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Su1526 Pathological Features of Laterally Spreading Tumors Diagnosed by Endocytoscopy
Abstracts
Su1525 Vascular Features of Colorectal Mucosa and Neoplasia With Endocytoscopic-Narrow Band Imaging (EC-NBI): A Pilot Study Yoshiki Wada, Shin-Ei Kudo, Masashi Misawa, Takemasa Hayashi, Kunihiko Wakamura, Yuichi Mori, Nobunao Ikehara Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
38.8%(17.3-64.3%) and 100%(86.3-100%) for LST-NG respectively. Conclusion: Although this study was conducted with a limited number of lesions, our EC classification corresponded well to the pathological diagnoses after endoscopic and surgical resection. Therefore, endocytoscopy could provide an accurate histological diagnosis of LSTs without requiring a biopsy.
Background: Narrow-band imaging (NBI) emphasizes the surface microvasculature of the gastrointestinal tract. The endocytoscopy (EC) system is a recent developed technique which in contrast to others, such as confocal endomicroscopy, does not require fluorescein administration. Recent pilot studies have suggested the potential of EC to enable microscopic observation at the cellular level in vivo and to diagnose malignant lesions in esophagus and colon. Aim: The aim of this study was to evaluate the vessel of colorectal lesions with endocytoscopic narrow band imaging (EC-NBI) in vivo and clarify the vessel feature in tissue characterization. Material and Methods: The subject was compound of 86 consecutive patients who underwent colonoscopy, from Feburuary 2009 to May 2010. A total of 94 lesions (63 adenomas and 31 invasive cancers limited to submucosal layer) were evaluated in 86 patients. In 11 randomly selected cases, the adjacent mucosa of the lesions that looked normal by conventional endoscopy was analyzed. In this study, an integrated type endocytoscope (XCF-Q260EC1, Olympus, Tokyo) providing about 450x magnification power was used. The picture of endocytoscope was regular quadrilateral and not fisheye lens. The length of its side was 426m and established as the standard. The diameter of vessels in colorectal mucosa or lesions was measured and calculated. Result: The average diameter of normal vessels was 7.8⫾1.0m. The average vascular diameter of adenoma was 15.2⫾5.9m. Adenomatous vessel thickness was almost uniform and as regular pitted surrounding. The average vascular diameter of submucosal slightly cancer (SMs) was 16.2⫾6.9m. That of submucosal massively cancer (SMm) was 24.1⫾10.1m. The vascular feature of SMm was unusually large in caliber and with network interruption. The maximum diameter of normal vessels was 9.0⫾0.6m. The maximum vascular diameter of adenoma, SMs and SMm were 23.0⫾5.9m, 22.7⫾5.9m and 36.8⫾8.2m respectively. Both average and maximum diameters of neoplastic vessels were greatly larger than those of normal vessels (p⬍.01). Those of submucosal massively cancerous vessels were also greatly larger than those of the other neoplastic vessel types (p⬍.01). Conclusion: EC-NBI allows a real time observation of colorectal vessels. It was possible to distinguish neoplastic from nonneoplastic lesions, and SMm from adenoma/SMs. EC system does not only provide realtime histological images in vivo but also clarifies the vascular features of colorectal mucosa and neoplasia with NBI system.
Su1526 Pathological Features of Laterally Spreading Tumors Diagnosed by Endocytoscopy Yasutoshi Kobayashi1, Shin-Ei Kudo1, Kunihiko Wakamura1, Nobunao Ikehara1, Yuichi Mori1, Takemasa Hayashi1, Yoshiki Wada1, Hideyuki Miyachi1, Kazuo Ohtsuka1, Haruhiro Inoue1, Shigeharu Hamatani2 1 Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan; 2Department of Pathology, Showa University Northern Yokohama Hospital, Yokohama, Japan Introduction: An endocytoscope is an outstanding modality that with ultra-high magnification, provides real time information about the structural and cellular atypia of a lesion in vivo. Laterally spreading tumors (LSTs) are flat colonic neoplasms that spread extensively and circumferentially along the colonic wall with low depth. Although LSTs seldom invade into the submucosal layer, it is crucial to diagnose the depth of LSTs to decide up on the best therapeutic strategy. However, there has been little researched about the efficacy of endocytoscopy for LSTs. Aims and Methods: This prospective study was conducted to clarify the pathological and endocytoscopic features of LSTs from April 2001 to December 2009. LSTs are defined as colorectal tumors that have a diameter greater than 10mm and spread extensively along the colonic wall. LSTs are classified into two types; granular (LST-G) and non-granular (LST-NG). An integrated endocytoscope (XCF-260EC, Olympus, Tokyo, Japan) was used in this study. Correlations between (i) the gross appearance and size of LSTs, (ii) the gross appearance and the rate of submucosal cancer of LSTs, (iii) the endocytoscopic features (EC classification) and the final pathological diagnosis of LSTs stratified by the gross appearance were evaluated in this study. Results: 12,895 colorectal tumors were assessed, and among them there were 1,329 (10.3%) LSTs, of which, 611 lesions were LST-G and 718 lesions were LST-NG. Reagrding the rate of submucosal cancer among LSTs, LST-NG was significantly greater than LST-G (13.6% vs 7.6% P⬍0.01) and larger LSTs tended to invade the submucosa to a greater depth. 71 lesions of the LSTs were investigated with the endocytoscope. When LSTs were diagnosed by our EC classification, the sensitivity, specificity, and positive, and negative predictive values for invasive cancers were 100%(95%CI:29.2-100%), 92.0%(74.0-99.0%), 60.0(14.5-94.7%) and 100%(85.2-100%) for LST-G and 100%(95%CI:59.0-100), 69.4%(51.9-83.7%),
