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Immunoscopy®-extended diagnostics of colorectal carcinomas
COLON AND R E C T U M
~
333
335
OF UPPER AND LOWER GASTROINTESTINAL ENDOSCOPY IN THE EVALUATION OF IRON DEFICIENCY ANEMIA: PROSPECTIVE STUDY. V.L. Kaila, H.M. EINewihi, R.J. Maliakkal and A.A. Mihas. Division of Gastroenterology, VA Medical center and University of Mississippi school of Medicine, J a c k s o n , MS. Chronic occult gastrointestinal(GI) bleeding is frequently the cause of iron deficiency anemia(IDA), perticularly in elderly male patients. Between July 1994 and December 1994, patients referred to our service with a diagnosis of IDA were prospectively evaluated for the source and etiology of GI blood loss. All patients underwent esophagogastroduodenoscopy (EGD), colonoscopy(C) and small bowel series(SBS). Patients with frank bleeding, incomplete endoscopic evaluation and, those who had had surgery of the GI tract were excluded. Patients' clinical and laboratory characteristics m• a r e s h o w n in t h e t a b l e :
COLONOSCOPY USING AN ENTEROSCOPE: A NEW TECHNIQUE. M. Kaw, R. Carter, J. Ahn, G.J. Brodmerkel, Jr. Division of Gastroenterology, Allegheny General Hospital/Allegheny Campus, The Medical College of PA a n d H a f i n e m a n n University, Pittsburgh, PA
CLINICAL
DATA
ENDOSCOPIC
FINDINGS
Sex: M a l e (100%) Procedure Y i e l d (%) Age: 67 • 1 . 9 Hct: 29 • 0 . 8 EGD 12 MCV: 74 • 1.2 Colonoscopy 36 Fe: 19 • 1 . 6 Both 33 T I B C : 347 • 16 Neither 19 Ferritin: 42• O f t h e 12 p a t i e n t s w i t h o n l y a c o l o n i c s o u r c e of b l o o d l o s s 4 h a d C A of t h e c o l o n . T h e r e m a i n i n g 8 patients had colonic polyps, some of them in conjunction with small AVMs. Of the 4 patients with only an UGI tract source 2 had gastric ulcers, 1 had an AVM and the 4th had eeophagitis. Im oonr i) Colonoscopy r e m a i n s t h e p r o c e d u r e o f c h o i c e in t h e e v a l u a t i o n o f IDA. 2) T h e d i a g n o s t i c v a l u e o f E G D is l i m i t e d even in cases with a negative colonoscopy.
Background and Aim: Congenital malrotations, variations in normal colonic anatomy, adhesions resulting from previous surgery or radiation may make colonoscopic insertion difficult, time consuming a n d sometimes impossible. No data are available on the use of an enteroscope to perform colonoscopic exams in these difficult situations. The push enteroscope design provides extra flexibility a n d a longer shaft length. We present our experience with the use of an enteroscope in colonoscopic exams which failed with a conventional colonoscope. Methods: The small bowel push enteroscope used was an Olympus SIF Type 100L forward viewing scope (working length: 217 cm; outer diameter: 11.3 mm; inner diameter of biopsy channel: 2.8 mm). The scope was inserted initially using conventional colonoscopic technique. The stiffening overtube (working length: 80 cm; outer diameter: 15 ram) was then:used to straighten the sigmoid colon. The overtube was then advanced over the scope until the tip was visible in the transverse colon, resulting in straightening of the long r e d u n d a n t sigmoid a n d descending colon. The passage of the stiffening tube was observed u n d e r fluoroscopy. The scope was then advanced to the cecum. Results: 4 patients with failed eolonoseopic exam (average of 2 attempts) underwent eolonoseopy using an enteroscope. The indicationsincluded GI bleeding (hemoccult positive stools) in 3 and unexplained abdominal pain in one. Colonoscopywas successful in all patients with complete visualization to the cecum or terminal ileum. No complications were noted. O n e patient was found to have cecal mass (adenoearcinoma). This patient undelvcent successful right hemicolectomy (Duke's stage B2 with tumor free margins). A n o t h e r patient had A V M s at ileocolonic anastomosis (treated with endoscopic coagulation). Conclusions: We recommend the use of an enteroscope with a stiffening overtube in technically difficult colonoscopic examinations.
