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Optical diagnosis of colorectal neoplasia. GastroMilitary 2021. https://youtu.be/ejJXIN97ESM
- 1. Optical diagnosis of Colorectal Neoplasia By Dr. Yasser M Abdel Halim, FRCP London Head of Gastroenterology Department, International Medical Centre Gastro-Military 25-11-2021 ميحرلا نمحرلا هللا مسب
- 2. Objective Real time diagnosis of the pathological type of the neoplastic lesion during colonoscopy.
- 3. Contents Introduction: Pathological Classification, How to do Optical diagnosis?, Conclusion.
- 4. Contents Introduction: Pathological Classification, How to do Optical diagnosis?, Conclusion.
- 5. Histopathology (Vienna) classification Description (West viewpoint) Negative for neoplasia Category 1 Indefinite for neoplasia Category 2 Non-invasive low grade neoplasia Low grade adenoma (raised lesion) or dysplasia (flat lesion) Category 3 Non-invasive high-grade neoplasia Category 4 4.1 High grade adenoma/dysplasia 4.2 Non-invasive carcinoma (carcinoma in situ) 4.3 Suspicion of invasive carcinoma Invasive neoplasia Category 5 5.1 Intramucosal carcinoma (Esophagus & stomach) 5.2 Submucosal carcinoma or beyond (Colorectal) Gut 2000;47:251–255 251.
- 6. Why the Colon & Rectum are Different? • Lymphatics are found only below the crypt bases in the deep submucosa. • LN metastasis requires deep submucosal invasion. • Invasive carcinoma down to the superficial submucosa is not associated with LN mets. & is suitable for endoscopic therapy.
- 7. Optical diagnosis classification Resection Method Clinical class Vienna Description ? No resection Hyperplastic polyp Category 1 Hyperplastic. Endoscopic resection Piece meal Low grade Adenoma Category 2 & 3 Low-grade adenoma/dysplasia. en bloc HG adenoma & Superficially invasive lesion Category 4, 5.1 & 5.2 superf. High-grade adenoma/dysplasia, Intramucosal carcinoma & Superficial (<1000 µm) submucosal (sm) carcinoma. Surgical resection Deep invasive Cancer Category 5.2 (deep) Deeply invasive (>1000 µm submucosal) cancer.
- 8. Full Lesion vs Forceps Biopsy Full Lesion Forceps Biopsy Lesion representation A full lesion biopsy A minute part of the lesion (sampling error). Included lesion Depth Down to the deepest predicted invasion level. Not more than the lamina propria (superficiality error). Lesion base invasion status Can be assessed. Can not be assessed. Margins invasion status Can be assessed. Can not be assessed.
- 9. Contents Introduction: Pathological Classification, How to do Optical diagnosis?, Conclusion.
- 10. Contents Introduction: Pathological Classification, How to do Optical diagnosis?, Conclusion.
- 11. Endoscopic Optical diagnosis Classification Enhancement Magnifying Kudo (Pit pattern) Contrast dye Magnifying Sano (Vascular pattern) NBI JNET NICE Non- Magnifying WASP Signs of deep invasion: None (conventional White light) Morphology type Others
- 12. Endoscopic Optical diagnosis Classification Enhancement Magnifying Kudo (Pit pattern) Contrast dye Magnifying Sano (Vascular pattern) NBI JNET NICE Non- Magnifying WASP Signs of deep invasion: None (conventional White light) Morphology type Others
- 13. Pit/Surface & vascular pattern Explanation Dark: crypt opening (hard to be seen without magnification, perpendicularly illuminated pits). White: Apical view of marginal crypt opening epithelium. Red: lamina propria capillaries underneath single surface layer of epithelium.
- 14. Pit/Surface & vascular pattern Explanation Large tubular White marginal epithelium lines (Kudo type IV) Regular red meshed capillary vessels surrounding the pits of the crypts (Sano Type II)
- 15. Pit Pattern (Kudo’s) classification Kudo et al. Diagnosis of colorectal tumorous lesions by magnifying endoscopy. Gastrointest Endosc 1996; 44: 8-14.
- 16. Pit Pattern (Kudo’s) classification Kudo et al. Diagnosis of colorectal tumorous lesions by magnifying endoscopy. Gastrointest Endosc 1996; 44: 8-14.
- 17. Pit Pattern (Kudo’s) classification Type Shape Correlated Histopathology Type I Round uniform pits Normal or inflammatory mucosa Patterns: normal (type I), hyperplastic or serrated (type II), neoplastic
- 18. Pit Pattern (Kudo’s) classification Type Shape Correlated Histopathology Type II Type II open Serrated or star like Hyperplastic polyp Wada Y, et al. Diagnostic accuracy of pit pattern and vascular pattern analyses in colorectal lesions. Dig Endosc. 2010;22:192–9.
