In Japan, endoscopic submucosal dissection (ESD) is standardized for large colorectal tumors. However, its validity in the elderly population is unclear. We aimed to evaluate the safety and efficacy of ESD for colorectal tumors in elderly patients aged over 80 years.

ESD was performed on 178 tumors in 165 consecutive patients aged over 80 years between December 2008 and December 2018. We retrospectively evaluated the clinicopathological characteristics and clinical outcomes of ESD. We also assessed the prognosis of 160 patients followed up for more than 12 months.

The mean patient age was 83.7 ± 3.1 years. The number of patients with comorbidities was 100 (62.5%). Among all patients, 106 (64.2%) were categorized as class 1 or 2 according to the American Society of Anesthesiologists classification of physical status (ASA-PS), and 59 (35.8%) were classified as class 3. The mean procedure time was 97.7 ± 79.3 min. The rate of histological en bloc resection was 93.8% (167/178). Delayed bleeding in 11 cases (6.2%) and perforation in 7 cases (3.9%) were treated conservatively. The 5-year survival rate was 89.9%. No deaths from primary disease (mean follow-up time: 35.3 ± 27.5 months) were observed. Overall survival rates were significantly lower in the non-curative resection group that did not undergo additional surgery than in the curative resection group (P = 0.0152) and non-curative group that underwent additional surgery (P = 0.0259). Overall survival rates were higher for ASA-PS class 1 or 2 patients than class 3 patients (P = 0.0105). Metachronous tumors (> 5 mm) developed in 9.4% of patients.

ESD for colorectal tumors in patients aged over 80 years is safe. Colorectal cancer-associated deaths were prevented although comorbidities pose a high risk of poor prognosis.

• Colorectal cancer
• Colorectal tumor
• Elderly
• Endoscopic submucosal dissection (ESD)
• Long-term prognosis
• The American Society of Anesthesiologists classification of physical status (ASA-PS) class

• Colonic polyps
• Colorectal cancer
• Kudo pit pattern
• NICE classification

• Colon
• Colonic Polyps/diagnostic imaging
• Colonoscopy
• Colorectal Neoplasms
• Humans
• Observer Variation
• Prospective Studies
• Sensitivity and Specificity

• Early colorectal cancer
• Early gastric cancer
• Endoscopic resection
• Guideline
• Superficial esophageal squamous cell carcinoma

• Early colorectal cancer
• Early gastric cancer
• Endoscopic resection
• Guideline
• Superficial esophageal squamous cell carcinoma

• Korean Society of Gastrointestinal Endoscopy

In recent years, two new narrow-band imaging (NBI) classifications have been proposed: The NBI international colorectal endoscopic (NICE) classification and Japanese NBI expert team (JNET) classification. Most validation studies of the two new NBI classifications were conducted in classification setting units by experienced endoscopists, and the application of use in different centers among endoscopists with different endoscopy skills remains unknown.

To evaluate clinical application and possible problems of NICE and JNET classification for the differential diagnosis of colorectal cancer and precancerous lesions.

Six endoscopists with varying levels of experience participated in this study. Eighty-seven consecutive patients with a total of 125 lesions were photographed during non-magnifying conventional white-light colonoscopy, non-magnifying NBI, and magnifying NBI. The three groups of endoscopic pictures of each lesion were evaluated by the six endoscopists in randomized order using the NICE and JENT classifications separately. Then we calculated the six endoscopists’ sensitivity, specificity, accuracy, positive predictive value, and negative predictive value for each category of the two classifications.

The sensitivity, specificity, and accuracy of JNET classification type 1 and 3 were similar to NICE classification type 1 and 3 in both the highly experienced endoscopist (HEE) and less-experienced endoscopist (LEE) groups. The specificity of JNET classification type 1 and 3 and NICE classification type 3 in both the HEE and LEE groups was > 95%, and the overall interobserver agreement was good in both groups. The sensitivity of NICE classification type 3 lesions for diagnosis of SM-d carcinoma in the HEE group was significantly superior to that in the LEE group (91.7% vs 83.3%; P = 0.042). The sensitivity of JNET classification type 2B lesions for the diagnosis of high-grade dysplasia or superficial submucosal invasive carcinoma in the HEE and LEE groups was 53.8% and 51.3%, respectively. Compared with other types of JNET classification, the diagnostic ability of type 2B was the weakest.

The treatment strategy of the two classification type 1 and 3 lesions can be based on the results of endoscopic examination. JNET type 2B lesions need further examination.

