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

Diagnostic Performance of a Novel Ultra-Thin Endoscopy under Narrow-Band Imaging for Superficial Squamous Cell Carcinoma of the Pharynx and Esophagus

This study aimed to evaluate the diagnostic utility of the ultra-thin endoscope (UTE) for superficial squamous cell carcinoma (SSCC) compared to magnifying endoscopy (ME) under narrow-band imaging. Participants underwent endoscopic examination, and images of pharyngeal and esophageal SCCs, as along with suspicious SSCC lesions, were collected using UTE and ME on the same day. Three image catalogs (UTE, ME-1, and ME-2) were created and reviewed by three expert endoscopists. ME-1 and ME-2 contained the same endoscopic images. The primary endpoint was the intra-observer agreement for diagnosing SCC. Eighty-six lesions (SCC = thirty-nine, non-SCC = forty-seven) in 43 participants were identified. The kappa values for the intra-observer agreement between UTE and ME-1 vs. the control (ME-1 vs. ME-2) were 0.74 vs. 0.84, 0.63 vs. 0.76, and 0.79 vs. 0.88, respectively. The accuracies for diagnosing SCC by UTE and ME-1 were 87.2% vs. 86.0%, 78.0% vs. 73,2%, and 75.6 vs. 82.6%, respectively, with no significant differences (p > 0.05). The rates of lesions that were diagnosed with confidence by UTE and ME-1 were 30.2% vs. 27.9%, 55.8% vs. 62.8%, and 58.1% vs. 55.8%, respectively. UTE demonstrates substantial diagnostic performance for SSCC in the pharynx and esophagus.

Clinical significance of type IV vascularization of laryngeal lesions according to the Ni classification

Background

Scattered, small, dot-like intraepithelial papillary capillary loops (IPCLs) represent type IV epithelial vascularization according to "Ni classification" and are considered to be nonmalignant. According to the European Laryngological Society classification, these loops are malignant vascular changes. This contradiction has high clinical importance; therefore, clarification of the clinical significance of type IV vascularization according to the Ni classification is needed.

Methods

The study was performed between June 2015 and December 2022. All recruited patients (n = 434) were symptomatic, with macroscopic laryngeal lesions (n = 674). Patients were investigated using the enhanced endoscopic methods of narrow band imaging (NBI) and the Storz Professional Image Enhancement System (IMAGE1 S). The microvascular patterns in the lesions were categorized according to Ni classification from 2011 and all lesions were examined histologically.

Results

A total of 674 lesions (434 patients) were investigated using flexible NBI endoscopy and IMAGE1 S endoscopy. Type IV vascularization was recognized in 293/674 (43.5%) lesions. Among these 293 lesions, 178 (60.7%) were benign (chronic laryngitis, hyperplasia, hyperkeratosis, polyps, cysts, granulomas, Reinkeho oedema and recurrent respiratory papillomatosis); 9 (3.1%) were squamous cell carcinoma; 61 (20.8%) were mildly dysplastic, 29 (9.9%) were moderately dysplastic, 14 (4.8%) were severe dysplastic and 2 (0.7%) were carcinoma in situ. The ability to recognize histologically benign lesions in group of nonmalignant vascular pattern according to Ni (vascularization type I-IV) and distinguish them from precancers and malignancies was with accuracy 75.5%, sensitivity 54.4%, specificity 94.4%, positive predictive value 89.6% and negative predictive value 69.9%.

Conclusion

Laryngeal lesions with type IV vascularization as defined by Ni present various histological findings, including precancerous and malignant lesions. Patients with type IV vascularization must be followed carefully and, in case of progression mucosal lesion microlaryngoscopy and excision are indicated.

Endoscopic Diagnosis of Superficial Gastrointestinal Cancer

White light image (WLI) findings are important for detection and characterization in the GI tract. However, magnified endoscopic examination with image enhanced endoscopy (IEE-NE) is becoming increasingly important for qualitative diagnosis of GI neoplastic lesions. IEE-ME is extremely useful for diagnosis of invasion depth in esophageal squamous cell cancer (ESCC) and colorectal cancer, whereas macroscopic findings of WLI are still useful in Barrett's adenocarcinoma (BAC) and gastric cancer. IEE-ME is also useful for diagnosis of tumor extent in BAC and gastric cancer, whereas chromoendoscopy with indigo carmine is useful in colorectal cancer and iodine staining is indispensable in ESCC.

Recent advances in head and neck surgical oncology

In recent years, the field of head and neck oncology has witnessed a remarkable transformation with unprecedented advances that have revolutionized the management of complex tumors in this region. As an intricate subspecialty within oncology, head and neck surgical procedures demand detailed knowledge of the complex anatomy meticulous precision in surgical technique, and expertise to preserve vital functions while ensuring optimal oncological outcomes. With the relentless pursuit of improved patient outcomes, the integration of innovative technologies has significantly enhanced the surgical armamentarium. Robotics, endoscopic platforms, and image-guided navigation have revolutionized the surgical approach, enabling precise tumor resection and sparing healthy tissues. Furthermore, the application of advanced imaging modalities and molecular biomarker profiling has opened new avenues for personalized treatment strategies. From targeted therapies and immunotherapies to adaptive radiation techniques, clinicians are now equipped with an array of tailored options, ushering in a new era of personalized care for patients with head and neck malignancies. This article delves into the unfolding narratives of clinical triumphs, exploring the transformative potential of emerging therapies and the collaborative efforts propelling head and neck surgical oncology toward a future of hope and healing.

Association between continuous cessation or reduction of drinking alcohol and improvement of multiple dysplastic lesions in patients with esophageal squamous cell carcinoma after endoscopic resection

BACKGROUND

Multiple development of squamous cell carcinoma (SCC) in the upper aerodigestive tract has been explained by the 'field cancerization phenomenon' associated with alcohol drinking. Squamous dysplastic lesion is clinically visualised as a Lugol-voiding lesion (LVL) by chromoendoscopy. Whether cessation or reduction of alcohol drinking improves multiple LVL and reduces the risk of field cancerization has not been elucidated.

METHODS

We analysed 330 patients with newly diagnosed superficial esophageal SCC (ESCC) enrolled in the cohort study. The grade of LVL was assessed in all patients every 6 months. We instructed the patients to stop smoking and drinking and recorded their drinking and smoking status every 6 months.

