Photodiagnostic techniques for the endoscopic detection of premalignant gastrointestinal lesions

Considerable attention is given to the clinical diagnosis of gastrointestinal (GI) malignancies as they remain the second leading cause of cancer‐associated deaths in developed countries. Detection and intervention at an early stage of preneoplastic development significantly improve patient survival. High‐risk assessment of asymptomatic patients is currently performed by strict endoscopic surveillance biopsy protocols aimed at early detection of dysplasia and malignancy. However, poor sensitivity associated with frequent surveillance programs incorporating conventional screening tools, such as white light endoscopy and multiple random biopsy, is a significant limitation. Recent advances in biomedical optics are illuminating new ways to detect premalignant lesions of the GI tract with endoscopy. The present review presents a summary report on the newest developments in modern GI endoscopy, which are based on novel optical endoscopic techniques: fluorescence endoscopic imaging and spectroscopy, Raman spectroscopy, light scattering spectroscopy, optical coherence tomography, chromoendoscopy, confocal fluorescence endoscopy and immunofluorescence endoscopy. Relying on the interaction of light with tissue, these ‘state‐of‐the‐art’ techniques potentially offer an improved strategy for diagnosis of early mucosal lesions by facilitating targeted excisional biopsies. Furthermore, the prospects of real‐time ‘optical biopsy’ and improved staging of lesions may significantly enhance the endoscopist's ability to detect subtle preneoplastic mucosal changes and lead to curative endoscopic ablation of these lesions. Such advancements within this specialty will be rewarded in the long term with improved patient survival and quality of life.     

Endoscopic detection of early lower gastrointestinal cancer

The prognosis for patients with malignancies of the lower gastrointestinal tract is strictly dependent on early detection of premalignant and malignant lesions. What should an ideal screening and surveillance colonoscopy be able to accomplish? The technique should allow detection of large but also discrete mucosal alterations. Ideally, endoscopic discrimination between neoplastic and non-neoplastic lesions would be possible during the ongoing procedure. At present, endoscopy can be performed with powerful new endoscopes. Comparable to the rapid development in chip technology, the optical features of the newly designed endoscopes offer resolutions, which allow new surface details to be seen. In conjunction with chromoendoscopy, the newly discovered tool video colonoscopy is much easier and more impressive today than with the previously used fibre-optic endoscopes. Recently, new endoscopic technologies such as narrow band imaging, endocytoscopy, or confocal laser endoscopy have allowed the discovery of a whole new world of image details which will surely improve the diagnostic yield in the field of early malignancies. This review summarises newly available technologies and clinical data about the diagnosis of early lower gastrointestinal cancers.     

New optical technologies for earlier endoscopic diagnosis of premalignant gastrointestinal lesions

Gastrointestinal malignancies continue to be the second leading cause of cancer-related deaths in the developed world. The early detection and treatment of gastrointestinal preneoplasms has been demonstrated to significantly improve patient survival. Conventional screening tools include standard white light endoscopy (WLE) and frequent surveillance with biopsy. Well-defined endoscopic surveillance biopsy protocols aimed at early detection of dysplasia and malignancy have been undertaken for groups at high risk. Unfortunately, the poor sensitivity associated with WLE is a significant limitation. In this regard, major efforts continue in the development and evaluation of alternative diagnostic techniques. This review will focus on notable developments made at the forefront of research in modern gastrointestinal endoscopy based on novel optical endoscopic modalities, which rely on the interactions of light with tissues. Here we present the 'state - of - the - art' in fluorescence endoscopic imaging and spectroscopy, Raman spectroscopy, optical coherence tomography, light scattering spectroscopy, chromoendoscopy, confocal fluorescence endoscopy, and immunofluorescence endoscopy. These new developments may offer significant improvements in the diagnosis of early lesions by allowing for targeted mucosal excisional biopsies, and perhaps may even provide 'optical biopsies' of equivalent histological accuracy. This enhancement of the endoscopist's ability to detect subtle preneoplastic changes in the gastrointestional mucosa in real time and improved staging of lesions could lead to curative endoscopic ablation of these lesions and, in the long term, improve patient survival and quality of life.     

