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      Endoscopic tri-modal imaging for surveillance in ulcerative colitis: randomised comparison of high-resolution endoscopy and autofluorescence imaging for neoplasia detection; and evaluation of narrow-band imaging for classification of lesions

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          Abstract

          Background:

          Endoscopic tri-modal imaging (ETMI) incorporates white light endoscopy (WLE), autofluorescence imaging (AFI) and narrow-band imaging (NBI).

          Aims:

          To assess the value of ETMI for the detection and classification of neoplasia in patients with longstanding ulcerative colitis.

          Design:

          Randomised comparative trial of tandem colonoscopies.

          Setting:

          Academic Medical Centre Amsterdam, Netherlands.

          Patients and methods:

          Fifty patients with ulcerative colitis underwent surveillance colonoscopy with ETMI. Each colonic segment was inspected twice, once with AFI and once with WLE, in random order. All detected lesions were inspected by NBI for Kudo pit pattern analysis and additional random biopsies were taken.

          Main outcome measures:

          Neoplasia miss-rates of AFI and WLE, and accuracy of the Kudo classification by NBI.

          Results:

          Among patients assigned to inspection with AFI first (n = 25), 10 neoplastic lesions were primarily detected. Subsequent WLE detected no additional neoplasia. Among patients examined with WLE first (n = 25), three neoplastic lesions were detected; subsequent inspection with AFI added three neoplastic lesions. Neoplasia miss-rates for AFI and WLE were 0% and 50% (p = 0.036). The Kudo classification by NBI had a sensitivity and specificity of 75% and 81%; however, all neoplasia was coloured purple on AFI (sensitivity 100%). No additional patients with neoplasia were detected by random biopsies.

          Conclusion:

          Autofluorescence imaging improves the detection of neoplasia in patients with ulcerative colitis and decreases the yield of random biopsies. Pit pattern analysis by NBI has a moderate accuracy for the prediction of histology, whereas AFI colour appears valuable in excluding the presence of neoplasia.

          Trial registration number:

          ISRCTN05272746

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          Most cited references38

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          Cyclosporine in severe ulcerative colitis refractory to steroid therapy.

          S Lichtiger, D Present, A Kornbluth … (1994)
          There has been no new effective drug therapy for patients with severe ulcerative colitis since corticosteroids were introduced almost 40 years ago. In an uncontrolled study, 80 percent of 32 patients with active ulcerative colitis refractory to corticosteroid therapy had a response to cyclosporine therapy. We conducted a randomized, double-blind, controlled trial in which cyclosporine (4 mg per kilogram of body weight per day) or placebo was administered by continuous intravenous infusion to 20 patients with severe ulcerative colitis whose condition had not improved after at least 7 days of intravenous corticosteroid therapy. A response to therapy was defined as an improvement in a numerical symptom score (0 indicated no symptoms, and 21 severe symptoms) leading to discharge from the hospital and treatment with oral medications. Failure to respond to therapy resulted in colectomy, but some patients in the placebo group who had no response and no urgent need for surgery were subsequently treated with cyclosporine. Nine of 11 patients (82 percent) treated with cyclosporine had a response within a mean of seven days, as compared with 0 of 9 patients who received placebo (P < 0.001). The mean clinical-activity score fell from 13 to 6 in the cyclosporine group, as compared with a decrease from 14 to 13 in the placebo group. All five patients in the placebo group who later received cyclosporine therapy had a response. Intravenous cyclosporine therapy is rapidly effective for patients with severe corticosteroid-resistant ulcerative colitis.
          Article 0 comments Cited 282 times – based on 0 reviews     Review now
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            Update on the paris classification of superficial neoplastic lesions in the digestive tract.

