An international group of endoscopists, surgeons, and pathologists gathered in Paris for an intensive workshop designed to explore the utility and clinical relevance of the Japanese endoscopic classification of superficial neoplastic lesions of the GI tract. This report summarizes the conclusions of the workshop and proposes a general framework for the endoscopic classification of superficial lesions of the esophagus, stomach, and colon. The clinical relevance of this classification is demonstrated in tables that show the relative proportion of each subtype in the esophagus, stomach, and colon, assessing the risk of submucosal invasion and the risk of lymph node metastases. In the esophagus, stomach, and colon, neoplastic lesions of the digestive tract are called ‘‘superficial’’ at endoscopy when the endoscopic appearance suggests either a small cancer or a noninvasive neoplastic lesion (dysplasia/adenoma). If invasive, ‘‘superficial’’ tumors correspond to the T1 stage of the TNM classification, in which invasion is limited to the mucosa and submucosa. ‘‘Superficial’’ tumors are nonobstructive, usually are asymptomatic, and often are detected as an incidental finding or by screening. In Japan, neoplastic lesions of the stomach with a ‘‘superficial’’ endoscopic appearance are classified as subtypes of ‘‘type 0.’’ The term ‘‘type 0’’ was chosen to distinguish the classification of ‘‘superficial’’ lesions from the Borrmann classification, proposed in 1926 for ‘‘advanced’’ gastric tumors, which included types 1 to 4. Within type 0, there are polypoid and non-polypoid subtypes. The nonpolypoid subtypes include lesions with a small variation of the surface (slightly elevated, flat, and slightly depressed) and excavated lesions. The Japanese Gastric Cancer Association (JGCA) also added a type 5 for unclassifiable advanced tumors. The complete modification for gastric tumors becomes:

The Paris endoscopic classification of superficial neoplastic lesions : esophagus, stomach and colon.

The Glasgow Coma Scale (GCS) is the most widely used scoring system for comatose patients in intensive care. Limitations of the GCS include the impossibility to assess the verbal score in intubated or aphasic patients, and an inconsistent inter-rater reliability. The FOUR (Full Outline of UnResponsiveness) score, a new coma scale not reliant on verbal response, was recently proposed. The aim of the present study was to compare the inter-rater reliability of the GCS and the FOUR score among unselected patients in general critical care. A further aim was to compare the inter-rater reliability of neurologists with that of intensive care unit (ICU) staff. In this prospective observational study, scoring of GCS and FOUR score was performed by neurologists and ICU staff on 267 consecutive patients admitted to intensive care. In a total of 437 pair wise ratings the exact inter-rater agreement for the GCS was 71%, and for the FOUR score 82% (P = 0.0016); the inter-rater agreement within a range of ± 1 score point for the GCS was 90%, and for the FOUR score 92% (P = ns.). The exact inter-rater agreement among neurologists was superior to that among ICU staff for the FOUR score (87% vs. 79%, P = 0.04) but not for the GCS (73% vs. 73%). Neurologists and ICU staff did not significantly differ in the inter-rater agreement within a range of ± 1 score point for both GCS (88% vs. 93%) and the FOUR score (91% vs. 88%). The FOUR score performed better than the GCS for exact inter-rater agreement, but not for the clinically more relevant agreement within the range of ± 1 score point. Though neurologists outperformed ICU staff with regard to exact inter-rater agreement, the inter-rater agreement of ICU staff within the clinically more relevant range of ± 1 score point equalled that of the neurologists. The small advantage in inter-rater reliability of the FOUR score is most likely insufficient to replace the GCS, a score with a long tradition in intensive care.

/pdf/inter-rater-reliability-of-the-full-outline-of-2twnqx5lp7.pdf

Inter-rater reliability of the Full Outline of UnResponsiveness score and the Glasgow Coma Scale in critically ill patients: a prospective observational study