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Su1527 Improved Accuracy of Colorectal Polyp Measurement With a Modified “Ruler Snare” Asma Anwar1,2, Darby Robinson-O’Neill2, Jason a. Dominitz1,2 1 VA Puget Sound Health Care System, Seattle, WA; 2Division of Gastroenterology, University of Washington, Seattle, WA Background: Accurate measurement of colorectal polyp size is necessary for determination of surveillance intervals. Prior studies have shown that endoscopists cannot reliably estimate polyp size without use of endoscopic rulers or the “open biopsy forceps technique”, though use of these devices adds time and cost when snare polypectomy is planned. We developed a prototype “ruler snare” that includes markings at 5mm intervals on the distal end of the snare’s sheath to facilitate measurement without use of additional devices. Aim: To determine if a “ruler snare” improves the accuracy of estimation of colorectal polyp size. Methods: Using an ex vivo artificial colon model (AO Scientific Instruments “Pathology in Colon Model” with spherical beads of known size (4mm-25mm) sewn in to represent colon polyps) endoscopists measured 10 ”polyps” using a standard snare and then again using the “ruler snare”. Endoscopists were not instructed on how to measure polyps, other than to use their usual approach for size estimation and then to use the markings on the ”ruler snare” as a reference. Results: 34 endoscopists (24 GI attendings (11 private practice, 8 university, 5 VA), 9 GI fellows and 1 surgical resident) completed the study procedures. With the standard snare, endoscopists underestimate polyp size by a mean of 3.6mm (40.5%, range of difference from true size of ⫺18 mm to 10mm). The “ruler snare” improved the measurement to a mean underestimate of 1.8mm (17.9%, range ⫺15mm to 17mm). The absolute value of the error was 3.9mm with the standard snare vs. 2.7mm with the “ruler snare” (p⬍0.0001). This translates into a 44% improvement in overall estimation of polyp size. Measurement errors for attendings only were similar (mean ⫺3.5mm (range ⫺15mm to 17mm) vs. ⫺1.5mm (range ⫺15mm to 17mm) for standard vs. “ruler snare”). When classifying polyps as diminutive (⬉5mm), small (6-9mm) or large (ⱖ10mm), the “ruler snare” improved accuracy from 48.5% (Table 1) to 60.3% (Table 2). Limiting the analysis to attendings only yielded similar accuracy (48.8% vs. 62.1%). Importantly, only 36% of large polyps were properly classified with the standard snare vs. 58% with the “ruler snare”. Ease of use of the ruler snare was rated as easy by 17, neither easy nor difficult by 11 and difficult by 6. Conclusion: Endoscopists tend to underestimate polyp size but the modified “ruler snare” lessens this underestimation and improves accuracy of categorization of polyp size in an ex vivo model. Snare manufacturers could readily adopt this modification to aid in categorizing polyp size since recommendations for surveillance are undoubtedly affected by the observed inaccuracy. Devices to improve estimation of polyp size should be adopted into clinical practice in order to improve neoplasia surveillance recommendations. Table 1. Comparing True vs. Estimated Polyp Size Using the Standard Snare Estimate
True 0-5mm
True 6-9mm
True >10mm
0-5mm 6-9mm ⱖ10mm
99 3 0
62 5 1
58 51 61
Accuracy⫽48.5% (accurate estimates shown in bold) Table 2. Comparing True vs. Estimated Polyp Size Using the ”Ruler Snare” Estimate
True 0-5mm
True 6-9mm
True >10mm
0-5mm 6-9mm ⱖ10mm
95 7 0
51 11 6
15 56 99
Accuracy⫽60.3% (accurate estimates shown in bold)
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB293
Su1525 Vascular Features of Colorectal Mucosa and Neoplasia With Endocytoscopic-Narrow Band Imaging (EC-NBI): A Pilot Study Yoshiki Wada, Shin-Ei Kudo, Masashi Misawa, Takemasa Hayashi, Kunihiko Wakamura, Yuichi Mori, Nobunao Ikehara Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
38.8%(17.3-64.3%) and 100%(86.3-100%) for LST-NG respectively. Conclusion: Although this study was conducted with a limited number of lesions, our EC classification corresponded well to the pathological diagnoses after endoscopic and surgical resection. Therefore, endocytoscopy could provide an accurate histological diagnosis of LSTs without requiring a biopsy.
