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Su1615 Diagnostic Characteristics of Depressed Type Colorectal Neoplasms in Magnifying Endoscopy and Endocytoscopy
Abstracts magnified endoscopic findings with NBI might predict that resection of the CRC with a negative vertical margin by ESD is not possible.
Su1615 Diagnostic Characteristics of Depressed Type Colorectal Neoplasms in Magnifying Endoscopy and Endocytoscopy Shin-ei Kudo*, Masataka Ogawa, Matsudaira Shingo, Yuichi Fukami, Yukiko Shakuo, Yuta Kouyama, Tomokazu Hisayuki, Yuichi Mori, Masashi Misawa, Toyoki Kudo, Kunihiko Wakamura, Takemasa Hayashi, Atsushi Katagiri, Hideyuki Miyachi, Toshiyuki Baba, Eiji Hidaka, Fumio Ishida Showa University Northern Yokohama Hospital, Yokohama, Japan Introduction&Aim: Colorectal cancers are generally recognized to develop from“polyps”. This “adenoma-carcinoma sequence” theory has been in the mainstream of development of colorectal cancers. But recently the existence of many depressedtype cancers has been revealed, which are considered to emerge directly from normal epithelium, not through the adenomatous stage. This theory is called “de novo” pathway. Now, it is possible to presume the histology of colorectal lesions using magnifying endoscopy(pit pattern classification) and endocytoscopy(EC).We can observe not only the structural atypia but also the cellular atypia in living colorectal lesions. The aim is to clarify the diagnostic characteristics of depressed-type colorectal neoplasms, demonstrating the validity of pit pattern diagnosis and EC classification. Methods: A total of 25180 colorectal neoplasms excluding advanced cancers were resected endoscopically or surgically in our unit from April 2001 to June 2015.Of these, 16879 lesions were low-grade dysplasia, 5096 were high-grade dysplasia and 1007 were submucosally invasive (T1) carcinomas. According to the developmental morphology classification, they were divided into 3 types: depressed, flat and protruded type. We investigated the rate of T1 carcinomas and the characteristics of depressed-type neoplasms concerning pit pattern and EC classification. Results: The rate of T1 carcinomas in depressed-type lesions reached to 63.4%,meanwhile that in flat-type and protruded-type lesions was 3.5% and 2.9%,respectively.Within less than 5mm in diameter, that was 10.9% ,0% and 0%,respectively. Most (90.1% and 91.5%) of the flat-type and protruded-type lesions showed type IIIL or IV pit pattern corresponding to adenomas, whereas 94.6% of the depressed-type lesions were characterized by type IIIS, VI and VN pit pattern corresponding to carcinomas. As for endocytoscopy, most of the flat-and protrudedtype lesions showed EC2 corresponding to adenomas. In contrast, the depressedtype lesions were observed as EC3a (38.9%) and EC3b (58.0%) corresponding to invasive carcinomas. Conclusions: This study revealed the diagnostic characteristics of depressed-type lesions. They show typically type IIIS, VI and VN pit pattern in magnifying endoscopy and type EC3a or EC3b in endocytoscopy. These lesions tend to invade the submucosal layer even when they are small. Therefore, it is important to consider deeply and examine the developmental morphology of colorectal neoplasms.