RESULTS

Among 330 patients, we excluded 98 with no LVL or no drinking habit. Of the remaining 232 patients, 158 continuously ceased or reduced their drinking habit. Patients who ceased or reduced their drinking habit significantly showed improvement in the grade of LVL. Multivariate analysis showed that continuous cessation or reduction of drinking habit improved the grade of LVL (hazard ratio [HR] = 8.5, 95% confidence interval [CI] 1.7-153.8, p = 0.0053). Higher grade of LVL carried a high risk of multiple ESCC and head and neck SCC (HNSCC) (HR = 3.7, 95% CI 2.2-6.4, p < 0.0001). Improvement in LVL significantly decreased the risk of multiple ESCC and HNSCC (HR = 0.2, 95% CI 0.04-0.7, p = 0.009).

CONCLUSIONS

This is the first report indicating that field cancerization was reversible and cessation or reduction of drinking alcohol could prevent multiple squamous dysplastic lesion and multiple ESCC and HNSCC development.

CLINICAL TRIALS REGISTRY NUMBER

UMIN000001676.

Hypopharynx Cancer Incidence in Kazakhstan: 2017-2021

OBJECTIVE

The article studies the geographical features of the incidence of hypopharynx cancer (HPC) in Kazakhstan.

METHODS

The retrospective study was done for the period 2017-2021. Descriptive and analytical methods of ecoepidemiology were used. Crude (CR), age-specific (ASIR), age-standardized (ASR), equalized incidence rates and approximation were calculated. The dynamics of indicators was investigated using component analysis according to methodological recommendations. The method of drawing up a cartogram based on the determination of the standard deviation (σ) from the mean (x) was applied.

RESULT

During the study period, 814 new cases of HPC were registered. The incidence rate decreased from 0.898 (2017) to 0.895 in 2021 and the overall decline was 0.003 per 100,000 population, including due to the age structure - ∑ΔA=+0.04, due to the risk of acquiring illness - ∑ΔR=-0.05 and their combined effect - ∑ΔRA=+0.01. The component analysis revealed that the increase in the number of patients with HPC was mainly due to the growth of the population (ΔP=+37.0%), changes in its age structure (ΔA=+106.1%) and changes associated with the risk of acquiring illness (ΔR=-133.4%). The cartograms were allocated according to the following criteria: low - up to 0.730/0000, average - from 0.73 to 1.180/0000, high - above 1.180/0000. The results of the spatial assessment showed the highest levels of HPC incidence in following regions: Atyrau (1.960/0000) and West Kazakhstan (1.580/0000).

CONCLUSION

Thus, this is the first epidemiological study of HPC, which assessed the role of the influence of various factors, including demographic and risk of acquiring illness, on the dynamics of incidence, taking into account gender differences and geographical variability.

Application of convolutional neural network-based endoscopic imaging in esophageal cancer or high-grade dysplasia: A systematic review and meta-analysis

BACKGROUND

Esophageal cancer is the seventh-most common cancer type worldwide, accounting for 5% of death from malignancy. Development of novel diagnostic techniques has facilitated screening, early detection, and improved prognosis. Convolutional neural network (CNN)-based image analysis promises great potential for diagnosing and determining the prognosis of esophageal cancer, enabling even early detection of dysplasia.

AIM

To conduct a meta-analysis of the diagnostic accuracy of CNN models for the diagnosis of esophageal cancer and high-grade dysplasia (HGD).

METHODS

PubMed, EMBASE, Web of Science and Cochrane Library databases were searched for articles published up to November 30, 2022. We evaluated the diagnostic accuracy of using the CNN model with still image-based analysis and with video-based analysis for esophageal cancer or HGD, as well as for the invasion depth of esophageal cancer. The pooled sensitivity, pooled specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR) and area under the curve (AUC) were estimated, together with the 95% confidence intervals (CI). A bivariate method and hierarchical summary receiver operating characteristic method were used to calculate the diagnostic test accuracy of the CNN model. Meta-regression and subgroup analyses were used to identify sources of heterogeneity.

RESULTS

A total of 28 studies were included in this systematic review and meta-analysis. Using still image-based analysis for the diagnosis of esophageal cancer or HGD provided a pooled sensitivity of 0.95 (95%CI: 0.92-0.97), pooled specificity of 0.92 (0.89-0.94), PLR of 11.5 (8.3-16.0), NLR of 0.06 (0.04-0.09), DOR of 205 (115-365), and AUC of 0.98 (0.96-0.99). When video-based analysis was used, a pooled sensitivity of 0.85 (0.77-0.91), pooled specificity of 0.73 (0.59-0.83), PLR of 3.1 (1.9-5.0), NLR of 0.20 (0.12-0.34), DOR of 15 (6-38) and AUC of 0.87 (0.84-0.90) were found. Prediction of invasion depth resulted in a pooled sensitivity of 0.90 (0.87-0.92), pooled specificity of 0.83 (95%CI: 0.76-0.88), PLR of 7.8 (1.9-32.0), NLR of 0.10 (0.41-0.25), DOR of 118 (11-1305), and AUC of 0.95 (0.92-0.96).

CONCLUSION

CNN-based image analysis in diagnosing esophageal cancer and HGD is an excellent diagnostic method with high sensitivity and specificity that merits further investigation in large, multicenter clinical trials.

Second esophageal neoplasms after head and neck index tumor: Incidence, risk factors and prognosis

OBJECTIVE

Patients with head and neck squamous cell carcinoma (HNSCC) have an increased risk of second esophageal neoplasms. The aim of the present study is to evaluate the incidence, risk factors and prognosis of second esophageal neoplasms in patients with HNSCC.

METHODS

A retrospective study of 4711 patients with index tumor in the oral cavity, oropharynx, hypopharynx or larynx between 1985 and 2020 was conducted.

RESULTS

During the period analysed 149 patients (3.2%) had a second esophageal neoplasm. The incidence of second esophageal neoplasia was 0.42% per year and remained nearly constant throughout the follow-up period. According to the results of a multivariate study, the risk factors related to the appearance of second esophageal neoplasms were a history of high alcohol consumption and the location of the primary tumor in the oropharynx or hypopharynx. The 5-year disease-specific survival rate in patients with a second esophageal neoplasm, calculated from the diagnosis of this second neoplasm, was 10.5%.

