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Endocytoscopy for the differential diagnosis of colorectal low-grade adenoma: a novel possibility for the “resect and discard” strategy

Published:November 27, 2019DOI:https://doi.org/10.1016/j.gie.2019.11.029

      Background and Aims

      Endocytoscopy, a next-generation endoscopic system, facilitates observation at a maximum magnification of ×520. To our knowledge, no study has reported high-precision diagnosis of colorectal low-grade adenoma, endoscopically. We aimed to reveal which endocytoscopic findings may be used as indicators of low-grade adenoma and to assess whether a “resect and discard” strategy using endocytoscopy is feasible.

      Methods

      Lesions diagnosable with endocytoscopy were examined retrospectively between May 2005 and July 2017. A normal pit-like structure in endocytoscopic images was considered a normal pit (NP) sign and used as an indicator of low-grade adenoma. The primary outcome was the diagnostic accuracy of the NP sign for low-grade adenoma. We evaluated agreement rates between endocytoscopic and pathologic diagnosis for surveillance colonoscopy interval recommendation (SCIR) and performed a validation study to verify the agreement rates.

      Results

      For 748 lesions in 573 cases diagnosed as colorectal adenoma using endocytoscopy, the results were as follows: sensitivity of the NP sign for low-grade adenoma, 85.0%; specificity, 90.7%; positive predictive value, 96.6%; negative predictive value, 66.1%; accuracy, 86.4%; and positive likelihood ratio, 9.2 (P < .001). The agreement rate between endocytoscopic and pathologic diagnosis for SCIR was 94.4% (95% confidence interval [CI], 92.2%-96.1%; P < .001) under United States guidelines and 96.3% (95% CI, 94.5%-97.7%; P < .001) under European Union guidelines. All inter- and intraobserver agreement rates for expert and nonexpert endoscopists had κ values ≥0.8 except one nonexpert pair.

      Conclusions

      Endocytoscopy is an effective modality in determining the differential diagnosis of colorectal low-grade adenoma. (University Hospital Medical Information Network Clinical Trials database registration number: UMIN000018623.)

      Graphical abstract

      Abbreviations:

      CI (confidence interval), NBI (narrow-band imaging), NP (normal pit), NPV (negative predictive value), PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations), PPV (positive predictive value), SCIR (surveillance colonoscopy interval recommendation), SSA/P (sessile serrated adenoma/polyp)
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      References