- 19. Pit Pattern (Kudo’s) classification Type Shape Correlated Histopathology Type II Type II open Opened with mucin producing Sessile Serrated Adenoma/Polyp (SSA/P)
- 20. Pit Pattern (Kudo’s) classification Type Pit Shape Correlated Histopathology Type IIIL Type IIIs Large tubular Low Grade tubular Adenoma (often polypoid lesion)
- 21. Pit Pattern (Kudo’s) classification Type Pit Shape Correlated Histopathology Type IIIL Type IIIs Tiny tubular or roundish HG Adenoma/ Superficially invasive lesions or carcinoma (often depressed lesion) Type IIIs adenoma probably is the precursor lesion for flat and depressed superficial cancers and carries a high risk of minute mucosal cancer nests.
- 22. Pit Pattern (Kudo’s) classification Type Shape Correlated Histopathology Type IV sulcus-, branch- or gyrus-like (Regular/Homogenous) Low grade villous Adenoma (often polypoidal type)
- 23. Pit Pattern (Kudo’s) classification Type Shape Correlated Histopathology Type VI Low grade Irregular pits in an area with smooth margins Adenoma (LG/HG/superficially invasive neoplasia).
- 24. Pit Pattern (Kudo’s) classification Type Shape Correlated Histopathology Type VI High grade Irregular, narrow pits in an area with rough margins Deeply submucosal invasive cancer (≥SM2)
- 25. Pit Pattern (Kudo’s) classification Type Shape Correlated Histopathology Type VN lost (left) or broken down (right) pit pattern structure. Deeply submucosal invasive cancer (≥SM2) Type V areas (Vi high grade, VN) indicate a high risk of submucosal invasion
- 26. Pit Pattern (Kudo’s) classification Diagnostic performance of Kudo’s classification: Result 89.0% Pooled sensitivity 85.7% Pooled specificity 0.9354 . Area under the SROC curve Hayashi et al: Relationship between Narrow-Band Imaging Magnifying Observation and Pit Pattern Diagnosis in Colorectal Tumors. Digestion 2013;87:53-58.
- 27. Endoscopic Optical diagnosis Classification Enhancement Magnifying Kudo (Pit pattern) Contrast dye Magnifying Sano (Vascular pattern) NBI JNET NICE Non- Magnifying WASP Signs of deep invasion: None (conventional White light) Morphology type Others
- 28. Endoscopic Optical diagnosis Classification Enhancement Magnifying Kudo (Pit pattern) Contrast dye Magnifying Sano (Vascular pattern) NBI JNET NICE Non- Magnifying WASP Signs of deep invasion: None (conventional White light) Morphology type Others
- 29. Vascular pattern (Sano’s) classification Sano Y, et al. Sano's capillary pattern classification for narrow-band imaging of early colorectal lesions. Dig Endosc. 2011 May;23 Suppl 1:112-5.
- 30. Vascular pattern (Sano’s) classification Sano Y, et al. Sano's capillary pattern classification for narrow-band imaging of early colorectal lesions. Dig Endosc. 2011 May;23 Suppl 1:112-5.
- 31. Vascular pattern (Sano’s) classification Type Shape Correlated Histopathology Type I no or hardly seen meshed capillary vessels Hyperplastic polyp
- 32. Vascular pattern (Sano’s) classification Type Shape Correlated Histopathology Type II meshed capillary vessels surrounding the pits of the crypts Low grade Adenoma/dysplasia
- 33. Vascular pattern (Sano’s) classification Type Shape Correlated Histopathology Type IIIA meshed capillary vessels that are highly dense, non-uniform, irregular, branching with blind ends Adenoma (LG/HG/superficially invasive).
- 34. Vascular pattern (Sano’s) classification Type Shape Correlated Histopathology Type IIIB nearly avascular or has loose micro capillary vessels SMd invasive cancer
- 35. Vascular pattern (Sano’s) classification Diagnostic performance of Sano’s classification: NPV PPV Specif. Sensit. Accur. 90% 97.3% 92.3% 96.4% 95.3% Type I versus Type II 97.1% 90.3% 97.1% 90.3% 95.5% Type II versus Type III 94.5% 71.8% 88.7% 84.8% 87.7% Type IIIA versus Type IIIB Iwatate M, Ikumoto T, Hattori S, Sano W, Sano Y, Fujimori T. NBI and NBI Combined with Magnifying Colonoscopy. Diagn Ther Endosc. 2012;2012:173269.
