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Linked Color Imaging identified UC Associated Colorectal Cancer. A case report.

Hisamatsu T1, Ohno A1, Chiba T2.

Dig Endosc. 2017 Nov 27. doi: 10.1111/den.12992. [Epub ahead of print]

Ulcerative colitis (UC) associated colorectal cancer (CRC) is an important issue in long-term management of patients with UC. Lesions with chronic inflammatory mucosa as background may often be difficult to identify even by endoscopic observation. Traditionally, a random biopsy strategy was recommended, but problems with patient compliance, increased burden on endoscopic staff and pathologists, were left. This article is protected by copyright. All rights reserved.

1 Third Department of Internal Medicine, Kyorin University School of Medicine.
2 Department of Pathology, Kyorin University School of Medicine.


Linked-color imaging combined with the NICE classification system for optical diagnosis of colon polyps: new image-enhanced endoscopic technology for pathological prediction.

Wu CH1,2, Chen TH1,2,3, Hsu CM1,2, Su MY1,2, Chiu CT1,2, Wu RC4, Lai CC5.

Ther Clin Risk Manag. 2017 Oct 3;13:1317-1321.

Introduction: Linked-color imaging (LCI) is a recently developed system used in endoscopy. It creates clear and bright endoscopic images using short-wavelength, narrow-band laser light combined with white laser light. The illuminating light and signal processing emphasize slight color differences in abnormal regions that approximate the normal color of the mucosa. As a result, regions initially appearing red become a deeper shade of red, while regions originally appearing white become brighter, yet with natural tones. This process facilitates recognition of slight differences in the color of the mucosa and clarifies the boundaries of the mucosal pit.

Aim: To determine whether LCI of the colon can improve the correlation between endoscopic findings and pathological diagnosis.

Methods: Consecutive patients who underwent colonoscopy requiring polypectomy or removal by biopsy forceps if possible were recruited. Probable polyp histology was assessed by two endoscopists using the Narrow-band imaging International Colorectal Endoscopic (NICE) classification and LCI data. All detected polyps were sent to the pathology department for pathological diagnosis by two pathologists.

Results: In total, 94 polyps were found in 43 patients. The sensitivity, specificity, positive predictive value, and negative predictive value for neoplastic lesion prediction (NICE type2/3) were 96.5%, 83.8%, 90.2%, and 93.9%, respectively.

Conclusion: LCI combined with the NICE classification system is a powerful tool for predicting probable histology of colon polyps.

1 Department of Gastroenterology and Hepatology, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan.
2 Chang Gung University, College of Medicine, Taoyuan.
3 Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan.
4 Department of Pathology, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan.
5 Department of Colon and Rectal Surgery, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan.


Linked color imaging improves the visibility of various featured colorectal polyps in an endoscopist’s visibility and color difference value.

Yoshida N, Naito Y,  Itoh Y. et al.

Int J Colorectal Dis. 2017 Jul 19. doi: 10.1007/s00384-017-2855-z.

Background and study aims: Linked color imaging (LCI) and blue laser imaging (BLI) are novel image-enhanced endoscopy technologies with strong, unique color enhancement. We investigated the efficacy of LCI and BLI-bright compared to conventional white light imaging (WLI) by measuring the color difference between early gastric cancer lesions and the surrounding mucosa.

Patients and methods: Images of early gastric cancer scheduled for endoscopic submucosal dissection were captured by LCI, BLI-bright, and WLI under the same conditions. Color values of the lesion and surrounding mucosa were defined as the average of the color value in each region of interest. Color differences between the lesion and surrounding mucosa (ΔE) were examined in each mode. The color value was assessed using the CIE L*a*b* color space (CIE: Commission Internationale d’Eclairage).

Results: We collected images of 43 lesions from 42 patients. Average ΔE values with LCI, BLI-bright, and WLI were 11.02, 5.04, and 5.99, respectively. The ΔE was significantly higher with LCI than with WLI ( P  < 0.001). Limited to cases of small ΔE with WLI, the ΔE was approximately 3 times higher with LCI than with WLI (7.18 vs. 2.25). The ΔE with LCI was larger when the surrounding mucosa had severe intestinal metaplasia ( P  = 0.04). The average color value of a lesion and the surrounding mucosa differed. This value did not have a sufficient cut-off point between the lesion and surrounding mucosa to distinguish them, even with LCI.

Conclusion: LCI had a larger ΔE than WLI. It may allow easy recognition and early detection of gastric cancer, even for inexperienced endoscopists.


Therapeutic application of linked color imaging for colorectal endoscopic mucosal resection

Goda Y1, Mori H1, Kobara H1, Nishiyama N1, Kobayashi N1, Yachida T1, Masaki T1.