        • Winawer S.J.
        • Zauber A.G.
        • Ho M.N.
        • et al.
        Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup.
        N Engl J Med. 1993; 329: 1977-1981
        • Zauber A.G.
        • Winawer S.J.
        • O'Brien M.J.
        • et al.
        Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths.
        N Engl J Med. 2012; 366: 687-696
        • Rex D.K.
        Narrow-band imaging without optical magnification for histologic analysis of colorectal polyps.
        Gastroenterology. 2009; 136: 1174-1181
        • Ignjatovic A.
        • East J.E.
        • Suzuki N.
        • et al.
        Optical diagnosis of small colorectal polyps at routine colonoscopy (Detect InSpect ChAracterise Resect and Discard; DISCARD trial): a prospective cohort study.
        Lancet Oncol. 2009; 10: 1171-1178
        • Rex D.K.
        • Kahi C.
        • O'Brien M.
        • et al.
        The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on real-time endoscopic assessment of the histology of diminutive colorectal polyps.
        Gastrointest Endosc. 2011; 73: 419-422
        • Rastogi A.
        • Early D.S.
        • Gupta N.
        • et al.
        Randomized, controlled trial of standard-definition white-light, high-definition white-light, and narrow-band imaging colonoscopy for the detection of colon polyps and prediction of polyp histology.
        Gastrointest Endosc. 2011; 74: 593-602
        • Paggi S.
        • Rondonotti E.
        • Amato A.
        • et al.
        Resect and discard strategy in clinical practice: a prospective cohort study.
        Endoscopy. 2012; 44: 899-904
        • Rees C.J.
        • Rajasekhar P.T.
        • Wilson A.
        • et al.
        Narrow band imaging optical diagnosis of small colorectal polyps in routine clinical practice: the Detect Inspect Characterise Resect and Discard 2 (DISCARD 2) study.
        Gut. 2017; 66: 887-895
        • Inoue H.
        • Kazawa T.
        • Sato Y.
        • et al.
        In vivo observation of living cancer cells in the esophagus, stomach, and colon using catheter-type contact endoscope, "Endo-Cytoscopy system".
        Gastrointest Endosc Clin N Am. 2004; 14 (x-xi): 589-594
        • Sasajima K.
        • Kudo S.E.
        • Inoue H.
        • et al.
        Real-time in vivo virtual histology of colorectal lesions when using the endocytoscopy system.
        Gastrointest Endosc. 2006; 63: 1010-1017
        • Kudo S.E.
        • Wakamura K.
        • Ikehara N.
        • et al.
        Diagnosis of colorectal lesions with a novel endocytoscopic classification - a pilot study.
        Endoscopy. 2011; 43: 869-875
        • Mori Y.
        • Kudo S.
        • Ikehara N.
        • et al.
        Comprehensive diagnostic ability of endocytoscopy compared with biopsy for colorectal neoplasms: a prospective randomized noninferiority trial.
        Endoscopy. 2013; 45: 98-105
        • Kudo T.
        • Kudo S.E.
        • Mori Y.
        • et al.
        Classification of nuclear morphology in endocytoscopy of colorectal neoplasms.
        Gastrointest Endosc. 2017; 85: 628-638
        • Kudo S.
        • Hirota S.
        • Nakajima T.
        • et al.
        Colorectal tumours and pit pattern.
        J Clin Pathol. 1994; 47: 880-885
        • Hayashi N.
        • Tanaka S.
        • Hewett D.G.
        • et al.
        Endoscopic prediction of deep submucosal invasive carcinoma: validation of the narrow-band imaging international colorectal endoscopic (NICE) classification.
        Gastrointest Endosc. 2013; 78: 625-632
        • Sano Y.
        • Tanaka S.
        • Kudo S.E.
        • et al.
        Narrow-band imaging (NBI) magnifying endoscopic classification of colorectal tumors proposed by the Japan NBI Expert Team.
        Dig Endosc. 2016; 28: 526-533
        • Sumimoto K.
        • Tanaka S.
        • Shigita K.
        • et al.
        Clinical impact and characteristics of the narrow-band imaging magnifying endoscopic classification of colorectal tumors proposed by the Japan NBI Expert Team.
        Gastrointest Endosc. 2017; 85: 816-821
        • Ichimasa K.
        • Kudo S.E.
        • Mori Y.
        • et al.
        Double staining with crystal violet and methylene blue is appropriate for colonic endocytoscopy: an in vivo prospective pilot study.
        Dig Endosc. 2014; 26: 403-408
        • Hamilton S.
        • Aaltonen L.
        World health organization classification of tumors: Pathology and genetics of tumors of the digestive system.
        IARC Press, Lyon, France1999
        • Kudo S.E.
        • Mori Y.