- 36. Endoscopic Optical diagnosis Classification Enhancement Magnifying Kudo (Pit pattern) Contrast dye Magnifying Sano (Vascular pattern) NBI JNET NICE Non- Magnifying WASP Signs of deep invasion: None (conventional White light) Morphology type Others
- 37. Endoscopic Optical diagnosis Classification Enhancement Magnifying Kudo (Pit pattern) Contrast dye Magnifying Sano (Vascular pattern) NBI JNET NICE Non- Magnifying WASP Signs of deep invasion: None (conventional White light) Morphology type Others
- 38. Japan NBI Expert Team (JNET) classification Dig Endosc 2016; 28: 526–33.
- 39. Japan NBI Expert Team (JNET) classification Dig Endosc 2016; 28: 526–33.
- 40. Japan NBI Expert Team (JNET) classification Type 1: Hyperplastic polyp or SSP/A • Vascular pattern: – Invisible & if visible the caliber is similar to surrounding normal mucosa • Surface patterns: – Regular dark or white spots or just similar to the surrounding mucosa
- 41. Japan NBI Expert Team (JNET) classification Type 2A: Low grade Adenoma • Vascular pattern: – Regular caliber – Regular distribution (Meshed/spiral pattern) • Surface patterns: – Regular (tubular/branched/papillary)
- 42. Japan NBI Expert Team (JNET) classification Type 2B: HG Adenoma or Superficially invasive neoplaasia • Vascular pattern: – Variable caliber – irregular distribution • Surface patterns: – Irregular or obscure
- 43. Japan NBI Expert Team (JNET) classification Type 3: deeply submucosal invasive cancer • Vascular pattern: – Loose vessels area – Interruption of thick vessels • Surface patterns: – Amorphous areas
- 44. Japan NBI Expert Team (JNET) classification Diagnostic performance of JNET classification: Accur. NPV PPV Specif. Sensit. 99.3% 99.4% 97.5% 99.9% 87.5% Type 1 77.1% 38.7% 98.3% 92.7% 74.3% Type 2A 78.1% 88.2% 50.9% 82.8% 61.9% Type 2B 96.6% 96.6% 95.2% 99.8% 55.4% Type 3 Gastrointest Endosc. 2017 Apr;85(4):816-821. Gastrointest Endosc. 2017 Oct;86(4):700-709. 2B JNET class Vi high Vi low Kudo Deeply invasive cancer LG/HG/Superficially invasive Adenoma Pathology
- 45. classification with a Non-zoom endoscope? Non-Zoom HD endoscope Zoom endoscope 40 fold magnification: by getting close to the epithelial surface up to 2 mm 100-150 folds Magnifying power 1.5 digital magnification 40 X 1.5 = 60 fold magnification
- 46. Imagine you are in a forest & see a lion Infront of you. What to do?
- 47. Imagine you are in a forest & see a lion Infront of you. What to do? Stop imagining
- 48. Endoscopic Optical diagnosis Classification Enhancement Magnifying Kudo (Pit pattern) Contrast dye Magnifying Sano (Vascular pattern) NBI JNET NICE Non- Magnifying WASP Signs of deep invasion: None (conventional White light) Morphology type Others
- 49. Endoscopic Optical diagnosis Classification Enhancement Magnifying Kudo (Pit pattern) Contrast dye Magnifying Sano (Vascular pattern) NBI JNET NICE Non- Magnifying WASP Signs of deep invasion: None (conventional White light) Morphology type Others
- 50. NBI International Colorectal Endoscopic (NICE) Classification
- 51. NBI International Colorectal Endoscopic (NICE) Classification Gastroenterology2012; 143:599–607.
