equip training session 2
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EQUIP Training session 2. Introduction to dye and optical staining and classification methods. Session 1 overview. EQUIP goals review. Session 2 goals. Paris classification system review Dye and optical staining methods Role in detection Role in classification; Kudo & Sano - PowerPoint PPT PresentationTRANSCRIPT
EQUIPEQUIPTraining session 2Training session 2
Introduction to dye and Introduction to dye and optical staining and optical staining and
classification methodsclassification methods
Session 1 overviewSession 1 overview
EQUIP goals reviewEQUIP goals review
Session 2 goalsSession 2 goals
Paris classification system reviewParis classification system review
Dye and optical staining methods Dye and optical staining methods Role in detectionRole in detection Role in classification; Kudo & SanoRole in classification; Kudo & Sano
Understand settings they are useUnderstand settings they are use Utilize to differentiate neoplastic potential Utilize to differentiate neoplastic potential
The Paris ClassificationThe Paris Classification
Snare polypectomy
EMR en bloc Or piecemeal
EMR en bloc,ESD, or surgery
Adenoma
High gradeadenoma
Carcinoma
Histology Resection
I-p
I-s
II-a -b
III
mixed
-c
Paris ClassificationParis Classification
I-p (pedunculated) I-s (sessile) II-a (flat elevated)
II-b (flat flat) III (flat ulcerated)IIc (flat depressed)
Dye and optical “staining” Dye and optical “staining”
ChromoendoscopyChromoendoscopy Detection Detection Classification: Classification:
Kudo pit patternsKudo pit patterns
Narrow band imagingNarrow band imaging DetectionDetection Classification:Classification:
Sano capillary patternSano capillary pattern
Classification methods test casesClassification methods test cases
ChromoendoscopyChromoendoscopy
DetectionDetection Does pan-chromoendsocopy increase Does pan-chromoendsocopy increase
adenoma detection?adenoma detection?
ClassificationClassification Kudo pit patternsKudo pit patterns
Meta-analysis of Pan Chromo in Meta-analysis of Pan Chromo in Average Risk PatientsAverage Risk Patients
4 Randomized Controlled Trials4 Randomized Controlled Trials
Odds RatioOdds Ratio 95% CI95% CI
Patients Patients with any with any adenomaadenoma
1.611.61 1.24-2.091.24-2.09
3 or more 3 or more adenomasadenomas
2.552.55 1.49-4.361.49-4.36
Brown; Cochrane DB Syst Rev, 2007;4:6439
Kudo pit patternsKudo pit patternsObjectivesObjectives
UnderstandUnderstand What Kudo pit patterns representWhat Kudo pit patterns represent Use of dye staining to observe pit patternsUse of dye staining to observe pit patterns
Use Kudo pit patterns to:Use Kudo pit patterns to: Distinguish neoplasia from non-neoplasiaDistinguish neoplasia from non-neoplasia Differentiate neoplastic lesions in terms of Differentiate neoplastic lesions in terms of
degree of dysplasia degree of dysplasia
Kudo pit patternsKudo pit patterns
Developed for use in Developed for use in chromoendoscopychromoendoscopy Indigo carmine remains in depressions Indigo carmine remains in depressions
(pits)(pits) The violet dyes actually stain the The violet dyes actually stain the
mucosamucosa Results not replicated with NBI in Results not replicated with NBI in
absence of dye staining.absence of dye staining.