• Narrow-band imaging international colorectal endoscopic
• Japanese narrow-band imaging expert team
• Colorectal neoplasms
• Precancerous lesions
• Colorectal endoscopy
• Narrow-band imaging

Although surgery was the standard treatment for early gastrointestinal cancers, endoscopic resection is now a standard treatment for early gastrointestinal cancers without regional lymph node metastasis. High-definition white light endoscopy, chromoendoscopy, and image-enhanced endoscopy such as narrow band imaging are performed to assess the edge and depth of early gastrointestinal cancers for delineation of resection boundaries and prediction of the possibility of lymph node metastasis before the decision of endoscopic resection. Endoscopic mucosal resection and/or endoscopic submucosal dissection can be performed to remove early gastrointestinal cancers completely by <i>en bloc</i> fashion. Histopathological evaluation should be carefully made to investigate the presence of risk factors for lymph node metastasis such as depth of cancer invasion and lymphovascular invasion. Additional treatment such as radical surgery with regional lymphadenectomy should be considered if the endoscopically resected specimen shows risk factors for lymph node metastasis. This is the first Korean clinical practice guideline for endoscopic resection of early gastrointestinal cancer. This guideline was developed by using mainly de novo methods and encompasses endoscopic management of superficial esophageal squamous cell carcinoma, early gastric cancer, and early colorectal cancer. This guideline will be revised as new data on early gastrointestinal cancer are collected.

• Early colorectal cancer
• Early gastric cancer
• Endoscopic resection
• Guideline
• Superficial esophageal squamous cell carcinoma

• Early colorectal cancer
• Endoscopic ultrasonography
• Invasion depth
• Narrow band imaging-magnifying endoscopy

• Colorectal Neoplasms/diagnostic imaging
• Colorectal Neoplasms/pathology
• Endosonography
• Humans
• Narrow Band Imaging
• Neoplasm Invasiveness
• Sensitivity and Specificity

• Lymph node metastasis
• Risk factors for lymph node metastasis
• T1 colorectal cancer

• Adult
• Aged
• Aged, 80 and over
• Colorectal Neoplasms/diagnosis
• Colorectal Neoplasms/pathology
• Endoscopy
• Female
• Humans
• Lymphatic Metastasis/diagnosis
• Lymphatic Metastasis/pathology
• Male
• Middle Aged
• Neoplasm Invasiveness
• Retrospective Studies
• Risk Factors

• Colonoscopy
• Colorectal cancer
• Colorectal polyps
• Deep learning
• Endoscopic imaging
• Endoscopy
• Optical diagnosis
• Resect and discard

To determine the usefulness of assigning narrow-band imaging (NBI) scores for predicting tumor grade and invasion depth in colorectal tumors.

A total of 161 colorectal lesions were analyzed from 138 patients who underwent endoscopic or surgical resection after conventional colonoscopy and magnifying endoscopy with NBI. The relationships between the surface and vascular patterns of the lesions, as visualized with NBI, and the tumor grade and depth of submucosa (SM) invasion were determined histopathologically. Scores were assigned to distinct features of the surface microstructures of tubular and papillary-type lesions. Using a multivariate analysis, a model was developed for predicting the tumor grade and depth of invasion based on NBI-finding scores.

NBI findings that correlated with a high tumor grade were associated with the “regular/irregular” (P < 0.0001) surface patterns and the “avascular area” pattern (P = 0.0600). The vascular patterns of “disrupted vessels” (P = 0.0714) and “thick vessels” (P = 0.0133) but none of the surface patterns were associated with a depth of invasion of ≥ 1000 μm. In our model, a total NBI-finding score ≥ 1 was indicative of a high tumor grade (sensitivity: 0.97; specificity: 0.24), and a total NBI-finding score ≥ 9 (sensitivity: 0.56; specificity: 1.0) was predictive of a SM invasion depth ≥ 1000 μm. Scores less than these cutoff values signified adenomas and a SM invasion depth < 1000 μm, respectively. Associations were also noted between selected NBI findings and tumor tissue architecture and histopathology.

Our multivariate statistical model for predicting tumor grades and invasion depths from NBI-finding scores may help standardize the diagnosis of colorectal lesions and inform therapeutic strategies.

• Colorectal cancer
• Magnifying narrow-band imaging
• Score
• Surface pattern
• Vascular pattern

• Aged
• Colonoscopy/methods
• Colorectal Neoplasms/diagnostic imaging
• Colorectal Neoplasms/pathology
• Colorectal Neoplasms/surgery
• Female
• Humans
• Male
• Middle Aged
• Models, Statistical
• Narrow Band Imaging/methods
• Neoplasm Grading/methods
• Neoplasm Invasiveness/pathology
• Retrospective Studies
• Sensitivity and Specificity

• Endoscopy
• Image Interpretation, Computer-Assisted

• colon
• colonoscopy
• magnification
• polyp
• surveillance

The indications for colorectal endoscopic submucosal dissection (ESD) vary in clinical practice. To establish colorectal ESD as a standard treatment, standard indications are essential. For establishing standard indications for colorectal ESD, we surveyed the preferences and criteria of endoscopists for colorectal ESD in their practices.