Endoscopy. 2017 Oct 17. doi: 10.1055/s-0043-119984. [Epub ahead of print]

Linked color imaging (LCI; Fujifilm Co., Tokyo, Japan) is a newly developed image- enhanced technique that has shown high diagnostic performance in the field of gastrointestinal endoscopy. LCI enhances color separation of the mucosal layer, making red regions redder and white regions whiter. This contributes to the detection of gastric cancer [1], ulcerative colitis [2], colorectal polyps [3, 4], and other lesions. Although the diagnostic productivity is steadfast, the treatment benefit of LCI remains unclear or limited [5]. We herein introduce an advantage of LCI with respect to increasing the safety of endoscopic mucosal resection (EMR), illustrating the efficacy of LCI in the treatment field.

Compared with white-light imaging, narrow- band imaging, and bright-light imaging, the view of the blood vessels in the superficial layer is much more conspicuous when obtained by LCI. When performing EMR, local injection is the first crucial step and the basis of later procedures such as polyp removal by snaring. However, injury to the superficial vessels invisible with white light sometimes induces hematoma formation, making subsequent snaring difficult (▶Fig. 1 a). LCI can more precisely reveal the running of the superficial vessels around a colorectal polyp than can white light imaging (▶Fig. 1 b) and bright-light imaging (▶Fig. 1 c). LCI enhances the reddish, glaring characteristics of the vessels, pinpointing safe sites for needling (▶Fig. 1 d). Consequently, the clinician can avoid needling blood vessels near the polyp (▶Fig. 1 e) and prevent unnecessary bleeding and hematoma formation (▶Fig. 1 f), leading to secure completion of EMR.

White-light imaging, bright-light imaging, and LCI for EMR local injections are compared in ▶Video 1. Only LCI shows the reddish network pattern of the superficial blood vessels. This leads to sufficient swelling of the submucosal layer and appropriate removal of colorectal polyps.

Fig. 1 Endoscopic images illustrating the advantages of linked color imaging (LCI) during endoscopic mucosal resection. a Improper injection can induce hematoma formation. b Superficial vessels around a colorectal polyp are invisible with white-light imaging. c Superficial vessels are also unclear with bright-light imaging. d LCI shows the orientation of vessels around the polyp. e The injection needle pinpoints a site lacking vessels. f Unnecessary hematoma formation and bleeding can be avoided during mucosal injection.

Video 1 White-light imaging only ambiguously shows the blood vessel routes, whereas linked color imaging (LCI) indicates the vessels clearly as a vivid reddish color. From injection to snaring, LCI allows the clinician to avoid unnecessary bleeding.

1Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan.


BASIC (BLI Adenoma Serrated International Classification) classification study for colorectal polyp characterization with blue light imaging

Raf Bisschops1, Cesare Hassan2,3, Pradeep Bhandari4, Emmanuel Coron5, Helmut Neumann6, Oliver Pech7, Loredana Correale2, Alessandro Repici3

Endoscopy 2018; 50: 1-17 / https://doi.org/10.1055/s-0043-121570

Backgound and study aim: Advanced endoscopic imaging has revolutionized the characterization of lesions during colonoscopy. The aim of this study was to create a new classification for differentiating subcentimetric hyperplastic and adenomatous polyps, and deeply invasive malignant lesions using blue-light imaging (BLI) with high definition, with and without optical magnification, as well as to assess its interobserver concordance.

Methods: A video library consisting of 48 videos/still images (with/without optical magnification) from 24 histologically verified polyps/cancer with BLI was prospectively created. In the first step, seven endoscopists with experience in electronic chromoendoscopy reviewed 12 BLI videos/still images with/without magnification representative of the different histotypes, and individually identified possible descriptors. In the second step, these descriptors were categorized and summarized with a modified Delphi methodology. In the third step, the seven endoscopists independently reviewed the remaining 36 videos/still images with/without optical magnification, and the interobserver agreement for the new descriptors was assessed. The interobserver agreement between endoscopists was assessed using Gwet’s AC1.

Results: By reviewing the initial 12 videos/still images, 43 descriptors were proposed. By a modified Delphi process, the endoscopists eventually agreed on summarizing 12 descriptors into three main domains. The main domains identified were: polyp surface (mucus, yes/no; regular/irregular; [pseudo]depressed, yes/no), pit appearance (featureless, yes/no; round/nonround with/without dark spots; homogeneous/heterogeneous distribution with/without focal loss), and vessels (present/absent, lacy, pericryptal, irregular). Interobserver agreement for the polyp surface domain appeared to be almost perfect for mucus (AC1 0.92 with and 0.88 without optical magnification), substantial for the regular/irregular surface (AC1 0.67 with and 0.66 without optical magnification). For the pit appearance domain, interobserver agreement was good for featureless (AC1 0.9 with and 0.8 without optical magnification), and round/nonround (AC1 0.77 with and 0.69 without optical magnification) descriptors, but less consistent for the homogeneity of distribution (AC1 with/without optical magnification 0.58). Agreement was almost perfect for the vessel domain (AC1 0.81 – 0.85).

