Early detection of superficial squamous cell carcinoma in the head and neck region and esophagus by narrow band imaging: a multicenter randomized controlled trial

Ultrathin endoscope flexibility can predict discomfort associated with unsedated transnasal esophagogastroduodenoscopy

AIM

To evaluate the effects of choice of insertion route and ultrathin endoscope types.

METHODS

This prospective study (January-June 2012) included 882 consecutive patients who underwent annual health checkups. Transnasal esophagogastroduodenoscopy (EGD) was performed in 503 patients and transoral EGD in 235 patients using six types of ultrathin endoscopes. Patients were given a choice of insertion route, either transoral or transnasal, prior to EGD examination. For transoral insertion, the endoscope was equipped with a thin-type mouthpiece and tongue depressor. Conscious sedation was not used for any patient. EGD-associated discomfort was assessed using a visual analog scale (VAS; no discomfort 0- maximum discomfort 10).

RESULTS

Rates of preference for transnasal insertion were significantly higher in male (male/female 299/204 vs 118/117) and younger patients (56.8 ± 11.2 years vs 61.3 ± 13.0 years), although no significant difference was found in VAS scores between transoral and transnasal insertion (3.9 ± 2.3 vs 4.1 ± 2.5). Multivariate analysis revealed that gender, age, operator, and endoscope were independent significant predictors of VAS for transnasal insertion, although gender, age, and endoscope were those for transoral insertion. Further analysis revealed only the endoscopic flexibility index (EFI) as an independent significant predictor of VAS for transnasal insertion. Both EFI and tip diameter were independent significant predictors of VAS for transoral insertion.

CONCLUSION

Flexibility of ultrathin endoscopes can be a predictor of EGD-associated discomfort, especially in transnasal insertion.

Utility and stability of transnasal endoscopy for examination of the pharynx - a prospective study and comparison with transoral endoscopy

OBJECTIVE

Transnasal endoscopy may be used to observe the head and neck part readily without excessive reflexes. We aimed to evaluate the utility and stability of transnasal esophagogastroduodenoscopy (TN-EGD) in comparison with transoral EGD (TO-EGD) for observation of the pharynx.

STUDY DESIGN

Prospective study

METHODS

A total of 497 patients received unsedated TN-EGD with a 5.5 mm diameter endoscope or unsedated TO-EGD with endoscopes of 6.5 mm, 7.9 mm and 9.2 mm diameter. The rate of completion of pharyngeal observation and numbers of gag reflexes and cough reflexes were recorded.

RESULTS

TN-EGD was performed in 175 patients and TO-EGD was performed in 322 patients. Pharyngeal observation was completed in 173 patients (98.9%) in the TN-EGD group and 235 patients (73.2%) in the TO-EGD group, a significant difference (p<0.001). The TN-EGD group had a low rate of occurrence of gag reflex (0.57%), in contrast, 28.3% of the TO-EGD group had a gag reflex, a significant difference (p<0.01). Multivariable analyses revealed that the use of TN-EGD was the only predictive factor for completion of pharyngeal observation (p<0.0001).

CONCLUSIONS

TN-EGD is ideally suited to observation of the pharynx by unsedated EGD.

Preoperative iodine staining may complicate the demarcation of esophageal carcinoma

A 53-year-old man was suspected of having an esophageal neoplasm. An endoscopic examination including Lugol chromoendoscopy suggested an esophageal squamous cell neoplasm limited to the lamina propria. A targeted biopsy showed atypical squamous cells, and an endoscopic submucosal dissection was performed 22 days after the previous endoscopy. Although a single 40 mm unstained area was observed by preoperative Lugol chromoendoscopy, intraoperative endoscopy revealed a 25 mm iodine-unstained area, with small unstained areas scattered on the oral side. We included the small unstained areas in the extent of the resection through assessment by preoperative endoscopy. Histopathologically, the tumor extent appeared to coincide with the preoperative assessment. Tumor cells were found in the basal-parabasal layers of the mucosa, in which small unstained areas were scattered, although the superficial layers exhibited well-differentiated cells containing glycogen in the cytoplasm. Although Lugol chromoendoscopy, which can induce chemical esophagitis, is widely used, re-epithelialization after mucosal damage by preoperative iodine staining may complicate the intraoperative demarcation of tumors.

Optical molecular imaging in the gastrointestinal tract

Recent developments in optical molecular imaging allow for real-time identification of morphologic and biochemical changes in tissue associated with gastrointestinal neoplasia. This review summarizes widefield and high-resolution imaging modalities in preclinical and clinical evaluation for the detection of colorectal cancer and esophageal cancer. Widefield techniques discussed include high-definition white light endoscopy, narrow band imaging, autofluoresence imaging, and chromoendoscopy; high-resolution techniques discussed include probe-based confocal laser endomicroscopy, high-resolution microendoscopy, and optical coherence tomography. New approaches to enhance image contrast using vital dyes and molecular-specific targeted contrast agents are evaluated.

Feasibility of a "resect and watch" strategy with endoscopic resection for superficial pharyngeal cancer

BACKGROUND

After endoscopic resection (ER) for superficial pharyngeal cancer (SPC), additional treatments such as radical surgical resection or radiation therapy may be needed in cases of possible incomplete resection. However, the benefit of prophylactic additional treatment is unclear.

OBJECTIVE

To evaluate the feasibility of a "resect and watch" strategy with ER for SPC.

DESIGN

Retrospective, single-center cohort study.

SETTING

Tertiary cancer center.

PATIENTS

A total of 32 patients with 47 SPCs were eligible.

INTERVENTION

A "resect and watch" strategy of initial ER and observation until development of secondary diseases, including local recurrence, neck lymph node metastasis (LNM), and metachronous pharyngeal cancer.

MAIN OUTCOME MEASUREMENTS

Complications, tumor recurrence, development of metachronous pharyngeal cancer, overall survival, and cause-specific survival.

RESULTS

There were no severe complications related to ER. Median length of follow-up was 43 months (range, 7-76 months). Cumulative development of secondary diseases at 5 years was 44% (95% CI, 24.5%-63.8%). Local recurrence (N = 4) and neck LNM (N = 5) were successfully treated by local resection (2 partial surgical resections and 2 additional ERs) and neck dissection, respectively. Metachronous pharyngeal cancers (N = 6) were completely removed by ER. The overall survival and cause-specific survival rates at 5 years were 84.4% (95% CI, 70.0%-98.8%) and 100%, respectively. No patient needed radical surgery as an additional therapy. Thus, the larynx and its function were preserved in all patients.

LIMITATIONS

Retrospective nature, single-center setting, relatively small sample size.

CONCLUSIONS

A "resect and watch" strategy with ER for SPC is feasible and rational.

Utility of unsedated transnasal endoscopy for pharyngeal observation during esophagogastroduodenoscopy. A prospective study to assess cardiopulmonary function

OBJECTIVES

Emergence of image-enhanced endoscopy has enabled an early detection of pharyngeal carcinoma. Pharyngeal observation during esophagogastroduodenoscopy (EGD) is sometimes difficult because of excessive reflexes and is a great burden to the patients and impacts on their cardiopulmonary function. In this study, the authors aimed to evaluate the utility of transnasal EGD (TN-EGD) in comparison with sedated and unsedated transoral EGD (TO-EGD) in pharyngeal observation using a continuous monitoring device.