CONCLUSIONS

Patients with a HNSCC have an increased risk of developing of a second esophageal neoplasm. The risk factors associated with the appearance of a second esophageal neoplasm were severe alcohol consumption and the location of the primary tumor in the oropharynx or hypopharynx.

Blue light imaging and linked color imaging as a screening mode for esophageal squamous cell carcinoma in high-risk patients: Multicenter randomized trial

OBJECTIVES

Blue light imaging (BLI) and linked color imaging (LCI) are superior to conventional white light imaging for detecting esophageal squamous cell carcinoma (ESCC). Hence, we compared their diagnostic performances in ESCC screening.

METHODS

This open-labeled, randomized controlled trial was performed at seven hospitals. Patients with a high risk of ESCC were randomly assigned to the BLI group (BLI followed by LCI) and LCI group (LCI followed by BLI). The primary end-point was the detection rate of ESCC in the primary mode. The main secondary end-point was its miss rate in the primary mode.

RESULTS

In total, 699 patients were enrolled. The detection rate of ESCC did not significantly differ between the BLI and LCI groups (4.0% [14/351] vs. 4.9% [17/348]; P = 0.565); however, the number of patients with ESCC tended to be smaller in the BLI group (19 vs. 30). Notably, the miss rate of ESCC was lower in the BLI group (26.3% [5/19] vs. 63.3% [19/30]; P = 0.012) and LCI detected no ESCCs missed by BLI. The sensitivity was higher in BLI (75.0% vs. 47.6%; P = 0.042); on the other hand, the positive predictive value in BLI tended to be lower (28.8% vs. 45.5%; P = 0.092).

CONCLUSIONS

The detection rates of ESCC did not significantly differ between BLI and LCI. Although BLI may have the potential to be advantageous over LCI for the diagnosis of ESCC, it is still unclear whether BLI is superior to LCI, and a further large-scale study is needed.

TRIAL REGISTRATION

Japan Registry of Clinical Trials (jRCT1022190018-1).

The Effectiveness of White Light Endoscopy Combined With Narrow Band Imaging Technique Using Ni Classification in Detecting Early Laryngeal Carcinoma in 114 Patients: Our Clinical Experience

INTRODUCTION

By displaying tumor-specific neoangiogenesis, narrow band imaging (NBI), a novel imaging approach, enhances the diagnosis of head and neck cancers and makes it more accurate OBJECTIVE: To determine the effect of NBI in combination with white light endoscopy (WLE) for diagnosis of preneoplastic or neoplastic laryngeal cancers according to Ni classification and to conclude if higher Ni classification and tumor stage are related.

METHODS

We enrolled 114 patients with various laryngeal cancer between December 2018 and June 2021. Patients were examined with WLE and NBI. Squamous cell carcinoma (SCC) accounted for 46 cases, benign lesions 30 cases, and nondysplastic, low-grade, and severe dysplasias for 38 cases. Based on characteristics of the intraepithelial papillary capillary loop (IPCL), endoscopic NBI results were divided into five categories (I, II, III, IV, and V). Type I-IV are regarded to be benign, while type V is considered to be cancerous. An incisional biopsy was conducted to assess histopathology, and the histopathology was compared to the NBI results. We assessed the negative predictive value (NPV), positive predictive value (PPV), specificity, and sensitivity for WLE alone and WLE combined with NBI. Analyses were conducted using SPSS software version 26.

RESULTS

The WLE combined with NBI showed excellent sensitivity (96%) compared to WLE (86.4%). Specificity was higher in the WLE combined with NBI (96.4%) than WLE alone (91.7%). WLE combined with NBI saw a NPV of 89% as compared with WLE with 88%. WLE and WLE in combination with NBI, recorded a PPV of 90% and 98%, respectively.

CONCLUSION

The accuracy of detecting laryngeal cancer increases when WLE and NBI are combined. Combined NBI with WLE remains highly sensitive to early glottis cancer. Accuracy of preoperative NBI was high. In the diagnosis of laryngeal cancer, a higher Ni classification closely correlates with the late stages of the glottis tumor.

Muscular injury as an independent risk factor for esophageal stenosis after endoscopic submucosal dissection of esophageal squamous cell cancer

BACKGROUND AND AIMS

Stenosis after esophageal endoscopic submucosal dissection (ESD) has a high incidence, and muscular injury is an important risk factor for esophageal stenosis. Hence, this study aimed to classify muscular injury degrees and investigate their association with postoperative stenosis.

METHODS

This retrospective study included 1033 patients with esophageal mucosal lesions treated with ESD between August 2015 and March 2021. Demographic and clinical parameters were analyzed, and stenosis risk factors were identified using multivariate logistic regression. A novel muscular injury classification system was proposed and used to investigate the association between different muscular injury degrees and postoperative stenosis. Finally, a scoring system was established to predict muscular injury.

RESULTS

Of 1033 patients, 118 (11.4%) had esophageal stenosis. The multivariate analysis demonstrated that the history of endoscopic esophageal treatment, circumferential range, and muscular injury were significant risk factors for esophageal stenosis. Patients with type II muscular injuries tended to develop complex stenosis (n = 13 [36.1%], P < .05), and type II muscular injuries were more likely to predispose patients to severe stenosis than type I (73.3% and 92.3%, respectively). The scoring system showed that patients with high scores (3-6) were more likely to have muscular injury. The score model presented good discriminatory power in the internal validation (area under the receiver-operating characteristic curve, .706; 95% confidence interval, .645-.767) and goodness-of-fit in the Hosmer-Lemeshow test (P = .865).

CONCLUSIONS

Muscular injury was an independent risk factor for esophageal stenosis. The scoring system demonstrated good performance in predicting muscular injury during ESD.

Usefulness of the aldehyde breath test for predicting metachronous recurrence in patients with esophageal squamous cell carcinoma and hypopharyngeal squamous cell carcinoma

BACKGROUND

The rate of metachronous recurrence after endoscopic submucosal dissection for early-stage esophageal squamous cell carcinoma and hypopharynx squamous cell carcinoma is as high (10-15%). The acetaldehyde breath test may detect acetaldehyde dehydrogenase 2 gene polymorphisms. Therefore, we evaluated its usefulness in assessing metachronous recurrence in patients with esophageal squamous cell carcinoma and hypopharynx squamous cell carcinoma.