Conclusions: The new BASIC classification takes into account both morphological features of the polyp, as well as crypt and vessel characteristics. A high concordance among the observers was shown for most of the summarized descriptors. Optical magnification had a beneficial effect in terms of interobserver agreement for most of the descriptors.

1 Department of Gastroenterology and Hepatology, Catholic University of Leuven (KUL), TARGID, University Hospitals Leuven, Leuven, Belgium.
2 Gastroenterology, Nuovo Regina Margherita Hospital, Rome, Italy.
3 Digestive Endoscopy Unit, Humanitas University, Milan, Italy.
4 Solent Centre for Digestive Diseases, Portsmouth Hospital, Portsmouth, United Kingdom.
5 Hepatogastroenterology, Centre Hospitalier Universitaire Hotel Dieu, Nantes, France.
6 First Medical Department, University Medical Center Mainz, Mainz, Germany.
7 Department of Gastroenterology and Interventional Endoscopy, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany.



The Combination Use of an Acetic Acid Indigo Carmine Mixture and Linked-Color Imaging to Detect Early Gastric Cancer.

Kono Y1, Kawahara Y2, Okada H1.

Clin Gastroenterol Hepatol. 2017 Sep 1. pii: S1542-3565(17)31045-5.

Chromoendoscopy (CE) and image-enhanced endoscopy are useful for accurately diagnosing gastric neoplasms. However, unclear lesions, such as those with a flat morphology or normochromic color, sometimes can be missed. We herein present a case in which CE was performed with the combined use of an acetic acid indigo carmine mixture (AIM) and linked-color imaging (LCI), and this method was effective for detecting early gastric cancer. A Japanese man in his 70s underwent esophagogastroduodenoscopy for screening purposes. It was difficult to identify any lesions by white-light imaging (Figure A).

However, when performing image-enhanced endoscopy with LCI, a shallow depressed lesion was identified in the prepyloric area and this modality made it easier to detect the lesion, but the visibility was insufficient to distinguish clearly between the lesion and the surrounding area (Figure B). CE using an AIM with LCI enhanced not only the surface color, but also the demarcation line of the lesion (Figure C). A histologic examination of a biopsy specimen showed differentiated-type adenocarcinoma, and endoscopic submucosal dissection thereafter was performed.

The pathologic diagnosis of the resected specimen showed well-differentiated adenocarcinoma of the stomach (Figure D). Performing CE using an AIM and LCI is useful for detecting gastric neoplasms.


Linked Color Imaging Technology for Diagnosis of Gastric Mucosa-associated Lymphoid Tissue Lymphoma.

Deng P1, Min M2, Ma CY1, Liu Y1.

Chin Med J (Engl). 2017 Sep 7. doi: 10.4103/0366-6999.214137. Epub ahead of print

Mucosa‑associated lymphoid tissue (MALT) lymphoma has previously been diagnosed only by a histological examination of gastric specimens, which made the diagnosis of MALT lymphoma very difficult. Endoscopic findings of gastric MALT lymphoma are variable, and current conventional white‑light endoscopy cannot distinguish the cancerous tissue of MALT lymphoma from inflammation due to its histomorphological similarities. A new endoscopic modality known as linked color imaging (LCI) has been developed that may help in the diagnosis of gastric MALT lymphoma. Here, we reported a case of MALT lymphoma diagnosed by LCI.


Magnified endoscopic observation of small depressed gastric lesions using linked color imaging with indigo carmine dye.

Kitagawa Y, Hara T, Yamaguchi T, Suzuki T. et al.

Endoscopy. 2017 Sep 27. doi: 10.1055/s-0043-119212. Epub ahead of print

Background and study aims: Magnifying linked color imaging with indigo carmine dye (M-Chromo-LCI) enables sterically enhanced and color image-magnified observation of the superficial gastric mucosa. This study investigated the usefulness of M-Chromo-LCI for the differential diagnosis of gastric lesions.

Patients and methods: 100 consecutive small depressed lesions were examined with conventional white-light imaging (C-WLI), magnifying blue-laser imaging (M-BLI), and M-Chromo-LCI. Endoscopic images were reviewed by three experts and three non-experts. Diagnostic accuracy and interobserver agreement were compared among the modalities.

