So, good morning everyone. So, these are a few cases from my private and public practice in Mexico. So, I live in the border with California. So, it's Baja California. It's a small town Mexicali. So, we have a lot of patients with premalignant conditions. I mean, mostly in the colon. So, I'm going to show you a few cases. So, the first patient is a 50 year old patient. I mean, a healthy patient with a family history of colon cancer. So, he went to a screening colonoscopy. So, we're in the rectum. This is a lesion. So, he has no symptoms. So, there's a nodular lesion about 5-6 centimeters from the anal verge. So, it's like a nodular lesion between 1.5-2 centimeters. So, there's a magnification image. So you have any questions from the faculty? Yeah, let's see the video a little bit more, then I will ask some questions to the audience. This is really, yes, gross appearance. For me, this looks like invasive cancer, but because of small region size, somebody wants to remove by endoscopic means. Is there anybody wants to do endoscopic resection for this case? Everybody agree not to do endoscopic resection? Is this the biopsy or what? Biopsy? No, no, no, no, no, so this is the first, the first. So the result was adenocarcinoma. What is the location of this case? Well differentiated, I'm sorry? What is the location of the region? It's six centimeters. So lower rectum. Yeah, lower anterior section, but if you try to remove. Could you use a microphone? Yeah, if you try to remove it endoscopically, then you can convert potentially resectable cancer into contamination of the peri-rectal space and then radical surgery will not be possible. I would strongly against attempt of endoscopic removal. But what about doing an endoscopic ultrasound confirming that it's limited to the mucosa without any evidence of submucosal invasion? It would not help because this is invasive cancer. The endoscopic ultrasound can answer correctly if there are any lymph nodes around the rectum, but the depth of invasion will not be reliable to determine with that. I would not risk it. But we sometimes perform EUS to confirm the really deep submucosal invasion. But the gross appearance of this region is a typical invasive cancer because we can see the clear demarcation line and also very sick neoplasmic vessels around the region. And also, it is very important to recognize the irregularity of the deepest area. So even though this is a really small region, this is typical really deep submucosal invasive cancer. I would like to ask Dr. Saito to give us some comment for this region. Yes, I absolutely agree with Professor Ehaghi's diagnosis. The macroscopic appearance, the Paris classification is 0 to A plus 2C. And in the BLI with magnification, you are really showing us the very beautiful image of the magnified BLI of the depressed component. And in the BLI, we could see the normal mucosa around the region. So that's why this is a non-polyploid growth cancer. And the BLI magnification, I diagnose the J-Net type III. J-Net type III suggesting SMDP invasive cancer. So the therapeutic strategy is surgery with lymph node dissection. Of course, in the future, maybe there are some possibility endoscopic R0 resection with chemotherapy will be the future option. But at this moment, still the treatment should be surgery. I think it is important to just separate those words. You know, invasive cancer is invasive cancer. If it's superficially invasive, still invasive cancer. So what we're talking about is a deeply invasive, which is a higher risk for lymph node metastasis. If it's shallow invasion, on the other hand, then there's an option to remove it with the ESD and get the precise pathological diagnosis as well. Especially in United States, we have so much of comorbidities. Patient is in an unfaithful surgery, and patient frequently want the cancer to be removed, but surgery is not possible. Let's say BMI is 45, there's morbid obesity with diabetes and cardiac condition. I think if this is potentially superficial invasion, then option to do endoscopic resection is viable. This is great pictures, by the way. I see that the wall deformity behind it, too, there's a slight convergence, convergency. I mean, that make me worried, really worried for deep invasion already. So I agree that I wouldn't necessarily take this out, but those are two different things we're talking about. Invasive cancer is not only thing. Superficially invasive or deeply invasive. In the lesion with maybe more subtle features, would you try and lift it to see if there's a lift and then, based on that, attempt resection? And if there's no lift, maybe say we won't resect it? I think the non-lifting