内镜窄带成像技术在胃癌及癌前病变诊断中的应用

目的 探讨内镜窄带成像技术(NBI)对胃癌及癌前病变的诊断价值.方法 217例患者依次在普通内镜、NBI、0.2%靛胭脂染色及内镜放大(×80)模式下观察病变轮廓、胃小凹及微血管形态,评价各检查方法图像的清晰度,并结合病理学检查进行分析.结果 217例患者中,非萎缩性胃炎85例,萎缩性胃炎38例,轻度异型增生19例,中度异型增生9例,重度异型增生4例,早期胃癌5例,进展期胃癌20例,伴有肠化生者91例.NBI对病变轮廓的显示明显优于普通内镜和靛胭脂染色(P值均=0.000).经内镜放大后,NBI对胃微血管形态的显示亦优于普通内镜和靛胭脂染色(P值均=0.000).NBI模式下萎缩性胃炎胃小凹主要表现为Ⅲ、Ⅳ、Ⅴ1型,肠化生主要表现为Ⅲ、Ⅳ、Ⅴ1、Ⅴ2型,异型增生主要表现为Ⅴ1型及Ⅳ型,胃癌主要表现为Ⅵ型.结论 NBI电子染色结合放大技术有助于提高胃癌及异型增生的活检准确率和早期胃癌检出率.     

Narrow-band imaging with magnifying endoscopy for the evaluation of gastrointestinal lesions

Narrow band imaging(NBI) endoscopy is an optical image enhancing technology that allows a detailed inspection of vascular and mucosal patterns, providing the ability to predict histology during real-time endoscopy. By combining NBI with magnification endoscopy(NBI-ME), the accurate assessment of lesions in the gastrointestinal tract can be achieved, as well as the early detection of neoplasia by emphasizing neovascularization. Promising results of the method in the diagnosis of premalignant and malignant lesions of gastrointestinal tract have been reported in clinical studies. The usefulness of NBI-ME as an adjunct to endoscopic therapy in clinical practice, the potential to improve diagnostic accuracy, surveillance strategies and cost-saving strategies based on this method are summarized in this review. Various classification systems of mucosal and vascular patterns used to differentiate preneoplastic and neoplastic lesions have been reviewed. We concluded that the clinical applicability of NBI-ME has increased, but standardization of endoscopic criteria and classification systems, validation in randomized multicenter trials and training programs to improve the diagnostic performance are all needed before the widespread acceptance of the method in routine practice. However, published data regarding the usefulness of NBI endoscopy are relevant in order to recommend the method as a reliable tool in diagnostic and therapy, even for less experienced endoscopists.     

Endoscopic detection of early upper GI cancers

The detection of early-stage neoplastic lesions in the upper GI tract is associated with improved survival and the potential for complete endoscopic resection that is minimally invasive and less morbid than surgery. Despite technological advances in standard white-light endoscopy, the ability of the endoscopist to reliably detect dysplastic and early cancerous changes in the upper GI tract remains limited. In conditions such as Barrett's oesophagus, practice guidelines recommend periodic endoscopic surveillance with multiple biopsies, a methodology that is hindered by random sampling error, inconsistent histopathological interpretation, and delay in diagnosis. Early detection may be enhanced by several promising diagnostic modalities such as chromoendoscopy, magnification endoscopy, and optical spectroscopic/imaging techniques, as these modalities offer the potential to identify in real-time lesions that are inconspicuous under conventional endoscopy. The combination of novel diagnostic techniques and local endoscopic therapies will provide the endoscopist with much needed tools that can considerably enhance the detection and management of early stage lesions in the upper GI tract.     

CT仿真内镜与电子内镜诊断胃肠道疾病的对照研究

目的对比分析CT仿真内镜(CTVE)与电子内镜对胃肠道疾病的诊断价值。方法对84例可疑胃肠道疾病患者行CTVE检查,同时行电子胃镜或电子结肠镜检查,其中47例经内镜及手术病理证实,24例经内镜下病理活检确定诊断。结果84例中胃癌17例,结直肠癌48例,以手术及病理确诊为标准,内镜和CTVE对肿瘤的诊断符合率均为98.46%(64/65),CTVE还检出胃肠外转移病灶29例;内镜下检出结直肠息肉20例,其中CTVE检出15例,符合率为75%;CTVE对炎症性肠病及溃疡性病变的检出率为40%(2/5)。结论CTVE是一种无创的胃肠道检查新技术,对于胃肠道肿瘤的诊断与电子内镜同样有高度敏感性,并能完整显示胃肠道及肠外病灶,但对于小息肉的敏感性不高,对炎症性及扁平病灶的检出率相对较低。     