Kudo pit patternsKudo pit patterns
TechniqueTechnique Feces & mucous must be washed away Feces & mucous must be washed away
before stainingbefore staining 2 – 7ml applied to lesion, excess 2 – 7ml applied to lesion, excess
suctioned before observationsuctioned before observation Spray catheter or syringe injection for indigo Spray catheter or syringe injection for indigo
carminecarmine Violet dyes require 30 – 60 seconds to Violet dyes require 30 – 60 seconds to
stain prior to observationstain prior to observation
KudoKudo
Pits = openings of the colonic crypts Pits = openings of the colonic crypts Pit pattern = arrangement of openings on Pit pattern = arrangement of openings on
mucosal surfacemucosal surface Pit patterns categoriesPit patterns categories
Normal mucosa – pit pattern INormal mucosa – pit pattern I Hyperplastic – pit pattern IIHyperplastic – pit pattern II Adenomatous – pit pattern III-L Adenomatous – pit pattern III-L High grade adenoma: pit pattern III-s, and IVHigh grade adenoma: pit pattern III-s, and IV Cancerous – pit pattern VCancerous – pit pattern V
Kudo non-neoplastic patternsKudo non-neoplastic patternsI & III & II
Type I: Normal mucosaType I: Normal mucosa Roundish pits with Roundish pits with regularregular distribution distribution Represent Represent straight, non-branching cryptsstraight, non-branching crypts
Type II: HyperplasticType II: Hyperplastic Large star-like or “onion”-like pits, Large star-like or “onion”-like pits, regularregular Represent Represent straight, non-branching cryptsstraight, non-branching crypts
Kudo neoplastic patternsKudo neoplastic patternsIII-L : Adenomatous lesionsIII-L : Adenomatous lesions
III-L: Adenoma (low-grade)III-L: Adenoma (low-grade) Tubular or round Tubular or round eLongatedeLongated pits pits Pits are Pits are Larger Larger than normalthan normal
Non-neoplasticType II: Hyperplastic
NeoplasticType III-L: Adenoma
Large, star like (or onion)crypts.Regular pattern
Tubular or round, elongated, large pits.
Kudo pit patternsKudo pit patterns
Kudo neoplastic patternsKudo neoplastic patternsIII-s, IV: High grade lesionsIII-s, IV: High grade lesions
III-s: III-s: Compactly arranged tubular (or round) pits Compactly arranged tubular (or round) pits Pits are Pits are SmallerSmaller than normal than normal Tend to be depressed lesionsTend to be depressed lesions
IV: IV: Pits look Pits look branched or gyrus likebranched or gyrus like Often have a focal cancer Often have a focal cancer
Non-neoplasticType II: Hyperplastic
NeoplasticType III-s: High grade lesion
Large, star like (or onion)crypts.Regular pattern
Compact, smaller than normal pits.
Kudo pit patternsKudo pit patterns
AdenomaType III-L:
Advanced adenomaType V: High grade lesion
Tubular, elongated, large pits. Pits look branched or gyrus like
Kudo pit patternsKudo pit patterns
AdenomaType III-L:
Advanced adenomaType III-s: High grade lesion
Tubular, elongated, large pits. Pits look branched or gyrus like
Kudo pit patternsKudo pit patterns
Kudo neoplastic patternsKudo neoplastic patternsV: CarcinomasV: Carcinomas
V: CancerV: Cancer Irregular pit pattern; ViIrregular pit pattern; Vi Advanced cancers (Vn) may be rough & Advanced cancers (Vn) may be rough &
ulceratedulcerated May be devoid of pits or “non-structural” May be devoid of pits or “non-structural”
patternpattern
Kudo Pit PatternsKudo Pit Patterns
I
II
IIIL
IIIs
IV
V
The Kudo ClassificationThe Kudo ClassificationPit PatternsPit Patterns
Nothing
EMR en bloc Or piecemeal
EMR en bloc,ESD, or surgery
Hyperplastic
High gradeadenoma
Carcinoma
Snare polypectomy
Adenoma
Histology ManagementI
II
III-L
III-S
IV
V
KudoKudo
Sensitivity/specificity for predictionSensitivity/specificity for prediction
Narrow band imagingNarrow band imaging
DetectionDetection How can NBI be used in detection?How can NBI be used in detection? Does NBI increase adenoma detection?Does NBI increase adenoma detection?