METHODS

A total of 70 patients receiving diagnostic EGD (unsedated TN-EGD, sedated TO-EGD, and unsedated TO-EGD) were enrolled in this study and were evaluated by the following three criteria: (1) numbers of patients with excessive gag and/or cough reflex, (2) vital signs before and during the pharyngeal observation, and (3) response to the request for vocalization or breath-holding.

RESULTS

Unsedated TN-EGD, sedated TO-EGD, and unsedated TO-EGD were performed in 30, 20, and 20 patients, respectively. The rate of gag reflex was significantly lower in TN-EGD than in both types of TO-EGD (0% vs. 30%, chi-square test, p < 0.005). The changes in average values of both arterial oxygen saturation (SpO2) and pulse rate (PR) in TN-EGD were smaller than those in sedated TO-EGD (-0.23% vs. -1.23% in SpO2 and 1.57 vs. 8.11 bpm in PR, p < 0.01, respectively). Unsedated TN-EGD patients could respond to the instructions of utterance and breath-holding during the observation (p < 0.05, p < 0.001, respectively).

CONCLUSION

Unsedated TN-EGD is safe and feasible for pharyngeal observation during normal EGD examination.

Epithelial maturation pattern of dysplastic epithelium and normal oral epithelium exposed to tobacco and alcohol: a scanning electron microscopic study

BACKGROUND

The detection of oral cancer at an early stage is an optimal strategy and is the most effective approach for preventing further progression. The rationale of the study was to evaluate the epithelial maturation pattern in oral mucosa exposed to tobacco/alcohol and on dysplastic oral mucosa using the scanning electron microscope.

METHODS

Fifteen subjects were selected based on clinical examination and divided into three groups: group 1-patients with apparently normal oral mucosa; group 2-patients with oral mucosa exposed to tobacco/alcohol; group 3-patients with clinical diagnosis of leukoplakia. An incisional biopsy was performed from the buccal mucosa. One part of the specimen was prepared for light microscopy and the other part was prepared for scanning electron microscopy.

RESULTS

Light microscopy revealed nonkeratinized stratified squamous epithelium in group 1, while group 2 demonstrated hyperparakeratinized stratified squamous epithelium with mild cytological atypia, and group 3 showed architectural and cytological changes. Scanning electron microscopy demonstrated flat-surfaced cells with equidistant parallel microridges in group 1, while group 2 showed irregular and widened microridges with numerous pits and absence of honeycomb pattern. Group 3 showed irregularly arranged broad and swollen cells with numerous pits and irregular microvilli projecting over the surface.

CONCLUSION

The present study establishes the relationship of the surface abnormalities to the tendency of the cells to become malignant and thus serves as a tool in early detection of squamous cell carcinoma. It also emphasizes the need of routine follow-up in these high-risk patients for progression of carcinoma.

Barrett's esophageal adenocarcinoma diagnosed by narrow-band imaging magnifying endoscopy

A 40-year-old man was referred to our hospital for detailed examination of a protuberant lesion in long-segment Barrett's esophagus (LSBE). Under white light endoscopy (WLE) the lesion appeared as a protuberant lesion with a rough surface and was diagnosed as 0-IIa-type tumor suspected to be a well-differentiated adenocarcinoma. A regular villous pattern was shown in the background mucosa of the LSBE by narrow-band imaging (NBI) magnifying endoscopy (NBI-ME). However, a slightly irregular villous pattern was observed on the lateral side of the main lesion. Therefore, a 0-IIa-type tumor was estimated to have a flatly lateral extension component (i.e. 0-IIb spreading). The 0-IIb spreading was unclear when using WLE, but could be diagnosed by NBI-ME based on the surface pattern differences. Markings were placed outside the edge of the flatly lateral extension, and endoscopic submucosal dissection was carried out.The pathological diagnosis of the protuberant lesion with flatly lateral spreading was well-differentiated adenocarcinoma. The macroscopic type was 0-IIa+IIb, 45 × 43 mm in size. The invasion depth was T1a (deep muscularis mucosae). Lymphatic and venous invasions were negative; horizontal and vertical margins were negative. In conclusion, NBI-ME was useful for the diagnosis of the flatly lateral extension of this 0-IIa+IIb esophageal adenocarcinoma in Barrett's esophagus. Further investigations with many cases are necessary.

Different healing process of esophageal large mucosal defects by endoscopic mucosal dissection between with and without steroid injection in an animal model

Background

Stricture formation is one of the major complications after endoscopic removal of large superficial squamous cell neoplasms of the esophagus, and local steroid injections have been adopted to prevent it. However, fundamental pathological alterations related to them have not been well analyzed so far. The aim of this study was to analyze the time course of the healing process of esophageal large mucosal defects resulting in stricture formation and its modification by local steroid injection, using an animal model.

Methods

Esophageal circumferential mucosal defects were created by endoscopic mucosal dissection (ESD) for four pigs. One pig was sacrificed five minutes after the ESD, and other two pigs were followed-up on endoscopy and sacrificed at the time of one week and three weeks after the ESD, respectively. The remaining one pig was followed-up on endoscopy with five times of local steroid injection and sacrificed at the time of eight weeks after the ESD. The esophageal tissues of all pigs were subjected to pathological analyses.

Results

For the pigs without steroid injection, the esophageal stricture was completed around three weeks after the ESD on both endoscopy and esophagography. Histopathological examination of the esophageal tissues revealed that spindle-shaped α-smooth muscle actin (SMA)-positive myofibroblasts arranged in a parallel fashion and extending horizontally were identified at the ulcer bed one week after the ESD, and increased contributing to formation of the stenotic luminal ridge covered with the regenerated epithelium three weeks after the ESD. The proper muscle layer of the stricture site was thinned with some myocytes which seemingly showed transition to the myofibroblast layer. By contrast, for the pig with steroid injection, esophageal stricture formation was not evident with limited appearance of the spindle-shaped myofibroblasts, instead, appearance of stellate or polygocal SMA-positive stromal cells arranged haphazardly in the persistent granulation tissue of the ulcer site.

Conclusions

Proliferation of spindle-shaped myofibroblasts arranged in a parallel fashion is likely to play an important role in stricture formation after circumferential mucosal defects by esophageal ESD, which may be related to the thinning of the proper muscle layer in the healing course of the defects. Local steroid injection seems to be effective to prevent the stricture through the modification of this process.

Characteristic magnifying narrow-band imaging features of colorectal tumors in each growth type

PURPOSE

We investigated the surface characteristics and vascular patterns of colorectal tumors according to growth type by means of magnifying narrow-band imaging (NBI).

METHODS

Four hundred ninety-seven colorectal tumors larger than 10 mm (204 tubular adenomas [TAs], 199 frankly invasive intramucosal carcinomas to shallow invasive submucosal [M/SM-s] carcinomas, and 94 deeply invasive submucosal [SM-d] carcinomas) were analyzed. These colorectal tumors were classified according to growth type as follows: polypoid type, n = 224; laterally spreading tumor-granular (LST-G) type, n = 133; and LST-non-granular (LST-NG) type, n = 140. Surface and vascular patterns were evaluated in relation to histology and growth type.

