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EQUIP Training session 2 Introduction to dye and optical staining and classification methods.

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Presentation on theme: "EQUIP Training session 2 Introduction to dye and optical staining and classification methods."— Presentation transcript:

1 EQUIP Training session 2 Introduction to dye and optical staining and classification methods

2 Session 1 overview EQUIP goals review EQUIP goals review

3 Session 2 goals Paris classification system review Paris classification system review Dye and optical staining methods Dye and optical staining methods Role in detection Role in detection Role in classification; Kudo & Sano Role in classification; Kudo & Sano Understand settings they are use Understand settings they are use Utilize to differentiate neoplastic potential Utilize to differentiate neoplastic potential

4 The Paris Classification Snare polypectomy EMR en bloc Or piecemeal EMR en bloc, ESD, or surgery Adenoma High grade adenoma Carcinoma HistologyResection I-p I-s II-a -b III mixed -c

5 Paris Classification I-p (pedunculated) I-s (sessile) II-a (flat elevated) II-b (flat flat) III (flat ulcerated) IIc (flat depressed)

6 Dye and optical staining Chromoendoscopy Chromoendoscopy Detection Detection Classification: Classification: Kudo pit patterns Kudo pit patterns Narrow band imaging Narrow band imaging Detection Detection Classification: Classification: Sano capillary pattern Sano capillary pattern Classification methods test cases Classification methods test cases

7 Chromoendoscopy Detection Detection Does pan-chromoendsocopy increase adenoma detection? Does pan-chromoendsocopy increase adenoma detection? Classification Classification Kudo pit patterns Kudo pit patterns

8 Pan Chromo in Average Risk Persons A Randomized Controlled Trial Lapalus, Endoscopy, 2006;38:444

9 Chromo in Average Risk N = 292 Chromo (146) Standard (146) Pts with Adenomas 40% 36% (p=0.47) Total adenomas 115 87 (p= 0.18) TotalHyperplastic110 67 9 (p=0.03) Colonoscopy time 27 min [14-75] 18 [8-60] (p<0.001)

10 Meta-analysis of Pan Chromo in Average Risk Patients 4 Randomized Controlled Trials 4 Randomized Controlled Trials Odds Ratio 95% CI Patients with any adenoma 1.611.24-2.09 3 or more adenomas 2.551.49-4.36 Brown; Cochrane DB Syst Rev, 2007;4:6439

11 Does Routine Pan Chromoendoscopy Increase Adenoma Detection? Yes, but with longer procedure times

12 Kudo pit patterns Objectives Understand Understand What Kudo pit patterns represent What Kudo pit patterns represent Use of dye staining to observe pit patterns Use of dye staining to observe pit patterns Use Kudo pit patterns to: Use Kudo pit patterns to: Distinguish neoplasia from non-neoplasia Distinguish neoplasia from non-neoplasia Differentiate neoplastic lesions in terms of degree of dysplasia Differentiate neoplastic lesions in terms of degree of dysplasia

13 Kudo pit patterns Developed for use in chromoendoscopy Developed for use in chromoendoscopy Indigo carmine remains in depressions (pits) Indigo carmine remains in depressions (pits) The violet dyes actually stain the mucosa The violet dyes actually stain the mucosa Results not replicated with NBI in absence of dye staining. Results not replicated with NBI in absence of dye staining.