Su1616 Tthe Growth Pathway and the Pathological Features of DepressedType Colorectal Carcinomas Shin-ei Kudo*, Kenichi Suzuki, Hideyuki Miyachi, Yuta Kouyama, Shingo Matsudaira, Katsuro Ichimasa, Hiromasa Oikawa, Yuichi Mori, Masashi Misawa, Toyoki Kudo, Tomokazu Hisayuki, Kenta Kodama, Takemasa Hayashi, Kunihiko Wakamura, Atsushi Katagiri, Toshiyuki Baba, Eiji Hidaka, Fumio Ishida Showa University Northern Yokohama Hospital, Yokohama, Japan 1. Background/Aim: Colorectal cancers are generally recognized to develop from protruded-type “polyps”. This “adenoma-carcinoma sequence” theory has been in the mainstream of development of colorectal cancers. But recently the existence of many depressed-type cancers has been revealed, which are considered to emerge directly from normal epithelium, not through the adenomatous stage. This theory is called “ de novo ” pathway. 2. Method: The aim is to clarify the pathological features of depressed-type colorectal carcinomas compared with flat- and protruded -type. A total of 25733 colorectal neoplasms excluding advanced carcinomas were resected endoscopically or surgically in our Center from April 2001 to June 2015. Of these, 1001 lesions were T1 carcinomas. According to the morphological/development classification, 237 lesions (23.7%) were depressed-type, 338 lesions (33.8%) were flat-type and 426 lesions (42.6%) were protruded-type. We analyzed the pathological features of these lesions. 3. Results and Discussion: The rate of submucosal invasion in all the lesions was 63.4% in depressed-type, 3.5% in flat-type and 2.9% in protruded-type. Within under 5mm in diameter, that was 10.9%, 0% and 0.03% respectively. Among T1 carcinomas, the rate of angiolymphatic invasion was 63.3% in depressed-type, 33.1% in flat-type and 38.7% in protruded-type, that of poorly differentiated or mucinous adenocarcinoma was 16.9%, 11.2% and 14.8%, that of massively submucosal invasion was 92.8%, 66.0% and 77.5%, and that of tumor budding was 36.7%, 16.0% and 18.1%, respectively. The rates of these pathological factors were significantly higher in the depressed-type lesions. On the other hand, the rate of adenomatous component was 6.3%, 52.7% and 52.1%, respectively. It was
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significantly lower in depressed-type lesions, suggesting that they emerge directly from normal epithelium without going through the adenoma stage. The rate of lymph node metastasis was 7.6%, 3.8% and 7.5%, respectively. Two depressed cases were with synchronous liver metastasis. 4. Conclusions: Depressed-type colorectal carcinomas invade massively even when they are small. They had higher risks of angiolymphatic invasion, poorly differentiated or mucinous adenocarcinoma, massively invasion, and tumor budding than flat- and protruded-types. Furthermore, they had a lower rate of adenomatous component, suggesting that they are “de novo” carcinomas. For their rapid growth and malignant nature, whether the lesion is depressed-type or not is very important in the diagnosis of colorectal neoplasms.
Su1617 T1 Colon Cancer: Is There a Need for Surgery After Endoscopic Submucosal Dissection? Seon Hee Lim*2,1, John M. Levenick1, Abraham Mathew1, Matthew T. Moyer1, Thomas J. McGarrity1 1 Section of Gastroenterology and Hepatology, Penn State Hershey, Hershey, PA; 2Gastroenterology, Seoul National University Hospital, Seoul, Korea (the Republic of) Background and Aims: Traditional endoscopic polypectomy is generally considered curative if the lesion is either an adenoma (with or without high grade dysplasia) or an adenocarcinoma without evidence of invasion into the submucosa. Endoscopic submucosal dissection (ESD) has a high curative resection rate for gastrointestinal mucosal lesions at this level, but evidence for complete endoscopic removal with deeper penetrating lesions is lacking. Materials and Methods: We retrospectively reviewed 334 polyps >2cm referred to our institution for endoscopic removal from 2009-2014. ESD was used to treat large colonic lesions that could not be resected by traditional endoscopic mucosal resection due to non-lifting or inability to engage in a snare. En-bloc resection, number of sessions for complete removal, complication rates, and the need for surgical intervention were analyzed. Results: Thirty-one polyps underwent ESD, 71% were performed in the right colon (nZ22). The mean lesion diameter was 3.67 1.42 cm (range 2.0–8.0 cm). En-bloc resection occurred in 29.0% (9/31) of polyps. Adenocarcinoma was present in 25.8% (8/31) and high grade dysplasia was 16.1% (5/31) of these lesions. Of the 8 adenocarcinomas, 5 patients underwent “curative” surgical resection, while 3 did not given underlying co-morbidities. Four of 5 (80%) had no evidence of residual cancer on the operative specimen in the colon or lymph nodes. Conclusion: ESD is useful and safe for complete resection of large colorectal polyps, even malignant polyps. Our study suggests that endoscopically removed T1 colon cancers invading the submucosa can safely and completely be removed endoscopically without need for surgical resection prior to systemic chemotherapy.