RESULTS

The absent and irregular surface patterns were observed in approximately 40 % of the SM-d carcinomas of the polypoid and LST-G type. The unclear surface pattern was more frequent in tumors of the LST-NG type than in those of other growth types, regardless of histology. Among TAs and M/SM-s carcinomas, the dense vascular pattern was most frequent in polypoid type, the dense and corkscrew vascular patterns were most frequent in the LST-G type, and the honeycomb and avascular and/or fragmentary patterns were most frequent in the LST-NG type. The avascular and/or fragmentary vessel pattern was more frequent in SM-d carcinomas than in TA and M/SM-s carcinomas, regardless of growth type.

CONCLUSIONS

A part of LST-NG was difficult to identify the NBI magnifying surface pattern. Although NBI magnifying findings were almost same in each type lesion in SM-d lesion, those of LST-NG were different from those of LST-G and polypoid type in M/SM-s lesion.

The new era of staging as a key for an appropriate treatment for esophageal cancer

Fluorodeoxyglucose-positron emission tomography (FDG-PET) and computed tomography (CT) have become the gold standard for staging of esophageal cancer by detecting distant metastases, but metastatic lymph nodes are often difficult to diagnose from the size and standardized uptake value (SUV). If we compare the diagnostic performance of endoscopic ultrasonography (EUS), CT, and FDG-PET in staging of esophageal cancer, EUS is the most sensitive method to identify the detection of regional lymph node metastases, whereas CT and FDG-PET are more specific tests. Combination study with CT, EUS and PETCT cannot make a precise diagnosis after neoadjuvant therapy (NAT). A precise staging might be determined by the fine needle aspiration biopsy (FNAB) under EUS and US screening in the neck and the abdomen even after NAT. Indication of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) for superficial cancer is sensitive because of difficulty in T1b cancer diagnosis. Detailed examination about vessel invasion and the possibility of residual tumor with dissected specimen will offer an appropriate additional therapy. New strategy like sentinel lymph node (SLN) navigation could supply more information about lymphatic routes and metastatic nodes. SLN navigation with ESD might become a new less invasive strategy for superficial esophageal cancer.

Chromoendoscopy to detect early synchronous second primary esophageal carcinoma in patients with squamous cell carcinomas of the head and neck?

Objective. To evaluate the use of flexible esophagoscopy and chromoendoscopy with Lugol's solution in the detection of early esophageal carcinomas (second primary carcinomas) in patients with squamous cell carcinoma of the head and neck (HNSCC). Methods. All patients with newly diagnosed HNSCC underwent office-based Lugol's chromoendoscopy. After flexible esophagoscopy with white light, 3.0% Lugol's iodine solution was sprayed over the entire esophageal mucosa. Areas with less-intense staining (LVLs) were evaluated and biopsies taken. Results. 132 patients with HNSCC were enrolled in this study. The most frequent primary tumors were oropharyngeal (49/132), tumors of the oral cavity (36/132), and larynx (35/132). The majority of subjects (107/132 patients, 81.1%) had advanced HNSCC carcinomas (stages III and IV). Multiple LVLs were discovered in 24 subjects (18.2%) and no LVLs in 108 (81.8%) subjects. Fifty-five LVL biopsy specimens were obtained and assessed. Squamous cell carcinomas were detected in two patients, peptic esophagitis in 11 patients, gastric heterotopic mucosa in two patients, hyperplasia in two patients, and low- and high-grade dysplasia in three patients. Conclusion. Although only two patients with synchronous primary carcinomas were found among the patients, esophagoscopy should be recommended after detection of HNSCC to exclude secondary esophageal carcinoma or dysplasia.

Surveillance after endoscopic mucosal resection or endoscopic submucosal dissection for esophageal squamous cell carcinoma

The objectives of surveillance after endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinoma are: (i) early detection and treatment of recurrence; and (ii) early detection and treatment of metachronous esophageal squamous cell carcinoma and second primary cancers. Protocols for follow up after EMR or ESD for esophageal squamous cell carcinoma should be based on the risks of lymph node metastasis and distant metastasis as assessed on the basis of tumor staging at initial treatment. Early detection of recurrence or metachronous carcinomas often allows curative or less invasive treatment. Particular attention should be paid to the development of metachronous esophageal squamous cell carcinomas and second primary cancers (in particular, head and neck cancer and gastric cancer because of their high incidence).

Endoscopic diagnostic strategy of superficial esophageal squamous cell carcinoma

The prognosis of the esophageal squamous cell carcinoma is still poor. Early detection is ideal to improve patient survival. In particular, superficial cancer limited within the mucosal layer is a good candidate for minimally invasive treatment by endoscopic resection with curative intent. However, an effective endoscopic diagnostic strategy is not established worldwide. Herein, we review the published papers on this subject.

Diagnostic strategies of superficial Barrett's esophageal cancer for endoscopic submucosal dissection

The indication of endoscopic submucosal dissection for Barrett's esophageal adenocarcinoma (BEA) is superficial BEA without lymph node metastasis. The characteristic endoscopic findings of superficial BEA are elevation, depression, and color change. Indigocarmine spreading is useful for the diagnosis of lateral extension. It is a simple and easy enhancement method. The observation of surface and vascular pattern by magnifying endoscopy with narrow-band imaging is also useful for the diagnosis of lateral extension. The incidence of gastric cancer is high in Japan. The majority of early gastric cancer is detected by conventional endoscopy without random biopsy, or target biopsydiagnosis. The background mucosa of gastric cancer has gastritis, and the carcinogenesis based on inflammation is the same as early BEA. However, random biopsy remains the universal standard for early detection of Barrett's high-grade dysplasia and superficial BEA. A surveillance system that does not use random biopsy can and should be established using high-resolution endoscopy with target biopsy.

Narrow band imaging with magnification can pick up esophageal squamous cell carcinoma more efficiently than lugol chromoendoscopy in patients after chemoradiotherapy

Aim. Little is known about the usefulness of narrow band imaging (NBI) for surveillance of patients after chemoradiotherapy for esophageal neoplasia. Its usefulness in detecting esophageal squamous cell carcinoma (SCC) or high-grade intraepithelial neoplasia (HGIN) in these patients was retrospectively compared to Lugol chromoendoscopy. Patients and Methods. We assessed the diagnostic ability of NBI with magnification based on the biopsy specimens obtained from iodine-unstained lesions. Seventy-two iodine-unstained lesions were biopsied and consecutively enrolled for this study. The lesions were divided into NBI positive and NBI negative. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of NBI with magnification and PPV of Lugol chromoendoscopy was calculated using histological assessment as a gold standard. Results. Forty-six endoscopic examinations using NBI with magnification followed by Lugol chromoendoscopy were performed to 28 patients. The prevalence of SCC and HGIN was 21.4%. Sensitivity, specificity, PPV, NPV, and accuracy of NBI were 100.0%, 98.5%, 85.7%, 100%, and 98.6%, respectively. On the contrary, PPV of Lugol chromoendoscopy were 8.3%. Compared to Lugol chromoendoscopy, NBI with magnification showed equal sensitivity and significantly higher PPV (P < 0.0001). Conclusion. NBI with magnification would be able to pick up esophageal neoplasia more efficiently than Lugol chromoendoscopy in patients after chemoradiotherapy.

