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Colorectal Case 21

Prof. Yasushi Sano

Kansai Medical University, Osaka, Japan

Sano Hospital, Kobe, Japan
Procedure Information

Scope: CF-EZ1500 DI

Case Findings: 0-IIa (LST-non-granular type), 25mm, JNET 2A+2B

Histology: Tubulovillous adenoma, low-grade dysplasia, including small foci of high-grade dysplasia with lymphoid follicular formation.

Organ: Transverse colon

Patient information: Male, 68 y.o.

Medical history: Postoperative for pharyngeal cancer, Screening colonoscopy

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

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

2. TXI
TXI mode 2 provides enhanced contrast, but the extent of the lesion remains unclear.

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

3. NBI
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

4. NBI with magnification
Small tubular or oval structures and regular brown meshed vessels are observed (JNET 2A).

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

5. NBI with magnification
The center of the lesion shows a 3-mm-sized depressed area. The structure of the area is indistinct, with irregular meshed vessels (JNET 2B).

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

6. Chromoendoscopy
Chromoendoscopy can diagnose as 0-IIa (LST-non-granular type), 25mm.

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

7. Chromoendoscopy with magnification
A small round pits are observed and diagnosed as Kudo's IIIs pit pattern.

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

8. Chromoendoscopy with magnification
The central depressed area shows an irregular pit structure and is diagnosed as Kudo's Vi pit pattern.

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

9. Crystal violet
Crystal violet staining shows a small irregular pit of uneven size in the depressed area. It is diagnosed as Kudo's Vi pit pattern.

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

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

11. Histology (low power)
The pathological diagnosis was tubulovillous adenoma, low-grade dysplasia (line A).

12. Histology (high power)
The histology of the depressed area of interest was diagnosed as adenoma with high-grade dysplasia. In the submucosa, a lymphoid follicular formation was observed (line B).

Case Video

Video 1: Observation by WL, TXI, NBI

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

Overall Comment

LST-NG lesions are considered precursor lesions of PCCRC 1,2) and should not be missed on colonoscopy. In this LST-NG case, the lesion was detected by pale redness. NBI observation was very useful in diagnosing the extent. In general, LST-NG lesions sometimes show a depressed area, and detailed endoscopic observation of this area is important for endoscopic diagnosis. In this case, a JNET 2B region was observed in the depressed area. The pathological diagnosis of the depressed area was adenoma with high-grade dysplasia. In Japan, it is recommended that dye endoscopy be added to the endoscopy to improve sensitivity when a lesion showing JNET 2B is observed.

 

1. Matsuda T, Fujii T, Sano Y, et al. Randomised comparison of post-polypectomy surveillance intervals following a two-round baseline colonoscopy: the Japan Polyp Study Workgroup. Gut. 2020 Nov 2;70(8):1469–78.

2. Sano Y, Hotta K, Matsuda T, et al. Japan Polyp Study Workgroup. Endoscopic Removal of Premalignant Lesions Reduces Long-Term Colorectal Cancer Risk: Results From the Japan Polyp Study. Clin Gastroenterol Hepatol. 2023 Aug 6:S1542-3565(23)00588-8.

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

Case 20: 0-Is (LST-mixed type), 22mm, JNET 2A with fern-like pits
Prof. Yasushi Sano Case 22: 0-Is (submucosal invasive carcinoma), 11mm, JNET 2B
Prof. Yasushi Sano
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