The yield of diagnostic upper endoscopy: results of a prospective audit

Because of its widespread availability and the generally increasing economic pressure, endoscopy needs critical scrutiny to establish appropriate clinical guidelines. We carried out a prospective evaluation of 200 consecutive upper gastrointestinal (GI) endoscopies to ascertain the frequency of abnormal findings when specific indications were the impetus to endoscopy. Those indications were esophageal complaints, upper GI bleeding, abdominal discomfort, known premalignant disorders and abnormal findings on barium meal. The overall frequency of abnormal findings for all indications was 66%. Abnormal endoscopic findings were most often present when upper GI bleeding or premalignant conditions (88 and 87%, respectively) were reasons for endoscopy. Endoscopic confirmation of lesions seen on barium meal was 64%. Only 37% of patients endoscoped for abdominal discomfort had abnormal findings. Moreover, as symptoms resolved in 70% of such patients within 1 to 9 weeks, the low yield of endoscopy suggests that our current threshold for endoscopy in this setting may be too low. Refinement of the indications for and reassessment of the timing of endoscopy are needed.     

Clinicopathological features of gastric cancer detected by endoscopy as part of annual health checkup

Background and Aim: Upper gastrointestinal endoscopy is generally accepted as the gold standard for the clinical evaluation of gastric cancer (GC). However, the efficacy of endoscopic screening for asymptomatic GC remains controversial. The present study is designed to clarify the efficacy of endoscopic screening for the detection of early GC by investigating the clinicopathological features. Methods: A total of 17 522 patients who had underwent endoscopic screening as a part of their annual health checkup at the Seirei Center for Health Promotion and Preventive Medicine between April 2002 and March 2006 were enrolled in this study. We investigated the clinicopathological findings of GC detected by endoscopy. Furthermore, in accordance with the screening interval at our center, patients with GC were categorized into two groups: group A, patients with repeated endoscopic screening within the last 2 years, and group B, patients without endoscopic screening within the last 2 years. Results: Thirty‐nine GC (mean age of patients: 62.2 ± 8.0 years, 36 males and three females) were detected in total (0.22%). The proportion of early GC was 87.2%. Notable differences between groups A and B were not found in the rate of early GC (P = 0.6342). However, eight of 27 cases (29.6%) in group A were treated by endoscopic resection, but none in group B (P = 0.0344). In six of 26 cases (23.1%) in group A, the recorded images from the previous endoscopic examination indicated some macroscopic abnormalities at the same location, suggesting GC or premalignant lesions. Conclusion: Endoscopic screening is useful for detecting GC at the early stages, and repeated examinations at short‐time intervals contribute to the detection of resectable lesions by endoscopy. Further studies are needed to decrease the false negative rate of endoscopic screening.     

New aspects of modern endoscopy

The prognosis for patients with malignancies of the ga-strointestinal-tract is strictly dependent on early detec-tion of premalignant and malignant lesions. However, small, flat or depressed neoplastic lesions remain dif-ficult to detect with these technologies thereby limiting their value for polyp and cancer screening. At the same time computer and chip technologies have undergone major technological changes which have greatly im-proved endoscopic diagnostic investigation. New imag-ing modalities and techniques are very notable aspects of modern endoscopy. Chromoendoscopy or filter-aided colonoscopy(virtual chromoendoscopy) with high defi-nition endoscopes is able to enhance the detection and characterization of lesions. Finally, confocal laser en-domicroscopy provides histological confirmation of the presence of neoplastic changes. The developing tech-niques around colonoscopy such as the retro-viewing colonoscope, the balloon-colonoscope or the 330-de-grees-viewing colonoscope try to enhance the efficacy by reducing the adenoma miss rate in right-sided, non-polypoid lesions. Colon capsule endoscopy is limited to identifying cancer and not necessarily small adenomas. Preliminary attempts have been made to introduce this technique in clinical routine.     

Miniprobe sonography in the evaluation of 169 patients with gastrointestinal disease

OBJECTIVE : It is still difficult to precisely differentiate elevated lesions of the gastrointestinal mucosa or estimate the depth of malignant lesions by using conventional endoscopy and biopsy. The aim of the present study was to assess the clinical value of miniprobe sonography (MPS). METHODS : A total of 169 patients (including 83 patients who underwent endoscopic treatment or surgery) with gastrointestinal disease were examined by using MPS in conjunction with endoscopic examination. The diagnosis according to MPS was compared with macroscopic findings, endoscopic biopsy and surgical results. RESULTS : In the case of elevated lesions of the gastrointestinal mucosa with negative biopsies, compared with surgical findings, the diagnostic accuracy of MPS was 98.3% (115/117). In the case of malignant lesions, MPS findings with regard to the lesion depth were 100% in agreement with those from surgical biopsy (31/31). CONCLUSION : The MPS technique is significantly superior to conventional endoscopy with pathological biopsy in the differentiation of elevated lesions of the gastrointestinal mucosa and thus has important clinical value. But in the case of malignant lesions, only the depth of infiltration into the gastrointestinal wall can be correctly assessed by MPS, so its value is limited in the identification of lymph nodes and distal metastases.     

