Flat Lesions Research Articles

Visibility evaluation of colorectal lesion using texture and color enhancement imaging with video.

ObjectiveTo evaluate the visibility of colorectal lesions using a novel image processing algorithm, texture and color enhancement imaging (TXI), that allows the acquisition of brighter images with enhanced color and surface structure.MethodsDuring August–September 2019, patients referred for endoscopic treatment were prospectively recruited. Electronic data acquired while observing colorectal lesions using white light imaging (WLI) were obtained and recorded: WLI, TXI mode1 (with color enhancement), and TXI mode2 (without color enhancement) videos were constructed. The lesions were also recorded using narrow‐band imaging (NBI) from the same perspective as WLI. Four video clips (WLI, TXI mode1, TXI mode2, and NBI) were made per lesion. Thereafter, video files for evaluations were prepared by randomly arranging all video clips. Finally, visualization scores were evaluated by four endoscopists, and the WLI, TXI mode1, TXI mode2, and NBI results were compared.ResultsOverall, 22 patients with 68 lesions were recruited; the video file for evaluation subsequently comprised 272 randomly arranged video clips. Mean visualization scores using WLI, TXI mode1, TXI mode2, and NBI were 70.0 (±20.1), 80.5 (±18.6), 75.6 (±18.1), and 69.0 (±20.6), respectively. Mean visualization scores for flat lesions using WLI, TXI mode1, TXI mode2, and NBI were 64.1 (±21.2), 76.5 (±20.18), 71.8 (±19.4), and 64.2 (±22.0), respectively. Visualization scores using TXI mode1 were significantly better than those using WLI, TXI mode2, or NBI.ConclusionsTXI enables improved visualization of colorectal lesions, even flat lesions, than WLI and NBI. TXI may allow better detection of colorectal lesions, although further prospective studies are required.

Non-demarcated nodular and flat lesion in the oropharynx associated with immunoglobulin G4-related disease.

Non-demarcated nodular and flat lesion in the oropharynx associated with immunoglobulin G4-related disease.

Predictors of pathologic complete response in patients with residual flat mucosal lesions after neoadjuvant chemoradiotherapy for locally advanced rectal cancer.

The accurate prediction of tumor response to neoadjuvant chemoradiotherapy (nCRT) remains challenging. Few studies have investigated pathologic complete response (ypCR) prediction in patients with residual flat mucosal lesions after treatment. This study aimed to identify variables for predicting ypCR in patients with residual flat mucosal lesions after nCRT for locally advanced rectal cancer (LARC). Data of patients with residual flat mucosal lesions after nCRT who underwent radical resection between 2009 and 2015 were retrospectively collected from the LARC database at Peking University Cancer Hospital. Univariate and multivariate analyses of the association between clinicopathological factors and ypCR were performed, and a nomogram was constructed by incorporating the significant predictors. Of the 246 patients with residual flat mucosal lesions included in the final analysis, 56 (22.8%) had ypCR. Univariate and multivariate analyses showed that pretreatment cT stage (pre-cT) ≤T2 (P=0.016), magnetic resonance tumor regression grade (MR-TRG) 1-3 (P=0.001) and residual mucosal lesion depth =0 mm (P<0.001) were associated with a higher rate of ypCR. A nomogram was developed with a concordance index (C-index) of 0.759 and the calibration curve showed that the nomogram model had good predictive consistency. The follow-up time ranged from 3.0 to 113.3 months, with a median follow-up time of 63.77 months. The multivariate Cox regression model showed that the four variables in the nomogram model were not risk factors for disease-free survival (DFS) or overall survival (OS). Completely flat mucosa, early cT stage and good MR-TRG were predictive factors for ypCR instead of DFS or OS in patients with LARC with residual flat mucosal lesions after nCRT. Endoscopic mucosal re-evaluation before surgery is important, as it may contribute to decision-making and facilitate nonoperative management or organ preservation.

CD47-targeted optical molecular imaging and near-infrared photoimmunotherapy in the detection and treatment of bladder cancer

Transurethral resection of bladder tumor (TURBT) followed by intravesical therapy remains the most effective strategy for the management of non-muscle-invasive bladder cancer worldwide. TURBT has two purposes: to remove all visible tumors and to obtain tumor specimens for histopathological analysis. However, the detection of flat and small malignant lesions under white-light cystoscopy is extremely challenging, and residual lesions are still the main reason for the high recurrence rate of bladder cancer. We hypothesized that visual enhancement of malignant lesions using targeted optical molecular imaging could potentially highlight residual tumors in the bladder during surgery, and near-infrared photoimmunotherapy (NIR-PIT) could kill exfoliated cancer cells and residual tumors. A mouse model of complete or partial bladder tumor resection was established under the guidance of optical molecular imaging mediated by indocyanine green and anti-CD47-Alexa Fluor 790, respectively. Once the tumor recurred, mouse model received repeated CD47-targeted NIR-PIT. After complete resection, there was no tumor recurrence. Furthermore, the growth rate of recurrent tumor decreased significantly after repeated NIR-PIT. Therefore, CD47-targeted optical molecular imaging can potentially assist urologists to detect and remove all tumors, and repeated NIR-PIT shows the potential to reduce tumor recurrence rates and inhibit the growth of recurrent tumor.

