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The Efficiency of Narrow Band Imaging with Magnification for the Estimation of Invasion Depth Diagnosis in Early Colorectal Cancer -A Prospective Study
Abstracts
W1349 Inter-Observer Agreement Amongst Non-Expert Endoscopists for Mucosal Morphology in Barrett’s Esophagus Wouter L. Curvers, Robert Lindeboom, Bert Baak, Clarisse Bohmer, Rosalie Mallant-Hent, Ton Naber, Arnout Van Oijen, Cyril Ponsioen, Pieter Scholten, Fiebo J. Ten Kate, Kausilia K. Krishnadath, Paul Fockens, Jacques J. Bergman Introduction: Mucosal and vascular patterns (e.g. mucosal morphology) can be used to differentiate non-dysplastic Barrett’s esophagus (BE) from high-grade dysplasia (HGD) or early cancer (EC). We have recently investigated the mucosal morphology of HGD/EC and non-dysplastic BE using narrow band imaging (NBI) and proposed a 3-step classification for the evaluation of BE: determination of the regularity of the mucosal pattern, the regularity of the vascular pattern and the presence of abnormal blood vessels. The aim of this study was to evaluate the interobserver agreement of this 3-step mucosal morphology classification model amongst non-expert endoscopists and to evaluate the appreciated difference in image quality between NBI and white light endoscopy (WL). Methods: 7 endoscopists from non-university hospitals with no specific experience in BE or advanced imaging techniques independently evaluated magnified still images of 50 areas of BE. They scored the overall, mucosal and vascular imaging quality on a 15 cm VAS. In addition, the 3 step classification system was scored. The endoscopists first assessed the WL images, followed by the corresponding NBI images (in random order), and finally evaluated the WL images and NBI images together. Results: Assessed independently, the overall imaging quality of WL received a higher rating than NBI (mean VAS score 11.9 vs. 11.0; p ! 0.05). When WL and NBI were assessed side-by-side, however, NBI images were scored as having a better overall imaging quality in 69% of the assessments, a better mucosal imaging quality (75%) and vascular imaging quality (83%).The inter-observer agreement of the 7 endoscopists for the items of the 3-step classification system was fair to moderate (kappa 0.37 to 0.53). The mean kappa scores of WL, NBI or WL-NBI for scoring the 3-step classification system and the sensitivities for detecting HGD/EC using the 3-step classification model are shown in Table 1. Conclusion: NBI was appreciated as a better imaging modality for magnified still images of BE when directly compared with WL. Inter-observer agreement of non-expert endoscopists for assessing the 3-step classification model was reasonable. In the setting of this study, however, the addition of NBI to WL did not improve interobserver agreement or sensitivity of detecting HGD/EC. Table 1 Kappa for regular vs irregular mucosal pattern Kappa for regular vs irregular vascular pattern Kappa for presence abnormal blood vessels Sensitivity for HGD/EC
HRE
NBI
HRE-NBI
0.53 0.50 0.41 0.84
0.51 0.44 0.37 0.77
0.53 0.44 0.41 0.86
W1350 Novel Autofluorescence Imaging System Is Useful for Detection of Neoplastic Lesion in Colon Tumor Shoichi Saito, Takahiro Mashiko, Hiroo Imazu, Hiroshi Arakawa, Mitsuru Kaise, Hisao Tajiri, Masahiro Ikegami, Osamu Tsuruta Introduction: In development of fluorescence-based diagnostic technologies, new CCD and the image processor were developed by Olympus Medical System Co. Ltd., (Tokyo Japan). This system uses dedicated videoendoscope (XCF-H240FZI), which incorporates two charged coupled devices (CCD) for the autofluorescence (AF) and conventional white light (WL) mode. Methods: 90 colorectal lesions including nine cases of large hyperplastic polyps (more than 15 mm diameter), six of colon submucosal tumors (SMT), 32 of tubular adenomas and 43 early colon cancers were excised endoscopically or surgically, were analyzed in this study. 