Claudio Rolim Teixeira

Pragmatic classification of superficial neoplastic colorectal lesions

Recently, the emerging role of nonpolypoid precursors of colorectal cancer has challenged the conventional polyp-cancer sequence. The impact of colonoscopy in cancer prevention depends on its reliability in the diagnosis of colorectal neoplasia when the lesion does not extend beyond the submucosa and is potentially curable. The estimation of the risk of progression is based on the prediction of histology from the morphological appearance of the lesion and includes (1) distinction between neoplastic and non-neoplastic lesions, (2) identification of different categories of non-serrated and serrated lesions, and (3) determination of the localization in the proximal or distal colon, which has an impact on the morphology and behavior of the lesion. The pragmatic classification Of superficial neoplastic lesions proposed in this text takes into account these changes and is based oil a 2-step strategy of endoscopic diagnosis with initial detection and characterization, followed by treatment implementation, Such as endoscopic resection, ablation, and Surgery

Flat-Elevated Colorectal Neoplasms Exhibit a High Malignant Potential

The potential of flat-elevated colorectal adenomas to undergo rapid malignant transformation and progression to invasive carcinoma is still under discussion. Therefore, a total of 130 colorectal neoplastic lesions > or = 1 cm in diameter were examined after endoscopic or surgical resection. Lesions were macroscopically classified into three categories: (1) flat elevation (22 lesions), superficially elevated lesion with a smooth surface; (2) granular laterally spreading tumor (GLST; 26 lesions), laterally spreading aggregates of nodules forming a lesion with granular surface, and (3) polypoid (82 lesions), pedunculated, subpedunculated and sessile polyps. The adenomatous component showed a tubulovillous architecture in 9/26 (35%) of GLST and 18/82 (22%) of polypoid lesions, however none of the flat-elevated lesions had a villous component (p <0.01; p <0.05). Carcinoma was present in 17/22 (77%) flat elevations, 37/82 (45%) polypoid lesions and 11/26 (42%) GLST (p <0.05). None of the carcinomas arising in GLST and only 1/37 (3%) of those developing in polypoid lesions were invasive carcinomas, but 4/17 (24%) carcinomas arising in flat elevations showed submucosal invasion. Moreover, while all 5 noncancerous flat elevations showed severe atypia, 17/82 (21%) polypoid lesions and 5/26 (19%) GLST showed moderate atypia. In conclusion, flat-elevated colorectal neoplasms have a high malignant potential and the role of these lesions as precursors of colorectal carcinomas deserves greater emphasis.

The Clinical Significance of the Histologic Subclassification of Colorectal Carcinoma

According to the histologic features at the deepest level of tumor invasion (the tumor apex), we classified colorectal carcinomas as follows: well differentiated (W), moderately differentiated (M), and mucinous (Muc). By assessing its glandular configuration and cellular arrangement, the M type was further subdivided in to two different groups: moderately well differentiated (Mw) and moderately poorly differentiated (Mp) carcinomas. In our sample there were 56 W, 53 Mw, 20 Mp and 13 Muc tumors. The malignant potential of each tumor was evaluated by examining for the presence or absence of lymphatic invasion, venous invasion, lymph node metastases and liver metastases. In comparison with the other tumors, the Mp tumors proved to harbor the highest malignant potential, exhibiting a higher incidence of lymphatic invasion (95%, 19/20 of the cases), venous invasion (75%, 15/20 of the cases), lymph node metastases (80%, 16/20 of the cases), and liver metastases (40%, 8/20 of the cases). Colorectal carcinomas are composed of multiple cell populations with different biological and malignant properties, and through the histologic subclassification we could identify that Mp tumors have the highest potential to invade normal tissue and metastasize.

Computerized virtual chromoendoscopy versus indigo carmine chromoendoscopy combined with magnification for diagnosis of small colorectal lesions: a randomized and prospective study.

Background and study aims Magnifying colonoscopy with indigo carmine dye and the analysis of the capillary and the pit patterns by computed virtual chromoendoscopy (Fujinon Intelligent Color Enhancement, FICE) with magnification are effective for the differential diagnosis of neoplastic and non-neoplastic lesions. This study aimed to compare the accuracy of virtual and real chromoendoscopy in differentiating neoplastic and non-neoplastic colorectal lesions. Patients and methods A prospective randomized trial of magnification colonoscopy with targeted FICE (Group I – 72 patients/111 lesions) versus magnification colonoscopy with targeted indigo carmine dye (Group II – 72 patients/137 lesions) was performed in consecutive patients with lesions 1 cm or less. Histopathology of the specimens was regarded as the gold standard. Results In group I, 86 (77.5%) lesions showed an intense vascular pattern (positive capillary meshwork), of which 80 (93%) were histologically confirmed as adenomas. From 25 lesions with negative capillary meshwork, 23 (92%) were non-neoplastic. Sensitivity, specificity, accuracy, positive and negative predictive values of the capillary meshwork for the differential diagnosis of these lesions was 97.8, 79.3, 92.8, 93 and 92%, respectively. The same parameters for pit pattern analysis by FICE were 92.7, 82.3, 90.1, 93.8 and 80%, respectively. Indigo carmine magnified chromoscopy showed sensitivity, specificity, accuracy, positive and negative predictive values of 97, 88.9, 94.9, 96.1 and 91.4%, respectively in the discrimination between neoplastic and non-neoplastic lesions. Conclusion Magnified virtual chromoendoscopy is as accurate as indigo carmine magnified chromoendoscopy in distinguishing between neoplastic from non-neoplastic small colorectal lesions.