Su1618 Colonic Stenting With Elective Surgery Versus Emergency Surgery for Acute Malignant Colonic Obstruction: Interim Analysis of a Multicentre Prospective Cohort Trial XiaoBing Cui, Wei Gong, Side Liu* Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China Colonic stenting as a bridge to elective surgery is an alternative for emergency surgery in patients with acute malignant colonic obstruction, but its benefit is contradictory. Patients with acute colonic obstructive caused by colon cancer were enrolled from 5 hospitals in the China and assigned to receive colonic stenting with elective surgery or emergency surgery. This interim analysis was conducted after first 30 days follow-up by statistical method intention to treat. This study is registered on ClinicalTrials.gov (NCT01997684). Between Sep 2013, and Mar 2015, 60 patients were assigned to receive colonic stenting (nZ49 patients) or emergency surgery (nZ11). The patient characteristics were balanced between two groups at baseline (Table 1). In the colonic stenting group, all 49 patients received WallFlex colonic stents (Boston Scientific, MA, USA) during the stent placement procedure. Stent placement was technically successful in 46 of 49 (93.88%) patients, and clinically successful in 43 of 49 (87.76%) patients. Then four patients with clinically failure received emergency surgery (within one day), two were treated conservatively followed by elective surgery. In total, elective surgery was done in 45 of 49 (91.84%) patients which were allocated to receive colonic stenting. A primary anastomosis was achieved in 43 (87.75%) patients, and a temporary stoma was done in 7 (14.28%) patients (with 1 prophylactic stoma). The mean hospitalization of cost was110343150 USD. In the emergency surgery group, 4 (36.36%) of 11 patients achieved primary anastomosis, and 9 (81.82%) patients maintained temporary stoma. The hospitalization cost was 85202615 USD. The difference between both study groups was statistically significant (pZ0.001, p<0.001 and pZ0.017, respectively). (Table 2). Post-surgery complications were encountered in 8 (16.33%) patients (10 cases) in the colonic stenting group compared to 2 (18.18%) patients in the emergency surgery group (pZ0.721). However, one 79 years male patient with stage IV sigmoid colon cancer, which failed to place the stent, died of multiple organ failure 7 days after the emergency surgery. (Table 2). In the colonic stenting group, we recorded
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB365
Su1615 Diagnostic Characteristics of Depressed Type Colorectal Neoplasms in Magnifying Endoscopy and Endocytoscopy Shin-ei Kudo*, Masataka Ogawa, Matsudaira Shingo, Yuichi Fukami, Yukiko Shakuo, Yuta Kouyama, Tomokazu Hisayuki, Yuichi Mori, Masashi Misawa, Toyoki Kudo, Kunihiko Wakamura, Takemasa Hayashi, Atsushi Katagiri, Hideyuki Miyachi, Toshiyuki Baba, Eiji Hidaka, Fumio Ishida Showa University Northern Yokohama Hospital, Yokohama, Japan Introduction&Aim: Colorectal cancers are generally recognized to develop from“polyps”. This “adenoma-carcinoma sequence” theory has been in the mainstream of development of colorectal cancers. But recently the existence of many depressedtype cancers has been revealed, which are considered to emerge directly from normal epithelium, not through the adenomatous stage. This theory is called “de novo” pathway. Now, it is possible to presume the histology of colorectal lesions using magnifying endoscopy(pit pattern classification) and endocytoscopy(EC).We can observe not only the structural atypia but also the cellular atypia in living colorectal lesions. The aim is to clarify the diagnostic characteristics of depressed-type colorectal neoplasms, demonstrating the validity of pit pattern diagnosis and EC classification. Methods: A total of 25180 colorectal neoplasms excluding advanced cancers were resected endoscopically or surgically in our unit from April 2001 to June 2015.Of these, 16879 lesions were low-grade dysplasia, 5096 were high-grade dysplasia and 1007 were submucosally invasive (T1) carcinomas. According to the developmental morphology classification, they were divided into 3 types: depressed, flat and protruded type. We investigated the rate of T1 carcinomas and the characteristics of depressed-type neoplasms concerning pit pattern and EC classification. Results: The rate of T1 carcinomas in depressed-type lesions reached to 63.4%,meanwhile that in flat-type and protruded-type lesions was 3.5% and 2.9%,respectively.Within less than 5mm in diameter, that was 10.9% ,0% and 0%,respectively. Most (90.1% and 91.5%) of the flat-type and protruded-type lesions showed type IIIL or IV pit pattern corresponding to adenomas, whereas 94.6% of the depressed-type lesions were characterized by type IIIS, VI and VN pit pattern corresponding to carcinomas. As for endocytoscopy, most of the flat-and protrudedtype lesions showed EC2 corresponding to adenomas. In contrast, the depressedtype lesions were observed as EC3a (38.9%) and EC3b (58.0%) corresponding to invasive carcinomas. Conclusions: This study revealed the diagnostic characteristics of depressed-type lesions. They show typically type IIIS, VI and VN pit pattern in magnifying endoscopy and type EC3a or EC3b in endocytoscopy. These lesions tend to invade the submucosal layer even when they are small. Therefore, it is important to consider deeply and examine the developmental morphology of colorectal neoplasms.