90 cases observed with AFI were evaluated retrospectively by two well-trained endoscopists. In addition, the brightness of magenta color of AFI imaging was divided into the following patterns; weakness, moderate and strength. It was analyzed whether the differences of fluorescence features between each lesion were determined by the location, macroscopic appearance and histology. Histological diagnosis was undertaken according to World Health Organization classifications. Results: All 75 epithelial neoplastic lesions were observed as the color of magenta whereas the normal background mucosa showed deep green (sensitivity and specificity 100%). In contrast, hyperplastic polyp and SMT were observed the same as the color of surrounding mucosa (15 cases). In macroscopic appearance, flat elevated lesion tended to show the more brightness, compared to the protruded lesion (100% VS. 92.6%). Therefore, the boundary of tumor was recognized clearly compared to the observation by WL (76.0%, 57/75 cases). The location of lesion could not determine the patterns of magenta. In histological
AB342 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
findings, the brightness was similar at histological grading or depth of tumor invasion. Conclusion: AFI system was very easy to use, because the pushed one button change the light from WL to AF without complicated work. Therefore, it was useful for differential diagnosis between epithelial neoplasia and non-neoplasia. Especially, it might be easily able to distinguish between adenomatous lesion and hyperplastic polyp, because of the change to magenta color. We expect AFI system will enable the detection of flat elevated lesions more easily because of strong brightness of magenta, comparing with conventional WL mode observation.
W1351 Evaluation for Enterography with Double-Balloon Enteroscopy for Patients with Crohn’s Disease-Introduction for New Method ‘‘Double-Balloon Sandwitch Fistulography Using Overtube-Attachment Backflow-Preventing Cap’’ Shingo Kato, Hidehiko Takabayashi, Naoya Miyagi, Sumiyo Watanabe, Tomoya Sakurada, Shigeo Ozawa, Masakatsu Yoshikawa, Shino Ono, Junichi Kawashima, Keiko Sato, Atsushi Yamauchi, Chiaki Kawamoto, Susumu Kurosawa, Koji Yakabi Backgrounds & Aims: Recent development of both capsule endoscopy and doubleballoon enteroscopy enabled precise diagnosis of small intestinal lesions of Crohn’s disease. However, it is often difficult to perform total enteroscopy because of stenosis and adhesion of small intestine. Critical complications, retention of capsule endoscopy and perforation by double- balloon enteroscopy, were reported. Here we examined the usefulness of enterography with double- balloon enteroscopy. And also we introduce the new method ‘‘double- balloon sandwitch fistulography using overtube- attachment backflow- preventing cap’’. Materials & Methods: We evaluated double-balloon enteroscopic examinations for 11 patients with Crohn’s disease from September 2005 to November 2006. We performed enterography with double- balloon enteroscopy using water-soluble contrast medium for patients who failed to perform total enteroscopy. However, it is often difficult to perform fistulography with double- balloon enteroscopy because contrast medium flows forward into luminal side. We successfully performed fistulography by doubleballoon sandwitch fistulography using overtube- attachment backflow- preventing cap. At first fistule was sandwitched between two balloons. Next backflowpreventing cap was attached on the distal side of overtube. Contrast medium, which was injecting into overtube, moved into the luminal space between two balloons. Results: One case was omitted because double-balloon enteroscopy was performed for the diagnosis of Crohn’s disease. Total enteroscopy was performed only in one case (10%). The reasons for failure of total enteroscopy were stricture (5/11, 50%), adhesion (2/11, 20%), and failure for fixation of overtube- balloon (2/11, 20%). 10 patients were performed enterography with double- balloon enteroscopy. Diagnosis for the area and location of stricture was obtained in 5 patients (50%). Two entero-entero fistula and one recto-vaginal fistula were detected (30%). In these three cases, two cases of fistula were diagnosed by doubleballoon sandwitch fistulography. Conclusions: Enterography with double- balloon enteroscopy was effective for the diagnosis of intestinal lesions of Crohn’s disease. Double-balloon sandwitch fistulography using overtube- attachment backflowpreventing cap enabled to perform precise diagnosis of fistula.