Background: Narrow-band imaging (NBI) emphasizes the surface microvasculature of the gastrointestinal tract. The endocytoscopy (EC) system is a recent developed technique which in contrast to others, such as confocal endomicroscopy, does not require fluorescein administration. Recent pilot studies have suggested the potential of EC to enable microscopic observation at the cellular level in vivo and to diagnose malignant lesions in esophagus and colon. Aim: The aim of this study was to evaluate the vessel of colorectal lesions with endocytoscopic narrow band imaging (EC-NBI) in vivo and clarify the vessel feature in tissue characterization. Material and Methods: The subject was compound of 86 consecutive patients who underwent colonoscopy, from Feburuary 2009 to May 2010. A total of 94 lesions (63 adenomas and 31 invasive cancers limited to submucosal layer) were evaluated in 86 patients. In 11 randomly selected cases, the adjacent mucosa of the lesions that looked normal by conventional endoscopy was analyzed. In this study, an integrated type endocytoscope (XCF-Q260EC1, Olympus, Tokyo) providing about 450x magnification power was used. The picture of endocytoscope was regular quadrilateral and not fisheye lens. The length of its side was 426m and established as the standard. The diameter of vessels in colorectal mucosa or lesions was measured and calculated. Result: The average diameter of normal vessels was 7.8⫾1.0m. The average vascular diameter of adenoma was 15.2⫾5.9m. Adenomatous vessel thickness was almost uniform and as regular pitted surrounding. The average vascular diameter of submucosal slightly cancer (SMs) was 16.2⫾6.9m. That of submucosal massively cancer (SMm) was 24.1⫾10.1m. The vascular feature of SMm was unusually large in caliber and with network interruption. The maximum diameter of normal vessels was 9.0⫾0.6m. The maximum vascular diameter of adenoma, SMs and SMm were 23.0⫾5.9m, 22.7⫾5.9m and 36.8⫾8.2m respectively. Both average and maximum diameters of neoplastic vessels were greatly larger than those of normal vessels (p⬍.01). Those of submucosal massively cancerous vessels were also greatly larger than those of the other neoplastic vessel types (p⬍.01). Conclusion: EC-NBI allows a real time observation of colorectal vessels. It was possible to distinguish neoplastic from nonneoplastic lesions, and SMm from adenoma/SMs. EC system does not only provide realtime histological images in vivo but also clarifies the vascular features of colorectal mucosa and neoplasia with NBI system.
Su1526 Pathological Features of Laterally Spreading Tumors Diagnosed by Endocytoscopy Yasutoshi Kobayashi1, Shin-Ei Kudo1, Kunihiko Wakamura1, Nobunao Ikehara1, Yuichi Mori1, Takemasa Hayashi1, Yoshiki Wada1, Hideyuki Miyachi1, Kazuo Ohtsuka1, Haruhiro Inoue1, Shigeharu Hamatani2 1 Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan; 2Department of Pathology, Showa University Northern Yokohama Hospital, Yokohama, Japan Introduction: An endocytoscope is an outstanding modality that with ultra-high magnification, provides real time information about the structural and cellular atypia of a lesion in vivo. Laterally spreading tumors (LSTs) are flat colonic neoplasms that spread extensively and circumferentially along the colonic wall with low depth. Although LSTs seldom invade into the submucosal layer, it is crucial to diagnose the depth of LSTs to decide up on the best therapeutic strategy. However, there has been little researched about the efficacy of endocytoscopy for LSTs. Aims and Methods: This prospective study was conducted to clarify the pathological and endocytoscopic features of LSTs from April 2001 to December 2009. LSTs are defined as colorectal tumors that have a diameter greater than 10mm and spread extensively along the colonic wall. LSTs are classified into two types; granular (LST-G) and non-granular (LST-NG). An integrated endocytoscope (XCF-260EC, Olympus, Tokyo, Japan) was used in this study. Correlations between (i) the gross appearance and size of LSTs, (ii) the gross appearance and the rate of submucosal cancer of LSTs, (iii) the endocytoscopic features (EC classification) and the final pathological diagnosis of LSTs stratified by the gross appearance were evaluated in this study. Results: 12,895 colorectal tumors were assessed, and among them there were 1,329 (10.3%) LSTs, of which, 611 lesions were LST-G and 718 lesions were LST-NG. Reagrding the rate of submucosal cancer among LSTs, LST-NG was significantly greater than LST-G (13.6% vs 7.6% P⬍0.01) and larger LSTs tended to invade the submucosa to a greater depth. 