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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

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Equip training session 2

EQUIPTraining session 2

Introduction to dye and optical staining and classification methods


Session 1 overview
Session 1 overview

  • EQUIP goals review


Session 2 goals
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


The paris classification
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


Paris classification

Paris Classification

I-p (pedunculated)

I-s (sessile)

II-a (flat elevated)

II-b (flat flat)

IIc (flat depressed)

III (flat ulcerated)


Dye and optical staining
Dye and optical “staining”

  • Chromoendoscopy

    • Detection

    • Classification:

      • Kudo pit patterns

  • Narrow band imaging

    • Detection

    • Classification:

      • Sano capillary pattern

  • Classification methods test cases


Chromoendoscopy
Chromoendoscopy

  • Detection

    • Does pan-chromoendsocopy increase adenoma detection?

  • Classification

    • Kudo pit patterns


Meta analysis of pan chromo in average risk patients
Meta-analysis of Pan Chromo in Average Risk Patients

  • 4 Randomized Controlled Trials

Brown; Cochrane DB Syst Rev, 2007;4:6439


Kudo pit patterns objectives
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


Kudo pit patterns
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.


Kudo pit patterns1
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


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


Kudo non neoplastic patterns i ii
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


Kudo neoplastic patterns iii l adenomatous lesions
Kudo neoplastic patternsIII-L : Adenomatous lesions

  • III-L: Adenoma (low-grade)

    • Tubular or round eLongated pits

    • Pits are Larger than normal


Kudo pit patterns2
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


Kudo neoplastic patterns iii s iv high grade lesions
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


Kudo pit patterns3
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


Kudo pit patterns4
Kudo pit patterns

Adenoma

Type III-L:

Advanced adenoma

Type V: High grade lesion

Pits look branched or gyrus like

Tubular, elongated, large pits.


Kudo pit patterns5
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.


Kudo neoplastic patterns v carcinomas
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


Kudo pit patterns6
Kudo Pit Patterns

IIIs

IV

V

I

II

IIIL


The kudo classification pit patterns
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


Kudo

  • Sensitivity/specificity for prediction


Narrow band imaging
Narrow band imaging

  • Detection

    • How can NBI be used in detection?

    • Does NBI increase adenoma detection?

  • Classification

    • Sano capillary patterns

      • overview


Does nbi increase adenoma detection

Does NBI Increase Adenoma Detection

Probably

(compared to standard def. white light, but not HD white light)

Does not increase procedure time


Does nbi increase adenoma detection systematic review randomized trials
Does NBI Increase Adenoma DetectionSystematic Review: Randomized Trials

Van den Broek et al. GIE 2009;69:124



‘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


Sano capillary patterns
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)


Sano capillary patterns cp i
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


Sano capillary patterns cp ii
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


Sano capillary patterns cp iii
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


Sano capillary patterns1
Sano capillary patterns

CP I:

Normal mucosa

Hyperplastic lesions

CP II:

Adenomatous lesions

Meshed capillary

vessels (‐)

Meshed capillary

vessels (+)


Sano capillary patterns2
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


Sano capillary patterns differential diagnosis of small lesions i vs ii
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


Sano capillary patterns3
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.


Sano capillary patterns4
Sano capillary patterns

  • Prediction of early colorectal neoplasia

    • 104 patients with 139 lesions

    • Only CP II or CP III lesions included


Sano capillary patterns prediction of neoplasia ii vs iii
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


Sano capillary patterns cp iii types depth of invasion
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,


Sano capillary patterns5
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


Sano capillary patterns6
Sano capillary patterns

Diagnostic accuracy of depth of invasion

  • 127 patients; 130 lesions CP type IIIA/IIIB

  • Endoscopic (IIIA) or surgical resection (IIIB)


Sensitivity specificity and diagnostic accuracy of cp type iii
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


Capillary III

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


Test cases
Test cases. III

  • Describe the following polyps in terms of:

    • Paris shape

    • Kudo (chromo) or Sano (NBI)


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