L INTERAZIONE CON L ENDOSCOPISTA

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1 L INTERAZIONE CON L ENDOSCOPISTA Roberto Fiocca DICMI, Anatomia Patologica - Università di Genova

2 Obiettivo principale Comunicare l entità del rischio

3 Indicazioni GISCoR Pathologica 2006;98: Istotipo Architettura (>80%) Grado di displasia Basso vs alto grado No K in situ/intramucoso Cancerizzazione Basso vs alto rischio

4 Margine libero Margine interessato Invasione vascolare Alto grado

5 Adenoma cancerizzato Stato del margine di resezione (polipectomia endoscopica) Viene considerato come coinvolto quando la infiltrazione è presente sul margine o giunge a < 1 (o 2) mm dal margine di resezione oppure è riscontrabile nel contesto della banda di diatermocoagulazione

6 Anti-pancitocheratine Tumor budding

7 Anti-pancitocheratine Tumor budding

8

9 Tumor grade Vascular invasion Cribriform pattern Tumor budding

10 Combinazione più efficiente

11 Profondità µm Ampiezza µm

12 Ampiezza e profondità di invasione della sottomucosa Ampiezza > 4000 µm Profondità > 2000 µm Ueno et al. 2004

13 Perdiamo >50% dei casi

14 Comunicare l entità del rischio Rischio mts linfo Adenoma Cancerizzato (tutti) 13.1% AC + 1 fattore di rischio 20.7% AC + >1 fattore di rischio 36.4% AC - NO fattori di rischio 0,7% AC - NO fattori di rischio (> µm) 0%

15 Comunicare l entità del rischio Adenoma cancerizzato Margine interessato: Tumore residuo/recidivo 14,3% Vascular invasion NO Tumor grade 1% Budding Ampiezza > 4000 µm Profondità =0% > 2000 µm ma

16 BENCHMARKS for K statistics Perfect Agreement Random Agreement fair moderate substantial 1.0

17 J Clin Epidemiol Mar;56(3): Interobserver agreement in the histologic diagnosis of colorectal polyps. The experience of the multicenter adenoma colorectal study (SMAC). Costantini M, Sciallero S, Giannini A, Gatteschi B, Rinaldi P, Lanzanova G,Bonelli L, Casetti T, Bertinelli E, Giuliani O, Castiglione G, Mantellini P,Naldoni C, Bruzzi P; SMAC Workgroup To evaluate the interobserver agreement of four pathologists in the diagnosis of histologic type of colorectal polyps and in the degree of dysplasia and of infiltrating carcinoma in adenomas. A median kappa of 0.89 (range ) was estimated for the interobserver agreement for the diagnosis of hyperplastic polyp vs. adenoma. The agreement in the diagnosis of tubular, tubulovillous, and villous type, was given by median kappa values of 0.50, 0.15, and 0.36, respectively. The median kappa for the diagnosis of infiltrating carcinoma was 0.78 (range ).

18 Cancer Epidemiol Biomarkers Prev Jul;11(7): Reliability in the classification of advanced colorectal adenomas. Terry MB, Neugut AI, Bostick RM, Potter JD, Haile RW, Fenoglio-Preiser CM. To evaluate the inter-observer agreement in the diagnosis of histologic type of colorectal polyps and in the degree of dysplasia. Histological type (villous, tubulovillous, and tubular): interobserver kappa = 0.48; 95%CI, Degree of dysplasia (none/mild, moderate, severe, CIS, and intramucosal): interobserver kappa = 0.42; 95% CI, Using broader classifications for degree of dysplasia substantially improved the reliability (interobserver agreement for high-grade dysplasia vs low-grade dysplasia: kappa = 0.69; 95% CI, ).

19 Gastrointest Endosc Nov;56(5): Comparison of inter- and intraobserver consistency for grading of esophagitis by expert and trainee endoscopists. Pandolfino JE, Vakil NB, Kahrilas PJ. Interobserver consistency for trainees was good when using both classifications (Los Angeles, kappa = 0.459; Hetzel-Dent, kappa = 0.427). Interobserver reproducibility was better for experts when using both classifications (Los Angeles, kappa = 0.556, Hetzel-Dent, kappa = 0.571).

20 Gut Aug;45(2): Endoscopic assessment of oesophagitis: clinical and functional correlates andfurther validation of the Los Angeles classification. Lundell LR, Dent J, Bennett JR, Blum AL, Armstrong D, Galmiche JP, Johnson F,Hongo M, Richter JE, Spechler SJ, Tytgat GN, Wallin L. Evaluation of circumferential extent of oesophagitis by the criterion of whether mucosal breaks extended between the tops of mucosal folds, gave acceptable agreement (mean kappa value 0.4) among observers. This approach is used in the Los Angeles system.

21 Gastroenterology Jul;111(1): The endoscopic assessment of esophagitis: a progress report on observer agreement. Armstrong D, Bennett JR, Blum AL, Dent J, De Dombal FT, Galmiche JP, Lundell L,Margulies M, Richter JE, Spechler SJ, Tytgat GN, Wallin L. Agreement between experienced endoscopists was acceptable to good for recognition of minimal changes (erythema, friability, mucosal edema; kappa = 0.46 to kappa = 0.8), mucosal breaks (discretely, demarcated areas of slough or erythema; kappa =0.84), and complications (ulceration, kappa = 0.92; stricturing, kappa = 0.80;columnar metaplasia, kappa = 0.81), although there was poor agreement when the circumferential extent and number of mucosal breaks were assessed.