High-resolution optical molecular imaging of changes in choline metabolism in oral neoplasia

This study was aimed at developing an optical molecular imaging approach to measure differences in uptake and intracellular retention of choline in clinically isolated tissue biopsies from head and neck cancer patients. An optically detectable analogue of choline (propargyl choline) was synthesized and evaluated in 2D and 3D models and clinically isolated paired biopsies (n = 22 biopsies). Fluorescence contrast between clinically abnormal and normal tissues based on uptake and intracellular retention of propargyl choline was measured and correlated with pathologic diagnosis. Results in 2D and 3D models demonstrated a rapid uptake of propargyl choline in cancer cells, uniform permeation in tissue models, and specific detection of intracellular entrapped propargyl choline using the click chemistry reaction with an azide-modified Alexa 488 dye. Fluorescence imaging measurements following topical delivery of propargyl choline in clinically isolated biopsies showed that the mean fluorescence intensity (MFI) of neoplastic tissues was four-fold to five-fold higher than the MFI of clinically and pathologically normal samples. This difference in fluorescence contrast was measured on the basis of comparison of paired biopsy sets isolated from individual patients as well as comparison of clinically abnormal and normal biopsies independent of anatomic locations in the head and neck cavity and across diverse patients. In conclusion, a novel imaging approach based on monoalkyne-modified choline was developed and validated using cell and tissue models. Results in clinically isolated tissue biopsies demonstrate a significant fluorescent contrast between neoplastic and normal tissues and illustrate high specificity of the optical imaging approach.

Initial staging of squamous cell carcinoma of the oral cavity, larynx and pharynx (excluding nasopharynx). Part I: Locoregional extension assessment: 2012 SFORL guidelines

OBJECTIVES

To set out good practice guidelines for locoregional extension assessment of squamous cell carcinoma of the head and neck (excluding nasopharynx, nasal cavities and sinuses).

MATERIALS AND METHODS

A critical multidisciplinary review of the literature on locoregional extension assessment of squamous cell carcinoma of the head and neck was conducted, applying levels of evidence in line with the French health authority's (HAS) literature analysis guide of January 2000.

CONCLUSION

Based on the levels of evidence of the selected articles and on work-group consensus, graded guidelines are set out for clinical, endoscopic and imaging locoregional extension assessment of head and neck cancer.

Use of narrow-band imaging in detection of nasopharyngeal carcinoma

Aim:

To compare narrow-band images of nasopharyngeal carcinoma with those of normal adenoidal tissue.

Method:

Patients with a nasopharyngeal mass were evaluated using both conventional white light and narrow-band light. Biopsies were performed and Epstein–Barr viral serology was tested for all patients.

Results:

Thirty consecutive patients were recruited. Twenty-one patients had normal adenoidal tissue and seven had nasopharyngeal carcinoma. One patient with papillary adenocarcinoma was excluded. The features of narrow-band imaging in normal adenoidal tissue were: (1) a regularly arranged follicular pattern, and (2) each ‘follicle’ comprising a pale centre with surrounding dark periphery. The features of narrow-band imaging in nasopharyngeal carcinoma were: (1) absence of surface patterns (n = 7), and/or (2) ‘reverse’, haphazard follicular pattern comprising a dark brown centre and pale periphery (n = 3).

Conclusion:

Narrow-band imaging of the surface of adenoidal tissue and nasopharyngeal carcinoma appears to identify distinct, characteristic features as described. Narrow-band imaging may be a useful adjunct in differentiating normal adenoidal tissue from malignancy. Further studies are needed to evaluate its diagnostic accuracy.

Clinical features of pharyngeal intraepithelial neoplasias and outcomes of treatment by endoscopic submucosal dissection

BACKGROUND

Endoscopic detection of superficial squamous epithelial lesions of the pharynx has increased.

OBJECTIVE

To clarify the association between macroscopic and histologic characteristics of intraepithelial pharyngeal neoplasias, and to evaluate the effectiveness of endoscopic submucosal dissection (ESD) for their treatment.

DESIGN

Retrospective analysis of the features of high-grade dysplasia or carcinoma in situ (HGD/CIS) versus low-grade dysplasia (LGD) and of ESD-based outcomes.

SETTING

Endoscopy department at a university hospital.

PATIENTS

Fifty-one patients with 66 lesions treated by ESD from November 2007 to March 2011.

RESULTS

Primary hypopharyngeal lesions were significantly more frequent in HGD/CIS than in LGD (54.1% vs 20.7%, P = .011), and oropharyngeal lesions were significantly less frequent in HGD/CIS (45.9% vs 79.3%, P = .011). HGD/CIS lesions were significantly larger than LGD lesions (median 8 mm vs 4 mm, P < .01). Morphologically, type 0-IIa was significantly more frequent in HGD/CIS lesions than in LGD lesions (37.8% vs 3.4%, P < .001), and type 0-IIb was significantly less frequent in HGD/CIS lesions (59.5% vs 96.6%, P < .001). The type IV intraepithelial papillary capillary loop pattern was significantly less frequent in HGD/CIS lesions than in LGD lesions (27.0% vs 55.2%, P = .025), and type V-2 was significantly more frequent in HGD/CIS lesions (18.9% vs 0%, P = .015). The en bloc resection rate was 97%. No serious complications occurred. There were no recurrent or metachronous tumors in the 41 patients followed for more than 1 year (median follow-up 27 months).

LIMITATIONS

Retrospective design and single-center study.

CONCLUSIONS

HGD/CIS and LGD differ in various clinical features. ESD appears to be an effective treatment for pharyngeal intraepithelial neoplasias.

Clinicopathological features of minute pharyngeal lesions diagnosed by narrow-band imaging endoscopy and biopsy

AIM: To evaluate the utility of magnified narrow-band imaging (NBI) endoscopy for diagnosing and treating minute pharyngeal neoplasia.

METHODS: Magnified NBI gastrointestinal examinations were performed by the first author. A magnification hood was attached to the tip of the endoscope for quick focusing. Most of the examinations were performed under sedation. Magnified NBI examinations were performed for all of the pharyngeal lesions that had noticeable brownish areas under unmagnified NBI observation, and an intrapapillary capillary loop (IPCL) classification was made. A total of 93 consecutive pharyngeal lesions were diagnosed as IPCL type IV and were suspected to represent dysplasia. Sixty-two lesions of approximately 1 mm in diameter were biopsied in the clinic, and 17 lesions with larger diameters were resected by endoscopic submucosal dissection (ESD) at the Hiroshima University Hospital. In addition to the histological diagnoses, the lesion diameters were microscopically measured in 45 of the 62 biopsies. Thirty-four of the 62 biopsied patients received endoscopic follow up.