METHODS

A total of 76 patients underwent endoscopic submucosal dissection for esophageal squamous cell carcinoma and hypopharynx squamous cell carcinoma and were followed up for at least 3 years (non-recurrence group: 52 patients; recurrence group: 24 patients). The risk factors for carcinogenesis were compared between the recurrence and non-recurrence groups, and the acetaldehyde-to-ethanol ratio was assessed. The cutoff acetaldehyde-to-ethanol ratio that correlated with recurrence was established, and the cumulative recurrence rate was evaluated.

RESULTS

The recurrence group had a higher acetaldehyde-to-ethanol ratio, daily alcohol consumption, and Lugol-voiding lesion grade than the non-recurrence group in the univariate analysis. The cutoff acetaldehyde-to-ethanol ratio for recurrence was 28.1 based on the receiver operating characteristic curve. The multivariate analysis revealed an acetaldehyde-to-ethanol ratio of > 28.1 and a Lugol-voiding lesion grade associated with carcinogenesis. Patients with an acetaldehyde-to-ethanol ratio of ≥ 28.1 had a significantly high recurrence rate using the Kaplan-Meier method.

CONCLUSIONS

The acetaldehyde-to-ethanol ratio detected using the acetaldehyde breath test could be a novel biomarker of metachronous recurrence after endoscopic submucosal dissection in patients with esophageal squamous cell carcinoma and hypopharynx squamous cell carcinoma.

TRIAL REGISTRATION NUMBER

UMIN000040615.

Human-Like Artificial Intelligent System for Predicting Invasion Depth of Esophageal Squamous Cell Carcinoma Using Magnifying Narrow-Band Imaging Endoscopy: A Retrospective Multicenter Study

INTRODUCTION

Endoscopic evaluation is crucial for predicting the invasion depth of esophagus squamous cell carcinoma (ESCC) and selecting appropriate treatment strategies. Our study aimed to develop and validate an interpretable artificial intelligence-based invasion depth prediction system (AI-IDPS) for ESCC.

METHODS

We reviewed the PubMed for eligible studies and collected potential visual feature indices associated with invasion depth. Multicenter data comprising 5,119 narrow-band imaging magnifying endoscopy images from 581 patients with ESCC were collected from 4 hospitals between April 2016 and November 2021. Thirteen models for feature extraction and 1 model for feature fitting were developed for AI-IDPS. The efficiency of AI-IDPS was evaluated on 196 images and 33 consecutively collected videos and compared with a pure deep learning model and performance of endoscopists. A crossover study and a questionnaire survey were conducted to investigate the system's impact on endoscopists' understanding of the AI predictions.

RESULTS

AI-IDPS demonstrated the sensitivity, specificity, and accuracy of 85.7%, 86.3%, and 86.2% in image validation and 87.5%, 84%, and 84.9% in consecutively collected videos, respectively, for differentiating SM2-3 lesions. The pure deep learning model showed significantly lower sensitivity, specificity, and accuracy (83.7%, 52.1% and 60.0%, respectively). The endoscopists had significantly improved accuracy (from 79.7% to 84.9% on average, P = 0.03) and comparable sensitivity (from 37.5% to 55.4% on average, P = 0.27) and specificity (from 93.1% to 94.3% on average, P = 0.75) after AI-IDPS assistance.

DISCUSSION

Based on domain knowledge, we developed an interpretable system for predicting ESCC invasion depth. The anthropopathic approach demonstrates the potential to outperform deep learning architecture in practice.

Long-term outcome of cervical lymph node metastasis in superficial pharyngeal squamous cell carcinoma after endoscopic submucosal dissection

BACKGROUND AND AIMS

Superficial pharyngeal squamous cell carcinoma (PSCC) has received increasing attention as a therapeutic target in the GI field with recent innovations in endoscopic submucosal dissection (ESD). However, there are currently no defined criteria for the application of ESD to superficial PSCC. One of the problems encountered during follow-up after ESD is cervical lymph node metastasis (LNM). Identifying the clinicopathologic predictors of cervical LNM can help to provide a basis for the refinement of therapeutic strategies for superficial PSCC.

METHODS

The risk of cervical LNM was evaluated in 331 patients with superficial PSCC who underwent initial ESD between 2008 and 2021. Since tumor size, rather than depth, is the dominant factor in the current TNM classification for PSCC, the correlation between tumor size and thickness was investigated.

RESULTS

The median follow-up period was 4.8 years. The cumulative 5-year cervical LNM rate was 6.1%. Multivariate Cox proportional hazards regression analysis identified tumor thickness ≥1000 μm and lymphatic invasion as significant independent predictors. Among 204 cases with subepithelial invasion, both factors were also revealed to be significant independent predictors, suggesting that tumor thickness was superior to tumor size in predicting cervical LNM. Despite the positive correlation between tumor thickness and size, there was noticeable variability in the values (R = .20), and the current staging was inadequate to identify groups at high risk for cervical LNM.

CONCLUSIONS

Tumor thickness and lymphatic invasion are validated as significant independent predictors for cervical LNM and can be useful indicators to optimize the therapeutic strategies for superficial PSCC.

Advanced diagnostic endoscopy in the upper gastrointestinal tract: Review of the Japan Gastroenterological Endoscopy Society core sessions

We held four upper gastrointestinal tract advanced diagnostic endoscopy sessions from the 89th to the 92nd Congress of the Japan Gastroenterological Endoscopy Society. The most common region addressed was the stomach in 25 presentations, followed by the esophagus in 23, duodenum in five, and other in one. Looking at techniques discussed, the most common image enhancement method discussed was narrowband imaging in 29 presentations, blue laser imaging, and linked color imaging (LCI) in 10 each, dual red imaging in three, and autofluorescence imaging in one. Furthermore, there were presentations of new techniques such as M-Chromo-LCI and acetic acid-indigo carmine mixture LCI. There were also six presentations regarding probe-based confocal laser endomicroscopy, and one of endocytoscopy techniques. We also saw presentations of images of gastric subepithelial tumors within the submucosa, 3D endoscopy, the development of computer-aided detection systems for early cancers, and fluorescent imaging.