- 52. Type 1: Hyperplastic polyp or SSP/A • Color: – Same or lighter than background. • Vessels: – None, or isolated lacy vessels may be present coursing across the lesion • Surface patterns: – Dark or white spots of uniform size, or homogeneous absence of pattern NBI International Colorectal Endoscopic (NICE) Classification
- 53. Type 2: LG, HG. Superficially invasive neoplasia. • Color: – Brown relative to background. • Vessels: – Brown vessels surrounding white structures. • Surface patterns: – Oval, tubular or branched white structures surrounded by brown vessels. NBI International Colorectal Endoscopic (NICE) Classification
- 54. Type 2: LG, HG. Superficially invasive neoplasia. • The presence of HG dysplasia or superficial submucosal carcinoma may be suggested by: – irregular vessel or surface pattern, and is often associated with atypical morphology for example depressed area. NBI International Colorectal Endoscopic (NICE) Classification
- 55. Type 3: deeply submucsal invasive cancer • Color: – Brown to dark brown relative to background; sometimes patchy whiter areas. • Vessels: – Has area(s) of disrupted or missing vessels • Surface patterns: – Amorphous or absent surface pattern. NBI International Colorectal Endoscopic (NICE) Classification
- 56. Diagnostic performance of NICE classification: Accuracy Specificity Sensitivity 99.5% 99.6% 86.0% Type 1 97.8% 85.2% 99.2% Type 2 99.3% 99.6% 81.8% Type 3 Hamada et al. Utility of the narrow-band imaging international colorectal endoscopic classification for optical diagnosis of colorectal polyp histology in clinical practice: a NBI International Colorectal Endoscopic (NICE) Classification
- 57. Endoscopic Optical diagnosis Classification Enhancement Magnifying Kudo (Pit pattern) Contrast dye Magnifying Sano (Vascular pattern) NBI JNET NICE Non- Magnifying WASP Signs of deep invasion: None (conventional White light) Morphology type Others
- 58. Endoscopic Optical diagnosis Classification Enhancement Magnifying Kudo (Pit pattern) Contrast dye Magnifying Sano (Vascular pattern) NBI JNET NICE Non- Magnifying WASP Signs of deep invasion: None (conventional White light) Morphology type Others
- 59. Workgroup serrAted polypS and Polyposis (WASP) classification
- 60. Workgroup serrAted polypS and Polyposis (WASP) classification Sessile serrated polyp Hyperplastic polyp Clouded Clear Surface Indistinct Distinct Border Irregular Regular Shape Yes No Dark spots
- 61. Relationship between various classifications Lesion types •Hyperplastic polyp •SSA/P •LG Adenoma •HG/Superficially invasive neoplas. •Deeply invasive cancer •Deeply invasive cancer Vienna 1 2 & 3 4, 5.1, 5.2s, 5.2d 5.2d Kudo II III, IV VI-LG ,VI-HG ,VN SANO Type I Type II Type IIIA Type IIIB JANT Type 1 Type 2A Type 2B Type 3 NICE Type 1 Type 2 Type 3
- 62. Endoscopic Optical diagnosis Classification Enhancement Magnifying Kudo (Pit pattern) Contrast dye Magnifying Sano (Vascular pattern) NBI JNET NICE Non- Magnifying WASP Signs of deep invasion: None (conventional White light) Morphology type Others
- 63. Endoscopic Optical diagnosis Classification Enhancement Magnifying Kudo (Pit pattern) Contrast dye Magnifying Sano (Vascular pattern) NBI JNET NICE Non- Magnifying WASP Signs of deep invasion: None (conventional White light) Morphology type Others
- 64. Signs of deep submucosal invasion Morphology type Risk of cancer Polypoid 0-I 1–15% Elevated/flat 0-IIa/b 4–6% Depressed 0-IIc 30–75% LST-NG, pseudo-depressed type (0-IIc+/- IIa). 70-75% LST-G nodular mixed type (0-IIa + 0-Is) (with dominant nodule > 10 mm,) 40-45% LST-NG, flat type (0-IIb, b) 20-29% LST-G homogeneous type (0-IIa) 0.9% Gastrointest Endosc. 2003;58:S3–43. Endoscopy. 2011;43:856–61. Gastrointest Endosc. 2008;68:S3–47. JAMA. 2008;299:1027–35.
- 65. Signs of deep submucosal invasion Depressed Morphology type: • Includes: Paris type 0-IIc & LST Pseudo depressed type. • 91% accuracy by using these findings: Folds conversion Irregular surface (protrusions) bottom Deep depression surface Expansion appearance Endoscopy. 2016;48 (5):456–64.
- 66. Endoscopic Optical diagnosis Classification Enhancement Magnifying Kudo (Pit pattern) Contrast dye Magnifying Sano (Vascular pattern) NBI JNET NICE Non- Magnifying WASP Signs of deep invasion: None (conventional White light) Morphology type Others
- 67. Endoscopic Optical diagnosis Classification Enhancement Magnifying Kudo (Pit pattern) Contrast dye Magnifying Sano (Vascular pattern) NBI JNET NICE Non- Magnifying WASP Signs of deep invasion: None (conventional White light) Morphology type Others
- 68. Signs of deep Submucosal invasion (Specific but not Sensitive) Non-lifting Sign: Accuracy. NPV PPV Specificity Sensitivity 94.8% 96% 80% 98.4% 61.5% Positive non-lifting sign Negative non-lifting sign Endoscopy 2007;39:701–5.
- 69. Signs of deep Submucosal invasion (Specific but not Sensitive) Others: Converging folds. Data from National Cancer Center Hospital, Tokyo (between 1999 and 2003).
- 70. Signs of deep Submucosal invasion (Specific but not Sensitive) Others: White spots. Data from National Cancer Center Hospital, Tokyo (between 1999 and 2003).
- 71. Signs of deep Submucosal invasion (Specific but not Sensitive) Others: Expansion. Data from National Cancer Center Hospital, Tokyo (between 1999 and 2003).
- 72. Signs of deep Submucosal invasion (Specific but not Sensitive) Others: Strong Redness. Data from National Cancer Center Hospital, Tokyo (between 1999 and 2003).
