Nonpolypoid (Flat and Depressed) Colorectal Neoplasms Roy Soetikno, Shai Friedland, Tonya Kaltenbach, Kazuaki Chayama, Shinji Tanaka  Gastroenterology  Volume 130, Issue 2, Pages 566-576 (February 2006) DOI: 10.1053/j.gastro.2005.12.006 Copyright © 2006 American Gastroenterological Association Terms and Conditions

Figure 1 Superficially elevated adenoma (“flat”) before (A) and after (B) indigo carmine (0.2% solution, American Regent Laboratories, Inc., Shirley, NY). Completely flat adenoma (C and D) and depressed submucosally invasive carcinoma (E and F). Images from Veterans Affairs Palo Alto Health Care System, Palo Alto, California. Gastroenterology 2006 130, 566-576DOI: (10.1053/j.gastro.2005.12.006) Copyright © 2006 American Gastroenterological Association Terms and Conditions

Figure 2 The invasive carcinoma is a function of size and also of endoscopic appearance. In contrast to the traditional teaching that the risk of invasive carcinoma corresponds primarily to the size of the lesion, more recent data show that the appearance of the lesions is also a determinant of the risk of invasive cancer. (Data from Kudo et al.36) Gastroenterology 2006 130, 566-576DOI: (10.1053/j.gastro.2005.12.006) Copyright © 2006 American Gastroenterological Association Terms and Conditions

Figure 3 The Paris endoscopic classification applied to colorectal neoplasm. Schematic representation of the major variants of type 0 neoplastic lesions is shown (modified from The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon38). The protrusion of the lesion (dark) is compared with the height of the closed cups of a biopsy forceps (2.5 mm). Gastroenterology 2006 130, 566-576DOI: (10.1053/j.gastro.2005.12.006) Copyright © 2006 American Gastroenterological Association Terms and Conditions

Figure 4 Japanese classification of early colorectal cancer based on macroscopic observations.35 Gastroenterology 2006 130, 566-576DOI: (10.1053/j.gastro.2005.12.006) Copyright © 2006 American Gastroenterological Association Terms and Conditions

Figure 5 Advanced colon cancer with ulceration. This lesion is not classified as a depressed NP-CRN. Image from Veterans Affairs Palo Alto Health Care System, Palo Alto, California. Gastroenterology 2006 130, 566-576DOI: (10.1053/j.gastro.2005.12.006) Copyright © 2006 American Gastroenterological Association Terms and Conditions

Figure 6 Small adenoma with pseudodepression before (A) and after (B) indigo carmine. Images from Veterans Affairs Palo Alto Health Care System and Stanford University School of Medicine, Palo Alto, California. Gastroenterology 2006 130, 566-576DOI: (10.1053/j.gastro.2005.12.006) Copyright © 2006 American Gastroenterological Association Terms and Conditions

Figure 7 Superficial elevated adenoma with depression (type 0 IIa + IIc) in the setting of ulcerative colitis. Initial view of the lesion (A), close-up (B), and after indigo carmine spray (C). The lesion was resected en bloc using the inject and cut endoscopic mucosal resection technique. The lesion was injected with saline (D), and a snare was placed around it (E). (F) The resection site showing complete resection. Images from Veterans Affairs Palo Alto Health Care System, Palo Alto, California. Gastroenterology 2006 130, 566-576DOI: (10.1053/j.gastro.2005.12.006) Copyright © 2006 American Gastroenterological Association Terms and Conditions

Figure 8 Schematic diagram representing the variable progression of 14 NP-CRN lesions (data from Matsui et al51). Retrospective review of prior endoscopic images (preindex) was performed to compare the macroscopic classification and size of the lesions at index endoscopy. The length of follow-up (in months) and depth of cancer at index endoscopy (sm1, cancer invasion to the upper one third of the submucosa; sm2, in the middle third; sm3, in the lower third; mp, muscularis propria; and ss, subserosa) are indicated within the parentheses. ⁎Biopsy was not performed at the preindex evaluation. Gastroenterology 2006 130, 566-576DOI: (10.1053/j.gastro.2005.12.006) Copyright © 2006 American Gastroenterological Association Terms and Conditions

Figure 9 Example of the natural history of depressed high-grade dysplasia over a 2-year period. The lesion was spontaneously bleeding (A). A depressed lesion was suspected after washing (B). Application of diluted indigo carmine (C) allowed its border and surface topography to be fully appreciated. The patient refused surgery but requested a follow-up colonoscopy. Invasive carcinoma was diagnosed (D). Images from Veterans Affairs Palo Alto Health Care System, Palo Alto, California. Gastroenterology 2006 130, 566-576DOI: (10.1053/j.gastro.2005.12.006) Copyright © 2006 American Gastroenterological Association Terms and Conditions

Figure 10 Example of the utility of indigo carmine to outline the mucosal pit pattern. The presence of innominate grooves traversing the lesion suggests a hyperplastic pathology. Innominate grooves are not seen in neoplastic lesions, whereas they are visible in normal colonic mucosa and nonneoplastic lesions. The lesion before (A) and after (B) indigo carmine. Images from Veterans Affairs Palo Alto Health Care System, Palo Alto, California. Gastroenterology 2006 130, 566-576DOI: (10.1053/j.gastro.2005.12.006) Copyright © 2006 American Gastroenterological Association Terms and Conditions

Figure 11 A flat lesion is shown using standard (A) and narrowband imaging (B). Rather than imaging the mucosa with white light, images of narrowband imaging system are obtained by illuminating the colon using spectrally narrowed light. Prior studies have shown that by using filters with central wavelengths of 415 nm to 500 nm, capillaries and crypts become more obvious.63 The narrow spectra of light also allows small polyps to be seen with brown staining. Studies are underway to determine whether narrowband imaging is useful for detection of flat and depressed and small colorectal neoplasms.63 Images from Hiroshima University School of Medicine, Hiroshima, Japan. Gastroenterology 2006 130, 566-576DOI: (10.1053/j.gastro.2005.12.006) Copyright © 2006 American Gastroenterological Association Terms and Conditions