sign is not a good indicator for the resectability. Sometimes the smoke plastic reaction below the lesion cause non-lifting sign, even though invasion depth is less than 1,000 micrometer. Yeah, I think what we're saying is it could be removed, but it's a deep semicosm invasive. So if you took it out, it might still be a stage one rectal cancer, but the risk of lymph node metastasis is kind of unacceptably high. So then, even if you take it out, they might still need surgery. So then you're not helping them. And the other situation is that sometimes you encounter a lesion like this, you take a biopsy. You know, you suspect cancer, right? But you take a biopsy, it shows high-grade dysplasia. You still suspect cancer, right? Do you go back in and try and do a resection at that point in time? Or do you go back in and do more biopsies? Location of taking biopsy is very important. If you take a biopsy from the lateral side, probably it will be very difficult. So we carefully check the morphology of the target lesion and select the appropriate area, which is depressed area in this case. If you remember, the first case I presented was T2 cancer. That was actually measured seven millimeter invasive cancer. So the size itself is not really indicative of the endoscopic treatment versus surgery. And that one actually, I biopsied, still came back as high-grade. So it was very difficult to convince everybody, but this is invasive, deeply invasive, not endoscopic treatment, so it's sent for surgery. I think those are the important thing to think about. Yeah, Norio, so that's a discussion point. Because in Japan, the pathologist could diagnose the interim causal cancer based on the nuclear ATP and the structure ATP. But in the Western countries, the pathologist doesn't diagnose cancer, even only when the cancer invaded some causal layer. That's why the biopsy in the West doesn't change the treatment strategy. How do you think about the difference between the Japan and the West for the histopathological diagnosis? Right, as you eloquently expressed, the site pathological finding is not translated to invasive cancer in Western pathologists. However, they look at the crib reforming, stromal changes. If they see abnormal stroma, they tend to call suspected invasive. So they don't look at just the cells, but the surrounding structure as well. So if you take a good chunk of biopsy, there is a good chance that they will call it invasive, even though there's no semicausal tissues involved. So you took the biopsy and it came up like high-grade dysplasia, but endoscopically there is a high concern. It could be more invasive. So I think the problem, one, it's in the rectum, and if you send him to the surgery, patient may end up with permanent colostomy. Most likely he need a period of remnant resection. So I think it's maybe very difficult to convince a surgeon to proceed with that kind of invasive surgery. So how do you communicate with them to convince them this? Is this the rectum? Yes, it's the rectum. High rectum? Middle rectum. Oh, I see. Six centimeter from the anus. Got it. Our surgeon made a huge complaint to me when we start doing the rectal ESD for cancer, because they want all the imaging study first to make a plan together. So if this is a cancer, the EOS definitely in the rectal area, EOS is helpful, slightly better T-staging than for early cancer than MRI, but they really want the MRI, the rectal MRI imaging beforehand. It was T2. It was T2 on the MRI? Yeah. So there's no convincing that they would know. Yeah, don't touch it. I think that, I think in the- We are doing some study about MRI reading, and sometimes, many times, even MRI show T3. Sometimes we can do ESD for tuberovirus adenoma, but for this case, I really agree to send a surgery, but based on Sloan's coronal colorectal surgeon study, they do neoadjuvant chemo. That's right. Neoadjuvant. So the current trend is to offer neoadjuvant even for T2 lesions. And they said 40% cancer disappear, and 20% cancer came back. So they are now figuring out which patient can reserve colon, rectum, and they're sending the residual adenoma for ESD form. So we are doing a cell-based ESD for adenomatous tissue. The rectal cancer is just a different beast. The recurrence rate is so high with even surgery, so the multimodal therapy is really needed. So if this is cancer, proven cancer, we really have to discuss in a multidisciplinary fashion. Sure. Okay, go ahead, please. Okay, the second one is a 70-year-old male. So he underwent colonoscopy. So he has hypertension, also diabetes. So he went to colonoscopy because of chronic diarrhea. So the lesion, it's in the descendant colon, right? So, there were no other particular findings, instead, very small polyps in the right colon. I think it was a sessile serrated adenoma, but it's the most important finding in the colonoscopy of the patient. So, unfortunately, it was the colonoscopy wasn't performed with magnification, so it's a regular colonoscope. So, I tried to do the procedure underwater to fully interrogate and characterize the lesion, yeah. This is also a wonderful case, which we can see the typical appearance of laterally spreading tumor with granular type. It's a kind of mixed granular type. I'd like to ask Dr. Saito again to give some comment to this region. Yes, this is a typical LST granular nodular mixed type, 1S plus 2A. And the estimate size is more around the four centimeter or less, so the, well, even without magnification, J-net classification could be type 2A. But for this kind of region, when the tumor size is larger than two centimeter or larger than three centimeter, the enbroke resection by conventional EMR is really challenging. And this could be focal cancer in adenoma, so our treatment strategy is enbroke resection using ESD for this region. This is very good candidate for ESD. Is there any question or some comment? In addition, for this kind of LST granular nodular mixed type, 20% of subcausal penetration could be occurred without under the large nodule or depressed component. That's why we recommend the enbroke resection. That's true. As you mentioned, even without magnification function, if we perform BLI or NBI observation underwater condition, we can get slight magnification effect. So that's why we can see the nice structure on this video image. That is really useful technical tip when we cannot use magnification function. Oh, you have electric magnification. Yeah, that's the digital magnification, yeah. So it tends to pixel, yeah. By the way, what did you do for this patient, EMR or something? So this is my first course of ESD, so I perform an EMR, yeah. Okay, that will be fine. Okay, next case, please. Okay. So this is a 53-year-old patient, a female patient who underwent colonoscopy because of a chronic diarrhea. So she has a history of T2 breast cancer. So we are working right now on the cecum of the patient. So this is like a kind of a long video. So it was a very tricky colon. So I was working with a pediatric colonoscope, so it was very hard to stay in the position. So I was washing, cleaning all the lesion and to fully interrogate. It's very important if there are lots of mucus or dirty stuff on the surface, we cannot see anything, especially for a flat region like this. But once we clean the lumen, we can get enough information. Yeah, we work with saline solution to clean the mucus, but sometimes it's kind of hard. Right behind that lesion, there's another lesion. Question. Does anybody use acetic acid anymore to spray and get a better assessment of the margins? Because that's where I'm thinking we would have an issue here, is really assessing the accurate margins in this lesion. We sometimes use acetic acid, especially under water conditions, we can nicely fix the surface structure. But in case of looking at the vascular structure, we should avoid using acetic acid. Could you hold the video a little bit more to show the tiny lesion behind the hole? Ricardo, the irrigation is very nice, but frequently we're so impatient, we increase the power and irrigate with a really rapid stream. And this is very nice. Is this like 50%, 60%? Because if you do it with really high pressure, you're going to make it bleed and you cannot evaluate. Oh, this is not the same one, different one. Oh, there you go. Stop. Yeah, yeah, yeah. By the way, do you have a setting, a foot pump? Sorry? You're using a foot pump, right? I use a Stratus pump. What? Which one? The Stratus pump from US Endoscopy, formerly known as US Endoscopy. Okay. So I don't like to use too much pressure because it forms a lot of bubbles. Yeah, and I hate bubbles. Yeah, that's a good point. Yeah. If you use high pressure water irrigation, it sometimes causes bleeding, which disturbs the following observation of the target region. Especially for the cancerous region, it easily bleeds a lot. Okay. Okay, this is the area of concern. What do you think about this region, Dr. Tsunaya? It seems to be 2C, but we want to see much more clearly. We can only see partially. But the region size must be around five millimeters in the diameter. Yeah. It's a very small region, but it's a typical appearance of 2C. It's quite a rare situation in the colon. Dr. Saito, do you have any comments? Could you see another image or white light? So you are really nicely observing the region with BLI image under water condition. But as for us, maybe even with NBI or BLI capability, we first observe the entire region with a white light image. And we look for the redness or depressed component. And then focusing on the focus point with NBI or BLI with magnification. Dr. Saito, frequently we use additional tool, like in the United States, probably biopsy forceps. It just holds the wall. Would you suggest any other tools to stabilize? Oh, yeah. What are you using? We are using the non-traumatic catheter to spray the endocrine or crystallized staining. It's really useful to stabilize the colon and to take a picture with very focused. Thank you. Ricardo, please. This is an image with acetic acid. Beautiful. We can see the nice surface structure with acetic acid spraying. 1.5. So I guess this small area is completely separated from the inner side. This is independent region, I guess. And the inner side is typical appearance of low-grade adenoma. But what do you think, Dr. Saito, for this small region? Oh, this is really beautiful to see region. It's quite rare in the colon. But still, after acetic acid spray, we could see some surface pattern in the depressed component. So this could be intramucosal cancer or high-grade dysplasia. That means this is a very good candidate for endoscopic resection. If this small region exists alone, we can do simple EMR for this case. But together with the low-grade adenoma located very close to this region, of course, we can perform ESD if you have enough skill. So I have a question for the faculty. So what is the experience with a patient with a flat lesion, and the patient is taking NSAIDs or aspirin, and then you check the surface, and then you stage the lesion, and you schedule the patient for a procedure next month, and then the lesion is not the same? A few months interval is okay. Usually, morphology and size doesn't change a lot. In case of waiting more than half a year, that will be a problem. But in case of waiting just a few months, there will be no problem, I guess. Do you agree? Okay. So do we move to another case? Yeah. By the way, what did you do for this case? No, no. I'm going to schedule the patient for an EMR. Oh, okay. Yeah, yeah, yeah. I think a big-time EMR. Let's move on to the next. Do you take biopsy? No. No, I didn't take biopsy. It wasn't up to biopsy. Don't take biopsy. Yes, because if we take biopsy, it will cause some fibrosis under the lesion, which disturbs following endoscopic resection. Especially EMR is not possible after biopsy. We usually take biopsy from the colonic region only for the case which we are planning to do surgical resection. If we are planning to do endoscopic resection, we should avoid taking biopsy because of the risk of having fibrosis. Yes, please. No, it wasn't on the CCAM. It's the CCAM, yeah. Yeah, yeah, yeah. One thing I wanted to raise the question to the U.S. physicians. The current recommendation, less than 10 millimeter, is cold snare, right? You might think, oh, this is small. We can take a cold snare. The problem is you may not get adequate semicosal or margin with a cold snare. I advocate those important lesions always use saline or fluid-assisted EMR, not the cold snare. Do you agree? Yes, of course. The next case is a 69-year-old male patient with a personal history of colon cancer. He went and left hemicolectomy about three or four years ago. This is a surveillance colonoscopy. Right now, we are in the transverse colon. So what do you think the participants maybe I'm sorry torturing you Dan what do you think? 2A plus C lesion I didn't get the whole size of it but looks about like I'd say 25 millimeters the whole thing it's on a fold the C portion maybe a J net 3 and yeah it looks depressed here as well could be some submucosal invasion maybe superficial the location is a tough one to do an ESD but do you want to ask him to do something else or this is adequate yeah I mean we would need to look behind the fold thank you yeah that's more important part so we don't we haven't seen the beyond there were there were chicken skin so it was a finding so I tried to do retroflexion view but I can't it wasn't very difficult so I think there's a better image of the posterior side of the lesion just a quick question if you know this lesion or if you let's say you saw pictures of it before and it was being referred to you would you go with a cap on the tip of your scope to just ahead of time to know that you can it would assist you in kind of assessing the whole lesion transparent food sometimes helpful to observe especially behind the hold we sometimes use yes cap and dr. Saito do you have any suggestion to observe entire region much better yeah again they're using the non-traumatic catheter or some the snare or a catheter to push the normal mucosa of the inner side of this region you could observe the depressed component in detail and endoscopic diagnosis for this region could be our 1s plus 2c LST ng non-granular type flat elevated type so my genet classification the mainly genet type to be even in the right side protruded vision but of course we need a chromoscopy or pit pattern diagnosis for the in more correct detail diagnosis but the at this moment this could be interim cause out to SM superficial cancer so good indication for endoscopic resection and unbroke easily unfortunately crystal violet staining is not available here in the United States what should we do in this situation or could you use the indiochloromine spray indiochloromine no so my association the acetic acid is one of the alternative for evaluating the detail the pit pattern I have a question so it's no room for something like hybrid DSE maybe it's possible because of the small region size but be careful not to injure the muscle layer because it's located on the house to our hold in case of applying snare wire after making circumferential because our incision it tends to go really deep so there will be some risk of having big perforation when we conduct the hybrid the EMR I would say if you're thinking of hybrid you need to when you do hybrid you really have to dissect away any area of fibrosis so you don't want to take a snare to it until it fully lifts off so you would have to dissect across that fold so you would be doing a lot of dissection also you know it seems like you're having trouble with stabilization so this is this would be a great case to use you know like an overtube that could get you deeper and then retroflex and certainly if you have access to a better retroflexing scope like a Olympus 190 TL that would be helpful because you're gonna have to approach a lot of this in a retroflex position and it might be even more stable in a retroflex position and it'll also help you assess the backside so I think you have to look at the backside before really even planning this resection. This is not your first ESD. If the patient breathing is affecting your scope of movement and if you cannot stabilize I can ask we can ask the anesthesiologist to intubate and also also the pediatric colonoscopy is very stable. And also yeah pocket occlusion method also yeah you can stabilize. Okay let's go ahead. Okay this is an 86 year old patient who underwent colonoscopy because constipation so he has personal history of Parkinson's disease. So we are working on a paddock flexure. So the colon was very very dirty so it has also fecal material on the right side. Thank you. So, is there any opinion from the audience regarding this region? Is this a good candidate for endoscopic resection or already become a surgical candidate? What is the diagnosis? Go ahead, please. Go ahead, please. Any other comments? Everybody agree? Dr. Saito, could you give us some comment? Oh, yeah. Thank you for showing us really beautiful images. This could be LSD energy flat elevated type or pseudo depressed type. The focus area is the center slightly depressed component. And with BLI image, there are some, the mucus exists. But maybe the vessel pattern is distorted and the surface pattern is almost vascular. So, I suspect the J-net type 3 and suggesting some cause a deep invasion in the center depressed component. And there is certain deformity at the center part. So, I also strongly suspect that some cause an invasion. Do you have any comment? What did you do for this patient? Surgery. Oh, surgery. Yes. And do you get the feedback? Yeah, it was adenocarcinoma. It was T2, T3? T2, T3. T3. It's surprising. Yeah, like six to seven symptoms, positives. So, it was the right decision not to touch this region. Yeah. So, the next case? Yeah. One comment with those you didn't demonstrate, but for American physician, you know, we try to see all these different patterns and we're sometimes not so sure. It's really center is a little more deformed. The best way is to see the wall deformity. So, I always do the changing air insuffilation, desuffilate. If this shape doesn't change, don't touch it. It's just already too deep. That's more of a simplified judgment. If you insuffilate, the configuration take photo, desuffilate, take photo, and it looks exactly the same, that's already really deep. Most likely T2 or deeper. Okay. That's it. Thank you so much. Great presentation. Thank you.

colonic lesions

endoscopic resection

descending colon

endoscopic submucosal dissection

cecum

transverse colon

surgical candidate