the retroflexion in the rectum (Fig. 1A). On the day of the third colonoscopy, digital rectal examination revealed a small, mobile mass. The colonoscopy result was normal except for a 2-cm mass on the dentate line (Fig. 1B). Biopsies revealed moderately differentiated adenocarcinoma. Results of CT scans of the chest, abdomen, and pelvis were normal. EUS of the rectum revealed a T2N0 tumor. The patient elected abdominoperineal resection. The pathologic stage was T2N1 (one lymph node positive). The patient underwent adjuvant chemotherapy and radiation. Although cancers that develop after colonoscopy are welldocumented, recent analyses suggest that most cancers arise from lesions that are missed.1 To my knowledge, there are no published previous cases in which an average-risk patient had a cancer arise in an area that was documented by photography as normal at a previous examination. Logically, the tumors in such cases would occur in areas that would be routinely photographed at colonoscopy, such as the cecal caput, ileocecal valve, and distal rectum. These areas also include anatomic landmarks that are fixed, namely the appendiceal orifice, ileocecal valve, and the dentate line, as seen on retroflexion in the rectum. It is possible that a lesion near the dentate line 5 years previously was hidden in retroflexion by the colonoscope. However, the endoscopist reports routinely rotating the instrument in retroflexion to see the full circumference of the 728 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 3 : 2011
Figure 1. A, Retroflexed view at a colonoscopy in January 2006. B, Retroflexed view in January 2011.
anorectal junction. Further, the endoscopist reports always deflecting the instrument tip, and rotating the instrument insertion tube in the same directions for every rectal retroflexion and further reports routinely taking the photograph as soon as the retroflexed view is achieved. This would seem to increase the chance that the instrument was in a very similar relationship to the anal canal and rectum in both photographs. This finding has several implications. First, interval cancers are at least sometimes not the result of a missed lesion. Second, the routine use of photography eliminated the possibility of operator error as the cause of an interval cancer. This suggests the value of routine photography as a means of reducing medical-legal risk. By extrapolation, routine use of videotaping2 also could reduce medicallegal risk when it documents a high-quality examination technique. Finally, although current recommendations for postpolypectomy surveillance3 are generally very protective against interval cancers when there is a high-quality examination performed, they should not be expected to be perfect. Documented events of this type (occurrence of a colorectal cancer 5 years later in an area that was documented to be normal) are exceedingly rare and should not, in my opinion, justify revision of recommendations or routine shortening of intervals by individual practitioners.4 www.giejournal.org
Letters to the Editor
Douglas K. Rex, MD Department of Medicine, Division of Gastroenterology Indiana University School of Medicine Indianapolis Indiana, USA
REFERENCES 1. Pohl H, Robertson DJ. Colorectalcancersdetectedaftercolonoscopyfrequently result from missed lesions. Clin Gastroenterol Hepatol 2010;8:858-64.
2. Rex DK, Hewett DG, Raghavendra M, et al. The impact of videorecording on the quality of colonoscopy performance: a pilot study. Am J Gastroenterol 2010;105:2312-7. 3. Winawer SJ, Zauber AG, Fletcher RH, et al. Guidelines for colonoscopy surveillance after polypectomy: a consensus update by the US MultiSociety Task Force on Colorectal Cancer and the American Cancer Society. Gastroenterology 2006;130:1872-85. 4. Bonelli L, Sciallero S, Senore C, et al. History of negative colorectal endoscopy and risk of rectosigmoid neoplasms at screening flexible sigmoidoscopy. Int J Colorectal Dis 2006;21:105-13. doi:10.1016/j.gie.2011.05.035
ERRATUM In the August 2011 Table of Contents, the author of “Training to competency in colonoscopy: assessing and defining competency standards” should be R. E. Sedlack (Gastrointest Endosc 2011;74:355-66).
www.giejournal.org
Volume 74, No. 3 : 2011 GASTROINTESTINAL ENDOSCOPY 729