71 lesions of the LSTs were investigated with the endocytoscope. When LSTs were diagnosed by our EC classification, the sensitivity, specificity, and positive, and negative predictive values for invasive cancers were 100%(95%CI:29.2-100%), 92.0%(74.0-99.0%), 60.0(14.5-94.7%) and 100%(85.2-100%) for LST-G and 100%(95%CI:59.0-100), 69.4%(51.9-83.7%),
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Su1527 Improved Accuracy of Colorectal Polyp Measurement With a Modified “Ruler Snare” Asma Anwar1,2, Darby Robinson-O’Neill2, Jason a. Dominitz1,2 1 VA Puget Sound Health Care System, Seattle, WA; 2Division of Gastroenterology, University of Washington, Seattle, WA Background: Accurate measurement of colorectal polyp size is necessary for determination of surveillance intervals. Prior studies have shown that endoscopists cannot reliably estimate polyp size without use of endoscopic rulers or the “open biopsy forceps technique”, though use of these devices adds time and cost when snare polypectomy is planned. We developed a prototype “ruler snare” that includes markings at 5mm intervals on the distal end of the snare’s sheath to facilitate measurement without use of additional devices. Aim: To determine if a “ruler snare” improves the accuracy of estimation of colorectal polyp size. Methods: Using an ex vivo artificial colon model (AO Scientific Instruments “Pathology in Colon Model” with spherical beads of known size (4mm-25mm) sewn in to represent colon polyps) endoscopists measured 10 ”polyps” using a standard snare and then again using the “ruler snare”. Endoscopists were not instructed on how to measure polyps, other than to use their usual approach for size estimation and then to use the markings on the ”ruler snare” as a reference. Results: 34 endoscopists (24 GI attendings (11 private practice, 8 university, 5 VA), 9 GI fellows and 1 surgical resident) completed the study procedures. With the standard snare, endoscopists underestimate polyp size by a mean of 3.6mm (40.5%, range of difference from true size of ⫺18 mm to 10mm). The “ruler snare” improved the measurement to a mean underestimate of 1.8mm (17.9%, range ⫺15mm to 17mm). The absolute value of the error was 3.9mm with the standard snare vs. 2.7mm with the “ruler snare” (p⬍0.0001). This translates into a 44% improvement in overall estimation of polyp size. Measurement errors for attendings only were similar (mean ⫺3.5mm (range ⫺15mm to 17mm) vs. ⫺1.5mm (range ⫺15mm to 17mm) for standard vs. “ruler snare”). When classifying polyps as diminutive (⬉5mm), small (6-9mm) or large (ⱖ10mm), the “ruler snare” improved accuracy from 48.5% (Table 1) to 60.3% (Table 2). Limiting the analysis to attendings only yielded similar accuracy (48.8% vs. 62.1%). Importantly, only 36% of large polyps were properly classified with the standard snare vs. 58% with the “ruler snare”. Ease of use of the ruler snare was rated as easy by 17, neither easy nor difficult by 11 and difficult by 6. Conclusion: Endoscopists tend to underestimate polyp size but the modified “ruler snare” lessens this underestimation and improves accuracy of categorization of polyp size in an ex vivo model. Snare manufacturers could readily adopt this modification to aid in categorizing polyp size since recommendations for surveillance are undoubtedly affected by the observed inaccuracy. Devices to improve estimation of polyp size should be adopted into clinical practice in order to improve neoplasia surveillance recommendations. Table 1. Comparing True vs. Estimated Polyp Size Using the Standard Snare Estimate
True 0-5mm
True 6-9mm
True >10mm
0-5mm 6-9mm ⱖ10mm
99 3 0
62 5 1
58 51 61
Accuracy⫽48.5% (accurate estimates shown in bold) Table 2. Comparing True vs. Estimated Polyp Size Using the ”Ruler Snare” Estimate
True 0-5mm
True 6-9mm
True >10mm
0-5mm 6-9mm ⱖ10mm
95 7 0
51 11 6
15 56 99
Accuracy⫽60.3% (accurate estimates shown in bold)
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB293