Digestive Endoscopy
Clinical utility of the SMSA grading tool for the management of colonic neoplastic lesions

All authors would like to commemorate Dr. Gianluca Rotondano, who died on November 24th, 2015. Gianluca was an exceptional person, respected and admired for his generosity and intelligence. He will be greatly missed by all who knew him and worked with him.
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Abstract

Background

Whilst polyp size has been traditionally used as a predictor of the complexity of endoscopic resection, the influence of other factors is increasingly recognised. The SMSA grading system takes into account polyp Site, Morphology, Size and Access, with higher scores correlating with increased technical difficulty.

Aims

To evaluate whether the SMSA grading tool correlates with endoscopic and clinical outcomes.

Methods

This retrospective study was conducted at two high volume centres in the United Kingdom and Italy. All polyps identified at colonoscopy were included in this study and classified as per the SMSA grading system.

Results

A total of 1668 lesions were resected in 1016 patients. There was a positive correlation between increasing SMSA level and the inability to resect lesions “en bloc” (p < 0.001). Histologically complete clearance was higher in the lower SMSA groups (p < 0.0001). Additional endoscopic therapies, were more commonly required with the higher SMSA groups to achieve histological clearance (p < 0.0001). Moreover, advanced histology in resection specimens and procedural complications were significantly less common in SMSA level 1 lesions compared to level 3 or 4 lesions (p < 0.0001).

Conclusions

The SMSA grading tool is a useful predictor of outcome following the resection of colonic neoplastic lesions.

Introduction

Adenomas identified at colonoscopy have the potential to progress to cancer through the widely-accepted adenoma-carcinoma sequence. The detection and removal of precancerous lesions interrupts the natural history of cancer, preventing death from colorectal cancer (CRC) [1]. Endoscopic resection (ER) of neoplastic colorectal lesions represents the main goal of screening colonoscopy. ER includes a variety of diverse technical modalities aimed to excise the superficial layers of the colonic wall to achieve a radical resection (R0) of early neoplastic lesions [2], [3].

Whilst polyp size has been traditionally used as a predictor of the complexity and risk for advanced histology [4], the influence of other factors is increasingly recognised. It’s self-evident that, size being equal, a peridiverticular or periappendiceal polyp can be challenging when compared to a rectal polyp [5]. Similarly, a depressed 0-IIc non-polypoid lesion (NPL) carries a higher risk of malignancy than a sessile polyp [6]. This has led researchers to study characteristics, other than polyp size, such as location, morphology, access, pit pattern as predictors of endoscopic outcome [7], [8], [9], [10], [11], [12], [13], [14], [15].

Ideally, a simple and robust score should provide us with meaningful information on technical risks of ER and final clinical outcome. Recently, the SMSA (Size, Morphology, Site, Access) classification system has been proposed by Gupta et al. [16]. This grades the complexity of neoplastic lesions by scoring on the above parameters, with higher scores correlating with increased technical difficulty and a greater incidence of procedural complications.

Little is known about the clinical utility of this grading tool and its correlation with clinical outcomes. A recent study from Longcroft-Wheaton et al. [17] has concluded that the SMSA scoring tool is easy to use and provides valuable information on the lesion complexity, success and complication rates of ER.

Our aim is to evaluate whether the SMSA grading score correlates with endoscopic and clinical outcomes following endoscopic resection of colonic neoplastic lesions.

Section snippets

Study design, setting, and patients

This was a retrospective study of all consecutive patients undergoing ER of colorectal neoplastic lesions in two tertiary high volume endoscopy units in the United Kingdom and Italy between 2010 and 2014. The Italian cohort of patients included those greater than 50 years old, who had positive faecal occult blood test (FOBT) as per a structured CRC screening program protocol. These procedures were performed by 5 expert endoscopists as defined by a lifetime procedure count of over 3000

Results

Between January 2010 and December 2014, a total of 1668 colorectal lesions were identified and removed in 1016 patients. Of these, 63% were male, with a mean age of 68.6 ± 12.2 years (range 28–90). Among all lesions, 62.5% were sessile, 14.4% were pedunculated, and 20.4% were NPL (Table 2). The majority of the lesions (62.6%) were located in the left colon, 37.4% in the right colon. Most (91.7%) were smaller than 30 mm, with 5.8% measuring 30–39 mm, and only 2.5% being larger than 40 mm. In 19% of

Discussion

Colorectal lesions are varied in character and complexity, they should not be considered equal. A score to objectively judge technically challenging polyps has many advantages, most importantly in the appropriate planning of therapy to optimise clinical outcomes. Ideally a score should be simple and reproducible, providing us with meaningful additional information on technical risks of ER and final clinical outcome.

The size of neoplastic lesions has traditionally been used as a main factor to

Conflict of interest

S. Sansone, M.A. Bianco, F. Manguso, S. Beg, A. Bagewadi, S. Din and G. Rotondano have no conflicts of interest or financial ties to disclose. K. Ragunath has received research support, educational grants, consultancy and speaker honoraria from Olympus, Cook Medical, Boston Scientific and Pentax.

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