- 73. Signs of deep Submucosal invasion (Specific but not Sensitive) Others: Firm consistency (Stiffness). Data from National Cancer Center Hospital, Tokyo (between 1999 and 2003).
- 74. Signs of deep Submucosal invasion (Specific but not Sensitive) Others: Ulceration. Data from National Cancer Center Hospital, Tokyo (between 1999 and 2003).
- 75. Signs of deep Submucosal invasion (Specific but not Sensitive) Others: Full stalk. Data from National Cancer Center Hospital, Tokyo (between 1999 and 2003).
- 76. Signs of deep Submucosal invasion (Specific but not Sensitive) Others: Advanced cancer (Narrow/Obstructed lumen).
- 77. Contents Introduction: Pathological Classification. How to do Optical diagnosis?, Conclusion.
- 78. Contents Introduction: Pathological Classification. How to do Optical diagnosis?, Conclusion.
- 79. Conclusion Pathological classification of CRN should be according to treatment decision. Real time treatment decision of CRNL is based on Optical diagnosis. Enhanced imaging is essential for optical diagnosis of CRNL. Conventional imaging is only reliable when it suggests deep invasion.
- 80. Thanks to the Japan Planet Gastroenterologists
Editor's Notes
- Good morning, & welcome to all my colleague. We are going to hear in the next 15 minutes about the Optical diagnosis of colorectal neoplasia. .
- I promise you an easy presentation as I can. My objective in this talk to present to you an evidence-based Real time prediction of the pathological diagnosis of the Colorectal neoplasia during ongoing colonoscopy. in order to make a real time decision making about the optimal treatment of these lesions. .
- We are going to start the presentation by introduction about the Vienna pathological classification of colorectal neoplasia, then the main part of how to predict the histological type endoscopically. & the presentation is going to the end by the conclusion. .
- Let us start by introduction about the Vienna classification. .
- There were large discrepancies between Western and Japanese pathologists in the diagnosis of adenoma/dysplasia versus carcinoma for Gastrointestinal neoplastic lesions. The Western pathologists defined gastrointestinal carcinoma by the presence of invasion to the basal membrane. While Japanese pathologists defined it by high grade of cell & architectural atypia & invasion was not mandatory. Therefore, Lesions that most Western pathologists identify as “High grade dysplasia” are often considered adenocarcinomas in Japan. These discrepancies therefore called for a united effort to reach a consensus on the nomenclature of gastrointestinal epithelial neoplastic lesions. The western & Japan field pioneers worked together in Vienna & developed the Vienna classification that satisfied both sides. It is based on both invasion status & cytological and architectural severity. & as you see the classified neoplastic lesions into 5 categories, Category 1 lesion is the lesion Negative for neoplasia. Category 2 lesion is the lesion Indefinite for neoplasia. Category 3 is the lesion with Non-invasive low grade neoplasia. . Category 4 is the lesion with Non-invasive high grade neoplasia & they satisfied the Japanese by putting their favorite terminology in this category which is the Non-invasive carcinoma or carcinoma in situ. & finally, Category 5 lesions with Invasive neoplasia . . But we have to know that the western definition of colorectal carcinoma is different from esophageal & gastric carcinoma. Stomach or esophagus carcinoma is defined by lamina propria invasion but in the colon by deep submucosal invasion. .
- But, why the colon & rectum are different. Because, the Lymphatics in colon wall are found only at the level of and below the crypt bases in the submucosa. Therefore, metastasis requires deep submucosal invasion. And the Invasive carcinoma down to <1000 μm in the submucosa, is associated with very little risk of LN metastasis & could be cured just by endoscopic local resection only. .
- It is recommended, that all neoplastic colonic colorectal lesion should be resected endoscopically if it is not associated with risk of LN metastasis. Therefore, in the colon our lesion pathological classification practically will be this. Category 1, Hyperplastic polyp, Category 2, Low grade Adenoma/dysplasia, Category 3, Superficially invaded Adenoma/dysplasia, & category 4, Cancer. Why I chose to put the classification like this, because it going to help my treatment decision, hyperplastic polyps could be followed up, low grade adenoma could be resected endoscopically piecemeal, superficially invaded adenoma should be resected en bloc to enable pathological assessment of lesion margin & base for invasion status. & finally the cancer should be resected surgically. As simple like that. .
- Till recently we tend to base treatment decisions largely on the histology of biopsy specimens, However, as we said before, depth of invasion, not just the cells & crypts atypia is very critical for our treatment decision & unfortunately that can not be assessed by forceps biopsy, it can only be assessed by full lesion biopsy, & that means endoscopic resection. Therefore, you have to find another method to diagnose the invasion depth before resection than the forceps biopsy. & the best method used now is by using the endoscopic image itself & that is why it is named optical diagnosis method. .