ClassificationClassification Sano capillary patternsSano capillary patterns
overviewoverview
Does NBI Increase Does NBI Increase Adenoma Adenoma DetectionDetection
Probably Probably (compared to standard def. white light, but not (compared to standard def. white light, but not
HD white light)HD white light)
Does not increase procedure timeDoes not increase procedure time
Does NBI Increase Adenoma Does NBI Increase Adenoma DetectionDetection
Systematic Review: Randomized Systematic Review: Randomized TrialsTrials
StudyStudy Pts with Pts with adenoma adenoma NBINBI
Pts with Pts with adenomadenoma WLEa WLE
adenoma/ptadenoma/pt
NBINBIadenoma/adenoma/ptpt
WLEWLE
O.R. O.R.
NBI vs WLENBI vs WLE
Rex 2007Rex 2007
N=217N=21765%65% 67%67% 1.861.86 1.821.82 0.90 (0.61-0.90 (0.61-
1.34)1.34)
Adler Adler 20072007
N= 198N= 198
23%23% 17%17% 0.330.33 0.260.26 1.27 (0.88-1.27 (0.88-1.84)1.84)
Inoue Inoue 20082008
N=122N=122
42%42% 34%34% 0.840.84 0.550.55 1.55 (1.14-1.55 (1.14-2.11)2.11)
PooledPooled 44%44% 41%41% 1.061.06 0.960.96 1.23 (0.93-1.23 (0.93-1.61)1.61)
Van den Broek et al. GIE 2009;69:124
Does NBI Increase Adenoma Does NBI Increase Adenoma DetectionDetection
Back to Back TrialsBack to Back Trials
TrialTrial Adenoma/ptAdenoma/pt
NBINBIAdenoma/ptAdenoma/pt
WLEWLE
Rastogi 2008Rastogi 2008
N=40N=400.730.73 1.081.08
East 2007East 2007
N=62N=620.340.34 0.400.40
Gross [in press]Gross [in press]
N=91N=910.250.25 0.34*0.34*
NBI vs White Light
Tandem Double Blind Trial
Standardfirst
(n=44)
NBIfirst
(n=47)
No. of patients with > 1 adenoma
0 5 10 15 20
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
Sano capillary patternsSano capillary patterns Developed with Narrow band imagingDeveloped with Narrow band imaging
Narrow spectrum allows visualization of Narrow spectrum allows visualization of capillary pattern in superficial layercapillary pattern in superficial layer
Capillary vessels appear brown on NBICapillary vessels appear brown on NBI Capillary pattern around glands change with Capillary pattern around glands change with
neoplasia neoplasia 3 capillary pattern types 3 capillary pattern types
CP I: Normal mucosa or hyperplastic lesionCP I: Normal mucosa or hyperplastic lesion CP II: Adenomatous lesionCP II: Adenomatous lesion CP III: Cancer (further subdivided into A & B)CP III: Cancer (further subdivided into A & B)
Sano capillary patternsSano capillary patternsCP ICP I
CP I: Normal mucosa and CP I: Normal mucosa and hyperplastic polypshyperplastic polyps Hyperplastic lesions appear light brown Hyperplastic lesions appear light brown
on NBIon NBI Messed capillaries not seen or faint, Messed capillaries not seen or faint, If MC seen (large lesions) will be in If MC seen (large lesions) will be in
a regular honeycomb patterna regular honeycomb pattern
Sano capillary patternsSano capillary patternsCP IICP II
CP II: Adenomatous lesionsCP II: Adenomatous lesions Adenomas appear dark brown on NBIAdenomas appear dark brown on NBI MC clearly seen MC clearly seen Round, oval or honeycomb patternRound, oval or honeycomb pattern Pattern may be elongated with Pattern may be elongated with
larger diameterlarger diameter
Sano capillary patternsSano capillary patternsCP IIICP III
CP III: Cancerous lesionsCP III: Cancerous lesions MC clearly seenMC clearly seen Increased density of microvesselsIncreased density of microvessels Unevenly sized thick capillariesUnevenly sized thick capillaries Branching and Branching and irregularityirregularity
Further subdivided based on depth of Further subdivided based on depth of invasioninvasion