RESULTS: Minute pharyngeal lesions were diagnosed in 93 of approximately 3000 patients receiving magnified NBI examinations at the clinic. Of the 93 patients with IPCL type IV lesions, 80 were men, and 13 were women. Fifty-six were drinkers, and 57 were smokers. Two had esophageal cancer. Twenty-one lesions were located on the posterior hypopharyngeal wall, and 72 lesions were located on the posterior oropharyngeal wall. All 93 lesions were flat and showed similar findings in the magnified and unmagnified NBI examinations. Although almost all of the IPCL type IV lesions showed faint redness when examined under white light, it was difficult to diagnose the lesions using only this technique because the contrast was weaker than that achieved in the NBI examinations. Of the 93 lesions, only 3 had diameters greater than 2.1 mm. Sixty-two lesions of approximately 1 mm were biopsied in the clinic, whereas 17 larger lesions were treated by ESD at the Hiroshima University Hospital. Of the 79 pharyngeal lesions that were biopsied or resected by ESD, 5 were histologically diagnosed as high-grade dysplasia, 39 were diagnosed as low-grade dysplasia, and 39 were determined to be non-dysplastic lesions. There were no cancerous lesions. Histologically, abnormal cell size variations and increased nuclear size were observed in all of the high-grade dysplasia lesions, while the incidence of these findings in the low-grade dysplasia lesions was low. Of the 62 biopsied lesions, 45 were microscopically measurable. The measured diameters ranged from 0.1 to 2.0 mm. The dysplasia ratios increased with the diameters. A follow-up endoscopic examination of the 34 biopsied patients found the rate of complete resection by biopsy to be 79%. The largest lesion in which complete resection was expected was a low-grade dysplasia of 1.9 mm in diameter.

CONCLUSION: Minute pharyngeal lesions suspected to be dysplasia that are identified by NBI magnifying endoscopy should be biopsied to determine the diagnosis and further treatment.

Nature of white opaque substance in gastric epithelial neoplasia as visualized by magnifying endoscopy with narrow-band imaging

BACKGROUND AND AIMS

Magnifying endoscopy (ME) with narrow-band imaging (NBI) revealed a white opaque substance (WOS) within the superficial part of the gastric neoplasia; however, its nature has remained obscure. A WOS noted within the duodenum was reported to comprise lipid droplets (LD) absorbed by the duodenal epithelium. We attempted to ascertain whether the WOS within gastric neoplasia could also comprise LD and whether the presence of this WOS could be correlated with a specific phenotype.

METHODS

Forty-three patients with early gastric epithelial neoplasia underwent ME with NBI. The presence or absence of WOS in the neoplasias was recorded based on the findings of ME with NBI. One biopsy specimen was taken from each of the neoplasias. Cryostat sections underwent oil red O staining for LD. Serial sections were immunostained using the first antibody of CD10, MUC2, CDX2, human gastric mucin, MUC5AC and MUC6. The tissue phenotype was classified as intestinal (I), gastric (G) and gastrointestinal (GI) type based on the results of immunostaining. In total, 49 gastric neoplasias from 43 patients were investigated.

RESULTS

Prevalence of LD in WOS-positive versus WOS-negative lesions was 96.2% (25/26) and 4.3% (1/23), respectively (P < 0.001, Fisher's exact test). WOS was present in GI- and I-type lesions, but not in G-type lesions.

CONCLUSIONS

WOS may be LD that have been accumulated in the superficial part of the gastric neoplasia of a certain intestinal phenotype.

Treatment outcomes of definitive chemoradiotherapy for patients with hypopharyngeal cancer

We analyzed the efficacy of definitive chemoradiotherapy (CRT) for patients with hypopharyngeal cancer (HPC). Subjects comprised 97 patients who were treated with definitive CRT from 1990 to 2006. Sixty-one patients (62.9%) with resectable disease who aimed to preserve the larynx received induction chemotherapy (ICT), whereas 36 patients (37.1%) with resectable disease who refused an operation or who had unresectable disease received primary alternating CRT or concurrent CRT (non-ICT). The median dose to the primary lesion was 66 Gy. The median follow-up time was 77 months. The 5-year rates of overall survival (OS), progression-free survival (PFS), local control (LC), and laryngeal preservation were 68.7%, 57.5%, 79.1%, and 70.3%, respectively. The T-stage was a significant prognostic factor in terms of OS, PFS and LC in both univariate and multivariate analyses. The 5-year rates of PFS were 45.4% for the ICT group and 81.9% for the non-ICT group. The difference between these groups was significant with univariate analysis (P = 0.006). Acute toxicity of Grade 3 to 4 was observed in 34 patients (35.1%). Grade 3 dysphagia occurred in 20 patients (20.6%). Twenty-nine (29.8%) of 44 patients with second primary cancer had esophageal cancer. Seventeen of 29 patients had manageable superficial esophageal cancer. The clinical efficacy of definitive CRT for HPC is thought to be promising in terms of not only organ preservation but also disease control. Second primary cancer may have a clinical impact on the outcome for HPC patients, and special care should be taken when screening at follow-up.

Is it proper to use non-magnified narrow-band imaging for esophageal neoplasia screening? Japanese single-center, prospective study

AIM

Most screening examinations in Japanese general hospitals are carried out by high-definition television-incompatible (non-HD) scopes and non-magnifying endoscopes. We evaluated the narrow-band imaging (NBI) real-time diagnostic yield of esophageal neoplasia in high-risk patients at a general hospital.

METHODS

In a single-center, prospective, non-randomized controlled trial, 117 consecutive screening patients with high risk for esophageal cancer received primary white-light imaging (WLI) followed by NBI and iodine-staining endoscopy (59 by HDTV-compatible [HD] endoscopy and 58 by non-HD endoscopy). The primary aim was to evaluate the diagnostic yield of non-magnified images in diagnosing esophageal neoplasia. The secondary aim was to compare HD endoscopy and non-HD endoscopy in terms of diagnostic performance.

RESULTS

Overall, the sensitivity of NBI for screening of esophageal neoplasia was superior to WLI, and equivalent to iodine staining (92% vs 42%; P < 0.05, 92% vs 100%; ns). The specificity of NBI was equivalent to WLI (89% vs 94%; ns). In HD, NBI sensitivity was equivalent to both iodine staining and WLI (100% vs 75%; ns). In non-HD, NBI sensitivity was equivalent to iodine staining, but WLI sensitivity was significantly inferior to NBI (88% vs 100%; ns, 25% vs 88%; P < 0.05). The NBI specificity was equivalent to WLI not only in HD but also in non-HD (90% vs 96%; ns, 88% vs 93%; ns).

CONCLUSION

In both HD and non-HD endoscopy, NBI is less likely than WLI to miss a lesion. Even with non-HD endoscopy, NBI is suitable for esophageal standard examinations in general hospitals.

Comparison of narrowband imaging with autofluorescence imaging for endoscopic visualization of superficial squamous cell carcinoma lesions of the esophagus

Aim. To compare narrowband imaging (NBI) and autofluorescence imaging (AFI) endoscopic visualization for identifying superficial esophageal squamous cell carcinoma (SCC). Methods. Twenty-four patients with superficial esophageal carcinomas diagnosed at previous hospitals were enrolled in this study. Lesions were initially detected using white-light endoscopy and then observed with both NBI and AFI. Endoscopic images documented each method, and three endoscopists experienced in esophageal imaging retrospectively reviewed respective images of histologically confirmed esophageal SCCs. Images were assessed for quality in identifying superficial SCCs and rated as excellent, fair, or poor by the three reviewers with interobserver agreement calculated using kappa (κ) statistics. Results. Thirty-one lesions histologically confirmed as superficial esophageal SCCs were detected in 24 patients. NBI images of 27 lesions (87%) were rated as excellent, three as fair, and one as poor compared to AFI images of 19 lesions (61%) rated as excellent, 10 as fair and two as poor (P < 0.05). Moderate interobserver agreement (κ = 0.42, 95% CI 0.24-0.60) resulted in NBI while fair agreement (κ = 0.35, 95% CI 0.18-0.51) was achieved using AFI. Conclusion. NBI may be more effective than AFI for visualization of esophageal SCC.