Necessity of pharyngeal anesthesia during transoral gastrointestinal endoscopy: a randomized clinical trial

BACKGROUND/AIMS

The necessity for pharyngeal anesthesia during upper gastrointestinal endoscopy is controversial. This study aimed to compare the observation ability with and without pharyngeal anesthesia under midazolam sedation.

METHODS

This prospective, single-blinded, randomized study included 500 patients who underwent transoral upper gastrointestinal endoscopy under intravenous midazolam sedation. Patients were randomly allocated to pharyngeal anesthesia: PA+ or PA- groups (250 patients/group). The endoscopists obtained 10 images of the oropharynx and hypopharynx. The primary outcome was the non-inferiority of the PA- group in terms of the pharyngeal observation success rate.

RESULTS

The pharyngeal observation success rates in the pharyngeal anesthesia with and without (PA+ and PA-) groups were 84.0% and 72.0%, respectively. The PA- group was inferior (p=0.707, non-inferiority) to the PA+ group in terms of observable parts (8.33 vs. 8.86, p=0.006), time (67.2 vs. 58.2 seconds, p=0.001), and pain (1.21±2.37 vs. 0.68±1.78, p=0.004, 0-10 point visual analog scale). Suitable quality images of the posterior wall of the oropharynx, vocal fold, and pyriform sinus were inferior in the PA- group. Subgroup analysis showed a higher sedation level (Ramsay score ≥5) with almost no differences in the pharyngeal observation success rate between the groups.

CONCLUSION

Non-pharyngeal anesthesia showed no non-inferiority in pharyngeal observation ability. Pharyngeal anesthesia may improve pharyngeal observation ability in the hypopharynx and reduce pain. However, deeper anesthesia may reduce this difference.

Determining Invasion Depth in Superficial Pharyngeal Carcinoma by Transoral Ultrasonography

OBJECTIVES

To examine the clinical usefulness of transoral ultrasonography (US) in determining the invasion depth of superficial pharyngeal carcinoma (SPC). Determining the invasion depth of SPC is crucial for transoral surgery including determining treatment strategy. This study aimed to examine the usefulness of transoral US in determining the invasion depth of SPC.

METHODS

Forty-six patients with 51 lesions who underwent both magnifying endoscopy with narrow-band imaging (ME-NBI) and transoral US were included. The primary outcomes were the sensitivity, specificity, positive (PPV), and negative predictive values (NPV) of ME-NBI and transoral US findings for pathological tumor depth in SPCs.

RESULTS

The accuracy (82.4%), sensitivity (85.2%), PPV (82.1%), and NPV (82.6%) rates of US for subepithelial propria (SEP) were higher than those of ME-NBI and macroscopic classification, indicating that transoral US is superior to ME-NBI in determining the invasion depth. All cases where the SEP was clearly invaded (SEP deep) could be diagnosed as SEP by transoral US.

CONCLUSIONS

Transoral US may be useful in determining the invasion depth of SPCs.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:2192-2197, 2023.

Clinical outcome of endoscopic-assisted transoral surgery for superficial cancer of pharyngo-esophageal junction

BACKGROUND

Endoscopic-assisted transoral surgery (TOS) for superficial cancer of the pharyngo-esophageal junction (PEJ) is risk of stricture, and therapeutic outcomes are unclear. This study aimed to evaluate clinical outcomes of endoscopic-assisted TOS for superficial PEJ cancers.

METHODS

We retrospectively compared clinical outcomes of endoscopic-assisted TOS for superficial PEJ cancers (group A) and of other sites in the hypopharynx (group B).

RESULTS

The group A comprised 12 lesions in 12 patients, and group B comprised 198 lesions in 146 patients. Group A and group B exhibited en bloc resection rates of 100% and 99%. Median operative times were 82 and 37 min (p < 0.001). The frequency of stricture and local recurrence in group A was significantly higher in group B (42% vs. 1%, p < 0.001; 25% vs. 6%, p = 0.036). All adverse events could be managed with conservative treatments.

CONCLUSIONS

Endoscopic-assisted TOS is not ideal for treating superficial PEJ cancers compared to other sites.

Synchronous Second Primary Cancers of Hypopharyngeal Carcinoma in the Image-Enhanced Endoscopy Era

OBJECTIVES

To explore the prevalence of hypopharyngeal carcinoma (HPC) with synchronous second primary malignancies (Syn-SPMs), their impact on clinical outcomes, and associated risk factors in the image-enhanced endoscopy era.

MATERIALS AND METHODS

We retrospectively analyzed 673 patients newly diagnosed with HPC at our cancer center between 2009 and 2019. The patients were divided into three groups: (a) no second primary malignancies (N-SPMs, n = 533); (b) synchronous carcinoma in situ (Syn-Tis, n = 60); (c) synchronous invasive tumors (Syn-invasive, n = 80). Propensity score matching was conducted to balance the N-SPMs and Syn-invasive groups at a 3:1 ratio.

RESULTS

Most (96.1%) underwent pretreatment esophagogastroduodenoscopy evaluation with image-enhanced endoscopy. The incidence rates were: Syn-SPMs, 20.8%; Syn-Tis, 8.9%; Syn-invasive, 11.9%. At a median follow-up of 66.7 months, the Syn-Tis and N-SPMs groups had a similar 5-year overall survival (OS; 45.6% vs. 44.5%; hazard ratio [HR], 0.956; 95% confidence interval [CI], 0.660-1.385; p = 0.806). Compared to the N-SPMs group, the Syn-invasive group had poorer 5-year OS (27.0% vs. 52.9%; HR, 2.059; 95% CI, 1.494-2.839; p < 0.001). Alcohol consumption was significantly associated with Syn-SPMs occurrence (odds ratio, 2.055, 2.414, and 3.807 for light, intermediate, and heavy drinkers, respectively).

CONCLUSION

The prevalence of Syn-SPMs among patients with HPC was high. Syn-invasive SPMs decreased the survival of patients with HPC. Routine screening with image-enhanced endoscopy should be recommended to detect early-stage SPMs, especially for heavy alcohol drinkers.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:1906-1913, 2023.