- .
- Now let us move to the main part of the presentation. How can we characterize or diagnose the pathological type of our neoplastic lesion by the use of the endoscope. .
- The answer is by using a number validated classifications. We are going to speak about the various validated classifications that are in use these days. . The start is going to be with Kudo’s then Sano’s classifications as they form the basis of the other classifications. .
- The answer is by using a number validated classifications. We are going to speak about the various validated classifications that are in use these days. . The start is going to be with Kudo’s then Sano’s classifications as they form the basis of the other classifications. .
- Let me first explain what are the pit pattern & the vascular pattern. In colonic mucosal image we are going to see three colors: Dark color which represents the crypt openings & actually it is very hard be seen without magnification except in type II open pit pattern characteristic of SSA. Then there is the White color which represents the apical view of marginal crypt epithelium. & finally there is the red color which represents the lamina propria capillaries underneath. .
- For example, this lesion shows Branched white marginal epithelium that correspond to Kudo type IV pit patter & Red meshed capillary vessels surrounding the pits of the crypts that correspond to Sano type II vascular pattern.
- Kudo found that the surface “pit pattern” is correlated with the pathological diagnosis of the neoplastic lesion. Therefore, he used the magnifying endoscopy plus the conventional chromoendoscopy with a contrast dye, to classify the pit pattern, into five main types & associated validated the association between each type with specific pathological diagnosis. .
- Kudo found that the surface “pit pattern” is correlated with the pathological diagnosis of the neoplastic lesion. Therefore, he used the magnifying endoscopy plus the conventional chromoendoscopy with a contrast dye, to classify the pit pattern, into five main types & associated validated the association between each type with specific pathological diagnosis. .
- Type 1 pit pattern has Round uniform pits & associated with Normal or inflammatory mucosa. .
- Type 2 pit pattern has Stellar or papillary pits & associated with Hyperplastic polyp. .
- Type 2 open pit pattern has Opened with mucin producing pits & associated with Sessile Serrated Adenoma/Polyp (SSA/P). .
- Type 3l or large pit pattern has Large tubular pits & associated with Low grade tubular adenoma that is often polypoidal. .
- Type 3s or small pit pattern has Tiny tubular or rounded pits & associated with Superficially invaded Adenoma or even deeply invaded carcinoma & often depressed type lesions. .
- Type 4 pit pattern has regular or homogenous sulcus, branched or gyrus-like pits & associated with Low grade villous adenoma that is often polypoidal. .
- & then we type five which is divided into three subtypes: Type 5i, or irregular low grade & Type 5I high grade & type 5n or non-structural. Type 5i low grade, has an Irregular pits in an area with smooth margin & with smooth transition from 5i to other regular pit patterns like three & four pit patterns & is associated with Low grade or high grade adenoma, or superficially invaded adenoma. .
- Type 5i high grade has an Irregular narrow pits in an area with rough or demarcated margins like depression, large nodule or reddened area & is associated with deeply invasive cancer. .
- & finally type 5n or non structural that has lost or broken down pit pattern structure & is associated with deeply invasive cancer. .
- It was found that the diagnostic performance of Kudo’s classification is satisfactory with a pooled sensitivity of kudo’s classification is satisfactory 89.0% and a pooled specificity of 85.7%. .
- The answer is by using a number validated classifications. We are going to speak about the various validated classifications that are in use these days. . The start is going to be with Kudo’s then Sano’s classifications as they form the basis of the other classifications. .
- The answer is by using a number validated classifications. We are going to speak about the various validated classifications that are in use these days. . The start is going to be with Kudo’s then Sano’s classifications as they form the basis of the other classifications. .
- The vascular pattern was found to be correlated with the pathological diagnosis of neoplastic colorectal lesion. Sano used the magnifying endoscopy plus virtual chromoendoscopy with narrow band imaging or NBI to classify the vascular patterns. We know that NBI imaging uses light with a wave length that is absorbed only by hemoglobin which is present inside the blood vessels, therefore, with the magnifying imaging it helps to visualize even the minute vascular structures with maximum contrast. Sano classified the vascular pattern into three main types & associated each type with certain pathological diagnosis. .
- The vascular pattern was found to be correlated with the pathological diagnosis of neoplastic colorectal lesion. Sano used the magnifying endoscopy plus virtual chromoendoscopy with narrow band imaging or NBI to classify the vascular patterns. We know that NBI imaging uses light with a wave length that is absorbed only by hemoglobin which is present inside the blood vessels, therefore, with the magnifying imaging it helps to visualize even the minute vascular structures with maximum contrast. Sano classified the vascular pattern into three main types & associated each type with certain pathological diagnosis. .
