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Colorectal Case 27

Prof. Yoji Takeuchi

Gunma University Hospital, Japan

Disclaimer:

NBI™ technology is not intended to replace histopathological sampling as a means of diagnosis

The positions and statements made herein by Prof. Takeuchi are based on Prof. Takeuchi’s experiences, thoughts and opinions. As with any product, results may vary, and the techniques, instruments, and settings can vary from facility to facility. The content hereof should not be considered as a substitute for carefully reading all applicable labeling, including the Instructions for Use. Please thoroughly review the relevant user manual(s) for instructions, risks, warnings, and cautions. Techniques, instruments, and setting can vary from facility to facility. It is the clinician’s decision and responsibility in each clinical situation to decide which products, modes, medications, applications, and settings to use.

The EVIS X1™ endoscopy system is not designed for cardiac applications. Other combinations of equipment may cause ventricular fibrillation or seriously affect the cardiac function of the patient. Improper use of endoscopes may result in patient injury, infection, bleeding, and/or perforation. Complete indications, contraindications, warnings, and cautions are available in the Instructions for Use (IFU)

1) Data on file with Olympus as of 07/17/2020

2) Data on file with Olympus (DC00510434 )

3) Data on file with Olympus (DC00479164, DC00478777)

4) Data on file with Olympus (DC00510434, DC00567392)

Procedure Information

Scope: CF-EZ1500DI

Case Findings: Intramucosal Carcinoma (High-grade Dysplasia)

Organ: Sigmoid Colon

Patient information: Female in Her 50s

Medical history: Colon Polypectomy (1 Year Prior)

1. White-light Observation

A 12 mm-sized superficial elevated (Paris, 0-IIa) lesion. A notch is visible at the center of the lesion.

Enhancement: A7
BAI-MAC: On

2. White-light Close Observation

The notch is located on the proximal side of the lesion. It looks a bit redder than the rest of the lesion.

Enhancement: A7
BAI-MAC: On

3. NBI™ Technology

A brown flat lesion. Brown lines (vessels) and white lines (surface structure) can be identified (NICE Type 2). They are not clear-cut, and are a bit obscure, especially at the center of the lesion.

Enhancement: A8
NBI Mode: On
BAI-MAC: On

4. NBI™ Technology

The shape of the lesion changes when deflated, indicating softness.

Enhancement: A8
NBI Mode: On
BAI-MAC: On

5. Chromoendoscopy (Indigo Carmine)

The border of the lesion and the surface structure are enhanced with blue dye pooling. There is no demarcated depressed area in the lesion.

Enhancement: A7
BAI-MAC: On

6. Chromoendoscopy (Indigo Carmine)

A whitish scar and fold conversion can be seen on the proximal side of the lesion by pressing distal part of the lesion, suggesting a recurrent lesion after previous polypectomy.

Enhancement: A7
BAI-MAC: On

7. NBI™ Technology (Close Observation, without Near Focus)

The vessels and surface pattern are clearly visible with close observation. The surface structure is straightforward and clear-cut on the right side of the lesion (JNET 2A) but more complicated and irregular on the left side (JNET 2B).

Enhancement: A8
NBI Mode: On
BAI-MAC: On
Near Focus: Off

8. NBI™ Technology (Close Observation, without Near Focus)

Close observation reveals a heterogeneous, complicated, curved surface structure with tortuous vessels of various sizes distributed in a non-uniform manner. The surface structure is particularly unclear at the center of the lesion.

Enhancement: A8
NBI Mode: On
BAI-MAC: On
Near Focus: Off

9. NBI™ Technology (Near Focus Mode)

Magnifying observation of the center of the lesion shows an unclear surface pattern with irregular microvessels (JNET 2B). In contrast, an oval-shaped surface structure with the regular microvessels can be seen on the right side.

Enhancement: A8
NBI Mode: On
BAI-MAC: On
Near Focus: On

10. Resected specimen (After ESD)

Resected specimen by ESD. No.4 corresponds to JNET 2B and No. 5 corresponds to JNET 2A in the endoscopic images.

11. Microscopic Findings of the Resected Specimen (No. 4)

Irregularly branched grands with shallow erosion, corresponding to the JNET 2B part in the endoscopic image, diagnosed as intramucosal carcinoma.

12. Microscopic Findings of the Resected Specimen (No. 5)

Straight, less irregular, non-branched glands, corresponding to the JNET 2A area in the endoscopic image, diagnosed as adenoma.

Overall Comment

This case presented a 12 mm-sized intra-adenoma carcinoma in the sigmoid colon. It was located near a previous polypectomy scar and was considered to be a residual recurrent lesion. Although en bloc resection would have been preferable, there was a risk that the lesion could not be resected en bloc by conventional EMR due to the presence of a scar, and ESD was chosen despite the small size of the lesion. Inadequate observation could have led to an easy choice of EMR, and we believe that the near focus observation with the CF-EZ1500 colonoscope allowed us to select an appropriate treatment option.

White-light observation showed a reddish, flat elevated lesion with a notch near the center, which appeared to be slightly thicker. At this point, the lesion should not be considered a simple low-grade adenoma, but a more dysplastic lesion that requires close examination, including near mode observation.

NBI™ technology provides more information than white-light observation because micro-vessels and surface structures can be enhanced at the switch’s flick¹. Normal focus NBI™ technology shows a uniform brown lesion, which can be classified as Type 2 in the NICE classification. However, the microvascular and surface structures are opaque and complex, especially near the center of the lesion, suggesting that further detailed observation should be performed. As optical zoom magnifying endoscopes are not commonly used in Europe and the USA, no further information used to be obtained.

The CF-EZ1500DI’s short focal length enables clear images to be obtained even when the lesion is as close as 3 mm², and microvascular and surface structures can be assessed without magnification. As the EZ1500DI does not require the difficult lever operations like conventional optical zoom magnification, a certain degree of magnification can be obtained simply by approaching the lesion, and it is possible to determine whether observation in Near Focus mode is required by pressing a button³.

The Near Focus mode enables detailed observation with magnification and the EDOF function widens the focal distance and facilitates focusing, making it easy to obtain sharp images even when the area of interest is slightly concave, as in this case.⁴

* Specifications, design and accessories are subject to change without any notice or obligation on the part of the manufacturer

Case 26: Large 40mm splenic flexure NG-LST (histology: tubular adenoma with high grade dysplasia)
Dr. Shiaw-Hooi Ho Case 28: Pedunculated polyp
Mr. Peter Borch-Johnsen

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Imaging Atlas