To the Editor: In their cross-sectional study, Dr Soetikno and colleagues1 reported that nonpolypoid colorectal neoplasms were relatively common in an older male veterans hospital population. We have several concerns regarding the study design and conclusions.
The terminology is unclear. A distinction must be made between the relatively flat lesions described in this study (defined as elevated lesions with a height less than half the diameter) and completely flat or depressed lesions. The authors note that “completely flat lesions are exceedingly rare” and were presumably absent in this study. Depressed lesions comprised less than 1% of all colorectal lesions (18/2770), only 4 of which were seen at screening. Therefore, nearly all nonpolypoid lesions were elevated from the surrounding mucosa, which is a critical distinction favoring detection at both standard colonoscopy and computed tomographic (CT) colonography.
Given the lack of metastatic potential, it is widely accepted that “carcinoma in situ” should be reported as “high-grade dysplasia” and not cancer.2 The majority of nonpolypoid “cancers” reported in this study (11/15) actually represent noninvasive advanced adenomas. It is unclear whether any depressed cancers were detected at screening with only 2 cases among the entire cohort. The mean size of advanced nonpolypoid lesions was relatively large (1.6 cm) and similar in size to their polypoid counterparts (1.9 cm) and likely identifiable by standard optical or virtual colonoscopy. It appears that the authors employed chromoendoscopy only when flat lesions were suspected after standard evaluation and not as a screening technique. Furthermore, the generalizability of this Veterans Affairs cohort to general screening populations is uncertain.
In the National Polyp Study cohort, superficially elevated flat adenomas were routinely identified without supplemental chromoendoscopy but were actually less likely to harbor high-grade dysplasia than polypoid lesions.3 If important nonpolypoid lesions had been missed at initial evaluation in the National Polyp Study, more incident cancers should have developed during the surveillance interval.3
A large multicenter CT colonography screening study using combined 3-dimensional and 2-dimensional detection techniques reported a sensitivity of 83% for detecting flat adenomas 6 mm or larger.4 An even larger subsequent study with more than 6000 screening participants showed that CT colonography screening detected more flat advanced neoplasms than optical colonoscopy.5
Given the rarity of truly flat or depressed colorectal neoplasms in this and other US screening populations, this study further supports the notion that current standard high-quality optical colonoscopy or CT colonography will provide for adequate colorectal screening in clinical practice.
Financial Disclosures: Dr Pickhardt reported having served as a consultant for C. B. Fleet, Medicsight, Viatronix, and Covidien. Dr Levin reported serving on the advisory boards for GeneNews and Air-O-Scope and having received research support from Pfizer. Dr Bond reported no disclosures.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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