- Type 1, has no or hardly seen meshed capillary vessels & is associated with hyperplastic polyp. .
- Type 2, has visible meshed capillary vessels surrounding the pits of the crypts & is associated with low grade adenoma. .
- Type 3 A, has visible meshed capillary vessels that are highly dense, non-uniform, irregular, branching with blind ends. & is could be associated with Low grade or high grade adenoma, or superficially invaded adenoma. .
- & finally type 3 B. that is nearly avascular or has loose micro capillary vessels. & is associated with at least deep submucosal invasive cancer. .
- The overall diagnostic performance of Sano's classification, is satisfactory. However, the performance is weakest when differentiating superficially invasive adenoma in type 3A, from deeply invasive carcinoma in type 3B. .
- The answer is by using a number validated classifications. We are going to speak about the various validated classifications that are in use these days. . The start is going to be with Kudo’s then Sano’s classifications as they form the basis of the other classifications. .
- The answer is by using a number validated classifications. We are going to speak about the various validated classifications that are in use these days. . The start is going to be with Kudo’s then Sano’s classifications as they form the basis of the other classifications. .
- In 2014, The Japan NBI Expert Team (JNET) Classified colorectal neoplasia by using magnifying endoscopy & NBI. The classification includes 4 types, Type 1, Type 2 A, Type 2 B & type 3, type 1 linked to hyperplastic polyp or SSA/P, Type 2A linked to Low grade adenoma, Type 2 B linked to high grade & superficially invaded adenoma. & finally type 4 linked to deeply invasive cancer. .
- In 2014, The Japan NBI Expert Team (JNET) Classified colorectal neoplasia by using magnifying endoscopy & NBI. The classification includes 4 types, Type 1, Type 2 A, Type 2 B & type 3, type 1 linked to hyperplastic polyp or SSA/P, Type 2A linked to Low grade adenoma, Type 2 B linked to high grade & superficially invaded adenoma. & finally type 4 linked to deeply invasive cancer. .
- Type 1, has invisible vessels & if visible the caliber is similar to surrounding normal mucosa, & has surface pattern in the form of regular dark or white spots or just similar to the surrounding mucosa. & is associated with hyperplastic polyp. .
- Type 2 A, has visible regular in caliber & distribution vessels meshed or spiral in pattern. & the surface pattern is regular & may be tubular, branched or papillary. & is associated with low grade adenoma. .
- Type 2 B has visible vessels of variable caliber & irregular distribution. & irregular or obscure surface pattern. & is associated with high grade adenoma, superficially invasive adenoma & even deep submucosal cancer. .
- & finally type 3 B has loose vessels area with interruption of thick vessels & a surface pattern with amorphous areas. & is associated with high grade adenoma, superficially invasive adenoma & even deep submucosal cancer. .
- As it is shown here the diagnostic ability of Type 2B is the weakest. & it was found in one Japanese study that > 50% of Type 2B lesions were found to have deep submucosal cancer which means inappropriate endoscopic resection in stead of surgical resection. That led some to recommend using contrast agent to define the pit pattern before decision making of endoscopic resection. If it is type five I low grade Pit pattern, resect & if type V I high grade, do not. .
- Before leaving the magnifying endoscopy. I would like to answer that question: Can I do magnifying imaging classification with HD endoscopes? Before answering this question we need to know that while the zoom endoscope has a magnification power from 100-150 fold. We can reach about 60 fold magnification with the HD endoscope as the recent endoscopes have a physical magnification up to 2 mm distance from the epithelial surface, yielding an optical magnification of 40-fold. & in combination with the 1.5-times digital zoom, these endoscopes offer 60-fold magnification of the lesion. Therefore, my answer is yes. We can do those classifications by recent HD colonoscopes. .
- The answer is by using a number validated classifications. We are going to speak about the various validated classifications that are in use these days. . The start is going to be with Kudo’s then Sano’s classifications as they form the basis of the other classifications. .
- The answer is by using a number validated classifications. We are going to speak about the various validated classifications that are in use these days. . The start is going to be with Kudo’s then Sano’s classifications as they form the basis of the other classifications. .
- NBI international group developed the NBI International Colorectal Endoscopic classification or NICE classification in 2009. It is similar to JNET classification but without magnification, It has three types corresponding to the three types of JNET without subclassification of Type 2. However, they put down in the notes that the presence of high grade dysplasia or superficial submucosal carcinoma may be suggested by an irregular vessel or surface pattern, and is often associated with atypical morphology for example depressed area. & That practically could be a differentiation into 2 A & 2 B. .
- NBI international group developed the NBI International Colorectal Endoscopic classification or NICE classification in 2009. It is similar to JNET classification but without magnification, It has three types corresponding to the three types of JNET without subclassification of Type 2. However, they put down a notes that That practically could be a differentiation into 2 A & 2 B. .
