1 / 44

EQUIP Training session 2

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

mateja
Download Presentation

EQUIP Training session 2

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. EQUIPTraining session 2 Introduction to dye and optical staining and classification methods

  2. Session 1 overview • EQUIP goals review

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

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

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

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

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

  8. Meta-analysis of Pan Chromo in Average Risk Patients • 4 Randomized Controlled Trials Brown; Cochrane DB Syst Rev, 2007;4:6439

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

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

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

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

  13. Kudo non-neoplastic patternsI & II • Type I: Normal mucosa • Roundish pits with regular distribution • Represent straight, non-branching crypts • Type II: Hyperplastic • Large star-like or “onion”-like pits, regular • Represent straight, non-branching crypts

  14. Kudo neoplastic patternsIII-L : Adenomatous lesions • III-L: Adenoma (low-grade) • Tubular or round eLongated pits • Pits are Larger than normal

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

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

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

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

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

  20. Kudo neoplastic patternsV: Carcinomas • V: Cancer • Irregular pit pattern; Vi • Advanced cancers (Vn) may be rough & ulcerated • May be devoid of pits or “non-structural” pattern

  21. Kudo Pit Patterns IIIs IV V I II IIIL

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

  23. Kudo • Sensitivity/specificity for prediction

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

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

  26. Does NBI Increase Adenoma DetectionSystematic Review: Randomized Trials Van den Broek et al. GIE 2009;69:124

  27. Does NBI Increase Adenoma DetectionBack to Back Trials

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

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

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

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

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

  33. Sano capillary patterns CP I: Normal mucosa Hyperplastic lesions CP II: Adenomatous lesions Meshed capillary vessels （‐） Meshed capillary vessels （+）

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

  35. Sano capillary patternsDifferential diagnosis of small lesions (I vs. II) 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

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

  37. Sano capillary patterns • Prediction of early colorectal neoplasia • 104 patients with 139 lesions • Only CP II or CP III lesions included

  38. Sano capillary patternsPrediction of neoplasia (II vs. III) 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

  39. Sano capillary patternsCP III types: depth of invasion • CPIII-A: Cancerous lesion; (pSM & pSM1) • MC clearly seen, • CPIII-B: Cancerous lesion; (pSM2-3) • MC clearly seen,

  40. Sano capillary patterns CP III A: Cancerous lesions CP III B: Cancerous lesions 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

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

  42. Sensitivity, specificity and diagnostic accuracy of CP Type III 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) Ikematsu et al, BMC Gastroenterology 2010, 10:33

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

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

More Related