Risk factors for adverse events associated with endoscopic submucosal dissection for superficial pharyngeal cancer

BACKGROUND

Superficial pharyngeal cancer can be treated with curative intent while preserving function using minimally invasive peroral endoscopic resection techniques such as endoscopic submucosal dissection (ESD). However, severe adverse events occasionally occur, such as laryngeal edema requiring temporary tracheotomy and fistula formation. Therefore, we investigated the risk factors for adverse events associated with ESD for superficial pharyngeal cancer.

METHODS

This retrospective observational study was conducted at a single institution, and 63 patients who underwent ESD were enrolled. The primary outcome was the risk factors for adverse events associated with ESD. The secondary outcomes were adverse events associated with ESD and their frequency.

RESULTS

The overall adverse event rate was 15.9% (10/63). The incidence of laryngeal edema requiring prophylactic temporary tracheotomy was 11.1%, while laryngeal edema requiring emergency temporary tracheotomy, postoperative bleeding, aspiration pneumonia, fistula, abscess, and stricture formation occurred in 1.6% of patients, respectively. Logistic regression analyses showed that a history of radiotherapy for head and neck cancer was a risk factor for adverse events (odds ratio [OR], 16.67; 95% confidence interval [CI], 3.04-91.34; p = 0.001). After adjusting the model for differences in the baseline risk factors using the inverse probability of treatment weighting method, the adverse events were found to increase in association with a history of radiotherapy for head and neck cancer (OR, 39.66; 95% CI,5.85-268.72; p < 0.001).

CONCLUSION

History of radiotherapy for head and neck cancer is an independent risk factor for adverse events associated with ESD for superficial pharyngeal cancer. Among adverse events, laryngeal edema requiring prophylactic temporary tracheotomy was particularly high.

Preparing Well for Esophageal Endoscopic Detection Using a Hybrid Model and Transfer Learning

Early detection of esophageal cancer through endoscopic imaging is pivotal for effective treatment. However, the intricacies of endoscopic diagnosis, contingent on the physician's expertise, pose challenges. Esophageal cancer features often manifest ambiguously, leading to potential confusions with other inflammatory esophageal conditions, thereby complicating diagnostic accuracy. In recent times, computer-aided diagnosis has emerged as a promising solution in medical imaging, particularly within the domain of endoscopy. Nonetheless, contemporary AI-based diagnostic models heavily rely on voluminous data sources, limiting their applicability, especially in scenarios with scarce datasets. To address this limitation, our study introduces novel data training strategies based on transfer learning, tailored to optimize performance with limited data. Additionally, we propose a hybrid model integrating EfficientNet and Vision Transformer networks to enhance prediction accuracy. Conducting rigorous evaluations on a carefully curated dataset comprising 1002 endoscopic images (comprising 650 white-light images and 352 narrow-band images), our model achieved exceptional outcomes. Our combined model achieved an accuracy of 96.32%, precision of 96.44%, recall of 95.70%, and f1-score of 96.04%, surpassing state-of-the-art models and individual components, substantiating its potential for precise medical image classification. The AI-based medical image prediction platform presents several advantageous characteristics, encompassing superior prediction accuracy, a compact model size, and adaptability to low-data scenarios. This research heralds a significant stride in the advancement of computer-aided endoscopic imaging for improved esophageal cancer diagnosis.

Review of oral and pharyngolaryngeal benign lesions detected during esophagogastroduodenoscopy

Recent advancements in endoscopy equipment have facilitated endoscopists’ detection of neoplasms in the oral cavity and pharyngolaryngeal regions. In particular, image-enhanced endoscopy using narrow band imaging or blue laser imaging play an integral role in the endoscopic diagnosis of oral and pharyngolaryngeal cancers. Despite these advancements, limited studies have focused on benign lesions that can be observed during esophagogastroduodenoscopy in the oral and pharyngolaryngeal regions. Therefore, this mini-review aimed to provide essential information on such benign lesions, along with representative endoscopic images of dental caries, cleft palate, palatal torus, bifid uvula, compression by cervical osteophytes, tonsil hyperplasia, black hairy tongue, oral candidiasis, oral and pharyngolaryngeal ulcers, pharyngeal melanosis, oral tattoos associated with dental alloys, retention cysts, papilloma, radiation-induced changes, skin flaps, vocal cord paresis, and vocal fold leukoplakia. Whilst it is imperative to seek consultation from otolaryngologists or dentists in instances where the diagnosis cannot be definitively ascertained by endoscopists, the merits of attaining foundational expertise pertaining to oral and pharyngolaryngeal lesions are unequivocal. This article will be a valuable resource for endoscopists seeking to enhance their understanding of oral and pharyngolaryngeal lesions.

Advanced Imaging in Gastrointestinal Endoscopy: A Literature Review of the Current State of the Art

BACKGROUND AND AIMS

Gastrointestinal (GI) endoscopy has known a great evolution in the last decades. Imaging techniques evolved from imaging with only standard white light endoscopes toward high-definition resolution endoscopes and the use of multiple color enhancement techniques, over to automated endoscopic assessment systems based on artificial intelligence. This narrative literature review aimed to provide a detailed overview on the latest evolutions within the field of advanced GI endoscopy, mainly focusing on the screening, diagnosis, and surveillance of common upper and lower GI pathology.

METHODS

This review comprises only literature about screening, diagnosis, and surveillance strategies using advanced endoscopic imaging techniques published in (inter)national peer-reviewed journals and written in English. Studies with only adult patients included were selected. A search was performed using MESH terms: dye-based chromoendoscopy, virtual chromoendoscopy, video enhancement technique, upper GI tract, lower GI tract, Barrett's esophagus, esophageal squamous cell carcinoma, gastric cancer, colorectal polyps, inflammatory bowel disease, artificial intelligence. This review does not elaborate on the therapeutic application or impact of advanced GI endoscopy.

CONCLUSIONS

Focusing on current and future applications and evolutions in the field of both upper and lower GI advanced endoscopy, this overview is a practical but detailed projection of the latest developments. Within this review, an active leap toward artificial intelligence and its recent developments in GI endoscopy was made. Additionally, the literature is weighted against the current international guidelines and assessed for its potential positive future impact.