14 Kudo pit patterns Technique Technique Feces & mucous must be washed away before staining Feces & mucous must be washed away before staining 2 – 7ml applied to lesion, excess suctioned before observation 2 – 7ml applied to lesion, excess suctioned before observation Spray catheter or syringe injection for indigo carmine Spray catheter or syringe injection for indigo carmine Violet dyes require 30 – 60 seconds to stain prior to observation Violet dyes require 30 – 60 seconds to stain prior to observation

15 Kudo Pits = openings of the colonic crypts Pits = openings of the colonic crypts Pit pattern = arrangement of openings on mucosal surface Pit pattern = arrangement of openings on mucosal surface Pit patterns categories Pit patterns categories Normal mucosa – pit pattern I Normal mucosa – pit pattern I Hyperplastic – pit pattern II Hyperplastic – pit pattern II Adenomatous – pit pattern III-L Adenomatous – pit pattern III-L High grade adenoma: pit pattern III-s, and IV High grade adenoma: pit pattern III-s, and IV Cancerous – pit pattern V Cancerous – pit pattern V

16 Kudo non-neoplastic patterns I & II Type I: Normal mucosa Type I: Normal mucosa Roundish pits with regular distribution Roundish pits with regular distribution Represent straight, non-branching crypts Represent straight, non-branching crypts Type II: Hyperplastic Type II: Hyperplastic Large star-like or onion-like pits, regular Large star-like or onion-like pits, regular Represent straight, non-branching crypts Represent straight, non-branching crypts

17 Kudo neoplastic patterns III-L : Adenomatous lesions III-L: Adenoma (low-grade) III-L: Adenoma (low-grade) Tubular or round eLongated pits Tubular or round eLongated pits Pits are Larger than normal Pits are Larger than normal

18 Non-neoplastic Type II: Hyperplastic Neoplastic Type III-L: Adenoma Large, star like (or onion) crypts. Regular pattern Tubular or round, elongated, large pits. Kudo pit patterns

19 Kudo neoplastic patterns III-s, IV: High grade lesions III-s: III-s: Compactly arranged tubular (or round) pits Compactly arranged tubular (or round) pits Pits are Smaller than normal Pits are Smaller than normal Tend to be depressed lesions Tend to be depressed lesions IV: IV: Pits look branched or gyrus like Pits look branched or gyrus like Often have a focal cancer Often have a focal cancer

20 Non-neoplastic Type II: Hyperplastic Neoplastic Type III-s: High grade lesion Large, star like (or onion) crypts. Regular pattern Compact, smaller than normal pits. Kudo pit patterns

21 Adenoma Type III-L: Advanced adenoma Type V: High grade lesion Tubular, elongated, large pits. Pits look branched or gyrus like Kudo pit patterns

22 Adenoma Type III-L: Advanced adenoma Type III-s: High grade lesion Tubular, elongated, large pits. Pits look branched or gyrus like Kudo pit patterns

23 Kudo neoplastic patterns V: Carcinomas V: Cancer V: Cancer Irregular pit pattern; Vi Irregular pit pattern; Vi Advanced cancers (Vn) may be rough & ulcerated Advanced cancers (Vn) may be rough & ulcerated May be devoid of pits or non-structural pattern May be devoid of pits or non-structural pattern

24 Kudo Pit Patterns I II IIIL IIIs IV V

25 The Kudo Classification Pit Patterns Nothing EMR en bloc Or piecemeal EMR en bloc, ESD, or surgery Hyperplastic High grade adenoma Carcinoma Snare polypectomy Adenoma Histology Management I II III-L III-S IV V

26 Kudo Sensitivity/specificity for prediction Sensitivity/specificity for prediction

27 Narrow band imaging Detection Detection How can NBI be used in detection? How can NBI be used in detection? Does NBI increase adenoma detection? Does NBI increase adenoma detection? Classification Classification Sano capillary patterns Sano capillary patterns overview overview

28 Does NBI Increase Adenoma Detection Probably (compared to standard def. white light, but not HD white light) Does not increase procedure time

29 Does NBI Increase Adenoma Detection Hyperplasia Adenoma Advanced Ad White Light NBI

30 Does NBI Increase Adenoma Detection Systematic Review: Randomized Trials Study Pts with adenoma NBI Pts with adenoma WLE adenoma/ptNBIadenoma/ptWLEO.R. NBI vs WLE Rex 2007 N=21765%67%1.861.82 0.90 (0.61- 1.34) Adler 2007 N= 198 23%17%0.330.26 1.27 (0.88- 1.84) Inoue 2008 N=12242%34%0.840.55 1.55 (1.14- 2.11) Pooled44%41%1.060.96 1.23 (0.93- 1.61) Van den Broek et al. GIE 2009;69:124