Su1616 Tthe Growth Pathway and the Pathological Features of DepressedType Colorectal Carcinomas Shin-ei Kudo*, Kenichi Suzuki, Hideyuki Miyachi, Yuta Kouyama, Shingo Matsudaira, Katsuro Ichimasa, Hiromasa Oikawa, Yuichi Mori, Masashi Misawa, Toyoki Kudo, Tomokazu Hisayuki, Kenta Kodama, Takemasa Hayashi, Kunihiko Wakamura, Atsushi Katagiri, Toshiyuki Baba, Eiji Hidaka, Fumio Ishida Showa University Northern Yokohama Hospital, Yokohama, Japan 1. Background/Aim: Colorectal cancers are generally recognized to develop from protruded-type “polyps”. This “adenoma-carcinoma sequence” theory has been in the mainstream of development of colorectal cancers. But recently the existence of many depressed-type cancers has been revealed, which are considered to emerge directly from normal epithelium, not through the adenomatous stage. This theory is called “ de novo ” pathway. 2. Method: The aim is to clarify the pathological features of depressed-type colorectal carcinomas compared with flat- and protruded -type. A total of 25733 colorectal neoplasms excluding advanced carcinomas were resected endoscopically or surgically in our Center from April 2001 to June 2015. Of these, 1001 lesions were T1 carcinomas. According to the morphological/development classification, 237 lesions (23.7%) were depressed-type, 338 lesions (33.8%) were flat-type and 426 lesions (42.6%) were protruded-type. We analyzed the pathological features of these lesions. 3. Results and Discussion: The rate of submucosal invasion in all the lesions was 63.4% in depressed-type, 3.5% in flat-type and 2.9% in protruded-type. Within under 5mm in diameter, that was 10.9%, 0% and 0.03% respectively. Among T1 carcinomas, the rate of angiolymphatic invasion was 63.3% in depressed-type, 33.1% in flat-type and 38.7% in protruded-type, that of poorly differentiated or mucinous adenocarcinoma was 16.9%, 11.2% and 14.8%, that of massively submucosal invasion was 92.8%, 66.0% and 77.5%, and that of tumor budding was 36.7%, 16.0% and 18.1%, respectively. The rates of these pathological factors were significantly higher in the depressed-type lesions. On the other hand, the rate of adenomatous component was 6.3%, 52.7% and 52.1%, respectively. It was
www.giejournal.org
significantly lower in depressed-type lesions, suggesting that they emerge directly from normal epithelium without going through the adenoma stage. The rate of lymph node metastasis was 7.6%, 3.8% and 7.5%, respectively. Two depressed cases were with synchronous liver metastasis. 4. Conclusions: Depressed-type colorectal carcinomas invade massively even when they are small. They had higher risks of angiolymphatic invasion, poorly differentiated or mucinous adenocarcinoma, massively invasion, and tumor budding than flat- and protruded-types. Furthermore, they had a lower rate of adenomatous component, suggesting that they are “de novo” carcinomas. For their rapid growth and malignant nature, whether the lesion is depressed-type or not is very important in the diagnosis of colorectal neoplasms.