A single-center prospective study evaluating the usefulness of artificial intelligence for the diagnosis of esophageal squamous cell carcinoma in a real-time setting

BACKGROUND

Several pre-clinical studies have reported the usefulness of artificial intelligence (AI) systems in the diagnosis of esophageal squamous cell carcinoma (ESCC). We conducted this study to evaluate the usefulness of an AI system for real-time diagnosis of ESCC in a clinical setting.

METHODS

This study followed a single-center prospective single-arm non-inferiority design. Patients at high risk for ESCC were recruited and real-time diagnosis by the AI system was compared with that of endoscopists for lesions suspected to be ESCC. The primary outcomes were the diagnostic accuracy of the AI system and endoscopists. The secondary outcomes were sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and adverse events.

RESULTS

A total of 237 lesions were evaluated. The accuracy, sensitivity, and specificity of the AI system were 80.6%, 68.2%, and 83.4%, respectively. The accuracy, sensitivity, and specificity of endoscopists were 85.7%, 61.4%, and 91.2%, respectively. The difference between the accuracy of the AI system and that of the endoscopists was - 5.1%, and the lower limit of the 90% confidence interval was less than the non-inferiority margin.

CONCLUSIONS

The non-inferiority of the AI system in comparison with endoscopists in the real-time diagnosis of ESCC in a clinical setting was not proven.

TRIAL REGISTRATION

Japan Registry of Clinical Trials (jRCTs052200015, 18/05/2020).

The current state of artificial intelligence in endoscopic diagnosis of early esophageal squamous cell carcinoma

Esophageal squamous cell carcinoma (ESCC) is a common malignant tumor of the digestive tract. The most effective method of reducing the disease burden in areas with a high incidence of esophageal cancer is to prevent the disease from developing into invasive cancer through screening. Endoscopic screening is key for the early diagnosis and treatment of ESCC. However, due to the uneven professional level of endoscopists, there are still many missed cases because of failure to recognize lesions. In recent years, along with remarkable progress in medical imaging and video evaluation technology based on deep machine learning, the development of artificial intelligence (AI) is expected to provide new auxiliary methods of endoscopic diagnosis and the treatment of early ESCC. The convolution neural network (CNN) in the deep learning model extracts the key features of the input image data using continuous convolution layers and then classifies images through full-layer connections. The CNN is widely used in medical image classification, and greatly improves the accuracy of endoscopic image classification. This review focuses on the AI-assisted diagnosis of early ESCC and prediction of early ESCC invasion depth under multiple imaging modalities. The excellent image recognition ability of AI is suitable for the detection and diagnosis of ESCC and can reduce missed diagnoses and help endoscopists better complete endoscopic examinations. However, the selective bias used in the training dataset of the AI system affects its general utility.

Assessment of delayed bleeding after endoscopic submucosal dissection of early-stage gastrointestinal tumors in patients receiving direct oral anticoagulants

Delayed bleeding is a major and serious adverse event of endoscopic submucosal dissection (ESD) for early-stage gastrointestinal tumors. The rate of post-ESD bleeding for gastric cancer is higher (around 5%-8%) than that for esophagus, duodenum and colon cancer (around 2%-4%). Although investigations into the risk factors for post-ESD bleeding have identified several procedure-, lesion-, physician- and patient-related factors, use of antithrombotic drugs, especially anticoagulants [direct oral anticoagulants (DOACs) and warfarin], is thought to be the biggest risk factor for post-ESD bleeding. In fact, the post-ESD bleeding rate in patients receiving DOACs is 8.7%-20.8%, which is higher than that in patients not receiving anticoagulants. However, because clinical guidelines for management of ESD in patients receiving DOACs differ among countries, it is necessary for endoscopists to identify ways to prevent post-ESD delayed bleeding in clinical practice. Given that the pharmacokinetics (e.g., plasma DOAC level at both trough and Tmax) and pharmacodynamics (e.g., anti-factor Xa activity) of DOACs are related to risk of major bleeding, plasma DOAC level and anti-FXa activity may be useful parameters for monitoring the anti-coagulate effect and identifying DOAC patients at higher risk of post-ESD bleeding.

How to prevent human papillomavirus-related oropharyngeal cancer?

PURPOSE OF REVIEW

Human papillomavirus (HPV) is responsible of the increasing incidence rates of oropharyngeal squamous cell carcinoma (OPSCC) in high-income countries. This significant epidemiological change requires several and diverse prevention strategies.

RECENT FINDINGS

The cervical cancer prevention model is the paradigm of HPV-related cancer, and its success provides encouragement for the development of similar methods to prevent HPV-related OPSCC. However, there are some limitations that hinder its application in this disease. Here, we review the primary, secondary and tertiary prevention of HPV-related OPSCC and discuss some directions for future research.

SUMMARY

The development of new and targeted strategies to prevent HPV-related OPSCC is needed since they could definitely have a direct impact on the reduction of morbidity and mortality of this disease.

Risk factors for incomplete resection with pharyngeal endoscopic submucosal dissection and long-term prognosis after resection

BACKGROUND

Advances in endoscopic imaging technology have led to an increase in detection of superficial pharyngeal squamous carcinoma. Endoscopic submucosal dissection (ESD) has been reported to be effective for the treatment of these lesions, however there is still insufficient evidence on the long-term results of pharyngeal ESD.

METHODS

This is a single-center retrospective study of all cases of superficial pharyngeal cancer that underwent ESD as primary treatment between January 2010 and May 2022. A total of 83 lesions in 63 patients were analyzed.

RESULTS

The en bloc resection rate was 100%, and R0 resection rate was 59.0%, with an adverse event rate of 6.0%. During a mean observation period of 1134 days, there were 0 cases of disease-specific metastasis or death. However, the 5-year cumulative incidence of metachronous head and neck cancer after resection was 27.1% and the 5-year overall survival and 10-year overall survival after pharyngeal ESD were 87.0% and 69.6%, respectively. Of the 34 cases with non-R0 resection, local recurrence occurred in 8.8%. Location of lesion (p = 0.011), disparity between demarcation of the lesion with NBI and iodine staining (p = 0.026), and non-effective laryngeal elevation (p = 0.080) were risk factors for non-R0 resection.

CONCLUSION

Pharyngeal ESD is effective and safe. Further studies are needed to improve and standardize indications and strategies for pharyngeal ESD.

