The role of flat and depressed colorectal lesions in colorectal carcinogenesis: new insights from clinicopathological findings in high-magnification chromoscopic colonoscopy

High-magnification chromoscopic endoscopy is a new technique which has been recently introduced to the UK. This technology, initially pioneered by the Japanese in the 1980s, has changed our understanding of the pathogenesis of colorectal cancer and our subsequent therapeutic strategies aimed at the secondary prevention of cancer. Magnification colonoscopic techniques when combined with colonic chromoscopy (dye spraying of the colon) permit in vivo assessments of lesions at a magnification and resolution similar to a stereomicroscope. Furthermore, flat/depressed adenomas and cancers can be diagnosed with increasing frequency and new resection practices performed. This technique is known as endoscopic mucosal resection. As gastrointestinal endoscopists adopt these new techniques, close liaison with histopathologists is essential to provide the highest standards of diagnostic accuracy. The histopathologist also needs to be aware of the endoscopic findings when interpreting specimens and hence must understand new endoscopic terminologies and classification systems that accompany the introduction of new technologies and therapeutic techniques. This article describes the controversies relating to the flat and depressed colorectal lesion, where these new endoscopic technologies are ideally suited. It then provides a working description of high-magnification chromoscopic colonoscopy including the Japanese 'pit pattern' and morphological classification system-information which will be provided to histopathologists with specimens obtained by these new techniques. Finally, we describe the procedure of endoscopic mucosal resection, as the type and quality of specimens received for histopathological analysis will be highly influenced by these techniques.