W1352 The Efficiency of Narrow Band Imaging with Magnification for the Estimation of Invasion Depth Diagnosis in Early Colorectal Cancer -A Prospective Study Masakatsu Fukuzawa, Yutaka Saito, Takahisa Matsuda, Toshio Uraoka, Takahiro Horimatsu, Hiroaki Ikematsu, Yasushi Sano, Adolfo Parra-Blanco, Daizo Saito Background: Narrow Band Imaging (NBI) colonoscopy has enabled the detailed observation of surface microstructure and capillary network of colorectal polyps, which have recently been reported to be useful in differentiating neoplastic from non-neoplastic lesions. We have previously reported in a retrospective review using standard magnification colonoscopy that lesions with either wide caliber or tortuous microvessels are significantly frequent in sm2-3 cancers. Aim: To clarify the efficiency of NBI system with magnification colonoscopy for the estimation of invasion depth. Subjects and Methods: Sixty-one patients (m-sm1: 37, sm2-3: 24) with colonic cancers R10 mm were prospectively enrolled to this study and observed by NBI with magnification. Seven characteristics of microvascular architecture (1 distribution; peripheral or central, 2 caliber; narrow or wide, 3 caliber irregularity, 4 tortuosity, 5 regularity, 6 length of vessel; short or long, and 7 density of vessel; nondense of dense) were recorded just after the endoscopic examination and compared with histological depth of invasion. Results: In the univariate analysis, six factors, including wide caliber, irregular caliber, tortuous, irregular, short length and nondense arrangement were significantly frequent in sm2-3 cancers compared to m-sm1 cancers (p ! 0.001). In multivariate analysis, only irregularity remained as an independent factor (odds ratio Z 22.9, p Z 0.019). Conclusion: Visualization of mucosal vascular networks by NBI with magnification seems to be useful for the diagnosis of invasion in early colorectal cancer.
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W1349 Inter-Observer Agreement Amongst Non-Expert Endoscopists for Mucosal Morphology in Barrett’s Esophagus Wouter L. Curvers, Robert Lindeboom, Bert Baak, Clarisse Bohmer, Rosalie Mallant-Hent, Ton Naber, Arnout Van Oijen, Cyril Ponsioen, Pieter Scholten, Fiebo J. Ten Kate, Kausilia K. Krishnadath, Paul Fockens, Jacques J. Bergman Introduction: Mucosal and vascular patterns (e.g. mucosal morphology) can be used to differentiate non-dysplastic Barrett’s esophagus (BE) from high-grade dysplasia (HGD) or early cancer (EC). We have recently investigated the mucosal morphology of HGD/EC and non-dysplastic BE using narrow band imaging (NBI) and proposed a 3-step classification for the evaluation of BE: determination of the regularity of the mucosal pattern, the regularity of the vascular pattern and the presence of abnormal blood vessels. The aim of this study was to evaluate the interobserver agreement of this 3-step mucosal morphology classification model amongst non-expert endoscopists and to evaluate the appreciated difference in image quality between NBI and white light endoscopy (WL). Methods: 7 endoscopists from non-university hospitals with no specific experience in BE or advanced imaging techniques independently evaluated magnified still images of 50 areas of BE. They scored the overall, mucosal and vascular imaging quality on a 15 cm VAS. In addition, the 3 step classification system was scored. The endoscopists first assessed the WL images, followed by the corresponding NBI images (in random order), and finally evaluated the WL images and NBI images together. Results: Assessed independently, the overall imaging quality of WL received a higher rating than NBI (mean VAS score 11.9 vs. 11.0; p ! 