- Type 1, has a color same or lighter than background & no visible vessels & a surface pattern in the form of dark or white spots of uniform size, or homogeneous absence of pattern. & is associated with hyperplastic polyp or Sessile serrated adenoma or polyp. .
- Type 2, is brown in color & brown vessels surrounding the crypt s opening & a surface pattern in the form of oval, tubular or branched white structures surrounded by brown vessels. & is linked to low grade or high grade or superficially invasive adenoma.
- They added a note in type 2 that The presence of HG dysplasia or superficial submucosal carcinoma may be suggested by irregular vessel or surface pattern, and is often associated with atypical morphology for example depressed area. That note practically differentiate type 2 into type 2A & Type 2B like in JNET classification.
- Type 3, has a brown color with some times patchy whiter areas with areas of disrupted or missing vessels & amorphous or absent surface pattern. & is linked to deeply invasive cancer. .
- Here, is the diagnostic performance of NCE classification, & as you see Type 2 is actually performing very well. But why is that, why NICE type 2 is performing better than JNET Type 2 B, that is because it included all the low grade adenoma lesions, which constitutes the great majority of lesions in this type & therefore dominated the results. But still, NICE Type 2 is as problematic as or even more problematic than JNET type 2 B, because it includes a wide variety of lesions ranging from low-grade dysplasia to even deep submucosal lesions – making therapeutic decisions challenging. .
- The answer is by using a number validated classifications. We are going to speak about the various validated classifications that are in use these days. . The start is going to be with Kudo’s then Sano’s classifications as they form the basis of the other classifications. .
- Now let us go to the WASP classification. As we have seen in all the previous classifications, there was no classification, that can differentiate Hyperplastic polyp which is non-neoplastic, and can be left without resection, from sessile serrated polyp, which is precancerous & should be resected completely & sent for pathology. Therefore, the The Workgroup Serrated Polyps and Polyposis group developed the WASP classification to identify identification of sessile serrated adenoma. .
- If the NICE type 1 lesion is having two feature of the following four: clouded surface, indistinct border, irregular shape or dark spots inside the crypts, then the diagnosis is Sessile serrated polyp, otherwise it is Hyperplastic polyp.
- This is the relationship between different enhanced image classifications & Vienna categories. As we see, there is no classification that can differentiate, lesions with Kudo’s type 5i high grade, that need surgical resection from 5i low grade, that can be resected endoscopically. Except the Kudo,s classification it self that unfortunately using the unpopular contrast agent.
- Now we finished talking about the enhanced imaging, Now to the conventional white light use in the optical diagnosis of colorectal neoplasia. Actually there are not much information you can get from the white light imaging that can be of help in our subject. These are, the morphological type & other signs of deep invasion. The next is the Morphology type. .
- Theses are the average risk of deep invasion in various morphological types. & as you see, the most risky morphological types are Paris type IIc, LST Pseudodepressed type, Nodular mixed with dominant nodule & the LST flat type.
- In one study, the accuracy of deep invasion in a depressed lesion is 91% if it showed one these findings: 1, expansion appearance of the tumor & or the surrounding area like if there is a submucosal tumor, 2, deep depression surface, 3 irregular bottom of depression surface with protrusions, and 4, folds converging toward the tumor. If you found any of these findings in a depressed lesion, you could refer him to surgery straight away.
- Finally we have certain signs, which can be identified by conventional white light that are indicative of deep submucosal invasion. These signs are specific but not sensitive, therefore, If one of these findings is detected, then surgery could be considered. While, absence of all of them does not exclude deep invasion and you should rely on enhanced imaging before endoscopic excision. .
- The first one is the non-lifting sign.
- The second is the Converging mucosal folds towards the tumor.
- The third is the white spots or the chicken-skin appearance, which represent a cholesterol deposition at the periphery of the cancer lesion.
- The fourth is the expansion sign: which is protrusion and overextension of the tumor and or surrounding normal mucosa, like a submucosal tumor.
- The fifth is the Strong redness. .
- The sixth is the tumor stiffness. .
- The seventh is the Bleeding ulceration.
- The eights is the full or swollen stalk of pedunculated polyp.
- & finally ulceration & narrow or obstructed non-inflatable lumen that are indicative of advanced cancer.
- Finally the conclusion.
- In conclusion: Pathological classification of colorectal neoplasia should be according to treatment decision options. Real time treatment decision of colorectal neoplastic lesion is based on Optical diagnosis of its pathological type. Enhanced imaging is essential for optical diagnosis of the colorectal neoplastic lesion pathological type. Conventional imaging is only reliable when it suggests deep invasion.
- At the end, thanks to our colleagues in the JAPAN Planet & Thank you.