ASGE Masterclass: Expert Performance Approach to Colonoscopy (Live/Virtual) | February 2026-Recognizing Invasive Pathology

Video Transcription

Video Summary

The transcript explains a systematic endoscopic approach to distinguishing benign/superficial colorectal lesions from malignant, deeply submucosal invasive cancer—because management differs. “Malignant” here generally means deep submucosal invasion (or beyond), which requires surgery, while superficial invasion (roughly <1 mm below the muscularis mucosae) can often be treated endoscopically. Pathology features such as lymphovascular invasion or tumor budding also suggest higher risk and favor surgery.<br /><br />Endoscopists first assess gross (macroscopic) appearance, then apply lesion classifications (e.g., Paris/LST subtypes) to estimate invasion risk, and finally use image-enhanced endoscopy (IEE, e.g., NBI) to confirm and target biopsy.<br /><br />High-risk macroscopic signs for deep invasion include fold convergence (“octopus sign”) with thickened folds, submucosal “expansion” or loss of lobulation (“puffer fish”), depression with a clear step-down, ulceration (not typical of superficial neoplasms), spontaneous bleeding, and a “stuck”/non-lifting appearance. In LST classification, any true or pseudo-depressed lesion carries the highest invasion risk; homogeneous granular lesions have the lowest.<br /><br />With IEE, the key warning sign is an area with absent/structureless pit or vascular pattern (“bald tire”), which should be biopsied and typically prompts tattooing and surgical referral rather than snare removal. The “valley sign” is contrasted as a benign crease seen in some small adenomas, not a true depression.

Asset Subtitle

Roy Soetikno and Tonya Kaltenbach

Meta Tag

Concept Colorectal Lesion

Concept Submucosal Invasion

Concept Endoscopic Feature

Concept Gross Morphology

Concept Lesion morphology

Keywords

colorectal lesion invasion assessment

deep submucosal invasive cancer

laterally spreading tumor (LST) classification

high-risk macroscopic signs (octopus sign, puffer fish)

image-enhanced endoscopy (NBI)

structureless pit/vascular pattern (bald tire sign)

endoscopic vs surgical management criteria

Colorectal Lesion

Submucosal Invasion

Endoscopic Feature

Gross Morphology

Lesion morphology