Dermoscopic and histopathological correlation in macular hyperpigmented facial lesions

Background/Aim: Solar lentigo, seborrheic keratosis, actinic keratosis, lentigo maligna are confusable hyperpigmented lesions. Dermoscopy is an important tool to distinguish the pigmented lesions on the face. This study aimed to determine the reliability of dermoscopy by comparatively analyzing dermoscopic findings with the histopathologic examination of facial hyperpigmented flat lesions. Methods: Patients with hyperpigmented flat lesions on the face such as solar lentigo, seborrheic keratosis, and actinic keratosis were included in this retrospective cohort study. Those with other causes of facial hyperpigmentation were excluded from the study, based on history, clinical evaluation, Wood's lamp examination, and dermoscopic findings. The dermoscopic criteria form, prepared for solar lentigo, seborrheic keratosis, actinic keratosis, and lentigo maligna were filled out. Biopsy was taken for histopathologic evaluation. Results: Fifty-one patients, 26 males, and 25 females, with 53 skin lesions were evaluated. We did not statistically evaluate 3 lesions that had a histopathologic diagnosis of actinic keratosis + solar lentigo. The other 50 lesions’ histopathologic diagnoses were actinic keratosis in 32 lesions, seborrheic keratosis in 9, and solar lentigo in 9. Kappa test was used for statistical analysis, which revealed a value of 0.645 (P

Congenital Epidermodysplasia Verruciformis in Skin of Color: New Dermoscopic Features.

Sir, Epidermodysplasia verruciformis (EDV) is a rare inherited disorder associated with infection of human papillomavirus (HPV). Only a few authors have described the dermoscopic features in EDV.[123] We hereby describe newer dermoscopic features in a rare case of congenital EDV in an Indian family. A 24-year-old female presented to us with multiple white to reddish-brown coloured flat lesions on the trunk, and upper and lower limbs since birth. Her two children, that is, a six year old girl and four year old boy also had similar lesions. However, there was no similar history among the parents or siblings of the patient. Cutaneous examination revealed multiple well-defined erythematous to hypopigmented macules resembling pityriasis versicolor (PV) along with multiple well-defined, verrucous dark-brown coloured plaques of size approximately 1 × 1 cm2 on chest, abdomen, back, and all extremities [Figure 1a and b]. Other dermatological and systemic examination were normal. Complete blood count, serum biochemistry, and urine analysis were normal. Human immunodeficiency virus (HIV), Hepatitis B antigen (HbsAg), and anti-Hepatitis C antibodies (anti-HCV) serology were non-reactive.Figure 1: (a and b) Multiple well-defined hypopigmented (pityriasis versicolor-like) and dark brown keratotic lesionsDermoscopy was done using Dermlite DL-4 under 10× polarized mode. It revealed hypopigmented to erythematous background with red dots, white scaling, and slight crusting in hypopigmented/PV-like macules [Figure 2a]. Margins of most of the lesions had a characteristic continuous scaling [Figure 2a and b]. Verrucous plaques showed brownish-black areas admixed with hypopigmented areas [Figure 2c]. Histopathological examination of skin biopsy showed basket-weave hyperkeratosis, parakeratosis, and mild acanthosis of epidermis. Keratinocytes in the superficial layers were enlarged and swollen with abundant basophilic cytoplasm containing numerous round keratohyaline granules did not mention about vacuolation? Upper dermis showed mild perivascular lymphoplasmacytic infiltrate [Figure 2d]. A final diagnosis of EDV was made. The patient was started on oral isotretinoin.Figure 2: (a) Hypopigmented (pityriasis versicolor-like) lesions: Showing hypopigmented to erythematous background with red dots (orange arrow) and lesional white scales (green arrow) and continuous marginal scaling (black arrows). (b) Continuous marginal scaling (black arrows), brownish-black areas admixed with hypopigmented areas (pink arrows).(c) Admixture of hypopigmented areas with brownish-black areas (red circle). (Dermlite DL-4;10× polarised mode) (d) Basket weave hyperkeratosis and parakeratosis and enlarged keratinocytes with swollen abundant basophilic cytoplasm containing keratohyaline granules (H&E 40x)EDV is characterised by an impairment of cell-mediated immunity which results in disseminated skin eruptions by HPV clinically presenting with lesions resembling PV, verruca plana, and seborrheic keratosis (SK). There are very few reports of EDV, wherein dermoscopic features have been described.[123] Dermoscopy of lesions in EDV has shown demarcated hypopigmented to erythematous background with scaling, unfocused dotted vessels, and diluted hair pigment. SK-like lesions have demonstrated comedo-like openings with abrupt border.[12] Similar findings were seen in our patient except in any lesion, we did not observe dilution of hair pigment, comedo-like opening, or milia-like cysts. Additionally, we observed an admixture of brownish and hypopigmented background with brown globules and a characteristic marginal continuous scaling. These newer features observed in our patient might be due to different skin type and stages of the lesions than the previous reports. A similarity in dermoscopy of different lesions of EDV has been attributed to common etiology.[1] On dermoscopy, the admixture of different areas might also be due to the common etiology and it could be showing different stages of the EDV, which are not yet seen clinically. More such case reports and long-term follow-ups are needed to understand definitive dermoscopic features which would assist in the early diagnosis of malignant transformation. We hereby report this case due to its rarity and paucity of literature regarding its dermoscopic features. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgements Renuka Verma, M.D. Pathology, Assistant Professor, Department of Pathology, Pt. BD Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India (For histopathology pictures).