Treatment strategy for superficial pharyngeal squamous cell carcinoma synchronously combined with esophageal cancer

BACKGROUND

Esophageal squamous cell carcinoma (ESCC) is often synchronously accompanied by pharyngeal squamous cell carcinoma (PSCC). However, treatment strategies for these synchronous cancers have not been established.

AIM

To evaluate retrospectively the effects of both chemoradiotherapy (CRT) targeted for invasive ESCC on synchronous superficial PSCC and additional endoscopic resection (ER) for PSCC.

PATIENTS AND METHODS

Screening endoscopy in the pharynx was performed in newly diagnosed ESCC patients. CRT combined with 5-fluorouracil (5-FU) and cisplatin (CDDP) was administered to all patients. The effect on superficial PSCC was only evaluated for 5-FU-CDDP chemotherapy that excluded the pharynx from the radiation field. When PSCC was remnant or recurrent in patients evaluated at complete response (CR) of ESCC, ER was performed on the PSCC.

RESULTS

Fourteen cases of superficial PSCC (4.0%) were detected in 348 ESCC patients. Three PSCC reached CR in 8 ESCC-CR patients, while all 3 lesions recurred. No treatment response was found in the remaining 11 PSCC. As a second treatment, ER for 8 PSCC was completed in the 8 ESCC-CR patients, with one complication due to pneumonia.

CONCLUSIONS

Standard 5-FU-CDDP CRT targeted for invasive ESCC did not demonstrate a sufficient efficacy for superficial PSCC, while ER even for PSCC after chemotherapy was curative.

The impact of narrow band imaging for colon polyp detection: a multicenter randomized controlled trial by tandem colonoscopy

BACKGROUND

Previous studies have yielded conflicting results on the adenoma detection rate with narrow band imaging (NBI) compared with white light imaging (WLI). To overcome the confounding factors of these studies, we aimed to evaluate the colonic adenoma detection rate with primary NBI versus that with primary WLI by using consistent NBI system, endoscope, and imaging settings, and experienced colonoscopists.

METHODS

In this multicenter prospective trial, 813 patients were randomized to undergo high-definition, tandem colonoscopy in the right colon with either NBI followed by WLI (NBI-WLI group) or WLI followed by NBI (WLI-NBI group). The NBI settings were fixed at surface structure enhancement level A-5 and adaptive index of hemoglobin color enhancement level 3. All detected polyps were resected or biopsied for histopathological analysis. The primary and secondary outcome measures were the adenoma detection rates and miss rates, respectively, with primary imaging.

RESULTS

The NBI-WLI and WLI-NBI groups comprised 389 and 393 patients, respectively, who met the inclusion criteria. The groups did not differ significantly in age, gender, institution, indication for colonoscopy, bowel preparation, or observation time. The adenoma detection rates of primary NBI and WLI were 42.3 and 42.5 %, respectively [difference not significant (NS)]. The adenoma miss rate was significantly less with primary NBI than with primary WLI (21.3 vs. 27.8 %; p = 0.03).

CONCLUSIONS

NBI does not improve the adenoma detection rate during primary colonoscopy; however, it has a lower miss rate for adenoma lesions in the proximal colon than WLI.

Role of narrow band imaging in endoscopic submucosal dissection

Narrow band imaging (NBI) is a new image enhancement system employing optic digital methods to enhance images of blood vessels on mucosal surfaces, allowing improved visualization of mucosal surface structures. Studies have progressed over the last several years, and the clinical usefulness has been demonstrated. NBI has become frequently applied for preoperative diagnosis before endoscopic submucosal dissection (ESD) of digestive tract cancers, as well as for assessment of the range of ESD for en-bloc resection of large lesions. Consensus has been reached with regard to the usefulness of NBI for detecting micro-lesions of esophageal squamous cell carcinoma indicated for ESD, for the diagnosis of the range and depth. NBI has also been attracting attention for diagnosing gastric cancer based on the observation of micro blood vessels on the mucosal surface and mucosal surface microstructures. The usefulness of NBI has been reported in relation to various aspects of colon cancer, including diagnoses of the presence, quality, range, and depth of lesions. However, as NBI has not surpassed diagnostic methods based on magnifying observation combined with the established and widely employed dye method, its role in ESD is limited at present. Although NBI is very useful for the diagnosis of digestive tract cancers, comprehensive endoscopic diagnosis employing the combination of conventional endoscopy including dye spraying, EUS, and NBI may be important and essential for ESD.

Clinical outcomes of endoscopic mucosal resection and endoscopic submucosal dissection as a transoral treatment for superficial pharyngeal cancer

BACKGROUND

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have been introduced for the treatment of superficial pharyngeal cancer.

METHODS

Sixty superficial pharyngeal cancers in 45 patients were treated by EMR or ESD. Resectability and curability, complications, and survival were analyzed retrospectively.

RESULTS

The en bloc resection and curative resection rate were higher with ESD (100; 81.6%) than with EMR (59; 50%). In subgroup analysis with regard to tumor size ≤ 10 mm, both resection rates were comparative. All the patients had preserved larynx and swallowing, speech, and airway function. Two of the 45 patients died of other diseases, local recurrence was observed in 4 of 18 patients with noncurative resection with a median observation period of 38 months. No recurrence was observed in patients with curative resection.

CONCLUSIONS

ESD or EMR for superficial pharyngeal cancer is minimally invasive treatment and lesions larger than 10 mm should be referred for ESD.

Usefulness of the DL in ME with NBI for determining the expanded area of early-stage differentiated gastric carcinoma

AIM: To investigate whether magnifying endoscopy with narrow band imaging (ME-NBI) is useful for evaluating the area of superficial, depressed- or flat-type differentiated adenocarcinoma of the stomach.

METHODS: This procedure was performed in Saitama Medical University International Medical Center, Japanese Red Cross Kumamoto Hospital and Kitakyushu Municipal Medical Center. The subjects were 31 patients in whom biopsy findings, from superficial, depressed- or flat-type gastric lesion, suggested differentiated adenocarcinoma in the above 3 hospitals between January and December 2009. Biopsy was performed on the lesion and non-lesion sides of a boundary (imaginary boundary) visualized on ME-NBI. The results were pathologically investigated. We evaluated the accuracy of estimating a demarcation line (DL) on ME-NBI in comparison with biopsy findings as a gold standard.

RESULTS: The DL that could be recognized at 2 points on the orifice and anal sides of each lesion during ME-NBI was consistent with the pathological findings in 22 patients with 0-IIc lesions, 7 with 0-IIb lesions, and 2 with 0-IIb + IIc lesions, showing an accuracy of 100%.

CONCLUSION: The results suggest the usefulness of ME-NBI for evaluating the area of superficial, depressed- and flat-type differentiated adenocarcinoma of the stomach.