0.05). When WL and NBI were assessed side-by-side, however, NBI images were scored as having a better overall imaging quality in 69% of the assessments, a better mucosal imaging quality (75%) and vascular imaging quality (83%).The inter-observer agreement of the 7 endoscopists for the items of the 3-step classification system was fair to moderate (kappa 0.37 to 0.53). The mean kappa scores of WL, NBI or WL-NBI for scoring the 3-step classification system and the sensitivities for detecting HGD/EC using the 3-step classification model are shown in Table 1. Conclusion: NBI was appreciated as a better imaging modality for magnified still images of BE when directly compared with WL. Inter-observer agreement of non-expert endoscopists for assessing the 3-step classification model was reasonable. In the setting of this study, however, the addition of NBI to WL did not improve interobserver agreement or sensitivity of detecting HGD/EC. Table 1 Kappa for regular vs irregular mucosal pattern Kappa for regular vs irregular vascular pattern Kappa for presence abnormal blood vessels Sensitivity for HGD/EC
HRE
NBI
HRE-NBI
0.53 0.50 0.41 0.84
0.51 0.44 0.37 0.77
0.53 0.44 0.41 0.86
W1350 Novel Autofluorescence Imaging System Is Useful for Detection of Neoplastic Lesion in Colon Tumor Shoichi Saito, Takahiro Mashiko, Hiroo Imazu, Hiroshi Arakawa, Mitsuru Kaise, Hisao Tajiri, Masahiro Ikegami, Osamu Tsuruta Introduction: In development of fluorescence-based diagnostic technologies, new CCD and the image processor were developed by Olympus Medical System Co. Ltd., (Tokyo Japan). This system uses dedicated videoendoscope (XCF-H240FZI), which incorporates two charged coupled devices (CCD) for the autofluorescence (AF) and conventional white light (WL) mode. Methods: 90 colorectal lesions including nine cases of large hyperplastic polyps (more than 15 mm diameter), six of colon submucosal tumors (SMT), 32 of tubular adenomas and 43 early colon cancers were excised endoscopically or surgically, were analyzed in this study. 90 cases observed with AFI were evaluated retrospectively by two well-trained endoscopists. In addition, the brightness of magenta color of AFI imaging was divided into the following patterns; weakness, moderate and strength. It was analyzed whether the differences of fluorescence features between each lesion were determined by the location, macroscopic appearance and histology. Histological diagnosis was undertaken according to World Health Organization classifications. Results: All 75 epithelial neoplastic lesions were observed as the color of magenta whereas the normal background mucosa showed deep green (sensitivity and specificity 100%). In contrast, hyperplastic polyp and SMT were observed the same as the color of surrounding mucosa (15 cases). In macroscopic appearance, flat elevated lesion tended to show the more brightness, compared to the protruded lesion (100% VS. 92.6%). Therefore, the boundary of tumor was recognized clearly compared to the observation by WL (76.0%, 57/75 cases). The location of lesion could not determine the patterns of magenta. In histological
AB342 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
findings, the brightness was similar at histological grading or depth of tumor invasion. Conclusion: AFI system was very easy to use, because the pushed one button change the light from WL to AF without complicated work. Therefore, it was useful for differential diagnosis between epithelial neoplasia and non-neoplasia. Especially, it might be easily able to distinguish between adenomatous lesion and hyperplastic polyp, because of the change to magenta color. We expect AFI system will enable the detection of flat elevated lesions more easily because of strong brightness of magenta, comparing with conventional WL mode observation.