        • Wakamura K.
        • et al.
        Endocytoscopy can provide additional diagnostic ability to magnifying chromoendoscopy for colorectal neoplasms.
        J Gastroenterol Hepatol. 2014; 29: 83-90
        • Lieberman D.A.
        • Rex D.K.
        • Winawer S.J.
        • et al.
        Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer.
        Gastroenterology. 2012; 143: 844-857
        • Hassan C.
        • Quintero E.
        • Dumonceau J.M.
        • et al.
        Post-polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.
        Endoscopy. 2013; 45: 842-851
        • Tsuruta O.
        • Toyonaga A.
        • Ikeda H.
        • et al.
        Clinicopathological study of superficial-type invasive carcinoma of the colorectum.
        Int J Oncol. 1997; 10: 1003-1008
        • Hewett D.G.
        • Kaltenbach T.
        • Sano Y.
        • et al.
        Validation of a simple classification system for endoscopic diagnosis of small colorectal polyps using narrow-band imaging.
        Gastroenterology. 2012; 143: 599-607.e1
        • Hassan C.
        • Pickhardt P.J.
        • Rex D.K.
        A resect and discard strategy would improve cost-effectiveness of colorectal cancer screening.
        Clin Gastroenterol Hepatol. 2010; 8 (9.e1-3): 865-869
        • Ladabaum U.
        • Fioritto A.
        • Mitani A.
        • et al.
        Real-time optical biopsy of colon polyps with narrow band imaging in community practice does not yet meet key thresholds for clinical decisions.
        Gastroenterology. 2013; 144: 81-91
        • Hotta K.
        • Imai K.
        • Yamaguchi Y.
        • et al.
        Diminutive submucosally invasive cancers of the colon and rectum.
        Endoscopy. 2015; 47: E2-E3
        • Kuiper T.
        • Marsman W.A.
        • Jansen J.M.
        • et al.
        Accuracy for optical diagnosis of small colorectal polyps in nonacademic settings.
        Clin Gastroenterol Hepatol. 2012; 10 (quiz e79): 1016-1020
        • Patel S.G.
        • Schoenfeld P.
        • Kim H.M.
        • et al.
        Real-time characterization of diminutive colorectal polyp histology using narrow-band imaging: implications for the resect and discard strategy.
        Gastroenterology. 2016; 150: 406-418
        • East J.E.
        • Suzuki N.
        • Saunders B.P.
        Comparison of magnified pit pattern interpretation with narrow band imaging versus chromoendoscopy for diminutive colonic polyps: a pilot study.
        Gastrointest Endosc. 2007; 66: 310-316
        • Tischendorf J.J.
        • Wasmuth H.E.
        • Koch A.
        • et al.
        Value of magnifying chromoendoscopy and narrow band imaging (NBI) in classifying colorectal polyps: a prospective controlled study.
        Endoscopy. 2007; 39: 1092-1096
        • East J.E.
        • Suzuki N.
        • Bassett P.
        • et al.
        Narrow band imaging with magnification for the characterization of small and diminutive colonic polyps: pit pattern and vascular pattern intensity.
        Endoscopy. 2008; 40: 811-817
        • Chiu H.M.
        • Chang C.Y.
        • Chen C.C.
        • et al.
        A prospective comparative study of narrow-band imaging, chromoendoscopy, and conventional colonoscopy in the diagnosis of colorectal neoplasia.
        Gut. 2007; 56: 373-379
        • Plumb A.A.
        • Nickerson C.
        • Wooldrage K.
        • et al.
        Terminal digit preference biases polyp size measurements at endoscopy, computed tomographic colonography, and histopathology.
        Endoscopy. 2016; 48: 899-908
        • Sakamoto T.
        • Matsuda T.
        • Nakajima T.
        • et al.
        Impact of clinical experience on type V pit pattern analysis using magnifying chromoendoscopy in early colorectal cancer: a cross-sectional interpretation test.
        BMC Gastroenterol. 2014; 14: 100
        • Soetikno R.M.
        • Kaltenbach T.
        • Rouse R.V.
        • et al.
        Prevalence of nonpolypoid (flat and depressed) colorectal neoplasms in asymptomatic and symptomatic adults.
        JAMA. 2008; 299: 1027-1035
        • Rondagh E.J.
        • Bouwens M.W.
        • Riedl R.G.
        • et al.
        Endoscopic appearance of proximal colorectal neoplasms and potential implications for colonoscopy in cancer prevention.
        Gastrointest Endosc. 2012; 75: 1218-1225
        • Kudo T.
        • Kudo S.E.
        • Wakamura K.
        • et al.
        Diagnostic performance of endocytoscopy for evaluating the invasion depth of different morphological types of colorectal tumors.
        Dig Endosc. 2015; 27: 754-761