Annular lichenoid diseases

Annular lichenoid diseases encompass a diverse range of pathologies that present as circular, raised, or flat lesions that may vary in size and number. Examples include annular lichenoid dermatitis of youth, annular lichen planus, erythema dyschromicum perstans, erythema multiforme, fixed drug eruption, lichen sclerosus, neonatal lupus, porokeratosis, subacute cutaneous lupus erythematosus, and lichenoid syphilis. Clinical morphology and histopathology can differentiate these entities.

Autosomal –dominant epidermodysplasia verruciformisun satisfactorily treated with ingenol mebutate: a case report

Background: Epidermodysplasia verruciformis (EV) is a rare, usually autosomal-recessive inherited disorder characterised by development of flat wartsortinea versicolor-like lesions on sun exposed area caused byspecific human papillomavirusis (HPVs). Several nonsurgical treatment modalities were tried with temporary results, but successful treatment of EV with ingenol mebutate (Picato) has been reported recently. In this case, autosomal-dominant EV unsatisfactorily treated with ingenol mebutate is shown. Case: A 58-year-old woman with EV was unsuccessfully treated with traditional therapeutical modalities. Ingenol mebutate (0,5%) was administered for 2 days and a significant improvement in lesion reduction was achieved. However, after 2 months there was a recurrence with the appearance of new lesions and an increase of existing ones. Conclusion: This report is another confirmation that EV remains a therapeutic challenge.

A Case Report on Ayurvedic Management of Perimenopausal Bleeding

Perimenopausal period is the transitional period where a woman passes from the reproductive to the non-reproductive stage. Abnormal uterine bleeding in the perimenopausal period accounts for 70% of all gynecological problems. Most of the abnormal uterine bleeding in this period is due to endometrial abnormalities. In Ayurveda the condition can be correlated to Asrigdhara. This is the case report of a 54 year aged lady who presented with complaints of excessive bleeding and frequent menstrual cycles since three months. Investigations were done to rule out malignancy. USG report showed endometrial hyperplasia of 17mm with bulky uterus. Pap smear and Colposcopy reports showed inflammatory and CIN I changes with HPV flat lesions respectively. Bleeding stopped after two weeks of internal medication. USG done after six months showed significant reduction in endometrial thickness. Pronounced changes were also seen in Pap smear and Colposcopy findings.

Comparison of precutting endoscopic mucosal resection and endoscopic submucosal dissection for large (20-30mm) flat colorectal lesions.

The complete and safe removal of large (≥20mm) colorectal lesions is an area of concern. Endoscopic submucosal dissection (ESD) effectively removes these lesions compared with endoscopic mucosal resection (EMR). However, ESD requires advanced techniques, longer procedure time, and high cost. Precutting EMR (EMR-P) is a modified EMR method that overcomes the limitations of EMR. This study aimed to compare the efficacy and safety of EMR-P and ESD in large (20-30mm) flat colorectal lesions. This was a retrospective analysis of cases in which 20- to 30-mm flat colorectal lesions were resected at Seoul St. Mary's Hospital from January 2014 to December 2019. Propensity score matching was performed to control for possible confounders. Two hundred and ninety-nine patients were included in this study. After matching, 90 patients were assigned to each group. There were no significant difference in complete resection rates (92.2% vs 92.2%, P=1.000), en bloc resection rates (95.6% vs 97.8%, P=0.682), and mean size of lesions (22.9±3.1mm vs 23.0±3.1mm, P=0.867) between EMR-P and ESD. Procedure time was significantly shorter with EMR-P (11.0±6.5min vs 37.0±19.3min, P<0.001). The adverse events rate was not significantly different between both groups. No local recurrence occurred in both groups. Precutting EMR was not significantly different to ESD in terms of complete resection rate and en bloc resection rate for 20- to 30-mm flat colorectal lesions without fibrosis. Furthermore, EMR-P has shorter procedure time than ESD. EMR-P could be considered one of standard treatments for large flat colorectal lesions.