Background and Study Aims: Neoplastic lesions in the digestive-tract mucosa are termed superficial when the depth of invasion is limited to the mucosa and submucosa. The endoscopic appearance has a predictive value for invasion into the submucosa, which is critical for the risk of nodal metastases. Materials and Methods: The endoscopic morphology of superficial lesions can be assessed with a standard video endoscope after spraying of a dye - an iodine-potassium iodide solution for the stratified squamous epithelium, or an indigo carmine solution for the columnar epithelium. In 2002, a workshop was held in Paris to explore the relevance of the Japanese classification. The conclusions were revised in 2003 in Osaka in relation to the definition of the subtypes used in endoscopy and the evaluation of the depth of invasion into the submucosa. In Japan, the description of advanced cancer in the digestive-tract mucosa using types 1 -4 is supplemented by a type 0 when the endoscopic appearance is that of a superficial lesion. Type 0 is divided into three categories: protruding (0-1), nonprotruding and nonexcavated (0-11), and excavated (0-III). Type 0-II lesions are then subdivided into slightly elevated (IIa), flat (IIb), or depressed (IIc). Nonprotruding depressed lesions are associated with a higher risk of submucosal invasion. After endoscopic resection, invasion into the submucosa is an important criterion for the necessity of additional surgical resection. Micrometer analysis of the depth of invasion in the specimen is more precise, and distinct cut-off limits have been established in the esophagus, stomach, and large bowel. Conclusions: The morphology of superficial and nonprotruding neoplastic lesions is relevant to the prognosis. Following endoscopic detection, the lesions are analyzed using chromoendoscopy and assigned a subtype of the type 0 classification. The choice between endoscopicorsurgical treatment is based on this description.

Update on the Paris classification of superficial neoplastic lesions in the digestive tract

https://www.giejournal.org/article/S0016-5107(10)01960-7/pdf

A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video).

Context Colorectal cancer is the second leading cause of cancer death in the United States. Prevention has focused on the detection and removal of polypoid neoplasms. Data are limited on the significance of nonpolypoid colorectal neoplasms (NP-CRNs). Objectives To determine the prevalence of NP-CRNs in a veterans hospital population and to characterize their association with colorectal cancer. Design, Setting, and Patients Cross-sectional study at a veterans hospital in California with 1819 patients undergoing elective colonoscopy from July 2003 to June 2004. Main Outcome Measures Endoscopic appearance, location, size, histology, and depth of invasion of neoplasms. Results The overall prevalence of NP-CRNs was 9.35% (95% confidence interval [95% CI], 8.05%-10.78%; n = 170). The prevalence of NP-CRNs in the subpopulations for screening, surveillance, and symptoms was 5.84% (95% CI, 4.13%-8.00%; n = 36), 15.44%
(95% CI, 12.76%-18.44%; n = 101), and 6.01% (95% CI, 4.17%-8.34%;
n = 33), respectively. The overall prevalence of NP-CRNs with in situ or submucosal invasive carcinoma was 0.82% (95% CI, 0.46%-1.36%;
n = 15); in the screening population, the prevalence was 0.32% (95% CI, 0.04%-1.17%; n = 2). Overall, NP-CRNs were more likely to contain carcinoma (odds ratio, 9.78; 95% CI, 3.93-24.4)
than polypoid lesions, irrespective of the size. The positive size-adjusted association of NP-CRNs with in situ or submucosal invasive carcinoma was also observed in subpopulations for screening (odds ratio, 2.01;
95% CI, 0.27-15.3) and surveillance (odds ratio, 63.7; 95% CI, 9.41-431).
The depressed type had the highest risk (33%). Nonpolypoid colorectal neoplasms containing carcinoma were smaller in diameter as compared with the polypoid ones (mean [SD] diameter, 15.9 [10.2] mm vs 19.2
[9.6] mm, respectively). The procedure times did not change appreciably as compared with historical controls. Conclusion In this group of veteran patients, NP-CRNs were relatively common lesions diagnosed during routine colonoscopy and had a greater association with carcinoma compared with polypoid neoplasms, irrespective of size.

/pdf/prevalence-of-nonpolypoid-flat-and-depressed-colorectal-3w82oq7p7v.pdf

Prevalence of nonpolypoid (flat and depressed) colorectal neoplasms in asymptomatic and symptomatic adults.

Endoscopic mucosal resection of the colon: the Japanese technique.

https://www.giejournal.org/article/S0016-5107(04)01880-2/pdf

Interobserver and intra-observer consistency in the endoscopic assessment of colonic pit patterns.

6968 Characteristics of depressed early colorectal carcinoma.

/pdf/the-characteristics-of-typ-is-iic-col-orectal-carcinoma-3e63024l3t.pdf

THE CHARACTERISTICS OF TYP Is+IIc COL, ORECTAL CARCINOMA

Pit pattern in colorectal neoplasia: endoscopic magnifying view.

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