W1351 Evaluation for Enterography with Double-Balloon Enteroscopy for Patients with Crohn’s Disease-Introduction for New Method ‘‘Double-Balloon Sandwitch Fistulography Using Overtube-Attachment Backflow-Preventing Cap’’ Shingo Kato, Hidehiko Takabayashi, Naoya Miyagi, Sumiyo Watanabe, Tomoya Sakurada, Shigeo Ozawa, Masakatsu Yoshikawa, Shino Ono, Junichi Kawashima, Keiko Sato, Atsushi Yamauchi, Chiaki Kawamoto, Susumu Kurosawa, Koji Yakabi Backgrounds & Aims: Recent development of both capsule endoscopy and doubleballoon enteroscopy enabled precise diagnosis of small intestinal lesions of Crohn’s disease. However, it is often difficult to perform total enteroscopy because of stenosis and adhesion of small intestine. Critical complications, retention of capsule endoscopy and perforation by double- balloon enteroscopy, were reported. Here we examined the usefulness of enterography with double- balloon enteroscopy. And also we introduce the new method ‘‘double- balloon sandwitch fistulography using overtube- attachment backflow- preventing cap’’. Materials & Methods: We evaluated double-balloon enteroscopic examinations for 11 patients with Crohn’s disease from September 2005 to November 2006. We performed enterography with double- balloon enteroscopy using water-soluble contrast medium for patients who failed to perform total enteroscopy. However, it is often difficult to perform fistulography with double- balloon enteroscopy because contrast medium flows forward into luminal side. We successfully performed fistulography by doubleballoon sandwitch fistulography using overtube- attachment backflow- preventing cap. At first fistule was sandwitched between two balloons. Next backflowpreventing cap was attached on the distal side of overtube. Contrast medium, which was injecting into overtube, moved into the luminal space between two balloons. Results: One case was omitted because double-balloon enteroscopy was performed for the diagnosis of Crohn’s disease. Total enteroscopy was performed only in one case (10%). The reasons for failure of total enteroscopy were stricture (5/11, 50%), adhesion (2/11, 20%), and failure for fixation of overtube- balloon (2/11, 20%). 10 patients were performed enterography with double- balloon enteroscopy. Diagnosis for the area and location of stricture was obtained in 5 patients (50%). Two entero-entero fistula and one recto-vaginal fistula were detected (30%). In these three cases, two cases of fistula were diagnosed by doubleballoon sandwitch fistulography. Conclusions: Enterography with double- balloon enteroscopy was effective for the diagnosis of intestinal lesions of Crohn’s disease. Double-balloon sandwitch fistulography using overtube- attachment backflowpreventing cap enabled to perform precise diagnosis of fistula.
W1352 The Efficiency of Narrow Band Imaging with Magnification for the Estimation of Invasion Depth Diagnosis in Early Colorectal Cancer -A Prospective Study Masakatsu Fukuzawa, Yutaka Saito, Takahisa Matsuda, Toshio Uraoka, Takahiro Horimatsu, Hiroaki Ikematsu, Yasushi Sano, Adolfo Parra-Blanco, Daizo Saito Background: Narrow Band Imaging (NBI) colonoscopy has enabled the detailed observation of surface microstructure and capillary network of colorectal polyps, which have recently been reported to be useful in differentiating neoplastic from non-neoplastic lesions. We have previously reported in a retrospective review using standard magnification colonoscopy that lesions with either wide caliber or tortuous microvessels are significantly frequent in sm2-3 cancers. Aim: To clarify the efficiency of NBI system with magnification colonoscopy for the estimation of invasion depth. Subjects and Methods: Sixty-one patients (m-sm1: 37, sm2-3: 24) with colonic cancers R10 mm were prospectively enrolled to this study and observed by NBI with magnification. Seven characteristics of microvascular architecture (1 distribution; peripheral or central, 2 caliber; narrow or wide, 3 caliber irregularity, 4 tortuosity, 5 regularity, 6 length of vessel; short or long, and 7 density of vessel; nondense of dense) were recorded just after the endoscopic examination and compared with histological depth of invasion. Results: In the univariate analysis, six factors, including wide caliber, irregular caliber, tortuous, irregular, short length and nondense arrangement were significantly frequent in sm2-3 cancers compared to m-sm1 cancers (p ! 0.001). In multivariate analysis, only irregularity remained as an independent factor (odds ratio Z 22.9, p Z 0.019). Conclusion: Visualization of mucosal vascular networks by NBI with magnification seems to be useful for the diagnosis of invasion in early colorectal cancer.
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