Su1617 T1 Colon Cancer: Is There a Need for Surgery After Endoscopic Submucosal Dissection? Seon Hee Lim*2,1, John M. Levenick1, Abraham Mathew1, Matthew T. Moyer1, Thomas J. McGarrity1 1 Section of Gastroenterology and Hepatology, Penn State Hershey, Hershey, PA; 2Gastroenterology, Seoul National University Hospital, Seoul, Korea (the Republic of) Background and Aims: Traditional endoscopic polypectomy is generally considered curative if the lesion is either an adenoma (with or without high grade dysplasia) or an adenocarcinoma without evidence of invasion into the submucosa. Endoscopic submucosal dissection (ESD) has a high curative resection rate for gastrointestinal mucosal lesions at this level, but evidence for complete endoscopic removal with deeper penetrating lesions is lacking. Materials and Methods: We retrospectively reviewed 334 polyps >2cm referred to our institution for endoscopic removal from 2009-2014. ESD was used to treat large colonic lesions that could not be resected by traditional endoscopic mucosal resection due to non-lifting or inability to engage in a snare. En-bloc resection, number of sessions for complete removal, complication rates, and the need for surgical intervention were analyzed. Results: Thirty-one polyps underwent ESD, 71% were performed in the right colon (nZ22). The mean lesion diameter was 3.67 1.42 cm (range 2.0–8.0 cm). En-bloc resection occurred in 29.0% (9/31) of polyps. Adenocarcinoma was present in 25.8% (8/31) and high grade dysplasia was 16.1% (5/31) of these lesions. Of the 8 adenocarcinomas, 5 patients underwent “curative” surgical resection, while 3 did not given underlying co-morbidities. Four of 5 (80%) had no evidence of residual cancer on the operative specimen in the colon or lymph nodes. Conclusion: ESD is useful and safe for complete resection of large colorectal polyps, even malignant polyps. Our study suggests that endoscopically removed T1 colon cancers invading the submucosa can safely and completely be removed endoscopically without need for surgical resection prior to systemic chemotherapy.
Su1618 Colonic Stenting With Elective Surgery Versus Emergency Surgery for Acute Malignant Colonic Obstruction: Interim Analysis of a Multicentre Prospective Cohort Trial XiaoBing Cui, Wei Gong, Side Liu* Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China Colonic stenting as a bridge to elective surgery is an alternative for emergency surgery in patients with acute malignant colonic obstruction, but its benefit is contradictory. Patients with acute colonic obstructive caused by colon cancer were enrolled from 5 hospitals in the China and assigned to receive colonic stenting with elective surgery or emergency surgery. This interim analysis was conducted after first 30 days follow-up by statistical method intention to treat. This study is registered on ClinicalTrials.gov (NCT01997684). Between Sep 2013, and Mar 2015, 60 patients were assigned to receive colonic stenting (nZ49 patients) or emergency surgery (nZ11). The patient characteristics were balanced between two groups at baseline (Table 1). In the colonic stenting group, all 49 patients received WallFlex colonic stents (Boston Scientific, MA, USA) during the stent placement procedure. Stent placement was technically successful in 46 of 49 (93.88%) patients, and clinically successful in 43 of 49 (87.76%) patients. Then four patients with clinically failure received emergency surgery (within one day), two were treated conservatively followed by elective surgery. In total, elective surgery was done in 45 of 49 (91.84%) patients which were allocated to receive colonic stenting. A primary anastomosis was achieved in 43 (87.75%) patients, and a temporary stoma was done in 7 (14.28%) patients (with 1 prophylactic stoma). The mean hospitalization of cost was110343150 USD. In the emergency surgery group, 4 (36.36%) of 11 patients achieved primary anastomosis, and 9 (81.82%) patients maintained temporary stoma. The hospitalization cost was 85202615 USD. The difference between both study groups was statistically significant (pZ0.001, p<0.001 and pZ0.017, respectively). (Table 2). Post-surgery complications were encountered in 8 (16.33%) patients (10 cases) in the colonic stenting group compared to 2 (18.18%) patients in the emergency surgery group (pZ0.721). However, one 79 years male patient with stage IV sigmoid colon cancer, which failed to place the stent, died of multiple organ failure 7 days after the emergency surgery. (Table 2). In the colonic stenting group, we recorded
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB365