Novel colorectal endoscopic in vivo imaging and resection practice: a short practice guide for interventional endoscopists

High-frequency mini probe ultrasound before endoscopic resection of colorectal polyps--is it useful?

BACKGROUND

Endoscopic resection of benign colorectal polyps and early cancer is well established. Local staging is of paramount importance to ensure that local resection is feasible. Endoscopic ultrasound has been used to evaluate the depth of lesions in the rectum, but its use in the colon is limited.

OBJECTIVE

This prospective study aims to evaluate the accuracy of 20-MHz mini probe ultrasound before the endoscopic resection of colorectal tumors.

DESIGN

All patients underwent 20-MHz high-frequency mini probe ultrasound of the colorectal lesion during colonoscopic examination. The mini probes were inserted through the working channel of the colonoscope, and acoustic coupling was achieved by instilling water to completely submerge the lesion. The depth of infiltration of the colorectal tumor was identified before resection. The lesions were sent for histological examination, and the level of infiltration was compared with the preoperative ultrasound depth.

SETTING

This study was conducted at a tertiary referral university teaching hospital.

PATIENTS

Consecutive patients referred for consideration of endoscopic resection were included in the study.

INTERVENTIONS

All patients were subject to colonoscopic high-frequency mini probe ultrasound to evaluate the depth of lesion before local resection.

MAIN OUTCOME MEASURES

There were 2 outcome measures: the ultrasound depth of colorectal lesion and the histological depth.

RESULTS

One hundred four patients were included with a mean age of 70 years. The surgical procedures included 59 endoscopic mucosal resections, 36 transanal endoscopic microsurgeries, and 9 endoscopic submucosal dissections. The 20-MHz ultrasound correctly staged 100 of 104 lesions, an overall accuracy of 96.1%. Eighty-eight of 89 mucosal lesions and 11 of 12 submucosal lesions were correctly staged.

LIMITATIONS

The ultrasound examination was performed by the main author only and is therefore dependent on his experience alone.

CONCLUSION

Colonoscopic high-frequency mini probe ultrasound has high accuracy in determining the depth of colorectal lesion and is useful before endoscopic resection.

Label-free imaging characteristics of colonic mucinous adenocarcinoma using multiphoton microscopy

Colorectal carcinoma (CRC) has high mortality and increased incidence rates. An early detection of CRC is very important. Multiphoton microscopy (MPM) with high resolution and high sensitivity is used to effectively distinguish the microstructure changes of normal and mucinous adenocarcinoma slices of ex vivo human colonic tissues. In mucinous adenocarcinoma mucosa, the glands are distorted and elongated, the gland cavity is indistinct, and the mesh collagen fibers are diminished. In the submucosa, the collagens are seriously disordered, elongated, pushed aside, and sparsely visible, the content of elastic fibers is also broken and almost disappearing. Many cancer cells, some in cavity-like shape full of mucus surrounded by some collagen fibers, occupied the submucosa, which are comparable to hematoxylin-eosin (HE) stained images. Second harmonic generation and two-photon excitation fluorescence (SHG/TPEF) intensity ratio can be used further to quantitatively evaluate normality and abnormality. The fast Fourier transform (FFT) images show that the normal collagen fibrils are dense and in random order, and the cancerous collagen is certainly organized. The exploratory results show that it has potential for the development of multiphoton mini-endoscopy in real-time early diagnosis of CRC.

In vivo endoluminal ultrasound biomicroscopic imaging in a mouse model of colorectal cancer

RATIONALE AND OBJECTIVES

The gold-standard tool for colorectal cancer detection is colonoscopy, but it provides only mucosal surface visualization. Ultrasound biomicroscopy allows a clear delineation of the epithelium and adjacent colonic layers. The aim of this study was to design a system to generate endoluminal ultrasound biomicroscopic images of the mouse colon, in vivo, in an animal model of inflammation-associated colon cancer.

