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

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