Diagnostic accuracy of pit pattern and vascular pattern in colorectal lesions Digestive Disease Center, Showa University Northern Yokohama Hospital Department of Pathology Yoshiki Wada, Shin-ei Kudo, Hiroshi Kashida, Masashi Misawa, Takemasa Hayashi, Toshihisa Hosoya, Kunihiko Wakamura, Nobunao Ikehara, Shigeharu Hamatani
Background Pit pattern analysis has been reported as useful for predicting the colorectal lesion s histological nature. Recently a new method of image-enhanced endoscopy called narrow band imaging (NBI) has been developed. The benefits of NBI over chromoendoscopy are that it is easier and time-saving. Aim The aim of this prospective study is to compare the usefulness of magnifying narrow band imaging (NBI) and magnifying chromoendoscopy in the diagnosis of colorectal lesions.
Subjects 3380 lesions (106 hyperplastic polyps, 3056 adenomas and 218 invasive cancers limited to submucosal layer) which were observed by magnifying scope with NBI and magnifying chromoendoscopy and treated endoscopically or surgically from January 2006 to June 2009.
Methods The scopes were CF-H260AZI (up to x 80). The diagnosis of NBI and pit pattern was made by endoscopists who were blinded to the final pathological diagnosis. The pit patterns were classified into I, II, III, IV, VI and VN according to Kudo s classification. VI pit pattern was divided into VI low-grade and VI high-grade. Our definitions for VI high-grade pit pattern were rough margin and narrowed lumen.
We classified colonic microvascular pattern into six; normal, faint, network, dense, irregular and sparse. Faint pattern was usually seen in hyperplastic polyps. Network and dense patterns were frequently recognized in benign adenomas. Irregular pattern was characteristic for protruded or flat cancers, and sparse pattern was predictive for depressed cancers.
Kudo S, et al. Gastrointest Endosc 1996; 44: 8-14
Classification of the degree of submucosal invasion carcinoma muscularis mucosa submucosa sm1 sm2 sm scanty sm massive submucosa sm3 muscularis propria resection margin Surgical Specimen EMR Specimen Tsuruta O, Toyonaga A, Ikeda H et al. Int J Oncology 1997; 10: 1003-08
Vascular Pattern Classification Normal pattern Faint pattern Network pattern
Dense pattern Irregular pattern Sparse pattern Wada Y, Kudo S, Kashida H et al. Gastrointest Endosc 2009; 70: 522-31
Pit Pattern Classification (Kudo s Classification) I II IIIs IIIL IV VI VN Kudo S et al. Endoscopy 2001; 33: 367-373
Definitions for VI high-grade pit pattern rough margin narrowed lumen
Comparison between vascular pattern and pathological diagnosis vascular pattern pathological diagnosis hyp* adenoma SMs SMm total faint 89 47** 136 network 17 2426 33 5 2481 dense 531 6 7 544 irregular 40 6 65 111 sparse 12 9 87 108 total 106 3056 54 164 3380 * hyperplastic polyp ** 31 lesions were sessile serrated adenomas.
Differential diagnosis between hyperplastic polyp and neoplasia by vascular pattern vascular pattern pathological diagnosis hyp neoplasia total faint 89 47** 136 network / dense irregular / sparse 17 3227 3244 total 106 3274 3380 sensitivity 84.0%, specificity 98.6%, accuracy 98.1% ** 31 lesions were sessile serrated adenomas.
Vascular patterns of submucosally invasive cancers vascular pattern pathological diagnosis SMm adenoma / SMs total irregular / sparse 152 67 219 network / dense / faint 12 3043 3055 total 164 3110 3274 sensitivity 92.7%, specificity 97.8%, accuracy 97.6%
Comparison between pit pattern and pathological diagnosis pit pattern pathological diagnosis hyp adenoma SMs SMm total II 96 20 116 IIIs 35 35 IIIL 9 1978 1987 IV 1 788 12 6 807 VI low-grade 222 35 16 273 VI high-grade 13 7 91 111 VN 51 51 total 106 3056 54 164 3380
Differential diagnosis between hyperplastic polyp and neoplasia by pit pattern pit pattern pathological diagnosis hyp neoplasia total II 96 20 116 III / IV / VI / VN 10 3274 3264 total 106 3294 3380 sensitivity 90.6%, specificity 99.4%, accuracy 99.1%
Pit patterns of submucosally invasive cancers pit pattern pathological diagnosis SMm adenoma / SMs total VN / VI high-grade 142 20 162 VI low-grade / IV / III /II 22 3090 3112 total 164 3110 3274 sensitivity 86.6%, specificity 99.4%, accuracy 98.7%
Case 1 Rectosigmoid colon, Is, 9mm VI high-grade irregular pattern Adenocarcinoma (tub1) with adenoma, sm2 (psm 1500µm), ly1, v0
Case 2 Rectosigmoid colon, IIa+IIc, 10mm VI high-grade sparse pattern Adenocarcinoma (tub2 > tub1), sm3 (psm 3250µm), ly1, v2, pn1, H1
Summary Both NBI and chromoendoscopy can be useful tools for distinguishing between neoplastic and non-neoplastic lesions. In the diagnosis of submucosal cancer, pit pattern diagnosis was a little superior to vascular pattern diagnosis.
Conclusion It is desirable to perform not only NBI but also chromoendoscopy for distinguishing between SMm and SMs and determining treatment selection, endoscopic or surgical.
Diagnostic accuracy of pit pattern and vascular pattern in colorectal lesions Digestive Disease Center, Showa University Northern Yokohama Hospital Department of Pathology # Yoshiki Wada, Shin-ei Kudo, Hiroshi Kashida, Masashi Misawa, Takemasa Hayashi Toshihisa Hosoya, Kunihiko Wakamura, Nobunao Ikehara, Shigeharu Hamatani