Endoscopic photodynamic diagnosis: oral aminolevulinic acid is a marker of GI cancer and dysplastic lesions.

BACKGROUND: Dysplasia and early cancer of the upper gastrointestinal (GI) tract often are undetected at white-light endoscopy. We describe oral administration of 5-aminolevulinic acid for the in vivo photodynamic diagnosis of premalignant and malignant lesions during endoscopy. METHODS: Four patients with known gastric adenoma (n = 1), macroscopically undetected but histologically proven esophageal squamous cell cancer (n = 1), suspected early cancer of the esophagus (n = 1), and multiple duodenal adenomas (n = 1) were sensitized with 5-aminolevulinic acid administered orally (15 mg/kg body weight). Photodynamic diagnosis was conducted after a retention time of 6 to 7 hours with a special light source capable of delivering either white or violet-blue light. Red fluorescence was detected through the gastroscope with an image-intensifying camera. RESULTS: All malignant lesions exhibited red or bluish fluorescence during photodynamic diagnosis. Fluorescence-negative mucosal areas proved to be histologically benign. CONCLUSION: Fluorescence induced with 5-aminolevulinic acid might be useful for the endoscopic detection of dysplasia and early carcinoma in the upper GI tract. Further investigations are needed to evaluate the sensitivity and specificity of photodynamic diagnosis for different tumor entities.     

Nonsurgical approaches to esophageal malignancy

Esophageal cancer remains one of the leading causes of cancer death worldwide. Patients generally present with progressive dysphagia, malnutrition, and weight loss. The diagnosis commonly involves radiologic studies and conventional esophagogastroduodenoscopy. Advances in endoscopic evaluation have allowed early detection of premalignant and malignant lesions. These techniques include chromoscopy, which can be performed in conjunction with high-resolution/magnification endoscopy, and fluorescent endoscopy. Such techniques as endoscopic ultrasound with dedicated echoendoscopes or high-frequency probes, positron emission tomography, optical coherence tomography, endoscopic magnetic resonance imaging, and tactile sensing may complement conventional imaging by CT to enhance staging accuracy. Because the majority of patients present with incurable disease at the time of diagnosis, nonsurgical approaches to their management have evolved. These include endoscopic mucosal resection, stenting, tumor ablation, and palliative chemoradiotherapy. The ablative techniques include argon plasma coagulator therapy, laser, and photodynamic therapy. For patients with early malignancies of the esophagus who are not surgical candidates, such techniques may be used with curative intent.     

No Support for Endoscopic Surveillance for Gastric Cancer in Hereditary Non-Polyposis Colorectal Cancer

Background: The DNA mismatch repair gene mutations underlying hereditary non-polyposis colorectal cancer syndrome (HNPCC) also predispose, besides colorectal and endometrial cancer, to gastric cancer, usually of the intestinal type. The carcinogenetic pathway behind the elevated gastric cancer risk is largely unknown. Methods: The aim of this study was to determine whether there are any premalignant lesions to search for in gastric surveillance in HNPCC by comparing gastric histopathology between mutation-positive and mutation-negative family members. We searched for differences in occurrence of Helicobacter pylori , inflammation, atrophy, intestinal metaplasia and dysplastic changes. Upper gastrointestinal endoscopy was performed for 73 mutation-positive and 32 mutation-negative family members. Results: One case of duodenal cancer was detected in the mutation-positive group, but no gastric neoplastic lesions were seen in either group. There were no differences in the occurrence of polyps, H. pylori , inflammation, activity, atrophy nor intestinal metaplasia tested with binaric, logistic, regression analysis. Conclusions: We conclude that surveillance gastroscopy may not be beneficial in HNPCC, since neither cases of early cancer nor premalignant lesions could be detected in our series of 73 mutation-positive subjects.     