Tumor Microenvironment in Pancreatic Intraepithelial Neoplasia.

Simple SummaryPancreatic ductal adenocarcinoma (PDAC) is a very aggressive neoplasm with a poor survival rate. This is mainly due to late detection, which substantially limits therapy options. A better understanding of the early phases of pancreatic carcinogenesis is fundamental for improving patient prognosis in the future. In this article, we focused on the tumor microenvironment (TME), which provides the biological niche for the development of PDAC from its most common precursor lesions, PanIN (pancreatic intraepithelial neoplasias).Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive tumors with a poor prognosis. A characteristic of PDAC is the formation of an immunosuppressive tumor microenvironment (TME) that facilitates bypassing of the immune surveillance. The TME consists of a desmoplastic stroma, largely composed of cancer-associated fibroblasts (CAFs), immunosuppressive immune cells, immunoregulatory soluble factors, neural network cells, and endothelial cells with complex interactions. PDAC develops from various precursor lesions such as pancreatic intraepithelial neoplasia (PanIN), intraductal papillary mucinous neoplasms (IPMN), mucinous cystic neoplasms (MCN), and possibly, atypical flat lesions (AFL). In this review, we focus on the composition of the TME in PanINs to reveal detailed insights into the complex restructuring of the TME at early time points in PDAC progression and to explore ways of modifying the TME to slow or even halt tumor progression.

Performance of artificial intelligence for detection of subtle and advanced colorectal neoplasia.

There is uncertainty regarding the efficacy of artificial intelligence (AI) software to detect advanced subtle neoplasia, particularly flat lesions and sessile serrated lesions (SSLs), due to low prevalence in testing datasets and prospective trials. This has been highlighted as a top research priority for the field. An AI algorithm was evaluated on four video test datasets containing 173 polyps (35,114 polyp-positive frames and 634,988 polyp-negative frames) specifically enriched with flat lesions and SSLs, including a challenging dataset containing subtle advanced neoplasia. The challenging dataset was also evaluated by eight endoscopists (four independent, four trainees, according to the Joint Advisory Group on gastrointestinal endoscopy [JAG] standards in the UK). In the first two video datasets, the algorithm achieved per-polyp sensitivities of 100% and 98.9%. Per-frame sensitivities were 84.1% and 85.2%. In the subtle dataset, the algorithm detected a significantly higher number of polyps (P < 0.0001), compared to JAG-independent and trainee endoscopists, achieving per-polyp sensitivities of 79.5%, 37.2% and 11.5%, respectively. Furthermore, when considering subtle polyps detected by both the algorithm and at least one endoscopist, the AI detected polyps significantly faster on average. The AI based algorithm achieved high per-polyp sensitivities for advanced colorectal neoplasia, including flat lesions and SSLs, outperforming both JAG independent and trainees on a very challenging dataset containing subtle lesions that could have been overlooked easily and contribute to interval colorectal cancer. Further prospective trials should evaluate AI to detect subtle advanced neoplasia in higher risk populations for colorectal cancer.

Early verrucous cell carcinoma of the esophagus: a case report and endoscopic and histologic features

BackgroundVerrucous cell carcinoma of the esophagus (VCCE) is an extremely rare tumor and generally detected at advanced stage. Despite of its slow growth and well differentiation, it has very poor prognosis with high mortality. Therefore, early detection is a critical to improve patients’ survival. However, no early cases of VCCE have been reported and the endoscopic features of early VCCE are not well described. We herein report the endoscopic and histologic features of an early VCCE.Case presentationA 54-year-old man with a history of excessive alcohol and tobacco use was admitted to our hospital because of chronic persistent swallowing dysfunction for six months. White light endoscopy revealed a flat lesion covered with scattered leukoplakia in the middle esophagus. Magnifying endoscopy with narrow-band imaging showed tiny irregular papillary microsurface structure. The lesion was considered as early esophageal cancer and completely resected with endoscopic submucosal dissection. Histological examination confirmed that the lesion was early VCCE which was limited within the mucosal lamina propria (m2).ConclusionVCCE is rare with poor prognosis. This is a report of early VCCE and description of its endoscopic features which will contribute to early detection of these cancers.