Usefulness of Background Coloration in Detection of Esophago-Pharyngeal Lesions Using NBI Magnification

Background and Aim. We evaluated the usefulness of background coloration (BC), a color change in the area between intrapapillary capillary loops (IPCLs) in the early esophago-pharyngeal lesions using NBI with magnificaiton. Methods. Between April 2004 and March 2010, a total of 294 esophago-pharyngeal lesions were examined using NBI with magnification, and the presence of BC and IPCL patterns were assessed. Using BC, discrimination of squamous cell carcinoma (SCC) or high-grade neoplasia (HGN) from low-grade neoplasia (LGN) or nonatypia was conducted. Results. Among 294 lesions, 209 lesions (71.1%) were positive for BC, while 85 (28.9%) were negative. In the BC-positive group, 187 lesions (89.5%) were diagnosed as SCC/HGN. And 68 lesions (80.0%) in the BC-negative group were diagnosed as LGN/nonatypia. Overall accuracy of BC to discriminate SCC/HGN from LGN/nonatypia was 87.3%. The sensitivity and specificity were 91.9%, 76.7%. BC could discriminate SCC/HGN from LGN/nonatypia accurately (P < 0.0001). Among 68 lesions classified into the IPCL type IV, the BC-positive group (n = 26) included 21 SCC/HGN lesions, while there were 36 LGN/nonatypia lesions in the 42 BC-negative lesions. Conclusions. BC is a useful finding in differentiating SCC/HGN from LGN/nonatypia lesions in the esophagus especially when it is combined with IPCL pattern classification.

Safety and curative ability of endoscopic submucosal dissection for superficial esophageal cancers at least 50 mm in diameter

BACKGROUND AND AIM

Limited data are available regarding the use of endoscopic submucosal dissection (ESD) for superficial esophageal cancers ≥ 50 mm in diameter. The aim of the present study was to investigate the safety and success of ESD for superficial esophageal cancers ≥ 50 mm.

METHODS

A total of 39 patients with superficial esophageal squamous cell carcinoma ≥ 50 mm were treated with ESD at Osaka Medical Center for Cancer and Cardiovascular Diseases between January 2004 and April 2011, and were analyzed in a retrospective study.

RESULTS

En bloc resection was achieved in all patients. One mediastinal emphysema without perforation occurred during the procedure. Stricture developed in 11 of 39 patients, requiring a median of five endoscopic balloon dilatation procedures. Thirty-three clinical epithelial or lamina propria mucosal cancers were treated by ESD with curative intent, of which invasion into the muscularis mucosa or deeper was detected in seven and lymphovascular involvement in three. The en bloc resection rate was 100% with a tumor-free margin achieved in 92% of lesions. The curative resection and complication rates during ESD were 70% and 2.5%, respectively.

CONCLUSION

ESD achieved a high en bloc resection rate of 92% with a tumor-free margin. Curative resection rate of ESD in patients with clinical epithelial or lamina propria mucosal cancers was not low at 70%. However, the risk of stricture must be taken into account when considering the use of ESD in lesions ≥ 50 mm.

High specificity of combined narrow band imaging and autofluorescence mucosal assessment of patients with head and neck cancer

BACKGROUND

The purpose of this study was to evaluate combined autofluorescence (AF) and narrow band imaging (NBI) for detection of mucosal lesions additional to known primary head and neck cancers and to determine impact on management.

METHODS

Patients with head and neck cancer requiring preoperative screening or posttreatment surveillance had white light (WL), AF and NBI inspection of the head and neck and bronchus. Known primary cancers were not analyzed, only additional lesions. Moderate dysplasia or worse was considered significant.

RESULTS

In all, 73 patients were recruited. Respectively, there were 24 and 18 additional lesions in the head and neck and bronchus that had significant histopathology. In both regions, AF and NBI were more sensitive than WL for detecting significant dysplasia with NBI demonstrating better specificity than AF (p = .003); 11 of 73 patients (15.1%) had additional findings detected by AF and NBI, which had an impact on management.

CONCLUSION

Combined AF and NBI inspection is highly specific at panendoscopy and can influence management.

Prevalence of esophageal cancer during the pretreatment of hypopharyngeal cancer patients: routinely performed esophagogastroduodenoscopy and FDG-PET/CT findings

BACKGROUND

The prevalence of esophageal cancer accompanied by hypopharyngeal cancer (HPC) is high and increasing rapidly in Asia. The purpose of this prospective study was to evaluate the prevalence of esophageal cancer during the pretreatment of HPC patients who were routinely examined using esophagogastroduodenoscopy (EGD) and 18F-fluorodeoxyglucose/computed tomography (FDG-PET/CT) and to discuss the utility of these examinations.

MATERIAL AND METHODS

Between September 2005 and September 2010, 33 patients with newly diagnosed HPC (all with squamous cell carcinoma) underwent EGD (after a conventional endoscopy, iodine staining was performed) and FDG-PET/CT examinations. We evaluated the prevalence of esophageal cancer among HPC patients according to the EGD findings and determined the sensitivity of FDG-PET/CT for the detection of esophageal primary tumors for each clinical T classification.

RESULTS

In 17 of the 33 patients (51.5%), 29 biopsy-proven esophageal squamous cell carcinomas were diagnosed using EGD. In eight of the 17 (47.1%) patients, two or more esophageal cancer lesions were diagnosed. Twenty-four of the 29 (82.8%) lesions were superficial esophageal cancers, and the remaining five (17.2%) lesions were advanced esophageal cancers. In six of the 29 (20.7%) esophageal cancer lesions that were detected using FDG-PET/CT, only one of the 29 (3.4%) lesions was evaluated as being equivocal; the remaining 22 (75.9%) lesions were not detected. The distribution of the clinical T classifications detected using FDG-PET/CT was as follows: T1a, 0/21 (0%); T1b, 1/3 (33%); and T3, 5/5 (100%).

CONCLUSIONS

The prevalence of esophageal cancer during the pretreatment of HPC patients was 51.5%; this prevalence was higher than that in previous reports. We believe that the increasing proportion of superficial lesions (82.8%) detected using iodine staining and EGD may have led to the relatively high prevalence. FDG-PET/CT detected only 20.7% of the esophageal cancers, although FDG-PET/CT is capable of detecting unexpected primary malignant tumors other than esophageal cancer.

Serological antibodies against LY6K as a diagnostic biomarker in esophageal squamous cell carcinoma

OBJECTIVES

To evaluate the diagnostic values of autoantibodies against lymphocyte antigen 6 complex locus K (LY6K) in esophageal squamous cell carcinoma (ESCC).

METHODS

After cloning, expressing, and purifying LY6K as fusion proteins, LY6K autoantibodies were measured in 62 patient and 58 control serum samples using enzyme-linked immunosorbent assay (ELISA). Reverse transcription polymerase chain reaction (RT-PCR) was used to measure the LY6K mRNA levels in ESCC and adjacent tissues.

RESULTS

LY6K autoantibodies were found significantly higher in patients than controls. The area under the receiver-operating characteristic (ROC) curve (AUC) was 0.85, and the optimal sensitivity and specificity for ESCC detection were 80.6 and 78.7%, respectively. LY6K mRNA expressions in patients were upregulated.

CONCLUSIONS

Autoantibodies against LY6K may be a good diagnostic biomarker for ESCC.

Progress and challenges in colorectal cancer screening

Although faecal and endoscopic tests appear to be effective in reducing colorectal cancer incidence and mortality, further technological and organizational advances are expected to improve the performance and acceptability of these tests. Several attempts to improve endoscopic technology have been made in order to improve the detection rate of neoplasia, especially in the proximal colon. Based on the latest evidence on the long-term efficacy of screening tests, new strategies including endoscopic and faecal modalities have also been proposed in order to improve participation and the diagnostic yield of programmatic screening. Overall, several factors in terms of both efficacy and costs of screening strategies, including the high cost of biological therapy for advanced colorectal cancer, are likely to affect the cost-effectiveness of CRC screening in the future.