31 Does NBI Increase Adenoma Detection Back to Back Trials TrialAdenoma/ptNBIAdenoma/ptWLE Rastogi 2008 N=400.731.08 East 2007 N=620.340.40 Gross [in press] N=910.250.34*

32 A PROSPECTIVE RANDOMIZED BACK-TO-BACK TRIAL COMPARING NARROW BAND IMAGING TO CONVENTIONAL COLONOSCOPY FOR ADENOMA DETECTION Gross SA, Buchner AM, Cangemi JR, Wolfsen HC, DeVault KR, Crook J, Picco MF, Loeb DS, Woodward TA, Raimondo M, Wallace MB Mayo Clinic, Jacksonville, FL, USA

33 NBI vs White Light Tandem Double Blind Trial Standard first (n=44) NBI first (n=47) No. of patients with > 1 adenoma Standard (Std) 11/19 58% NBI 8/19 42% NBI 16/19 84% Std 3/19 16% Miss rate: Standard: 42% NBI: 16% p = 0.003 Gross, Wallace et al. Gastro/DDW 2008 Adenomas per patient

34 Sano capillary patterns Developed with Narrow band imaging Developed with Narrow band imaging Narrow spectrum allows visualization of capillary pattern in superficial layer Narrow spectrum allows visualization of capillary pattern in superficial layer Capillary vessels appear brown on NBI Capillary vessels appear brown on NBI Capillary pattern around glands change with neoplasia Capillary pattern around glands change with neoplasia 3 capillary pattern types 3 capillary pattern types CP I: Normal mucosa or hyperplastic lesion CP I: Normal mucosa or hyperplastic lesion CP II: Adenomatous lesion CP II: Adenomatous lesion CP III: Cancer (further subdivided into A & B) CP III: Cancer (further subdivided into A & B)

35 Sano capillary patterns CP I CP I: Normal mucosa and hyperplastic polyps CP I: Normal mucosa and hyperplastic polyps Hyperplastic lesions appear light brown on NBI Hyperplastic lesions appear light brown on NBI Messed capillaries not seen or faint, Messed capillaries not seen or faint, If MC seen (large lesions) will be in a regular honeycomb pattern If MC seen (large lesions) will be in a regular honeycomb pattern

36 Sano capillary patterns CP II CP II: Adenomatous lesions CP II: Adenomatous lesions Adenomas appear dark brown on NBI Adenomas appear dark brown on NBI MC clearly seen MC clearly seen Round, oval or honeycomb pattern Round, oval or honeycomb pattern Pattern may be elongated with larger diameter Pattern may be elongated with larger diameter

37 Sano capillary patterns CP III CP III: Cancerous lesions CP III: Cancerous lesions MC clearly seen MC clearly seen Increased density of microvessels Increased density of microvessels Unevenly sized thick capillaries Unevenly sized thick capillaries Branching and irregularity Branching and irregularity Further subdivided based on depth of invasion Further subdivided based on depth of invasion CPIII A: Sub-mucosal invasion <1000 CPIII A: Sub-mucosal invasion <1000 CPIII B: Sub-mucosal invasion > 1000 CPIII B: Sub-mucosal invasion > 1000

38 CP I: Normal mucosa Hyperplastic lesions CP II: Adenomatous lesions Meshed capillary vessels Meshed capillary vessels + Sano capillary patterns

