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Paris classification (2003)
삼성의료원 내과 이준행
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JGCA classification - Japanese Gastric Cancer Association -
• Type 0 – superficial polypoid, flat/depressed, or excavated
tumors
• Type 1 – polypoid carcinomas, usually attached on a wide
base
• Type 2 – ulcerated carcinomas with sharply demarcated and
raised margins
• Type 3 – ulcerated, infiltrating carcinomas without definite
limits
• Type 4 – nonulcerative, diffusely infiltrating carcinomas
• Type 5 – unclassifiable advanced carcinomas
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West vs East
• Western endoscopists consider the Japanese classification to be a botanical hobby, too complex for practical use.
• Japanese endoscopists have found that endoscopic classification of a lesion can be an important determinant when endoscopic therapy is considered.
• The East and West points of view are now much closer.
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Superficial neoplastic lesions
Type O
Polypoid Non-polypoid
depressed excavated flat elevated
0-I (Ip, Is) 0-IIa 0-IIb 0-IIc 0-III
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Superficial neoplastic lesions
Semi-pedunculated (Isp) polyps should be managed as sessile polyps.
Different meaning: really confusing
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What is polypoid and what is flat?
• In the operative specimen, the height of polypoid
lesion is more than double the thickness of the
adjacent mucosa.
• During endoscopy, the height of the closed cups
of the biopsy forceps (2.5 mm) is the
discriminating point.
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Type O-II lesions
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IIc + IIa lesions
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IIa + IIc lesions with two variants Depressed area
Relatively depressed area
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Type O-III lesions
In the stomach, the bottom of the lesion is non-neoplastic.
In Barrett’s esophagus, the neoplastic area covers the entire surface of the lesion.
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Various combinations: is it really useful?
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Updated Paris (2005)
삼성의료원 내과 이준행
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Update on the Paris classification of superficial neoplastic lesions in the digestive tract
• The endoscopic morphology of superficial lesions can be assessed with a standard video endoscope after spraying of a dye - an iodine-potassium iodide solution for the stratified squamous epithelium, or an indigo carmine solution for the columnar epithelium.
• In 2002, a workshop was held in Paris to explore the relevance of the Japanese classification.
• The conclusions were revised in 2003 in Osaka in relation to the definition of the subtypes used in endoscopy and the evaluation of the depth of invasion into the submucosa.
Endoscopy 2005;37:570-578
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Update on the Paris classification of superficial neoplastic lesions in the digestive tract
Endoscopy 2005;37:570-578
The cut-off limit is 2.5 mm in the columnar epithelium and
1.2 mm in the stratified epithelium of the esophagus.
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Update on the Paris classification of superficial neoplastic lesions in the digestive tract
Endoscopy 2005;37:570-578
The cut-off limit is 1.2 mm in the columnar epithelium and
0.5 mm in the stratified epithelium of the esophagus.
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Update on the Paris classification of superficial neoplastic lesions in the digestive tract
Endoscopy 2005;37:570-578
Endoscopic appearance of a superficial neoplastic lesion on the
surface of the digestive-tract mucosa: excavated type (0 - III).
An ulcer is seen.
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Update on the Paris classification of superficial neoplastic lesions in the digestive tract • Micrometer measurement should be generally used to
allow comparison of outcomes after either surgery or endoscopic mucosal resection (EMR).
• With regard to the depth of invasion into the submucosa, the empirical cut-off limit adopted in Japan for safety after mucosectomy (EMR) varies depending on the site of the lesion.
• It is estimated as less than 200 µm in the esophagus, 500 µm in the stomach, and 1000 µm in the large bowel.
• In the large bowel, this cut-off value only applies to sessile lesions.
Endoscopy 2005;37:570-578
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Update on the Paris classification of superficial neoplastic lesions in the digestive tract
Endoscopy 2005;37:570-578
In stomach In colon
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invasive carcinoma invasive carcinoma
4.3. suspicion of invasive
carcinoma
suspicious for invasive
carcinoma
4.2. carcinoma in situ carcinoma
lesions strongly
suspected of carcinoma
4.1. high grade
adenoma/dysplasia
high grade
adenoma/dysplasia
3. noninvasive low grade
neoplasia
low grade
adenoma/dysplasia
2. indefinite indefinite for dysplasia borderline lesion*
benign no neoplastic
lesion
1. negative for
neoplasia/dysplasia
negative for dysplasia normal and benign
lesion with no atypia
Vienna classification Western Japanese
* borderline lesion: adenoma, lesions difficult to decide as regenerative or neoplastic
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Endoscopic staging
• The less than perfect reliability of endoscopic staging can be improved by EUS, particularly with high frequency proves (20 MHz).
• Endoscopy tends to understage superficial lesions, and EUS tends to overstage them.
• When the two methods agree, the predictive value is high. (Yanai. GE 1997;46:212-216)
Gastrointest Endosc 2003;58(Suppl):S2