MATERIALS AND METHODS

Thirteen mice (Mus musculus) were used. A 40-MHz miniprobe catheter was inserted into the accessory channel of a pediatric flexible bronchofiberscope. Control mice (n = 3) and mice treated with azoxymethane and dextran sulfate sodium (n = 10) were subjected to simultaneous endoluminal ultrasound biomicroscopy and white-light colonoscopy. The diagnosis obtained with endoluminal ultrasound biomicroscopy and colonoscopy was compared and confirmed by postmortem histopathology.

RESULTS

Endoluminal ultrasound biomicroscopic images showed all layers of the normal colon and revealed lesions such as lymphoid hyperplasias and colon tumors. Additionally, endoluminal ultrasound biomicroscopy was able to detect two cases of mucosa layer thickening, confirmed by histology. Compared to histologic results, the sensitivities of endoluminal ultrasound biomicroscopy and colonoscopy were 0.95 and 0.83, respectively, and both methods achieved specificities of 1.0.

CONCLUSIONS

Endoluminal ultrasound biomicroscopy can be used, in addition to colonoscopy, as a diagnostic method for colonic lesions. Moreover, experimental endoluminal ultrasound biomicroscopy in mouse models is feasible and might be used to further develop research on the differentiation between benign and malignant colonic diseases.

Intracellular coenzymes as natural biomarkers for metabolic activities and mitochondrial anomalies

Mitochondria play a pivotal role in energy metabolism, programmed cell death and oxidative stress. Mutated mitochondrial DNA in diseased cells compromises the structure of key enzyme complexes and, therefore, mitochondrial function, which leads to a myriad of health-related conditions such as cancer, neurodegenerative diseases, diabetes and aging. Early detection of mitochondrial and metabolic anomalies is an essential step towards effective diagnoses and therapeutic intervention. Reduced nicotinamide adenine dinucleotide (NADH) and flavin adenine dinucleotide (FAD) play important roles in a wide range of cellular oxidation-reduction reactions. Importantly, NADH and FAD are naturally fluorescent, which allows noninvasive imaging of metabolic activities of living cells and tissues. Furthermore, NADH and FAD autofluorescence, which can be excited using distinct wavelengths for complementary imaging methods and is sensitive to protein binding and local environment. This article highlights recent developments concerning intracellular NADH and FAD as potential biomarkers for metabolic and mitochondrial activities.

Regional nodal staging for early stage colon cancer in the era of endoscopic resection and N.O.T.E.S

Advanced endoscopic technologies and techniques capable of providing localized resection of colonic primaries are entering clinical practice. As much as Natural Orifice Transluminal Endoscopic Surgery (N.O.T.E.S.) may ultimately provide for transmural resection with narrow margins, intraluminal techniques such as endoscopic submucosal resection can now effect excision of early stage tumors from within the colon. However, the limit on the application of these approaches is oncological providence as current staging requires en bloc mesenteric resection in every case to ensure that adequate nodal assessment is assured. Furthermore, this requirement is also a limiting factor on the advance of innovative procedures such as Single-Incision Laparoscopic Surgery and N.O.T.E.S.-hybrid techniques as these approaches, while likely adept at the definitive management of the primary, have limitations regarding their ability to provide full base mesenteric resection (due mostly to constraints on retraction capacity as well as operating field space and exposure). Therefore a means to accurately and efficiently identify those patients who are truly node negative (and so in whom radical mesenteric lymphadenectomy could be avoided) would allow all of these techniques to advance with a clear focus on address of the primary. This review analyses the current state of the art of regional staging in the colonic mesentery in place of formal lymphadenectomy. It includes deliberation of both preoperative non-invasive testing as well as novel means of employing N.O.T.E.S. approaches to allow direct determination of lymph node status (in particular that of sentinel nodes) by either rapid histopathological examination or by emerging technologies such as Optical Coherence Tomography that may provide optical or 'virtual' biopsy.