Efficacy of the revised Vienna Classification for diagnosing colorectal epithelial neoplasias

Abstract

AIM:To prospectively investigate the efficacy of the revised Vienna Classification for diagnosing colorectal epithelial neoplastic lesions in cold biopsy specimens. METHODS:Patients were selected for inclusion if they had colorectal epithelial lesions that were not considered suitable for direct endoscopic resection. These included colorectal polyps ≥ 10 mm and lesions suspected of being carcinomas capable of invading the colorectal submucosa or beyond, including strictures, based on the cold biopsies obtained from each lesion prior to resection. We investigated the relationship between diagnoses based on cold biopsy samples using the revised Vienna Classification and resected specimens of the same lesions, and the therapeutic implications of diagnoses made using the revised Vienna Classification. The same cold biopsy specimens were also examined using the Japanese Group Classification guidelines, and compared with the resected specimens of the same lesions for reference. RESULTS:A total of 179 lesions were identified. The sensitivity, specificity, positive and negative predictive values of the revised Vienna Classification for distinguishing between intramucosal lesions and submucosal invasive carcinomas in cold biopsy specimens was 22.2%, 100%, 100%, and 71.4%, r e s p e c t i v e l y, a n d f o r d i s t i n g u i s h i n g b e t w e e n intramucosal lesions and those invading the submucosa or beyond was 59.7%, 100%, 100%, and 37.6%, respectively. The sensitivity, specificity, positive and negative predictive values of the Japanese Group Classification for distinguishing between intramucosal lesions and submucosal invasive carcinomas in cold biopsy specimens was 83.3%, 91.4%, 83.3%, and 91.4%, respectively, and for distinguishing between intramucosal lesions and those invading the submucosa or beyond was 95.1%, 91.4%, 97.9%, and 82.1%, respectively. A total of 137 of 144 carcinomas that had invaded the submucosa or beyond and three high-grade intraepithelial neoplasias were diagnosed as "carcinoma" using the Japanese Group Classification system. CONCLUSION:The revised Vienna Classification for cold biopsy specimens has high positive predictive value in the diagnosis of colorectal carcinoma invasive to the submucosa or beyond.

More advanced or aggressive colorectal cancer is associated with a higher incidence of “high-grade intraepithelial neoplasia” on biopsy-based pathological examination

“…Clinicians should also pay attention to clinicopathologic features that have been reported to be helpful in distinguishing colorectal cancers from HGIN, including large tumor size ([1 cm), depressed ulceration, irregular contours, deformity, tumor necrosis, desmoplastic stroma and invasion of adjacent mucosa [6,13,26]. Besides, endoscopic ultrasonography, CT and MRI, which are useful in depicting the invasion depth and lymph node status of colorectal lesions, are helpful in preoperative evaluation of colorectal cancer [12,27,28].…”

“…Theoretically, the problem of underdiagnosis can be resolved effectively by adopting the Japanese Group Classification (JGC) of colorectal epithelial neoplasia, which is based on the severity of nuclear and structural changes, not on the depth of invasion [19]. However, it has been reported that, by adopting the JGC classification instead of the WHO classification criteria, the sensitivity of distinguishing colorectal cancer from HGIN in biopsy specimens increased from 59.7-95.1 %; but the specificity fell from 100-91.4 % at the same time, which meant the risk of overtreatment increased correspondingly [12]. It has also been reported that these problems could best be resolved by use of the revised Vienna classification [10].…”

“…Due to the sampling error, poor bowel preparation, defective equipment and limited expertise of the endoscopists, biopsy-based diagnosis may miss the invasive component of a tumor that is infiltrating the submucosa, and deeper structures may be missed on biopsy-based diagnosis [3]. A large proportion of cases of biopsy-proven high-grade intraepithelial neoplasia (HGIN) have been proven to be invasive colorectal cancer by analysis of the surgical specimens [3,[12][13][14][15]. This suggests that many colorectal cancer patients may not receive timely treatment due to underdiagnosis.…”

Early rectal cancer: the European Association for Endoscopic Surgery (EAES) clinical consensus conference

“…Considerable discrepancies have been reported between the diagnosis of adenomas containing invasive carcinoma from endoscopic biopsies and resected specimens of the same lesion because biopsy-based diagnoses are subject to the limitations of superficiality and sampling errors. It has been shown, however, that by applying the revised Vienna Classification to biopsy specimens the risk of finding an invasive carcinoma in the resected lesion can be effectively assessed [60]. Biopsy is of limited value in predicting the depth of invasion assigned to the resected specimens, especially for the diagnosis of early cancer.…”

The value of brush cytology and biopsy for the diagnosis of colorectal cancer

“…In the revised Vienna classification it is recommended to qualify a biopsy finding of intramucosal carcinoma as "at least 24 . However, the estimation of efficiency of the revised Vienna classification for biopsy diagnostics of colorectal epithelial neoplasa has shown its high positive predictive value, and low sensitivity in the diagnostics of colorectal carcinoma, if pathologists use the invasion of submucosis or deeper invasion as an obligatory criterion for the diagnosis of carcinoma 25 .…”