Today, extending the discussion of NICE 3 on the ASGE SuTab tip of the week. So first of all, in today's tip, what happens if you don't identify NICE 3 features and you proceed with endoscopic resection? So here is a fairly bulky granular lesion in the sigmoid and I did go over the surface of this very carefully and did not identify NICE 3 changes and I felt that it was a candidate for endoscopic resection. So I proceeded with EMR starting at the distal end of the lesion and proceeding proximally. Now again, a bulky lesion, a little bit harder to predict the presence of cancer and the sigmoid is narrowed and angulated, which makes it harder to look at the entire surface. So you can see a lot of the EMR has been completed going very smoothly and then at the proximal end, there's an area of morphologic change that has a whitish color to it in white light and you'll see that whitish color persists when we look at it in NBI and the vascular pattern, the NICE 2 pattern is disrupted. So that is NICE 3 and it predicts that the patient has deep semicosal invasion. So I've subjected the patient to the risks of endoscopic resection, which are not enormous for EMR and perhaps were not avoidable in this case, but I think it emphasizes the need to inspect the entire surface because I ultimately stopped the procedure at this point, biopsied that area and then sent the patient to surgery. So if I had seen that upfront, I could have avoided this endoscopic resection. I wish I could say that the last case that I showed you was the only time I've been burned on that issue of doing a partial resection and then finding NICE 3 changes in a lesion that totally changed the approach, ended up having the patient go to surgery. I've had it happen a couple of times in live courses. We have a live course on EMR every month at my center and a couple of times I've done partial resections and then found NICE 3 changes. So I'm emphasizing right now the importance of taking a few minutes if necessary to look over the entire lesion. Here's a huge granular lesion in the rectum and just at the end we see a nodule. This is almost the entire circumference and so I was getting ready to inject and remove this when finally in the course of inspection in this very large lesion, I saw this nodule and this nodule has NICE 3 changes in it that we're going to see in a moment in NBI. On the left you can see intact NICE 2, under the forceps you'll see NICE 3. So when you encounter this it's going to change your approach so try as best you can to inspect the entire surface of the lesion for these NICE 3 changes. Second and a point I've made before, NICE 3 changes in the head of a pedunculated polyp are not a contraindication to endoscopic resection because depth of invasion is not a clear adverse histologic predictor in a malignant pedunculated polyp. Finally, there are likely to be times when there are changes that you're not certain about whether they represent cancer. This is one of those. This is a granular LST in the proximal ascending colon and at the proximal edge of it you can see this area that is slightly red. It's effaced. It's very flat and smooth compared to the more granular polyp, the rest of the polyp. The rest of the polyp has typical NICE 2 features and we need to look closely at this area of effacement to determine if it has NICE 3 changes and so we're going to turn on the near focus so we have magnification on that we can get with the Olympus 190 series and now we've switched over to NBI and the vascular pattern here I think is irregular but it is intact. So here's the same lesion with this morphologically different area, the effaced area within the yellow line now. So it's effaced, it's flat compared to the lumpy bumpy rest of the lesion and also the blood vessel pattern is different. Outside the yellow line you see the typical NICE 2 pattern with big brown thick vessels, long tubular pits and within the yellow line you can see that the blood vessel pattern is tighter and the vessels are more irregular. On the other hand, there still is a vessel pattern unlike NICE 3 where you often have areas that are devascularized and the blood vessels are extremely irregular, completely amorphous in their pattern. This is a pattern where there is actually vasculature present but it's somewhat irregular compared to the standard NICE 2 pattern. So this gets at the JNET classification, the Japanese NBI expert team classification. That classification is made to be used with magnifying colonoscopes that magnify actually more than we magnify with 190 series scopes when they are set on near focus. But I think most experts think we can probably in most cases apply JNET using the near focus of the 190 series Olympus scopes. But in any case, the point is there are going to be times where there is uncertainty as to whether or not cancer is present if the vessel pattern is still largely there but just different, some irregularity of the vessels. The lesion is probably a candidate for endoscopic resection. Now what I did in this case is to isolate this area during EMR and I removed it on block, this area where the yellow line is, and I sent it separately to the pathologist, pinned it to a flat surface, and it came back showing high grade dysplasia. But some would argue that the entire lesion should be removed on block, preferably by ESD. To summarize the points that we've made today, first of all, check the entire lesion for features of NIS3. If it's a very large lesion, work at it trying to see if there are any features of NIS3 before you initiate the resection. Secondly, if there are NIS3 features in a pedunculated lesion, it's okay to proceed with endoscopic resection. Go low on the stalk, get as far away as you can from that cancer so you've got an increased chance of a clear margin. As I've explained in previous tips, I like to approach all large pedunculated lesions like that. Go very low on the stalk because you can't predict very well, even in the absence of NIS3, whether or not cancer is present. So get as far away as you can from any potential cancer in the head. Third, there are going to be situations where you've got uncertainty. The vessels are intact, but the vessels are irregular. That pattern is summarized in the JANET 2B classification, and this predicts an increased risk of advanced histology. I think a reasonable rule to follow in that situation is to consider referral or on-block resection. Thanks, and see you next week on the ASGE SuTab tip of the week.

NICE 3 features

endoscopic resection procedures

deep semicosal invasion

partial resections

pedunculated polyps