39 Differential diagnosis of small lesions Differential diagnosis of small lesions 92 eligible patients; 150 lesions <10mm 92 eligible patients; 150 lesions <10mm 39 (26%) hyperplastic 39 (26%) hyperplastic 111 (74%) adenoma 111 (74%) adenoma Invasive cancers excluded Invasive cancers excluded Magnifying NBI (no dye) Magnifying NBI (no dye) Endoscopic diagnosis (neoplastic vs. non- ) Endoscopic diagnosis (neoplastic vs. non- ) Based on presence or absence of MC Based on presence or absence of MC Accuracy compared to pathologic diagnosis Accuracy compared to pathologic diagnosis

40 Sano capillary patterns Differential diagnosis of small lesions (I vs. II) NeoplasticNon-neoplastic MC vessels (+) 1073 MC vessels (-) 436 MC vessels by NBI and histologic examination Sensitivity: 96.4%, Specificity: 92.3%, Accuracy: 95.3%, NPV (negative predictive value): 90.0%, PPV (positive predictive value): 97.3% MC, meshed capillaries

41 CP II: Adenomatous lesions CP III: Cancerous lesions Round, oval, honeycomb like pattern. May be elongated and large diameter. No honeycomb pattern. Irregularity of size, complex branching, disruption, or irregular winding. Sano capillary patterns

42 Prediction of early colorectal neoplasia Prediction of early colorectal neoplasia 104 patients with 139 lesions 104 patients with 139 lesions Only CP II or CP III lesions included Only CP II or CP III lesions included

43 Sano capillary patterns Prediction of neoplasia (II vs. III) Histological diagnosis LGD HGD/ invasive CA CP II (n =103) 1003 CP III (n = 31) 328 Sensitivity: 90.3%, Specificity: 97.1%, Accuracy: 95.5%, NPV (negative predictive value): 97.1%, PPV (positive predictive value): 90.3% LGD, low grade dysplasia; HGD, high grade dysplasia

44 Sano capillary patterns CP III types: depth of invasion CPIII-A: Cancerous lesion; (pSM & pSM1) CPIII-A: Cancerous lesion; (pSM & pSM1) MC clearly seen, MC clearly seen, CPIII-B: Cancerous lesion; (pSM2-3) CPIII-B: Cancerous lesion; (pSM2-3) MC clearly seen, MC clearly seen,

45 CP III A: Cancerous lesions CP III B: Cancerous lesions Lack of uniformity High density of capillary vessels Nearly avascular or loose Nearly avascular or loose micro capillary vessels micro capillary vessels Sano capillary patterns Meshed capillary vessels characterized by: blind ending, branching and curtailed irregularly

46 Sano capillary patterns Diagnostic accuracy of depth of invasion 127 patients; 130 lesions CP type IIIA/IIIB 127 patients; 130 lesions CP type IIIA/IIIB Endoscopic (IIIA) or surgical resection (IIIB) Endoscopic (IIIA) or surgical resection (IIIB)

47 Ikematsu et al, BMC Gastroenterology 2010, 10:33 Sensitivity, specificity and diagnostic accuracy of CP Type III Histological diagnosis M*, SM-superficial (SM1)** SM-deep (SM 2-3) # CP type IIIA 865 CP type IIIB 1128 Sensitivity: 84.8%, Specificity: 88.7%, Accuracy: 87.7%, NPV (negative predictive value): 94.5%, PPV (positive predictive value): 71.8% *intramucosal cancer, ** SM superficial invasion (<1000 μm), # SM deep invasion ( 1000 μm)

48 I II IIIA Endoscopic findings IIIB Meshed capillary vessels Meshed capillary vessels + Capillary vessel surrounds mucosal glands Meshed capillary vessels characterized by: blind ending, branching and curtailed irregularly Lack of uniformity High density of capillary vessels Nearly avascular or loose micro capillary vessels Schema Capillary pattern Capillary characteristics

49 Test cases. Describe the following polyps in terms of: Describe the following polyps in terms of: Paris shape Paris shape Kudo (chromo) or Sano (NBI) Kudo (chromo) or Sano (NBI)


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