Endoscopic classification of the capillary-vessel pattern of colorectal lesions by spectral estimation technology and magnifying zoom imaging

BACKGROUND Colonoscopy with spectral estimation technology and magnifying zoom imaging allows the characterization of the fine superficial capillary pattern of normal mucosa and of colorectal lesions. The endoscopic distinction of the capillary pattern of colorectal lesions might contribute to the differential diagnosis among normal, hyperplastic, and neoplastic lesions. OBJECTIVE By means of these latest technologic advances, the objective is to define a classification of the capillary-vessel pattern of colorectal lesions diagnosed during routine colonoscopy. DESIGN A total of 309 colorectal lesions endoscopically or surgically resected were prospectively examined. The capillary pattern was divided into 5 subtypes according to the number, morphology, and distribution of the fine blood vessels. Capillary patterns types I and II were characterized by a few short, straight, and sparsely distributed vessels; types III to V were of numerous, elongated, and tortuous capillaries irregularly distributed. RESULTS The overall accuracy of the capillary-vessel classification in determining the neoplastic or non-neoplastic nature of the colorectal lesions was 98.3% (304/309 lesions). Among 59 non-neoplastic lesions, 56 (94.9%) that showed patterns I or II were diagnosed as normal, inflammatory, or hyperplastic polyps. Of the 250 neoplastic lesions, 248 (99.2%) that had capillary pattern types III, IV, and V were diagnosed as adenomatous or carcinoma. The sensitivity of the capillary pattern classification for distinguishing neoplasia was 99.2% (95% CI, 98.2%-100%), and the specificity was 94.9% (95% CI, 92.5%-97.4%). LIMITATION A single-center study. CONCLUSION The endoscopic classification of the superficial capillary-vessel pattern of colorectal lesions is an accurate method of predicting the histopathologic findings.

Carcinoembryonic antigen staining patterns at the invasive tumor margin predict the malignant potential of colorectal carcinoma

Immunohistochemical carcinoembryonic antigen (CEA) staining patterns at the invasive tumor margin were correlated with malignant potential in 64 advanced colorectal carcinomas. Twenty-two (34%) carcinomas showed an apical and 42 (66%) a cytoplasmic staining pattern. Carcinomas with a cytoplasmic pattern had a higher incidence of lymph node (71 versus 41%; p < 0.05) and liver (50 versus 23%; p < 0.05) metastasis and higher levels of serum CEA (p < 0.01) than those with an apical staining pattern. Nine of 11 recurrent tumors had a cytoplasmic pattern and 2 had an apical pattern (p < 0.05). Among carcinomas having the same degree of differentiation, those with a cytoplasmic CEA staining pattern were more aggressive. Six (55%) well-differentiated carcinomas with a cytoplasmic pattern metastasized to the liver while none with an apical pattern did (p < 0.05). Moderately differentiated carcinomas with a cytoplasmic pattern had a significantly higher incidence of lymph node metastasis than those with an apical pattern (77 versus 46%; p < 0.05). When colorectal carcinomas are examined at the invasive tumor margin, an evaluation of the CEA staining pattern is useful in recognizing carcinomas having a higher potential to metastasize and recur after curative surgery.

Redução da prevalência de úlcera duodenal: um estudo brasileiro (análise retrospectiva na última década: 1996-2005)