Efficacy, immunogenicity, and safety of a quadrivalent HPV vaccine in men: results of an open-label, long-term extension of a randomised, placebo-controlled, phase 3 trial

The quadrivalent human papillomavirus (HPV) vaccine was shown to prevent infections and lesions related to HPV6, 11, 16, and 18 in a randomised, placebo-controlled study in men aged 16-26 years. We assessed the incidences of external genital warts related to HPV6 or 11, and external genital lesions and anal dysplasia related to HPV6, 11, 16, or 18, over 10 years of follow-up. The 3-year base study was an international, multicentre, double-blind, randomised, placebo-controlled trial done at 71 sites in 18 countries. Eligible participants were heterosexual men (aged 16-23 years) or men who have sex with men (MSM; aged 16-26 years). Men who had clinically detectable anogenital warts or genital lesions at screening that were suggestive of infection with non-HPV sexually transmitted diseases, or who had a history of such findings, were excluded. Eligible participants were randomly assigned (1:1) to receive three doses of either quadrivalent HPV vaccine or placebo on day 1, month 2, and month 6, administered as a 0·5-mL injection into the deltoid muscle. The 7-year, open-label, long-term follow-up extension study was done at 46 centres in 16 countries. Participants who received one or more doses of the quadrivalent HPV vaccine in the base study were eligible for enrolment into the long-term follow-up study (early vaccination group). Placebo recipients were offered the three-dose quadrivalent HPV vaccine at the end of the base study; those who received one or more quadrivalent HPV vaccine doses were eligible for enrolment into the long-term follow-up study (catch-up vaccination group). The primary efficacy endpoints were the incidence of external genital warts related to HPV6 or 11 and the incidence of external genital lesions related to HPV6, 11, 16, or 18 in all participants and the incidence of anal intraepithelial neoplasia (including anal warts and flat lesions) or anal cancer related to HPV6, 11, 16, or 18 in MSM only. The primary efficacy analysis was done in the per-protocol population for the early vaccination group, which included participants who received all three vaccine doses, were seronegative at day 1 and PCR-negative from day 1 through month 7 of the base study for the HPV type being analysed, had no protocol violations that could affect evaluation of vaccine efficacy, and had attended at least one visit during the long-term follow-up study. For the catch-up vaccination group, efficacy was assessed in the modified intention-to-treat population, which included participants who had received at least one vaccine dose, were seronegative and PCR-negative for HPV types analysed from day 1 of the base study to the final follow-up visit before receiving the quadrivalent HPV vaccine, and had at least one long-term follow-up visit. Safety was assessed in all randomised participants who received at least one vaccine dose. This study is registered with ClinicalTrials.gov, NCT00090285. Between Aug 10, 2010, and April 3, 2017, 1803 participants were enrolled in the long-term follow-up study, of whom 936 (827 heterosexual men and 109 MSM) were included in the early vaccination group and 867 (739 heterosexual men and 128 MSM) were included in the catch-up vaccination group. Participants in the early vaccination group were followed up for a median of 9·5 years (range 0·1-11·5) after receiving the third dose of the quadrivalent HPV vaccine, and participants in the catch-up vaccination group were followed up for a median of 4·7 years (0·0-6·6) after receiving the third dose. In early vaccine group participants during long-term follow-up compared with the placebo group in the base study, the incidence per 10 000 person-years of external genital warts related to HPV6 or 11 was 0·0 (95% CI 0·0-8·7) versus 137·3 (83·9-212·1), of external genital lesions related to HPV6, 11, 16, or 18 was 0·0 (0·0-7·7) versus 140·4 (89·0-210·7), and of anal intraepithelial neoplasia or anal cancer related to HPV6, 11, 16, or 18 in MSM only was 20·5 (0·5-114·4) versus 906·2 (553·5-1399·5). Compared with during the base study (ie, before quadrivalent HPV vaccine administration), during the long-term follow-up period, participants in the catch-up vaccination group had no new reported cases of external genital warts related to HPV6 or 11 (149·6 cases per 10 000 person-years [95% CI 101·6-212·3] vs 0 cases per 10 000 person-years [0·0-13·5]) or external genital lesions related to HPV6, 11, 16, or 18 (155·1 cases per 10 000 person-years [108·0-215·7] vs 0 cases per 10 000 person-years [0·0-10·2]), and a lower incidence of anal intraepithelial neoplasia or anal cancer related to HPV6, 11, 16, or 18 (886·0 cases per 10 000 person-years [583·9-1289·1] vs 101·3 cases per 10 000 person-years [32·9-236·3]). No vaccine-related serious adverse events were reported. The quadrivalent HPV vaccine provides durable protection against anogenital disease related to HPV6, 11, 16, and 18. The results support quadrivalent HPV vaccination in men, including catch-up vaccination. Merck Sharp & Dohme.

