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The techniques and clinical opinions presented in this material reflect the personal experience and professional judgment of the healthcare professional and do not necessarily represent the views of Olympus. This material is intended for healthcare professionals only. Users should always refer to the applicable Instructions for Use (IFU) and use Olympus products in accordance with the approved indications and local regulatory requirements. The healthcare professional presenting this material has been engaged by Olympus and compensated at fair market value for their services.

Colorectal Case 37

Yasushi Sano^1.2

MD, PhD, FJGES, and ANBIIG ³

Clinical Professor, Kansai Medical University Osaka, Japan
Director & Chief of Gastrointestinal Center Sano Hospital, Kobe, Japan
Secretary, Asian Novel Bio-Imaging and Intervention Group

Procedure information

Scope: CF-XZ1200I

Case: Characterization JNET 2B

Site of lesion: Lower rectum (Rs)

Patient information: M, 50s

Medical history: Melena

1. WLI

On white-light imaging, a 10-mm lesion is seen in the rectum (Rs). The lesion appears as a superficially elevated tumor with a central depressed area, corresponding to a macroscopic type 0-IIa+IIc lesion.

2. TXI

With TXI, the overall contour of the lesion becomes clearer, and the central depressed component is more easily appreciated than on conventional white-light imaging.

3. NBI

On NBI, the lesion shows heterogeneous findings. The central depressed area demonstrates irregular surface and vascular features suggestive of JNET Type 2B, whereas JNET Type 2A findings are also present at the lesion margin.

4. NBI+TXI

On NBI-TXI, the depressed component and the heterogeneous surface architecture are more clearly visualized. The contrast enhancement makes the difference between the central suspicious area and the peripheral adenomatous component easier to appreciate.

5. Zoom image NBI

Magnifying NBI demonstrates irregular vascular and surface findings in the central area.

6. NBI+TXI

Magnifying NBI-TXI more clearly demonstrates vascular caliber variation, irregular vessel course, and associated surface irregularity.

7. Chromoendoscopy

Indigo carmine chromoendoscopy clearly delineates the lesion margin and highlights the central depressed morphology.

8. Chromoendoscopy

Magnifying chromoendoscopy with crystal violet staining shows a type IV pit pattern in the peripheral area, while the central area demonstrates a Kudo type VI mildly irregular pit pattern with a focally severely irregular area measuring approximately 3 mm, suggesting SM1–2 invasion and supporting initial endoscopic treatment.

9. Pathological image

10. Pathological diagnosis

Pathological diagnosis: IIa+IIc, 10mm, Rectum (Rs) Adenocarcinoma (tub1) with TV adenoma pT1a (SM300μm), BD1(0), ly0, v0, pHM0, pVM0

11. Pathological image

Case Video

Overall Comment

This case demonstrates a 10-mm rectal lesion (Rs) of macroscopic type 0-IIa+IIc, showing a superficially elevated component with a central depressed area. On white-light imaging, the lesion appeared slightly elevated with an irregular surface, while TXI improved visualization of both the overall contour and the depressed component. Indigo carmine chromoendoscopy clearly delineated the lesion margin and confirmed the depressed morphology. On NBI, the central part of the lesion was optically diagnosed as JNET Type 2B, whereas JNET Type 2A findings were also present at the lesion margin, suggesting coexistence of adenomatous tissue. Magnifying chromoendoscopy demonstrated a mildly irregular Kudo type Vi pit pattern in the central area, along with an invasive pattern-positive area measuring approximately 3~5 mm in width, while a type IV pit pattern was observed at the margin, raising suspicion of coexisting tubulovillous adenoma. Based on these findings, PAEM (peranal endoscopic myectomy) was performed. Histopathological examination confirmed adenocarcinoma (tub1) with tubulovillous adenoma, pT1a (SM 300 μm), BD1, ly0, v0, pHM0, and pVM0. R0 resection was achieved, and the patient is currently under follow-up. This highly educational case illustrates that even a small lesion can contain both invasive carcinoma and adenomatous components, emphasizing the importance of combined assessment of macroscopic type, depressed morphology, JNET classification, pit pattern heterogeneity, and appropriate therapeutic decision-making.

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

Cases 36:Detection 0-IIa, SSL with CD
Prof. Yasushi Sano Cases 38:Characterization JNET 2B
Prof. Yasushi Sano

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