A multiple-choice questionnaire was sent to 27 members of the Korean Society of Gastrointestinal Endoscopy/ESD group. The indications of endoscopists for selecting ESD as a treatment for colorectal tumors ≥2 cm in diameter were surveyed.

On the basis of the preprocedural assessment of histology, adenoma with high-grade dysplasia, mucosal cancer, and shallow submucosa invasive cancer were included in the indication for ESD. Based on gross morphology, laterally spreading tumor (LST) granular nodular mixed type, LST-nongranular (LST-NG) flat elevated type, and LST-NG pseudodepressed type were included. On the basis of the pit pattern by Kudo classification, types III, IV, and V-I were included. Based on the narrow band imaging pattern by Sano classification, types II and III-a were included. Other lesions, such as sporadic localized tumors in chronic inflammation and local residual early carcinoma after endoscopic resection, were also included in the indication for ESD.

The indications of Korean endoscopists for colorectal ESD are broader than those in recent guidelines, and tend to include more benign-looking tumors. To find the appropriate indications for colorectal ESD, systematic data collection and analysis are required to reach a consensus in a timely manner.

• Colorectal neoplasms
• Endoscopic mucosal resection
• Indication

• Colonic Polyps/classification
• Colonic Polyps/diagnostic imaging
• Colonoscopy
• Humans
• Image Interpretation, Computer-Assisted/methods
• Machine Learning
• Neural Networks, Computer
• ROC Curve

• LST granular type
• diagnostic accuracy
• kappa value
• size of nodule
• subclassification

• Colorectal cancer
• Defocus information
• Dirichlet distribution
• Endoscopy
• Particle filter

• Dentate line
• Endoscopic submucosal dissection
• Hemorrhoid
• Rectal tumor

• Capsule Endoscopy
• Colorectal Neoplasms/diagnosis
• Humans
• Image Processing, Computer-Assisted
• Markov Chains
• Narrow Band Imaging/methods
• Support Vector Machine

• Acetic Acid
• Colonoscopy/methods
• Colorectal Neoplasms/diagnosis
• Colorectal Neoplasms/pathology
• Gentian Violet
• Humans
• Intestinal Mucosa/pathology
• Narrow Band Imaging/methods
• Prospective Studies
• Sensitivity and Specificity

• Japan
• clinicopathologic feature
• hyperplastic/serrated polyposis

• NBI
• NBI international colorectal endoscopic
• NICE
• SM-d
• deep submucosal invasion
• narrow-band imaging

• Adenoma/diagnosis
• Adenoma/pathology
• Carcinoma/diagnosis
• Carcinoma/pathology
• Colonoscopy/methods
• Colorectal Neoplasms/diagnosis
• Colorectal Neoplasms/pathology
• Delphi Technique
• Humans
• Intestinal Mucosa/pathology
• Narrow Band Imaging/methods
• Neoplasm Invasiveness
• Prospective Studies
• Reproducibility of Results
• Sensitivity and Specificity

• Colorectal subumucosal carcinoma
• Invasion depth
• Magnifying colonoscopy
• Narrow band imaging
• Pit pattern

• colorectal tumor
• endoscopic mucosal resection (emr)
• endoscopic submucosal dissection (esd)
• laterally spreading tumor (lst)

Narrow band imaging (NBI) is a new image enhancement system employing optic digital methods to enhance images of blood vessels on mucosal surfaces, allowing improved visualization of mucosal surface structures. Studies have progressed over the last several years, and the clinical usefulness has been demonstrated. NBI has become frequently applied for preoperative diagnosis before endoscopic submucosal dissection (ESD) of digestive tract cancers, as well as for assessment of the range of ESD for en-bloc resection of large lesions. Consensus has been reached with regard to the usefulness of NBI for detecting micro-lesions of esophageal squamous cell carcinoma indicated for ESD, for the diagnosis of the range and depth. NBI has also been attracting attention for diagnosing gastric cancer based on the observation of micro blood vessels on the mucosal surface and mucosal surface microstructures. The usefulness of NBI has been reported in relation to various aspects of colon cancer, including diagnoses of the presence, quality, range, and depth of lesions. However, as NBI has not surpassed diagnostic methods based on magnifying observation combined with the established and widely employed dye method, its role in ESD is limited at present. Although NBI is very useful for the diagnosis of digestive tract cancers, comprehensive endoscopic diagnosis employing the combination of conventional endoscopy including dye spraying, EUS, and NBI may be important and essential for ESD.

• Endoscopic submucosal dissection
• Narrow band imaging
• Digestive tract cancer