Prospective evaluation of the effectiveness of colonoscopic polyp resection

Background: Colon cancer incidence is on the rise and despite having undergone a colonoscopy to screen and remove all visible polyps as a preventive measure, nearly 1 in 110 patients will develop colon cancer within 3 years. The three main possible explanations for this are missing polyps, incompletely removed polyps, or rapidly growing tumors. Objective: To determine the proportion of colonic polyps ≤ 3 cm in size that show evidence of residual polyp tissue following colonoscopy and polypectomy. Methods: Patients who presented for colonoscopy at a community center were invited to participate in this study. Those who had confirmed adenoma were invited to repeat the procedure in 2 to 6 months with biopsies at the resection site to check for the presence of residual polyp tissue. Exclusion criteria included the absence of adenoma in the resected lesion, contraindication to polypectomy or follow-up colonoscopy, refusal to participate in follow-up examination, and other conditions increasing colon cancer risk. If polyps between 5 mm and 30 mm were found, the endoscopist resected them using the hot snare polypectomy technique or endoscopic mucosal resection (EMR). Results: Ninety-one patients completed the study protocol, with 105 lesions being studied. The second procedure was performed between 2 and 24 months. All analyzed lesions were adenoma, and three of them were associated with intramucosal adenocarcinoma. Others included 60 tubular lesions, 37 tubulovillous lesions, and 5 serrated lesions. Thirty-two lesions were flat and were removed by EMR; polypectomy was performed for 73 lesions. There was no residual tissue in the polypectomy group. The EMR group presented three cases of incomplete resection without adenocarcinomas. Conclusion: Our study showed that flat lesions might be an important cause of incomplete resection. In addition, we documented the complete resection of pedunculated lesions in all studied patients. This study provides more evidence to validate the empirical perception in the medical field that assumes the complete resection of pedunculated polyps. Therefore, we suggest that patients who undergo snare removal of pedunculated polyps should follow the regular protocol for colon cancer screening, with colonoscopy every 5 to 10 years. Meanwhile, the surveillance scheme should be reviewed for patients who undergo removal of flat lesions smaller than 30 mm.

Fluorescence-advanced videodermatoscopy (FAV) for the differential diagnosis of suspicious facial lesions: A single-centre experience with pattern analysis and histopathological correlation.

Fluorescence-advanced videodermatoscopy (FAV) is a new non-invasive high-resolution skin imaging technique to assess pigmented lesions in conjunction with the clinical examination and dermatoscopy. This is the first prospective study to identify morphologic descriptors and standardized terminology to examine facial pigmented lesions using FAV. The objectives were to identify FAV indicators, which can assist physicians in diagnosing suspicious flat facial pigmented lesions. Consecutive equivocal pigmented lesions were retrospective analysed. Histopathological examination was performed for all the lesions. The main cytomorphological and cytoarchitectural FAV features were described and correlated with histopathological characteristics. From January to October 2020, 21 consecutive clinically suspected pigmented lesions in 20 patients were analysed using dermatoscopy and FAV and then surgically excised. Histopathological examination identified lentigo maligna (LM), lentigo maligna melanoma (LMM), solar lentigo (SL), flat seborrheic keratosis (SK) and pigmented actinic keratosis (PAK). Thirteen malignant melanocytic lesions were removed (11 LM, 2 LMM), two were diagnosed as PAK, and the remaining six pigmented lesions were SL-SKs. With FAV, large ovoid pleomorphic and dendritic cells arranged in the intrafollicular disposition, are typical of most malignant melanocytic lesions (12/13, 92.3%). No benign lesions displayed these features. In dermatoscopy, this folliculotropism corresponded to the presence of an annular-granular pattern with slate grey dots that were aggregated asymmetrically around follicular openings. FAV features can provide an improved diagnostic approach in the differential diagnosis of flat pigmented facial lesions.

