Gastroenterology

Gastroenterology

Volume 138, Issue 6, May 2010, Pages 2140-2150
Gastroenterology

Advances in Endoscopic Imaging of Colorectal Neoplasia

https://doi.org/10.1053/j.gastro.2009.12.067Get rights and content

Colon cancer screening is arguably the most important activity performed by gastroenterologists. Recent decreases in rates of death from colorectal cancer indicate that screening methods such as colonoscopy have a positive impact. There is still room for improvement, however, particularly in prevention of right-sided colon cancer. Practice issues, such as making colonoscopy more comfortable, safer, and less costly, are keys to continued success in cancer prevention. Colonoscopy techniques, technologies, and quality control measures have advanced to improve detection, classification, and removal of early neoplasias. In particular, slow, careful inspection of the colon by gastroenterologists who have been trained in lesion recognition has improved rates of detection of polypoid and flat neoplasias. Image enhancement methods such as chromoendoscopy have greatly improved neoplasia detection in patients with chronic colitis, but are not widely used because they are perceived as inconvenient. More convenient methods, such as “digital” chromoendoscopy, show promise but have had mixed results. Ultra-high magnification systems, including optical magnification and confocal endomicroscopy, can be used during the colonoscopy examination to evaluate small polyps, allowing physicians to make immediate diagnoses and decisions about whether to remove polyps. In patients with inflammatory bowel disease, improved imaging techniques could eliminate the needs for analysis of randomly selected biopsy samples and resection of all (neoplastic and non-neoplastic) polyps. It is important to maintain high standards of quality for colonoscopy examination, detection, and removal of high-risk lesions, as well as to make colon cancer screening more widely accepted and affordable for the entire at-risk population.

Section snippets

Technologies for Imaging

In the past 40 years, we have seen remarkable advancements in optical and mechanical technologies for imaging the gastrointestinal tract. Since the first creation of flexible fiber optics and flexible endoscopy,6 the field has advanced to include video imaging via electronic charge-coupled devices capable of translating light energy into electronic video signals. As electronics improved and charge-coupled device chips became more densely packaged with pixels, high-definition colonoscopy became

Standard Video Imaging

Of all the methods currently available for colonoscopy, attention to standard, high-quality technique has the greatest potential for improvement in the effectiveness of colonoscopy. Although not definitively proven, the major reason colonoscopy fails to prevent all colon cancers is likely missed precancerous polyps, including flat, sessile, and pedunculated. Studies of missed polyps, using either back to back colonoscopy, or even surgical resection specimens, suggest that up to 26% of all

Chromoendoscopy

In chromoendoscopy, intravital dyes like indigo carmine or methylene blue are topically applied onto the mucosal surface to enhance superficial patterns and contrast of pathologic versus normal mucosa (Figure 1 and Supplementary Video 1, which can be found at www.gastrojournal.org). This relatively old technique can be used in an untargeted fashion (“panchromoendoscopy”) to detect lesions or in a targeted mode to define the borders of a lesion and its pit pattern.20 In the landmark study by

Whole-Body Molecular Imaging

As novel oncological treatments increasingly strive to target molecular pathways within the cancer cell, so the need for noninvasive molecular imaging also increases. Positron emission technology has considerable promise in this regard, as positron emission technology radiotracers allow the imaging of intracellular molecular processes known to be present in malignancy. Development of therapeutics, such as antiangiogenics, which target tumor blood flow, should be closely followed with

Endoscopic Ultrasound

The role of endoscopic ultrasound (EUS) in colorectal neoplasia is limited to rectal cancer staging and restaging. Colon cancer is virtually always treated surgically, independent of local stage, due to local complications of bleeding and obstruction, thus local staging with EUS does not affect clinical management. The primary role of EUS in this setting is detection of locally advanced rectal cancers that may benefit from neoadjuvant therapy followed by surgery. Harewood et al demonstrated

Summary and Future Directions

The ability to accurate detect, classify, and stage colorectal neoplasia with advanced imaging methods has allowed substantial improvements in the care and outcomes of these patients. Prior to these advances, the majority of colorectal neoplasia requires surgical resection. With the advent of colonoscopy, most polypoid precancerous lesions could be treated endoscopically. Now with advanced methods to classify and stage neoplasia, most flat neoplasia and even early cancers can be treated with

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    Conflicts of interest Dr Wallace has received research and educational funding from Mauna Kea below the federal threshold considered for conflict of interest. He also receives research from Olympus Co and Fujinon Co. Dr Kiesslich discloses no conflicts.

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