Results: For experts, M-BLI showed a significantly higher diagnostic accuracy than C-WLI (82.7 % vs. 67.0 %; P < 0.001). The diagnostic accuracy of M-Chromo-LCI was not different from M-BLI (87.7 % vs. 82.7 %; P = 0.31). For non-experts, M-BLI showed a significantly higher diagnostic accuracy than C-WLI (69.3 % vs. 52.3 %; P < 0.001). M-Chromo-LCI additionally showed a significantly higher diagnostic accuracy than M-BLI (79.7 % vs. 69.3 %; P = 0.005). M-Chromo-LCI had the highest interobserver agreement for each group.

Conclusions: M-Chromo-LCI is expected to become a useful modality for the accurate diagnosis of gastric lesions.


Evaluation of image-enhanced endoscopic technology using advanced diagnostic endoscopy for the detection of early gastric cancer: a pilot study

Daisuke Yamaguchi, Mitsuhiro Fujishiro, Kazuhiko Koike, et al.

Endosc Int Open. 2017 Sep; 5(9): E825–E833.

Background and study aims: Image-enhanced endoscopy (IEE) plays an important role in early detection and detailed examination of early gastric cancer (EGC). The current study aimed to clarify the efficacy of IEE using advanced diagnostic endoscopy for EGC detection without magnification.

Patients and methods: We performed endoscopic examinations without magnification in patients referred to our hospital with a diagnosis of upper gastrointestinal tumor detected through routine screening endoscopy. In this study, we used three IEE technologies: narrow-band imaging; blue laser imaging; and i-scan optical enhancement. The detection rates for EGC between IEE and white-light imaging (WLI) were compared.

Results: Between July 2013 and June 2014, 156 patients were enrolled. Among upper gastrointestinal tumors, we analyzed endoscopic examination results of 119 lesions that were histologically diagnosed as EGC in 109 patients. The EGC detection rate in the IEE plus WLI groups was 77.3 %. Although the EGC detection rate in the IEE group was higher than that in the WLI group (80.0 % vs. 70.3 %), there was no significant difference between these two modalities. An important detection factor using IEE was tumor circumference, where the rate of detection in the anterior wall and lesser curvature was significantly higher than that in the posterior wall and greater curvature ( P  = 0.046). An important detection factor using WLI was color variation, where the rate of occurrence of a reddened or pale tumor was significantly higher than that of normal colored tumors ( P  = 0.030).

Coclusions: The detection rate of EGC without magnification was similar between the IEE group and the WLI group. Important detection factors differed between IEE and WLI; therefore, the IEE and WLI modalities have different characteristics regarding EGC detection. Consequently, we propose to use both IEE and WLI in the evaluation of EGC.


Magnifying Blue Laser Imaging versus Magnifying Narrow-Band Imaging for the Diagnosis of Early Gastric Cancer: A Prospective, Multicenter, Comparative Study.

Dohi O1, Yagi N, Yoshida S, Ono S, Sanomura Y, Tanaka S, Naito Y, Kato M.

Digestion. 2017 Aug 26;96(3):127-134. doi: 10.1159/000479553.

Background/Aims: The diagnostic efficacy of magnifying blue laser imaging (M-BLI) and M-BLI in bright mode (M-BLI-bright) in the identification of early gastric cancer (EGC) was evaluated for comparison to that of magnifying narrow-band imaging (M-NBI).

Methods: This prospective, multicenter study evaluated 114 gastric lesions examined using M-BLI, M-BLI-bright, and M-NBI between May 2012 and November 2012; 104 EGCs were evaluated by each modality. The vessel plus surface classification system was used to evaluate the demarcation line (DL), microvascular pattern (MVP), and microsurface pattern (MSP).

Results: M-BLI, M-BLI-bright, and M-NBI revealed a DL for 96.1, 98.1, and 98.1% and irregular MVP for 95.1, 95.1, and 96.2% of lesions, respectively, with no significant difference. Irregular MSP was observed by M-BLI, M-BLI-bright, and M-NBI in 97.1, 90.4, and 78.8% of lesions, respectively, with significant differences (p < 0.001). The proportion of moderately differentiated adenocarcinoma with irregular MSP on M-BLI and absent MSP on M-NBI was significantly higher than that with irregular MSP on M-BLI and M-NBI (35.0 and 9.9%, respectively; p = 0.002).

Conclusion: M-BLI and M-BLI-bright provided excellent visualization of microstructures and microvessels similar to M-NBI. Irregular MSP in a moderately differentiated adenocarcinoma might be frequently visualized using M-BLI and M-BLI-bright compared with using M-NBI.