Validity of conventional endoscopy using “non-extension sign” for optical diagnosis of colorectal deep submucosal invasive cancer

Abstract

Background and study aims The non-extension sign relates to a localized increase in thickness and rigidity due to deep submucosal invasive (SM-d: depth of 1000 μm or more) cancer. The present study aimed to evaluate the efficacy of the non-extension sign in assessing the optical diagnosis of colorectal SM-d cancer.

Patients and methods We retrospectively analyzed 309 patients with 315 early colorectal cancers that had been endoscopically or surgically resected. The non-extension sign was judged from chromoendoscopy (CE) using conventional white-light imaging with indigo carmine, and is taken to be positive when any one of the findings of rigidity of a circular arc, trapezoid elevation, or converging mucosal folds are seen. We assessed comparing the accuracy of CE, magnifying chromoendoscopy (M-CE), and magnifying narrow-band imaging (M-NBI) for the optical diagnosis of colorectal SM-d cancer.

Results Sensitivity, specificity, and accuracy for the diagnosis of SM-d cancer were 66.0 %, 95.8 %, and 86.3 % for CE; 80 %, 90.7 %, and 87.3 % for M-CE; and 65.0 %, 94.4 %, and 85.1 % for M-NBI, respectively. The specificity of CE was significantly higher than that of M-CE (P = 0.034). The sensitivity of M-CE was significantly higher than that of CE (P = 0.026). In a comparison of positive and negative groups for the non-extension sign in SM-d cancer, SM invasion was significantly deeper in the positive group than in the negative group (3012.5 μm vs 2002.4 μm, respectively; P < 0.0001) and the rate of lymphovascular invasion was significantly higher in the positive group than in the negative group (63.6 % vs 41.2 %, respectively; P = 0.032).

Conclusions The non-extension sign offers high diagnostic specificity for SM-d cancer, and surgery should be considered in patients with a positive non-extension sign.