Endoscopic characteristics of short-segment Barrett's esophagus, focusing on squamous islands and mucosal folds

BACKGROUND AND AIM

Endoscopic definitions of Barrett's esophagus (BE) vary among countries, mainly because of the difficulty in diagnosing short-segment BE (SSBE) endoscopically. The aim of this study was to investigate whether the endoscopic identification of squamous islands and the specific position of columnar epithelium helps improve the diagnosis of SSBE.

METHODS

First, we prospectively enrolled 100 consecutive patients with SSBE and evaluated the number of identified squamous islands in the columnar epithelium with different modalities: white light (WL), narrow band imaging (NBI), and iodine chromoendoscopy. Second, in another group of 100 consecutive patients with tongue-like SSBE, the correlation of the location of Barrett's mucosa to the esophageal longitudinal folds (ridge or valley) was evaluated endoscopically.

RESULTS

It was possible to detect squamous islands in 48, 71, and 75 patients by WL, NBI, and iodine chromoendoscopy, respectively. The detection rate of squamous islands by NBI or iodine chromoendoscopy was significantly superior to that by WL. Tongue-like SSBEs were predominantly found on the ridge of mucosal folds (71%), similar to the location of mucosal breaks (84%).

CONCLUSIONS

Squamous islands in the columnar epithelium were efficiently observed by NBI or iodine chromoendoscopy. SSBE was found more frequently on the ridges but not in the valleys of esophageal longitudinal mucosal folds. NBI endoscopic observation focusing on columnar epithelium with squamous islands on the ridges of distal esophageal folds may improve endoscopic detection of SSBE.

A health-risk appraisal model and endoscopic mass screening for esophageal cancer in Japanese men

A strong association between inactive aldehyde dehydrogenase-2 (ALDH2) and risk of esophageal cancer has been demonstrated in East Asian drinkers. An alcohol flushing questionnaire asking about past and current tendency for facial flushing to occur after drinking a glass (≈180 mL) of beer predicts the presence of inactive ALDH2 among Japanese aged 40 years or older with a sensitivity and specificity of approximately 90%. We invented a health-risk appraisal (HRA) model that makes it possible to identify Japanese men who are at high risk for esophageal cancer based on their past and current alcohol flushing tendency, drinking, smoking, and intake of vegetables and fruits. Between 2008 and 2009, 2221 Japanese men aged 50 years or older filled out the HRA questionnaire before undergoing a screening examination by upper gastrointestinal endoscopy at five medical facilities. The endoscopic examination resulted in a diagnosis of esophageal cancer in 19 subjects, and 117 (5.27%) subjects had an HRA score ≥ 11. The proportion of subjects with an HRA score ≥ 11 was higher in the 50-69 age group (6.11-6.88%) than in 70-89 age group (2.84-2.86%). The esophageal cancer detection rate was 4.27% among the subjects with an HRA score ≥ 11 and only 0.67% among the other subjects. Based on a receiver operating characteristic curve analysis, when an HRA score of ≥ 9 was used for subjects aged 50-69 years and of ≥ 8 for those aged 70-89 years as the cutoff value to select individuals with a high risk for esophageal cancer, its sensitivity and false-positive rate was 52.6% and 15.2%, respectively, and the cancer detection rate was 2.91% in the high-risk group, as opposed to 0.48% in the other group. In conclusion, the high detection rates for esophageal cancer in the high-risk groups encouraged screening based on our HRA model in larger Japanese populations.

Subglottic cyst: the role of narrow-band imaging

A subglottic cyst is a rare cause of neonatal upper airway obstruction, which may be misinterpreted as a subglottic hemangioma. With the advent of narrow-band imaging, the application of its unique features in analyzing the mucosa surface's vascular structures in pediatric subglottic lesions remains to be investigated. Here, we report the case of a preterm baby who developed two subglottic cysts when he was 3-months old. Both traditional endoscopic examination and narrow-band imaging were performed pre-operatively. Both the potential impact of this new technique and the diagnosis and management of this disease are discussed.

Esophageal squamous cell carcinoma - precursor lesions and early diagnosis

Squamous cell carcinoma of the esophagus (SCCE) carries a poor prognosis due to late diagnosis. Early detection is highly desirable, since surgical and endoscopic resection offers the only possible cure for esophageal cancer. Population screening should be undertaken in high risk areas, and in low or moderate risk areas for people with risk factors (alcoholics, smokers, mate drinkers, history of head and neck cancer, achalasia and lye stricture of the esophagus). Esophageal balloon cytology is an easy and inexpensive sampling technique, but the current methods are insufficient for primary screening due to sampling errors. Conventional endoscopy with biopsy remains the standard procedure for the identification of pre-malignant and early malignant changes in esophageal mucosa and endoscopic detection. It may be enhanced by several techniques such as dye and optic chromoendoscopy, magnifying endoscopy, and optical-based spectroscopic and imaging modalities. Since more than 80% of SCCE deaths occur in developing countries, where expensive techniques such as narrow band imaging (NBI) and autofluorescence imaging are unavailable, the most cost-effective tool for targeting biopsies may be Lugol dye chromoendoscopy, since it is easy, accurate, inexpensive and available worldwide. In ideal conditions, or in developed countries, is it reasonable to think that optimal detection will require a combination of techniques, such as the combination of Lugol’s chromoendoscopy and NBI to identify esophageal areas that require further characterization by a high resolution technique. The efficacy and cost-effectiveness will determine whether these modalities will become part of standard endoscopy practice.

Ex vivo pig training model for esophageal endoscopic submucosal dissection (ESD) for endoscopists with experience in gastric ESD

BACKGROUND

Esophageal endoscopic submucosal dissection (ESD) has developed in recent years because of its high rate of en bloc resection. However, for many endoscopists, technical difficulty and risks of complications are great barriers to performing esophageal ESD. In this study, we developed an original training model for esophageal ESD using isolated pig esophagus and assessed this ex vivo model in endoscopists with experience in gastric ESD.

METHODS

Three endoscopists without experience in esophageal ESD but with some experience in gastric ESD performed esophageal ESD of artificial lesions in 10 consecutive sessions using this ex vivo model. The en bloc resection rate, operation time, number of muscularis propria layer injuries, and presence of perforation were recorded. We evaluated the effectiveness of this training in the three endoscopists by comparing results from the first five sessions (former period) with those from the last five sessions (latter period).

RESULTS

All three endoscopists achieved en bloc resections in all trials. In the former period, injury to the muscularis propria layer for each of the three endoscopists occurred a mean of 2.2 (1-3), 0.6 (0-1), and 3.2 (1-6) times, respectively. Perforation occurred in one session performed by one endoscopist. In the latter period, the mean number of muscularis propria layer injuries for each of the three endoscopists decreased to 0.2 (0-1), 0.2 (0-1), and 0.8 (0-2), respectively. The time of operation shortened from 35.0 (25-40), 36.4 (30-50), and 29.8 (23-43) min to 23.0 (16-31), 25.6 (23-28), and 29.2 (21-37) min, respectively.

CONCLUSIONS

This original ex vivo training model was helpful to endoscopists with experience in gastric ESD in acquiring the basic skills for performing esophageal ESD.