CPIII A: Sub-mucosal invasion <1000CPIII A: Sub-mucosal invasion <1000 CPIII B: Sub-mucosal invasion > 1000 CPIII B: Sub-mucosal invasion > 1000
CP I:Normal mucosaHyperplastic lesions
CP II:Adenomatous lesions
Meshed capillary vessels (‐ )
Meshed capillary vessels ( + )
Sano capillary patternsSano capillary patterns
Sano capillary patternsSano capillary patterns
Differential diagnosis of small lesionsDifferential diagnosis of small lesions 92 eligible patients; 150 lesions <10mm92 eligible patients; 150 lesions <10mm
39 (26%) hyperplastic39 (26%) hyperplastic 111 (74%) adenoma111 (74%) adenoma Invasive cancers excludedInvasive 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 MCBased on presence or absence of MC Accuracy compared to pathologic diagnosis Accuracy compared to pathologic diagnosis
Sano capillary patternsSano capillary patternsDifferential diagnosis of small Differential diagnosis of small
lesions (I vs. II)lesions (I vs. II)
NeoplastiNeoplasticc
Non-Non-neoplasticneoplastic
MC vessels MC vessels (+)(+) 107107 33
MC vessels (-)MC vessels (-) 44 3636
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
CP II:Adenomatous lesions
CP III:Cancerous lesions
Round, oval, honeycomb likepattern. May be elongated and large diameter.
No honeycomb pattern.Irregularity of size, complex branching, disruption, or irregular winding.
Sano capillary patternsSano capillary patterns
Sano capillary patternsSano capillary patterns
Prediction of early colorectal Prediction of early colorectal neoplasianeoplasia 104 patients with 139 lesions104 patients with 139 lesions Only CP II or CP III lesions includedOnly CP II or CP III lesions included
Sano capillary patternsSano capillary patternsPrediction of neoplasia (II vs. Prediction of neoplasia (II vs.
III)III)Histological diagnosisHistological diagnosis
LGDLGD HGD/ invasive HGD/ invasive CA CA
CP II CP II (n (n =103)=103)
100100 33
CP III CP III (n = 31) (n = 31) 33 2828
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
Sano capillary patternsSano capillary patternsCP III types: depth of CP III types: depth of
invasioninvasion 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,
CP III A:Cancerous lesions
CP III B:Cancerous lesions
Lack of uniformityLack of uniformityHigh density of High density of capillary vesselscapillary vessels
Nearly avascular or loose Nearly avascular or loose micro capillary vesselsmicro capillary vessels
Sano capillary patternsSano capillary patterns
Meshed capillary vessels characterized by: blind ending, branching and curtailed irregularly
Sano capillary patternsSano capillary patterns
Diagnostic accuracy of depth of Diagnostic accuracy of depth of invasioninvasion• 127 patients; 130 lesions CP type 127 patients; 130 lesions CP type
IIIA/IIIBIIIA/IIIB• Endoscopic (IIIA) or surgical resection Endoscopic (IIIA) or surgical resection
(IIIB)(IIIB)
Ikematsu et al, BMC GastroenteroIkematsu et al, BMC Gastroenterology 2010, 10:33logy 2010, 10:33
Sensitivity, specificity and Sensitivity, specificity and diagnostic accuracy of CP Type diagnostic accuracy of CP Type
IIIIIIHistological diagnosisHistological diagnosis
M*, SM-M*, SM-superficial superficial (SM1)**(SM1)**
SM-deep (SM 2-SM-deep (SM 2-3)3)##
CP type IIIACP type IIIA 8686 55CP type IIIBCP type IIIB 1111 2828
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)
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
Test cases.Test cases.
Describe the following polyps in Describe the following polyps in terms of:terms of: Paris shapeParis shape Kudo (chromo) or Sano (NBI)Kudo (chromo) or Sano (NBI)