• References

• 1 Nakajima T, Saito Y, Tanaka S. et al. Current status of endoscopic resection strategy for large, early colorectal neoplasia in Japan. Surg Endosc 2013; 27: 3262-3270
• 2 Fujiya M, Tanaka K, Dokoshi T. et al. Efficacy and adverse events of EMR and endoscopic submucosal dissection for the treatment of colon neoplasms: a meta-analysis of studies comparing EMR and endoscopic submucosal dissection. Gastrointest Endosc 2015; 81: 583-595
• 3 Minomoto T, Mai M, Ogino T. et al. Early invasive colorectal carcinomas metastatic to the lymph node with attention to their nonpolypoid development. Am J Gastroenterol 1993; 88: 1035-1039
• 4 Nusko G, Mansmann U, Partzsch U. et al. Invasive carcinoma in colorectal adenomas: Multivariate analysis of patient and adenoma characteristics. Endoscopy 1997; 29: 626-631
• 5 Sakuragi M, Togashi K, Konishi F. et al. Predictive factors for lymph node metastasis in T1 stage colorectal carcinomas. Dis Colon Rectum 2003; 46: 1626-1632
• 6 Kitajima K, Fujimori T, Fujii S. et al. Correlation between lymph node metastasis and depth of submucosal inavasion in submucosal invasive colorectal carcinoma: a Japanese collaborative study. J Gastroenterol 2004; 39: 534-543
• 7 Bosch SL, Teerenstra S, de Wilt JH. et al. Predicting lymph node metastasis in pT1 colorectal cancer: a systematic review of risk factors providing rationale for therapy decision. Endoscopy 2013; 45: 827-834
• 8 Tanaka S, Kashida H, Saito Y. et al. JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection. Dig Endosc 2015; 27: 417-434
• 9 Kudo S, Rubio CA, Teixeira CR. et al. Pit pattern in colorectal neoplasia: endoscopic magnifying view. Endoscopy 2001; 33: 367-373
• 10 Tanaka S, Kaltenbach T, Chayama K. et al. High-magnification colonoscopy (with video). Gastrointest Endosc 2006; 64: 604-613
• 11 Matsuda T, Fujii T, Saito Y. et al. Efficacy of the invasive/non-invasive pattern by magnifying chromoendoscopy to estimate the depth of invasion of early colorectal neoplasms. Am J Gastroenterol 2008; 103: 2700-2706
• 12 Wada Y, Kashida H, Kudo SE. et al. Diagnostic accuracy of pit pattern and vascular pattern analysis in colorectal lesions. Dig Endosc 2010; 22: 192-199
• 13 Sano Y, Horimatsu T, Fu KI. et al. Magnifying observation of microvascular architecture of colorectal lesions using a narrow band imaging system. Dig Endosc 2006; 18: S44-S51
• 14 Tanaka S, Hirata M, Oka S. et al. Clinical significance of narrow band imaging (NBI) in diagnosis and treatment of colorectal tumor. Gastroenterol Endosc 2008; 50: 1289-1297
• 15 Hisabe T, Yao K, Beppu T. et al. Validity of the usefulness of microvascular architecture and microsurface structure using magnifying endoscopy with narrow-band imaging in the colorectal neoplasm. Ann Gastroenterol 2013; 26: 45-51
• 16 Backes Y, Moss A, Reitsma JB. et al. Narrow Band Imaging, Magnifying Chromoendoscopy, and Gross Morphological Features for the Optical Diagnosis of T1 Colorectal Cancer and Deep Submucosal Invasion: A Systematic Review and Meta-Analysis. Am J Gastroenterol 2017; 112: 54-64
• 17 Nagahama T, Yao K, Imamura K. et al. Diagnostic performance of conventional endoscopy in the identification of submucosal invasion by early gastric cancer: the “non-extension sign” as a simple diagnostic marker. Gastric Cancer 2017; 20: 304-313
• 18 Japanese Society for Cancer of the Colon and Rectum. Japanese classification of colorectal carcinoma. 2^nd English Edition. Tokyo: Kanehara & Co: Endoscopy. Ltd; 2009 (Endoscopic Classification Review Group. Update on the Paris classification of superficial neoplastic lesions in the digestive tract. 2005 37. 570-578
• 19 Sano Y, Tanaka S, Kudo SE. et al. Narrow-band imaging (NBI) magnifying endoscopic classification of colorectal tumors proposed by the Japan NBI Expert Team. Dig Endosc 2016; 28: 526-533
• 20 Matsumoto K, Nagahara A, Terai T. et al. Evaluation of new subclasssification of type V(I) pit pattern for determining the depth and type of invasion of colorectal neoplasm. J Gastroenterol 2011; 46: 31-33
• 21 Ohta A, Tominaga K, Sakai Y. Efficacy of magnifying colonoscopy for the diagnosis of colorectal neoplasia: comparison with histopathological findings. Dig Endosc 2004; 16: 308-314
• 22 Nagata S, Tanaka S, Haruma K. et al. Pit pattern diagnosis of early colorectal carcinoma by magnifying colonoscopy: clinical and histological implications. Int J Oncol 2000; 16: 927-934
• 23 Konerding MA, Fait E, Gaumann A. 3D microvascular architecture of pre-cancerous lesions and invasive carcinomas of the colon. Br J Cancer 2001; 84: 1354-1362
• 24 Ikehara H, Saito Y, Matsuda T. et al. Diagnosis of depth of invasion for early colorectal cancer using magnifying colonoscopy. J Gastroenterol Hepatol 2010; 25: 905-912
• 25 Jang HW, Park SJ, Cheon JH. et al. Does magnifying narrow-band imaging or magnifying chromoendoscopy help experienced endoscopists assess invasion depth of large sessile and flat polyps?. Dig Dis Sci 2014; 59: 1520-1528
• 26 Nakadoi K, Tanaka S, Kanao H. et al. Management of T1 colorectal carcinoma with special reference to criteria for curative endoscopic resection. J Gastroenterol Hepatol 2011; 27: 1057-1062
• 27 Ikematsu H, Yoda Y, Matsuda T. et al. Long-term outcomes after resection for submucosal invasive colorectal cancers. Gastroenterol 2013; 144: 551-559
• 28 Sumimoto K, Tanaka S, Shigita K. et al. Clinical impact and characteristics of the narrow-band imaging magnifying endoscopic classification of colorectal tumors proposed by the Japan NBI Expert Team. Gastrointest Endosc 2017; 85: 816-821