THE ROLE OF EZH2 AND ARID1A IN THE DIAGNOSIS OF FLAT UROTHELIAL LESIONS WITH ATYP

Background. Diagnosis of urothelial carcinoma in situ is of great importance because it has prognostic and therapeutic value.We aim to determine the utility of EZH2 and ARID1A as a new tool in the diagnosis of carcinoma in situ.Material and Methods. This retrospective cross-sectional study included Twenty-four specimens of flat urothelial lesions, twenty specimens of CIS, and 10 of normal adjacent urothelium that was taken by cystoscopic resection biopsy procedure. immunohistochemical expression of EZH2 and ARID1A. were evaluated in all studied cases.Results. All normal urothelium specimens showed high nuclear staining for ARID1A and negative nuclear staining for EZH2. High EZH2 expression was observed in 80 % of CIS specimens compared to 20 % of flat urothelial lesions with atypia (p=0.001 ), while high ARID1A expression was observed in 70.8 % of flat urothelial lesions with atypia compared to 25 % of CIS specimens (p=0.001). EZH2 was more accurate and specific in the diagnosis of carcinoma in situ.Conclusion. EZH2 and ARID1A are promising diagnostic markers for urothelial CIS. EZH2 is more accurate and specific than ARID1A in the diagnosis of carcinoma in situ versus other flat urothelial lesions.

Compound Endoscopic Morphological Features for Identifying Non-Pedunculated Lesions ≥20 mm with Intramucosal Neoplasia.

Simple SummaryPiecemeal endoscopic mucosal resection (EMR) has proved to be an excellent resection technique for large colorectal polyps. However, a key limitation is the inaccurate histologic assessment of the sample in cases where there is invasion of the submucosa. Thus piecemeal EMR should be avoided if submucosal invasion is suspected. Furthermore, both western and eastern scientific societies have recently recommended that treatment should be based on optical diagnosis (ideally with magnification) which estimates the histology endoscopically. However, experience with magnification in western countries is limited. This study primarily aims to develop a classification system based on endoscopic features to identify intramucosal neoplasia (absence of submucosal invasion) in non-pedunculated lesions ≥20 mm assessed by western endoscopists with narrow band imaging (NBI) and without magnification. We observed that non-ulcerated LST-granular type and LST-non-granular flat elevated lesions represent 58.8% of all non-pedunculated lesions ≥20 mm and are associated with a low risk of submucosal invasion (3.8%). Therefore, we suggest these lesions be treated by piecemeal EMR. In the remaining lesions further diagnostic techniques such as magnifying endoscopy or en bloc resection should be considered.Background: The major limitation of piecemeal endoscopic mucosal resection (EMR) is the inaccurate histological assessment of the resected specimen, especially in cases of submucosal invasion. Objective: To classify non-pedunculated lesions ≥20 mm based on endoscopic morphological features, in order to identify those that present intramucosal neoplasia (includes low-grade neoplasia and high-grade neoplasia) and are suitable for piecemeal EMR. Design: A post-hoc analysis from an observational prospective multicentre study conducted by 58 endoscopists at 17 academic and community hospitals was performed. Unbiased conditional inference trees (CTREE) were fitted to analyse the association between intramucosal neoplasia and the lesions’ endoscopic characteristics. Result: 542 lesions from 517 patients were included in the analysis. Intramucosal neoplasia was present in 484 of 542 (89.3%) lesions. A conditional inference tree including all lesions’ characteristics assessed with white light imaging and narrow-band imaging (NBI) found that ulceration, pseudodepressed type and sessile morphology changed the accuracy for predicting intramucosal neoplasia. In ulcerated lesions, the probability of intramucosal neoplasia was 25% (95%CI: 8.3–52.6%; p < 0.001). In non-ulcerated lesions, its probability in lateral spreading lesions (LST) non-granular (NG) pseudodepressed-type lesions rose to 64.0% (95%CI: 42.6–81.3%; p < 0.001). Sessile morphology also raised the probability of intramucosal neoplasia to 86.3% (95%CI: 80.2–90.7%; p < 0.001). In the remaining 319 (58.9%) non-ulcerated lesions that were of the LST-granular (G) homogeneous type, LST-G nodular-mixed type, and LST-NG flat elevated morphology, the probability of intramucosal neoplasia was 96.2% (95%CI: 93.5–97.8%; p < 0.001). Conclusion: Non-ulcerated LST-G type and LST-NG flat elevated lesions are the most common non-pedunculated lesions ≥20 mm and are associated with a high probability of intramucosal neoplasia. This means that they are good candidates for piecemeal EMR. In the remaining lesions, further diagnostic techniques like magnification or diagnostic +/− therapeutic endoscopic submucosal dissection should be considered.