*334
336
COLONOSCOPY AND BARIUM ENEMA IN THE DETECTION OF COLORECTAL CANCER. S, Kaster, S. Bucklev. J. Haseman, T. Lemmel. E. Rahamni. M. Stanley, D. Rex. Indiana University School of Medicine, Indianapolis, IN. Colonoscopy (CS) is superior to barium enema (BE l for detection of polyps, but the two tests are considered roughly comparable for cancer detection in specialized centers. The relative performance of ca and BE for cancer detection in general clinical practice is uncertain. METHODS: Tumor registries in 9 central Indiana hospitals (2 university, 7 community) provided consecutive colorectal cancer cases from 1988-94. GI fellows reviewed medical records of 1157 cases to determine demographic and tumor features and all procedures performed. Patients diagnosed by sigmoidoscopy, CT or surgery were excluded. For the remaining 902 cases, RE or CS was identified as the primary diagnostic procedure according to whichever was performed first and within 3 years of diagnosis. RESULTS: Primary BE missed 69 of 456 cancers (15.1%) and missed more cancer than Ca (22 misses of 446 cases; 4.9%,p < O.OOl). Right colon (cecum, ascending, hepatic flexure) cancer accounted for 29% of all cancer cases but 41% of all BE misses (p < 0.04). The miss rate for double contrast BE (14.7%) was similar to that for single contrast BE (18%). The hospital BE miss range was 10%-19% and the miss rate at university hospitals (15%) did not differ from community hospitals. Missed cancer by BE resulted in a mean delay in diagnosis of 9.1 months. Tumor detected by CS had earlier Dukes classes (A 27%; B 39%; C 22%; D 12%) than detections by BE (A 12%; B 42%; C 30%; D 16%). CS misses were in the right colon in 41% of cases, but in only 18% of CS misses was the miss clearly related to failure to reach the cancer. The hospital miss range for CS was 0-15%. Missed cancer by CS resulted in a mean delay in diagnosis of 7.8 months. The miss rate during CS for gastroenterologists (GE) (1.8%) was lower than for non-GE (14%; p < 0.001). SUMMARY: i. In clinical practice BE misses 3 times more cancer than CS. 2. BE miss rates are as high in the right colon as the left, are high in all hospitals including university. 3. CS results in detection of earlier Dukes classes than BE. 4. Missed cancers by BE and CS frequently result in significant delays in diagnosis. 5. Non-GE miss more cancer at CS than GE. CONCLUSION: BE should be abandoned for indications and demographic features highly predictive of cancer. Any patient with persistent symptoms after negative BE should undergo CS. Although the level of training of non-GE was not certain for all practitioners, the results suggest that training in C8 results in superior performance.
lmmunoseopy | - extended ~agnost/es of colorectal carcinomas Keller R), Foerster E C 1, Winde G.2, Domschke W 1. Dept. of Medicine B 1 and Dept os Surgery2, University of MOnster, MOnster, Introduction: At present malig~mt early changes in long-standing ulcerative colitis or m tubule-villous coloadenomas can only be definitely assessed histologically. However, often it is not possible to deafly defure these areas macroscopicalty. Usually, existing coloraetal carcinomas can be definitely identified. For this reason the cnloreetal adenocarcinoma represents a good model to demonstrate malignant mucosal changes by means of immunoscopy, a combination of endoscopy and immunofluorescence. The results of this study may possibly be applied to malignant early changes of the colorectal mucesa. Method of procedure: Immunoscopy was first performed during routine endoscopic diagnostics in 8 samples of fresh tumor material and afterwards in two patients st~ffonng from coloreetal carcinoma as well. Visualization of the carcinoma was carried out atter havurg applied a purified monoclonal antibody to CEA which had been labded by fluorescent staining. In order to generate the appropriate light for the excitation maximum a special narrow band filter was additionally inserted behind the standard source of light. For assessing the specific fluorescence a second narrow band filter which could only be penetrated by the emattedlight was positioned in the light path in front of the investigator's eye. Via a catheter advanced through the operating channel of the colonoscope the labeled antibody was applied under optical m~itoting onto the tumor An incubation period of a few minutes was followed by irrigation with a buffer in order to dimmate unspecific fluorescence artifacts. Results: After rinsing of the unbound antibody loads a specific fluorescence limited to the tumor could be detected in the excitation light, whereas in the region of tumor necroses no fluorescence could be demonstrated A significant differentiation of the marginal tumor tissue was obvious in comparison with macroscopically unaffected mucosa. Biscusssion: By means of immunoscopy it is possible to discover tissue areas containing a cellular, membrane-based epitope which can be detected employing an antibody. Using fluorescence staining for visualization even tissue areas with only minor epitope binding can be identified. However, diagnosis of macroscopically clear-cut carcinomas shall not be the aim of this method Malignant early changes, particularly in long-standing ulcerative colitis or in tubulo-villoos colonic polyps may possibly be demonstrated this way. Corresponding investigations are presently being corned out.
