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Endoscopic Diagnosis and Treatment of Colorectal Cancers

Article information

J Korean Med Assoc. 2010;53(7):549-561
Publication date (electronic) : 2010 July 06
doi : https://doi.org/10.5124/jkma.2010.53.7.549
Dong Kyung Chang, MD
Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
Corresponding author: Dong Kyung Chang. dkchang@skku.edu
Received 2010 May 30; Accepted 2010 June 13.

Abstract

Colonoscopy is the best screening tool to detect colorectal cancer in early stage and also a potent arm to prevent development of cancer by removing colorectal adenoma. Superficial colorectal neoplastic lesions are primary targets of colonoscopic resection. Adenoma, carcinoma in situ, and cancer with minimal submucosal invasion are included in this category. One stage endoscopic treatment without the preceding biopsy confirmation is preferable, and thus endoscopic evaluation to identify the characteristics of the superficial neoplastic lesions is of importance. Gross endoscopic appearance and pit pattern and/or vascular pattern of the surface epithelium of the polypoid and nonpolypoid superficial lesions provide useful clue to predict histology of the lesions and depth of cancer invasion with reasonable accuracy. Appropriate treatment can be directed through this endoscopic evaluation step. Conventional snare polypectomy and endoscopic mucosal resection is mainstay of endoscopic treatment. Recently introduced endoscopic submucosal dissection facilitated en bloc resection of a large neoplastic lesion. After endoscopic resection, accurate pathologic evaluation is necessary to determine whether colonoscopic follow up or further surgical resection is needed. Poorly or undifferentiated cancers, cancers massively invading submucosal layer deeper than 1,000 micrometer, lymphovascular invasion of cancer cells, or presence of cancer cells on the resection margin are indications of further surgical resection because of the significant risk in metastasis to the regional lymph nodes. Colorectal polyps and early cancers are effectively treated by colonoscopy in most cases. Early detection by an adequate screening program is essential for this purpose.

Keywords: Colorectal polyp; Colorectal cancer; Colonoscopy; Polypectomy; Endoscopic submucosal dissection

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Copyright © 2010 Korean Medical Association

This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Figure 1

Figure 1

Conventional snare polypectomy.

Figure 2

Figure 2

Endoscopic mucosal resection.

Figure 3

Figure 3

Endoscopic mucosal resection with precutting.

Figure 4

Figure 4

Piecemeal endoscopic mucosal resection.

Figure 5

Figure 5

Endoscopic submucosal dissection.

Table 1

Guidelines for screening colonoscopy for the early detection of colorectal cancer and adenomas for average-risk women and men aged 50 years and older [1]

Table 1

Table 2

Guidelines for surveillance after polypectomy by ACS, USMTFCC, ACR [1]

Table 2

Table 3

Morphologic classification of type 0 lesions with superficial appearance at colonoscopy (Paris-Japanese classification) [11]

Table 3

*Polypoid lesions are elevated more than 2.5 mm above the surrounding mucosa. Nonpolypoid lesions are flat, elevated less than 2.5 mm, or are depressed less than 2.5 mm.

Slightly elevated lesions should not be mistaken for sessile or flat lesions.

Table 4

Subtypes of LST lesions: morphologic classification of LST lesions and their correspondence in the Paris-Japanese classification [11]

Table 4

Table 5

Categories of the pit pattern at the surface of the colonic mucosa [11]

Table 5

Table 6

Categories of the vasucular pattern at the surface of the colonic mucosa evaluated by narrow band imaging [11]

Table 6

Table 7

Endoscopic treatment methods of colon polyps or early colorectal cancers

Table 7

Table 8

Indications for ESD [22]

Table 8