            (2005)
            Neoplastic lesions in the digestive-tract mucosa are termed "superficial" when the depth of invasion is limited to the mucosa and submucosa. The endoscopic appearance has a predictive value for invasion into the submucosa, which is critical for the risk of nodal metastases. The endoscopic morphology of superficial lesions can be assessed with a standard video endoscope after spraying of a dye--an iodine-potassium iodide solution for the stratified squamous epithelium, or an indigo carmine solution for the columnar epithelium. In 2002, a workshop was held in Paris to explore the relevance of the Japanese classification. The conclusions were revised in 2003 in Osaka in relation to the definition of the subtypes used in endoscopy and the evaluation of the depth of invasion into the submucosa. In Japan, the description of advanced cancer in the digestive-tract mucosa using types 1 - 4 is supplemented by a type 0 when the endoscopic appearance is that of a superficial lesion. Type 0 is divided into three categories: protruding (0 - I), nonprotruding and nonexcavated (0 - II), and excavated (0 - III). Type 0 - II lesions are then subdivided into slightly elevated (IIa), flat (IIb), or depressed (IIc). Nonprotruding depressed lesions are associated with a higher risk of submucosal invasion. After endoscopic resection, invasion into the submucosa is an important criterion for the necessity of additional surgical resection. Micrometer analysis of the depth of invasion in the specimen is more precise, and distinct cut-off limits have been established in the esophagus, stomach, and large bowel. The morphology of superficial and nonprotruding neoplastic lesions is relevant to the prognosis. Following endoscopic detection, the lesions are analyzed using chromoendoscopy and assigned a subtype of the type 0 classification. The choice between endoscopic or surgical treatment is based on this description.
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              Dysplasia in inflammatory bowel disease: standardized classification with provisional clinical applications.

              Robert Riddell, Harvey Goldman, David F Ransohoff … (1983)
              Assessment of epithelial dysplasia in ulcerative colitis has been hindered by inconsistencies in and disagreements about nomenclature and interpretation. To resolve these issues, pathologists from ten institutions participated in three exchanges of multiple slides and, following each exchange, in discussions of the results. A classification system for the epithelial changes that occur in ulcerative colitis was developed, which should be applicable to other forms of inflammatory bowel disease as well. The classification makes use of standardized terminology, addresses specific problem areas, and offers practical solutions. The reproducibility of the system was studied by means of examinations of both inter- and intra-observer variations. The clinical implications of the findings were incorporated into suggestions for patient management. The basis of the classification is that the term "dysplasia" is reserved for epithelial changes that are unequivocally neoplastic and may therefore give rise directly to invasive carcinoma. Specimens are categorized as negative, indefinite, or positive for dysplasia. The negative category includes all inflammatory and regenerative lesions and indicates that only continued regular surveillance is required. The indefinite category is applied to epithelial changes that appear to exceed the limits of ordinary regeneration but are insufficient for an unequivocal diagnosis of dysplasia or are associated with other features that prevent such unequivocal diagnosis. Clinically, it indicates that early repeat biopsy is often required to assess the changes more accurately. The positive category is divided into two subcategories: 1) high-grade dysplasia, for which colectomy should be strongly considered after confirmation of the diagnosis, and 2) low-grade dysplasia, which also requires confirmation and early repeat biopsy or colectomy, depending on other findings.
              Article 0 comments Cited 187 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Gut
                Journal ID (publisher-id): gut
                Title: Gut
                Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                ISSN (Print): 0017-5749
                ISSN (Electronic): 1468-3288
                Publication date Collection: 2008
                Publication date (Print): August 2008
                Publication date (Electronic): 26 March 2008
                Publication date PMC-release: 26 March 2008
                Volume: 57
                Issue: 8
                Pages: 1083-1089
                Affiliations
                [1 ]Department of Gastroenterology and Hepatology, Academic Medical Centre Amsterdam, Netherlands
                [2 ]Pathology, Academic Medical Centre Amsterdam, Netherlands
                [3 ]Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre Amsterdam, Netherlands
                Author notes
                Correspondence to: Dr Evelien Dekker, Department of Gastroenterology and Hepatology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands; e.dekker@ 123456amc.uva.nl
                Article
                Publisher ID: gt144097
                DOI: 10.1136/gut.2007.144097
                PMC ID: 2564833
                PubMed ID: 18367559
                SO-VID: 4082c8bc-a611-47f0-8c4a-531a5b1de5ef
                Copyright © © van den Broek et al 2008
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date revision received : 22 February 2008
                Date accepted : 5 March 2008
                Categories
                Subject: Ulcerative Colitis

                ScienceOpen disciplines: Gastroenterology & Hepatology
                Data availability:
                ScienceOpen disciplines: Gastroenterology & Hepatology

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