No support for endoscopic surveillance for gastric cancer in hereditary non-polyposis colorectal cancer

BACKGROUND: The DNA mismatch repair gene mutations underlying hereditary non-polyposis colorectal cancer syndrome (HNPCC) also predispose, besides colorectal and endometrial cancer, to gastric cancer. usually of the intestinal type. The carcinogenetic pathway behind the elevated gastric cancer risk is largely unknown. METHODS: The aim of this study was to determine whether there are any premalignant lesions to search for in gastric surveillance in HNPCC by comparing gastric histopathology between mutation-positive and mutation-negative family members. We searched for differences in occurrence of Helicobacter pylori, inflammation, atrophy, intestinal metaplasia and dysplastic changes. Upper gastrointestinal endoscopy was performed for 73 mutation-positive and 32 mutation-negative family members. RESULTS: One case of duodenal cancer was detected in the mutation-positive group, but no gastric neoplastic lesions were seen in either group. There were no differences in the occurrence of polyps, H. pylori, inflammation, activity, atrophy nor intestinal metaplasia tested with binaric, logistic, regression analysis. CONCLUSIONS: We conclude that surveillance gastroscopy may not be beneficial in HNPCC, since neither cases of early cancer nor premalignant lesions could be detected in our series of 73 mutation-positive subjects.     

Perspectives of chromo and magnifying endoscopy: how, how much, when, and whom should we stain?

The goal of every routine endoscopy in the gut is the early diagnosis of malignant and premalignant changes of the mucosa. Chromo- and magnifying endoscopes are exciting new tools and offer detailed analysis of the colonic mucosal surface and pit pattern architecture. This review summarizes recent advances in endoscopic characterization of colorectal lesions using magnification endoscopy and chromoendoscopy. Surface analysis of the colon using chromoendoscopy allows a prediction between non-neoplastic and neoplastic lesions with high specificity. The precise delineation of the borders and a more detailed macroscopic analysis of the lesions are further advantages. In particular, flat adenomas and early depressed cancers are now more frequently recognized in western countries suggesting that significant lesions were overlooked by conventional endoscopy in the past. Furthermore, chromoendoscopy can be used in a targeted fashion to screen for sporadic adenomas. Finally, in surveillance colonoscopy, patients with long-standing ulcerative colitis have a valuable benefit if targeted biopsies are performed to detect intraepithelial neoplasias after pan-chromoendoscopy with methylene blue. Although there is a long learning curve, chromoendoscopy should thus belong to every endoscopists armamentarium. However, detailed knowledge about the technique, dyes, and specific staining patterns are mandatory before the yield of screening or surveillance colonoscopy can be increased. The new detailed images seen with magnifying chromoendoscopy are unequivocally the beginning of a new era where new optical developments will allow a unique look on cellular structures.     

From colonic polyps to colon cancer: pathophysiology, clinical presentation, screening and colonoscopic therapy

Colon cancer is the most common nondermatologic cancer in Italy and throughout Europe, with about 250,000 cases annually in Europe, about half of whom die. Yet, colon cancer is largely preventable through intensive, mass screening programs to remove premalignant colonic polyps. The persistently high incidence and mortality is largely due to ineffective implementation of established screening protocols due to patient fears about screening tests, physician under-referral for screening, and test costs. Colon cancer mostly arises from adenomas, recognized as colonic polyps, but may occasionally arise from the sessile serrated adenoma. Adenomatous polyposis coli (APC) gene mutation is the key molecular step in adenoma formation. Mismatch repair gene mutation is a less common alternative pathway. Progression from adenomas to colon cancer is a multistep process, involving mutations of the DCC, k-ras, and p53 genes; loss of heterozygosity in which cells loose one allele of some genes from chromosomal loss; and DNA methylation which can silence DNA expression. Numerous environmental factors can increase the risk of colon cancer, presumably by modulating these molecular pathways. While colon cancer in an advanced and incurable stage often produces clinical findings, premalignant adenomatous polyps and early, highly curable, colon cancer are often asymptomatic. This phenomenon renders adenomas or early cancers difficult to detect by clinical presentation and provides the rationale for mass screening of asymptomatic adults over 50 years old for early detection and prevention of colon cancer. Colonoscopy is the primary screening test. All polyps identified at colonoscopy are removed by colonoscopic polypectomy. Endoscopic mucosal resection is required for deeply penetrating noncancerous polyps. Colonoscopy is repeated every ten years if the index colonoscopy revealed no lesions, but is repeated more frequently if adenomatous polyps were identified at this colonoscopy due to an increased risk of subsequent polyps or colon cancer. Flexible sigmoidoscopy every few years with annual fecal occult blood testing is a significantly less sensitive screening protocol. Virtual colonoscopy is controversial as a screening test due to widely variable reported RESULTS: Computerized tomography is standardly used to preoperatively detect distant colon cancer metastases, while endosonography is being increasingly used for locoregional staging of rectal cancer. Stool genetic markers and videocapsule endoscopy are promising, but currently experimental, screening tests.     

