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High magnification chromoscopic colonoscopy or high frequency 20 MHz mini probe endoscopic ultrasound staging for early colorectal neoplasia: a comparative prospective analysis
  1. D P Hurlstone1,
  2. S Brown2,
  3. S S Cross3,
  4. A J Shorthouse2,
  5. D S Sanders1
  1. 1Gastroenterology and Liver Unit, Royal Hallamshire Hospital, Sheffield, UK
  2. 2Department of Surgery, Northern General Hospital NHS Trust, Sheffield, UK
  3. 3Academic Unit of Pathology, Section of Oncology and Pathology, Division of Genomic Medicine, University of Sheffield Medical School, Sheffield, UK
  1. Correspondence to:
    Dr D P Hurlstone
    17 Alexandra Gardens, Lyndhurst Rd, Nether Edge, Sheffield S11 9DQ, UK;


Background: Successful endoscopic management of early colorectal cancer using endoscopic mucosal resection requires the mandatory prediction of invasive depth and lymph node metastasis. Previous data using the Nagata crypt types Vn(B)/(C) as clinical indicators of T2/N+ disease have shown low specificity (50%) with a tendency to over stage lesions. New mini probe ultrasound “through the scope” imaging permits staging of lesions proximal to the rectum using direct endoscopic visualisation.

Aim: To compare the staging accuracy of the Nagata crypt type V with mini probe high frequency 20 MHz endoscopic ultrasound.

Methods: Sixty two patients with a Paris type II flat cancer were imaged using magnification colonoscopy followed by 20/12.5 MHz ultrasound in a “back to back” design. Crystal violet staining (0.05%) at 100× magnification permitted Nagata crypt criteria to be defined. Submucosal deep invasion (sm3+) was defined at ultrasound by the presence or absence of a disrupted third sonographic layer. Predicted T0/1:N0 lesions were resected using endoscopic mucosal resection with the remaining referred for surgery. Ultrasound and magnification staging were then compared with the resected histopathological specimens.

Results: One patient was excluded from the study due to poor bowel preparation. Fifty two lesions from 52 patients therefore met inclusion criteria (12 sm1/13 sm2/27 sm3+). Ultrasound (20 MHz) was significantly more accurate for invasive depth staging compared with Nagata stage (p<0.0001) (overall accuracy 93% and 59%, respectively). The sensitivity for lymph node metastasis detection using ultrasound and magnification was 80% and 31%, respectively (p<0.001). The negative predictive value of ultrasound for invasive depth was better than that observed using magnification (88%/47%, respectively). The prevalence of nodal disease overall was 19% (10/52), with 80% (8/10) node positive lesions occurring in the sm3+ lesion group.

Conclusions: High frequency 20 MHz ultrasound is superior to magnification alone when differentiating T1/2 disease with a high positive predictive value for sm3 differentiation. Sm3+ invasion was associated with nodal metastasis.

  • EMR, endoscopic mucosal resection
  • CRC, colorectal cancer
  • LNM, lymph node metastasis
  • HFUS, high frequency ultrasound
  • HMCC, high magnification chromoscopic colonoscopy
  • TTS, through the scope
  • IC, indigo carmine
  • CV, crystal violet
  • PT, Paris type
  • sm, submucosal
  • PPV, positive predictive value
  • NPV, negative predictive value
  • early colorectal cancer
  • high magnification
  • colonoscopy
  • endoscopic ultrasound
  • endoscopic mucosal resection

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  • Published online first 17 June 2005

  • Conflict of interest: None declared.