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Colorectal Case 20

Prof. Yasushi Sano

Kansai Medical University, Osaka, Japan

Sano Hospital, Kobe, Japan
Procedure Information

Scope: CF-EZ1500 DI

Case Findings: 0-Is (LST-mixed type), 22mm, JNET 2A with fern-like pits

Histology: Tubulovillous adenoma, low-grade dysplasia, including small foci of high-grade dysplasia with traditional serrated adenoma-like appearance.

Organ: Rectum

Patient information: Male, 73 y.o.

Medical history: FIT positive

1. WL
White light observation reveals an area of indistinct vascular penetration with an elevation in the center of the image

Enhancement : A8
NBI Mode : NA
TXI Mode : NA
RDI Mode : NA
BAI-MAC : On

2. WL close view
The close-up image shows disappearance of vascular transillumination and areas of small nodules.

Enhancement: A8
NBI mode: NA
TXI Mode: NA
RDI Mode: NA
BAI-MAC: On

3. TXI close view
The TXI mode 2 provides clearer contrast and clearly highlights the extent of the lesion.

Enhancement : A8
NBI Mode : NA
TXI Mode : On
RDI Mode : NA
BAI-MAC : On

4. NBI close view
EDOF colonoscope helps endoscopists get better details of the whole lesion quickly. And the brighter and improved NBI function clearly delineates the extent of the lesion in brown.

Enhancement : A8
NBI Mode : On (mode 3)
TXI Mode : NA
RDI Mode : NA
BAI-MAC : On

5. NBI with magnification
Tubular or branchial structures and regular brown blood vessels are observed (JNET 2A).

Enhancement : A8
NBI Mode : On (mode 3)
TXI Mode : NA
RDI Mode : NA
BAI-MAC : On

6. NBI with magnification
In the elevated portion of the lesion, vessels with corkscrew-like changes are observed around slightly thicker vessels (cicada wing-like findings). In addition, the structure is indistinct, and the surface is smooth. These are the endoscopic findings of traditional serrated adenoma.

Enhancement : A8
NBI Mode : On (mode 3)
TXI Mode : NA
RDI Mode : NA
BAI-MAC : On

7. Chromoendoscopy
Chromoendoscopy can diagnose as 0-Is (LST-mixed type), 20 mm in size.

Enhancement : A8
NBI Mode : NA
TXI Mode : NA
RDI Mode : NA
BAI-MAC : On

8. Chromoendoscopy with magnification
This area shows a type IV finding of the Kudo’s pit pattern.

Enhancement : A8
NBI Mode : NA
TXI Mode : NA
RDI Mode : NA
BAI-MAC : On

9. Chromoendoscopy with magnification
This is a type IV villous finding of the Kudo’s pit pattern. This is a type 4 villous finding of the Kudo pit pattern. The surface is smooth and the glandular pit morphology is indistinct.

Enhancement : A8
NBI Mode : NA
TXI Mode : NA
RDI Mode : NA
BAI-MAC : On

10. Chromoendoscopy with magnification
High magnification observation using the digital zoom function (x1.4) reveals numerous small pit openings on the surface.

Enhancement : A8
NBI Mode : NA
TXI Mode : NA
RDI Mode : NA
BAI-MAC : On

11. Crystal violet
Crystal violet staining shows a fern leaf-like pit.

Enhancement : A8
NBI Mode : NA
TXI Mode : NA
RDI Mode : NA
BAI-MAC : On

12. Crystal violet
Crystal violet staining shows Kudo type IV pit.

Enhancement : A8
NBI Mode : NA
TXI Mode : NA
RDI Mode : NA
BAI-MAC : On

13. Cutting line for histology
ESD was performed in this case. Sections were made on lines A and B.

14. Histology (low power)
The pathological diagnosis was tubulovillous adenoma, low-grade dysplasia, including small foci of high-grade dysplasia.

15. Histology (high power)
The pathological diagnosis of the area of cicada wing-like findings in the elevated area showed traditional serrated adenoma-like appearance.

Case Video

Video 1: Observation by WL, TXI, NBI

Video 2: Observation by chromoendoscopy with Indigo carmine and Crystal violet staining

Overall Comment

EVIS X1 with CF-EZ1500 DI colonoscope provides excellent image quality over previous generations of endoscope system.  The clarity and resolution of the endoscopic image are excellent, with the help of TXI function this will enhance the identification of lesions during examination.  Once a lesion has been identified, the clear focused image contributes accurate detailed examination of morphology of the lesion.  The excellent image quality extends to NBI mode, and together with optical magnification accurate characterization of the lesion can be made.

In this case, the parts of tubulovillous adenoma and traditional serrated adenoma (cicada wing-like findings) are mixed, and the differences in endoscopic findings can be well educated 1).

 

1. Sano Y, Saito Y, et al. Efficacy of magnifying chromoendoscopy for the differential diagnosis of colorectal lesions. Digestive Endoscopy. April 2005 Pages 105-116.

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

Case 19: LST-NG-PD (Pseudo-depressed type), pT1a colonic cancer
Dr. Ho Dang Quy Dung Case 21: 0-IIa (LST-non-granular type), 25mm, JNET 2A+2B
Prof. Yasushi Sano
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