BACKGROUND: The duodenal ulcer always represented a very prevalent pathology among the gastrointestinal tract diseases worldwide. The average prevalence is approximately 10% of the world population. In the 90s the literature (both European and North American) begin to show a crescent reduction of this prevalence in many countries. AIM: To show through a retrospective analysis the annual prevalence of the duodenal ulcer in the last 10 years in a Digestive Endoscopy Service which is referred to public medical system in Porto Alegre and its suburban area and countryside of the State of Rio Grande do Sul, Brazil. The data analyzed is from March 1996 to December 2005. Specific data: transversal retrospective study with documented analysis of endoscopic diagnosis of upper gastrointestinal endoscopy. METHODS: A retrospective analysis of the diagnosis of the 13.130 procedures of upper gastrointestinal endoscopy between 1996 and 2005. The Sakita classification was used to verify the duodenal ulcer activity taking into consideration the patients who have lesions on A1 to S1 levels. To verify if there was a statistical significant results, a linear regression test was done (linear regression model). RESULTS: A gradate decrease of the prevalence percentuals was observed, year after year, it began with 8.3% of prevalence in 1996 and finished with 3.3% in the beginning of 2006. The average annual reduction of this prevalence was calculated following the regression test and it was placed in the 1.3% a year in the studied period of time. In 2003, in an isolated way, it was an exception in the decrease of the percentage because it presented a prevalence increase of (6.5%) comparing to the first 6 years of study. CONCLUSION: In this study it was observed a decrease of duodenal ulcer prevalence, 1.3% a year to be more accurate in 10 years of study, showing a statistical significance in the linear regression test.

Magnifying colonoscopy: interobserver agreement in the assessment of colonic pit patterns and its correlation with histopathological findings

Background and study aimsMagnifying colonoscopy (MC) is recognized as an aid to the differential diagnosis between neoplastic and nonneoplastic lesions. This study evaluated interobserver agreement of experienced endoscopists in the assessment of colonic pit patterns through the Kudo’s classification and correlated morphological aspects with histopathological findings.Materials and methodsA total of 213 magnification chromoendoscopic pictures of colonic lesions were collected from 161 consecutive patients and presented to three independent observers who expressed opinion about predominant pit pattern. All lesions were excised and sent for histopathological study.ResultsKappa statistics showed that the general agreement index with respect to the aspects of the pits was good among the three observers (0.561). Regarding prediction of histopathology according to the pit pattern diagnosis, overall accuracy was 84%, sensitivity was 91.4%, specificity was 67.2%, positive predictive value was 86.6%, and negative predictive value was 79.3%.ConclusionAlthough the interobserver reproducibility of the colonic pit pattern is good for experienced endoscopists, MC must not be used to replace the histopathological analysis, since it does not differentiate with the necessary safety neoplastic from nonneoplastic lesions.

Heterotopic pancreas diagnosed by endoscopic ultrasonography and endoscopic injection of ethanol to make a histologic diagnosis

A gastric submucosal tumor in a 56-year-old man was presumed to be heterotopic pancreas on the basis of endoscopy and endoscopic ultrasonography. To obtain a histologic diagnosis we injected ethanol at the tumor site to create an artificial ulcer. This facilitated the removal of endoscopic biopsy specimens from the submucosal layer so that histologic examination could confirm the presence of heterotopic pancreatic tissue.

DESENVOLVIMENTO DE NEOPLASIAS/ ADENOMAS AVANÇADOS COLORRETAIS NO SEGUIMENTO A LONGO PRAZO DE PACIENTES SUBMETIDOS A COLONOSCOPIA COM POLIPECTOMIA

CONTEXT Colonoscopy with polypectomy reduces the incidence of colorectal cancer and its associated mortality. The ideal interval between surveillance examinations is determined by clinical features and endoscopic findings considered as risk factors to the development of advanced colonic neoplasias. OBJECTIVE To determine the development rate of advanced neoplasia in patients submitted to surveillance colonoscopy in a tertiary referral center. METHODS Three hundred and ninety two patients who underwent two or more complete colonoscopies between 1995 and 2005, and who have at least one diagnosed colorectal adenoma entered into the study. The endoscopic findings of the first and subsequent colonoscopies of each patient were analysed, considering advanced neoplasia as the main outcome. The patients enrolled were divided in accordance to the first colonoscopy findings in groups 1 or high risk; 2 or low risk; and 3 or without adenoma at the first colonoscopy. The development of advanced colorectal neoplasia and the period of surveillance until the outcome were analysed and compared among groups. RESULTS Twenty eight per cent of patients had advanced adenomas at index colonoscopy; 57.8% presented with low grade dysplasia neoplastic lesions and 14.1% had no adenoma at the first examination. The mean age was 59.54 +/- 11.74 years. Twenty six point four per cent of subjects from group 1 presented with advanced neoplasia during the surveillance period, while this outcome occurred in 10.9% and 5.3% of patients from groups 2 and 3, respectively (P<0,05). The mean period of surveillance was 123.35 months, and the mean time between the first examination and the one which presented with the outcome statistically differed among group 1 and the others, being 104.02, 115.31 and 120.61 months, respectively. CONCLUSIONS Patients with advanced neoplasia at index colonoscopy presented with a higher probability of harbouring this condition during the follow-up when compared with other two groups. These lesions also occur earlier in this patients than in the ones without these lesions at the first examination.