V O L U M E 41, NO. 4, 1995
GASTROINTESTINAL ENDOSCOPY
379
~
333
335
OF UPPER AND LOWER GASTROINTESTINAL ENDOSCOPY IN THE EVALUATION OF IRON DEFICIENCY ANEMIA: PROSPECTIVE STUDY. V.L. Kaila, H.M. EINewihi, R.J. Maliakkal and A.A. Mihas. Division of Gastroenterology, VA Medical center and University of Mississippi school of Medicine, J a c k s o n , MS. Chronic occult gastrointestinal(GI) bleeding is frequently the cause of iron deficiency anemia(IDA), perticularly in elderly male patients. Between July 1994 and December 1994, patients referred to our service with a diagnosis of IDA were prospectively evaluated for the source and etiology of GI blood loss. All patients underwent esophagogastroduodenoscopy (EGD), colonoscopy(C) and small bowel series(SBS). Patients with frank bleeding, incomplete endoscopic evaluation and, those who had had surgery of the GI tract were excluded. Patients' clinical and laboratory characteristics m• a r e s h o w n in t h e t a b l e :
COLONOSCOPY USING AN ENTEROSCOPE: A NEW TECHNIQUE. M. Kaw, R. Carter, J. Ahn, G.J. Brodmerkel, Jr. Division of Gastroenterology, Allegheny General Hospital/Allegheny Campus, The Medical College of PA a n d H a f i n e m a n n University, Pittsburgh, PA
CLINICAL
DATA
ENDOSCOPIC
FINDINGS
Sex: M a l e (100%) Procedure Y i e l d (%) Age: 67 • 1 . 9 Hct: 29 • 0 . 8 EGD 12 MCV: 74 • 1.2 Colonoscopy 36 Fe: 19 • 1 . 6 Both 33 T I B C : 347 • 16 Neither 19 Ferritin: 42• O f t h e 12 p a t i e n t s w i t h o n l y a c o l o n i c s o u r c e of b l o o d l o s s 4 h a d C A of t h e c o l o n . T h e r e m a i n i n g 8 patients had colonic polyps, some of them in conjunction with small AVMs. Of the 4 patients with only an UGI tract source 2 had gastric ulcers, 1 had an AVM and the 4th had eeophagitis. Im oonr i) Colonoscopy r e m a i n s t h e p r o c e d u r e o f c h o i c e in t h e e v a l u a t i o n o f IDA. 2) T h e d i a g n o s t i c v a l u e o f E G D is l i m i t e d even in cases with a negative colonoscopy.
Background and Aim: Congenital malrotations, variations in normal colonic anatomy, adhesions resulting from previous surgery or radiation may make colonoscopic insertion difficult, time consuming a n d sometimes impossible. No data are available on the use of an enteroscope to perform colonoscopic exams in these difficult situations. The push enteroscope design provides extra flexibility a n d a longer shaft length. We present our experience with the use of an enteroscope in colonoscopic exams which failed with a conventional colonoscope. Methods: The small bowel push enteroscope used was an Olympus SIF Type 100L forward viewing scope (working length: 217 cm; outer diameter: 11.3 mm; inner diameter of biopsy channel: 2.8 mm). The scope was inserted initially using conventional colonoscopic technique. The stiffening overtube (working length: 80 cm; outer diameter: 15 ram) was then:used to straighten the sigmoid colon. The overtube was then advanced over the scope until the tip was visible in the transverse colon, resulting in straightening of the long r e d u n d a n t sigmoid a n d descending colon. The passage of the stiffening tube was observed u n d e r fluoroscopy. The scope was then advanced to the cecum. Results: 4 patients with failed eolonoseopic exam (average of 2 attempts) underwent eolonoseopy using an enteroscope. The indicationsincluded GI bleeding (hemoccult positive stools) in 3 and unexplained abdominal pain in one. Colonoscopywas successful in all patients with complete visualization to the cecum or terminal ileum. No complications were noted. O n e patient was found to have cecal mass (adenoearcinoma). This patient undelvcent successful right hemicolectomy (Duke's stage B2 with tumor free margins). A n o t h e r patient had A V M s at ileocolonic anastomosis (treated with endoscopic coagulation). Conclusions: We recommend the use of an enteroscope with a stiffening overtube in technically difficult colonoscopic examinations.