Artificial intelligence-assisted endoscopic detection of esophageal neoplasia in early stage: The next step?

Esophageal cancer (EC) is a common malignant tumor of the digestive tract and originates from the epithelium of the esophageal mucosa. It has been confirmed that early EC lesions can be cured by endoscopic therapy, and the curative effect is equivalent to that of surgical operation. Upper gastrointestinal endoscopy is still the gold standard for EC diagnosis. The accuracy of endoscopic examination results largely depends on the professional level of the examiner. Artificial intelligence (AI) has been applied in the screening of early EC and has shown advantages; notably, it is more accurate than less-experienced endoscopists. This paper reviews the application of AI in the field of endoscopic detection of early EC, including squamous cell carcinoma and adenocarcinoma, and describes the relevant progress. Although up to now most of the studies evaluating the clinical application of AI in early EC endoscopic detection are focused on still images, AI-assisted real-time detection based on live-stream video may be the next step.     

胃内常见隆起性病变

胃内隆起性病变是胃镜检查过程中常见的病变,根据病变来源可分为黏膜组织来源、黏膜下组织来源及外源性压迫。常见胃黏膜组织来源病变有增生性息肉、胃底腺息肉、腺瘤等,黏膜下组织来源病变有胃肠道间质瘤、异位胰腺、脂肪瘤、胃囊肿、炎性纤维性息肉、胃肠道平滑肌瘤等,可统称为胃黏膜下肿瘤;外源性压迫有肝肿大、肝癌、胃壁外的脏器等所致。胃内隆起性病变临床表现缺乏特异性,其中胃底腺息肉、胃腺瘤、胃肠道间质瘤等病变具有恶变潜能。随着人们的饮食结构的改变、健康意识的提高及电子胃镜的广泛应用,胃内隆起性病变检出率及治愈率明显提高,对预防胃癌发生、发现早期胃癌和治疗早期胃癌有重要的临床意义。     

Endoscopic diagnosis of sessile serrated adenoma/polyp with and without dysplasia/carcinoma

Sessile serrated adenoma/polyps(SSA/Ps) are early precursor lesions in the serrated neoplasia pathway, which results in colorectal carcinomas with BRAF mutations, methylation for DNA repair genes, a Cp G island methylator phenotype, and high levels of microsatellite instability. Some of these lesions can rapidly become dysplastic or invasive carcinomas that exhibit high lymphatic invasion and lymph node metastasis potentials. Detecting serrated lesions, including SSA/Ps with and without dysplasia/carcinoma, is critical, but SSA/Ps can be difficult to detect, are inconsistently identified by endoscopists and pathologists, and are often incompletely resected. Therefore, SSA/Ps are considered to be major contributors to "interval cancers". If colonoscopists can identify the specific endoscopic characteristics of SSA/Ps, their detection and the effectiveness of colonoscopy may improve. Here, the endoscopic features of SSA/Ps with and without dysplasia/carcinoma, including the characteristics determined using magnifying endoscopy, are reviewed in the context of previous reports. Endoscopically, these subtle polyps are like hyperplastic polyps, because they are slightly elevated and pale. Unlike hyperplastic polyps, SSA/Ps are usually larger than 5 mm, frequently covered by a thin layer called the ‘‘mucus cap', and are more commonly located in the proximal colon. Magnifying narrow-band imaging findings, which include dark spots inside the crypts and varicose microvascular vessels, in addition to the type II-open pit patterns detected using magnifying chromoendoscopy, effectively differentiate SSA/Ps from hyperplastic polyps. The lesions' endoscopic characteristics, which include their(semi)pedunculated morphologies, double elevations, central depressions, and reddishness, and the use of magnifying endoscopy, might help to detect dysplasia/carcinoma within SSA/Ps. Greater awareness may promote further research into improving the detection, identification, and complete resection rates of SSA/Ps with and without dysplasia/carcinoma and reduce the interval cancer rates.