S1046 Predicting Histological Diagnosis After Endoscopic Submucosal Dissection With Demographic Characteristics and Endoscopic Lesion Characteristics: An Analysis of a Large Cohort in North America

Introduction: Endoscopic submucosal dissection (ESD) continues to gain traction as an important treatment for gastric neoplasia. Some gastric low-grade dysplasia (LGD) and high-grade dysplasia (HGD) on endoscopic forceps biopsy (EFB) are diagnosed as gastric adenocarcinoma (GAC) after ESD. To date, there are no large studies from the Western population on demographic or endoscopic characteristics that can help clinicians differentiate GAC from dysplastic lesions during endoscopy. We aimed to determine which patient or lesion characteristics could predict the histological diagnosis of gastric lesions after ESD. Further, we evaluated the factors associated with the pathologic upstaging from EFB to ESD. Methods: This retrospective study analyzed data from 309 patients who had gastric ESD at 25 centers in North America between 2010 and 2019. We used logistic regression to identify patient demographics and endoscopic features that could predict HGD or GAC on the resected specimens and upstage diagnosis. Results: We analyzed 85 LGD, 85 HGD, and 139 GAC cases. 119 GAC cases were differentiated and 20 were poorly differentiated. 4.1% of LGD and 12.8% of HGD on EFB were upstaged to GAC after ESD. Higher dysplasia grades after ESD were more likely in older patients, tumors in the upper and lower thirds of the stomach, polypoid or depressed lesions (vs. flat non-depressed lesions), and ulcerated lesions. Tumor size was not a significant predictor of dysplasia grade. Logistic regression revealed age (odds ratio [OR] = 1.050, P = 0.00004), the presence of ulceration (OR = 2.763, P = 0.0016), and tumors in the upper third (OR = 2.348, P = 0.0123) or lower third (OR = 1.920, P = 0.0149) significantly predicted GAC. Depressed lesions were more common in HGD or GAC as compared to LGD (OR = 2.831, P = 0.0034). Larger tumors and depressed lesions were associated with differentiated GAC as compared to poorly differentiated GAC (P = 0.0079 and 0.0110, respectively). Conclusion: In this large North American cohort of gastric ESD, we found that tumor location in the upper and lower thirds, ulceration, and patient age may predict GAC. Endoscopists should be cognizant of these characteristics as up to 16.9% of lesion pathology from EFB may be upstaged to GAC after endoscopic resection. Our findings emphasize the importance of recognizing demographic and lesion-based predictors of gastric cancers to better guide clinicians during endoscopy.Table 1.: Logistic regression of demographic patient characteristics and endoscopic lesion characteristics for the presence of adenocarcinoma after resection by endoscopic submucosal dissection

S909 Risk Factors for Colorectal Dysplasia and Colorectal Cancer (CRC) Among Patients With Inflammatory Bowel Disease (IBD) Undergoing Surveillance Colonoscopy in a Tertiary Care Center

Introduction: Patients with IBD are more likely to develop dysplasia and CRC than the general population. We aimed to evaluate risk factors for dysplasia and CRC among patients with IBD undergoing surveillance colonoscopy. Methods: We conducted a retrospective case-control study to evaluate risk factors for colorectal dysplasia/CRC in IBD patients who underwent surveillance colonoscopy in 2010-2020. Cases were patients with dysplasia/CRC found on surveillance colonoscopy and controls were those without. Dysplasia was limited to flat lesions and did not include dysplasia associated lesions/masses. Relevant data obtained from EMR included: age, gender, ethnicity, BMI, smoking status, medication hx, IBD subtype, diagnosis age, disease duration, clinical disease activity, previous IBD related surgery, h/o polyps, dysplasia, or CRC, h/o primary sclerosing cholangitis or extra-intestinal manifestations, family history of IBD, polyps, CRC, and genetic conditions. After summary statistics, logistic regression analysis was performed to examine the association between potential risk factors and incidence of dysplasia or CRC. Rstudio 4.0.2 was used for analysis. Results: 549 subjects were identified from our IBD database with 64 cases and 485 controls. The dysplasia/CRC group had a significantly larger proportion of males (67% vs 48%), patients with UC than CD (69% vs 47%), perianal disease (53% vs 25%), and were more likely to have moderate-severe disease vs remission-mild (36% vs 23%) than the control group. No significant differences were found between groups for the remaining variables. Univariate logistic regression model for each predictor variable of interest revealed statistically significant differences with gender (OR 2.25, 95% CI 1.31-3.97 p=0.004), IBD subtype (OR 2.44, 95% CI 1.42-4.35 p=0.002), disease activity (OR 1.86, 95% CI 1.06-3.21 p=0.028), and perianal disease (OR 3.49, 95% CI 2.05-5.97 p< 0.001). When fitting various multiple logistic regression models and adjusting for the three other variables, disease activity was no longer significant. Conclusion: Our case control study assessing risk factors for colorectal dysplasia or cancer in IBD found that gender, IBD subtype, and perianal disease are perhaps the most significant risk factors for this population. While previous cohorts have noted several of these as potential risk factors, perianal disease has not previously been considered a risk factor for dysplasia/CRC in IBD.