*334
336
COLONOSCOPY AND BARIUM ENEMA IN THE DETECTION OF COLORECTAL CANCER. S, Kaster, S. Bucklev. J. Haseman, T. Lemmel. E. Rahamni. M. Stanley, D. Rex. Indiana University School of Medicine, Indianapolis, IN. Colonoscopy (CS) is superior to barium enema (BE l for detection of polyps, but the two tests are considered roughly comparable for cancer detection in specialized centers. The relative performance of ca and BE for cancer detection in general clinical practice is uncertain. METHODS: Tumor registries in 9 central Indiana hospitals (2 university, 7 community) provided consecutive colorectal cancer cases from 1988-94. GI fellows reviewed medical records of 1157 cases to determine demographic and tumor features and all procedures performed. Patients diagnosed by sigmoidoscopy, CT or surgery were excluded. For the remaining 902 cases, RE or CS was identified as the primary diagnostic procedure according to whichever was performed first and within 3 years of diagnosis. RESULTS: Primary BE missed 69 of 456 cancers (15.1%) and missed more cancer than Ca (22 misses of 446 cases; 4.9%,p < O.OOl). Right colon (cecum, ascending, hepatic flexure) cancer accounted for 29% of all cancer cases but 41% of all BE misses (p < 0.04). The miss rate for double contrast BE (14.7%) was similar to that for single contrast BE (18%). The hospital BE miss range was 10%-19% and the miss rate at university hospitals (15%) did not differ from community hospitals. Missed cancer by BE resulted in a mean delay in diagnosis of 9.1 months. Tumor detected by CS had earlier Dukes classes (A 27%; B 39%; C 22%; D 12%) than detections by BE (A 12%; B 42%; C 30%; D 16%). CS misses were in the right colon in 41% of cases, but in only 18% of CS misses was the miss clearly related to failure to reach the cancer. The hospital miss range for CS was 0-15%. Missed cancer by CS resulted in a mean delay in diagnosis of 7.8 months. The miss rate during CS for gastroenterologists (GE) (1.8%) was lower than for non-GE (14%; p < 0.001). SUMMARY: i. In clinical practice BE misses 3 times more cancer than CS. 2. BE miss rates are as high in the right colon as the left, are high in all hospitals including university. 3. CS results in detection of earlier Dukes classes than BE. 4. Missed cancers by BE and CS frequently result in significant delays in diagnosis. 5. Non-GE miss more cancer at CS than GE. CONCLUSION: BE should be abandoned for indications and demographic features highly predictive of cancer. Any patient with persistent symptoms after negative BE should undergo CS. Although the level of training of non-GE was not certain for all practitioners, the results suggest that training in C8 results in superior performance.
lmmunoseopy | - extended ~agnost/es of colorectal carcinomas Keller R), Foerster E C 1, Winde G.2, Domschke W 1. Dept. of Medicine B 1 and Dept os Surgery2, University of MOnster, MOnster, Introduction: At present malig~mt early changes in long-standing ulcerative colitis or m tubule-villous coloadenomas can only be definitely assessed histologically. However, often it is not possible to deafly defure these areas macroscopicalty. Usually, existing coloraetal carcinomas can be definitely identified. For this reason the cnloreetal adenocarcinoma represents a good model to demonstrate malignant mucosal changes by means of immunoscopy, a combination of endoscopy and immunofluorescence. The results of this study may possibly be applied to malignant early changes of the colorectal mucesa. Method of procedure: Immunoscopy was first performed during routine endoscopic diagnostics in 8 samples of fresh tumor material and afterwards in two patients st~ffonng from coloreetal carcinoma as well. Visualization of the carcinoma was carried out atter havurg applied a purified monoclonal antibody to CEA which had been labded by fluorescent staining. In order to generate the appropriate light for the excitation maximum a special narrow band filter was additionally inserted behind the standard source of light. For assessing the specific fluorescence a second narrow band filter which could only be penetrated by the emattedlight was positioned in the light path in front of the investigator's eye. Via a catheter advanced through the operating channel of the colonoscope the labeled antibody was applied under optical m~itoting onto the tumor An incubation period of a few minutes was followed by irrigation with a buffer in order to dimmate unspecific fluorescence artifacts. Results: After rinsing of the unbound antibody loads a specific fluorescence limited to the tumor could be detected in the excitation light, whereas in the region of tumor necroses no fluorescence could be demonstrated A significant differentiation of the marginal tumor tissue was obvious in comparison with macroscopically unaffected mucosa. Biscusssion: By means of immunoscopy it is possible to discover tissue areas containing a cellular, membrane-based epitope which can be detected employing an antibody. Using fluorescence staining for visualization even tissue areas with only minor epitope binding can be identified. However, diagnosis of macroscopically clear-cut carcinomas shall not be the aim of this method Malignant early changes, particularly in long-standing ulcerative colitis or in tubulo-villoos colonic polyps may possibly be demonstrated this way. Corresponding investigations are presently being corned out.
V O L U M E 41, NO. 4, 1995
GASTROINTESTINAL ENDOSCOPY
379