We're going to focus initially on our first use of NBI, which is the identification of NICE 3 features. So this is an obvious cancer, but it's, I think, will show us what NICE 3 looks like, and it's got a big area of ulceration. And one of the first things that you'll find to be almost universally true is that when NICE 3 is present, there's some morphologic change on the surface of the lesion that, you know, goes along with it. The NICE 3 features are present in some form of ulceration. So the right side of this lesion, what we're looking at right now, this is NICE 2. The blood vessel pattern is regular. On the far left edge, you can see some of that. And then as we go down into this ulcer, we'll start to see that the blood vessel pattern is basically absent. Terms that are often used to describe it are amorphous, disrupted vascular pattern. It's very irregular. This is basically what NICE 3 is. So when we see this kind of disrupted pattern in what is obviously a cancer, this indicates that we've got deep submucosal invasion. Again, traditionally, this would be a reason to send the patient to surgery. If we think about this in lesions that look to be more like potential candidates, the last lesion was just an obvious cancer. Of course, it's got to go to surgery. This is a granular lateral spreading tumor in the cecum that was sent to me for endoscopic resection. So the first use that we put to MBI is to try to check the entire surface of the lesion to see whether the vascular pattern is intact. So over here on the lower right, we have NICE 2, which is an intact vascular pattern. And then down here again, you can see this morphologic area where it looks superficially ulcerated. The surface features are sort of effaced. And as we get down into it, you'll see that the blood vessel pattern that we saw up on the other parts of the lesion is basically absent, disrupted. It's very amorphous. So this is NICE 3. This is the presence of deep submucosal invasion. And when you biopsy this lesion, it's essential that you take the biopsy from the portion of the lesion that shows the abnormality. So what happens in, for example, in my referral practice is commonly that the patient is sent with a biopsy that shows adenoma, tubular adenoma, tubulovilous adenoma, something. And then when we see the lesion and we inspect the entire surface and we find some part of it that has NICE 3, and then we biopsy that specific part, we get cancer. And here you can see cancer, and you can actually measure this at more than two millimeters of invasion in the central part of this slide. So the key is to check the entire surface and then biopsy the affected area.

Narrow Band Imaging

NICE 3 features

deep submucosal invasion

cancerous lesions

irregular blood vessel pattern