Case report: a precancerous lesion associated with HPV in the anal canal diagnosed by magnifying endoscopy with narrow-band imaging and resected by endoscopic submucosal dissection

Although anal cancer remains rarely diagnosed in the world, its frequency is rising, especially in high-risk groups. The prognosis of advanced anal cancer is poor. However, there are still few reports on the endoscopic diagnosis and treatment of early anal cancer and its precancerous lesions. A 60-year-old woman was referred to our hospital for endoscopic treatment of a flat precancerous lesion in the anal canal, which was identified by narrow-band imaging (NBI) and confirmed by pathological examination in another hospital. The pathological results showed a high-grade squamous intraepithelial lesion (HSIL) in the biopsy specimen, and immunochemistry staining showed P16 positive, suggesting HPV infection. We performed pre-resection endoscopic examination for the patient. A lesion with a clear margin and tortuous dilated vessels was revealed under magnifying endoscopy with NBI (ME-NBI), which stayed unstained after iodine spraying. The lesion was successfully removed en bloc using ESD without complications, and the resected specimen was a low-grade squamous intraepithelial lesion (LSIL) with positive immunochemistry staining of P16. The patient underwent follow-up coloscopy a year after ESD, and the anal canal healed well with no suspicious lesions found. From this case, we can learn that ESD is safe and effective for curative resection of precancerous lesions of the anal canal.

Association of survival with adjuvant radiotherapy for pN0 esophageal cancer

INTRODUCTION

This study was conducted to elucidate the link between adjuvant radiotherapy and survival in pathologic node-negative (pN0) esophageal cancer patients with upfront esophagectomy.

METHODS

From 2000 to 2016, patients with pN0 esophageal cancer who underwent upfront esophagectomy were selected from the Surveillance, Epidemiology, and End Results (SEER) database. The association of high-risk covariates with survival after adjuvant radiotherapy was evaluated using propensity score matching and multivariate analysis.

RESULTS

We identified 3197 patients, 321 (10.0%) underwent postoperative radiotherapy and 2876 (90.0%) underwent esophagectomy alone. In the unmatched cohort, postoperative radiotherapy was associated with a statistically significant but modest absolute decrease in survival outcomes (P < 0.001). In the matched cohort, the survival differences disappeared. Additionally, adjuvant radiotherapy was linked to a 5-year overall survival (OS) benefit for patients with the pT3-4N0 disease (34.8% vs. 27.7%; P = 0.008). Adjuvant radiotherapy for pT3-4N0 disease with tumor length ≥3 cm, adenocarcinoma, and evaluated lymph node count <12 was shown to independently function as a risk factor for improved OS, as per a multivariate analysis (P < 0.01).

CONCLUSIONS

This population-based trial showed that high-risk patients with pT3-4N0 esophageal cancer had better OS following upfront esophagectomy followed by radiotherapy therapy. This discovery may have major significance in the use of adjuvant radiotherapy following upfront esophagectomy in patients with pN0 esophageal cancer.

Anatomical classification of pharyngeal and laryngeal endoscopic images using artificial intelligence

BACKGROUND

The entire pharynx should be observed endoscopically to avoid missing pharyngeal lesions. An artificial intelligence (AI) model recognizing anatomical locations can help identify blind spots. We developed and evaluated an AI model classifying pharyngeal and laryngeal endoscopic locations.

METHODS

The AI model was trained using 5382 endoscopic images, categorized into 15 anatomical locations, and evaluated using an independent dataset of 1110 images. The main outcomes were model accuracy, precision, recall, and F1-score. Moreover, we investigated focused regions in the input images contributing to the model predictions using gradient-weighted class activation mapping (Grad-CAM) and Guided Grad-CAM.

RESULTS

Our AI model correctly classified pharyngeal and laryngeal images into 15 anatomical locations, with an accuracy of 93.3%. The weighted averages of precision, recall, and F1-score were 0.934, 0.933, and 0.933, respectively.

CONCLUSION

Our AI model has an excellent performance determining pharyngeal and laryngeal anatomical locations, helping endoscopists notify of blind spots.

Increased incidence of rare cancers and varied age distributions by cancer group: A population-based cancer registry study in Hiroshima Prefecture, Japan

BACKGROUND

Epidemiological characteristics of many types of rare cancers are limited especially in Asia. Therefore, this study aimed to describe the burden and changing time trends of rare cancers in Hiroshima, Japan.

METHODS

The internationally agreed RARECAREnet list of rare cancers was used to identify patients diagnosed with cancers from 2005 to 2015 who were registered in the Hiroshima Prefecture Cancer Registry. Quality indicators specific to rare cancers were assessed by cancer grouping. Crude incidence rates (IRs) and age-standardized rates (ASRs) were calculated for 216 single cancers (rare and common) included in the list. A joinpoint regression was used to analyze age distribution and time trends in the ASRs for 12 internationally agreed rare cancer families. Quality indicators, ASRs, and IRs in Japan were identified to examine IR differences and the effects on data accuracy.

RESULTS

The 231,328 cases were used to calculate the IRs of each cancer. Epithelial tumors in rare families increased with age, but nonepithelial tumors occurred at any age. The proportion of rare cancer families to total cancers was stable. The time trend for families of head and neck cancers (annual percent change and 95 % confidence interval: 2.4 %; 1.2-3.7 %), neuroendocrine tumors (6.6 %; 5.1-8.1 %), and hematological cancers (4.3 %; 3.2-5.5 %) markedly increased.

CONCLUSION

The ASRs of several rare cancers increased because of increased knowledge of these diseases, improved diagnostic techniques, and aggressive diagnoses.

CLELNet: A continual learning network for esophageal lesion analysis on endoscopic images

BACKGROUND AND OBJECTIVE

A deep learning-based intelligent diagnosis system can significantly reduce the burden of endoscopists in the daily analysis of esophageal lesions. Considering the need to add new tasks in the diagnosis system, a deep learning model that can train a series of tasks incrementally using endoscopic images is essential for identifying the types and regions of esophageal lesions.

METHOD

In this paper, we proposed a continual learning-based esophageal lesion network (CLELNet), in which a convolutional autoencoder was designed to extract representation features of endoscopic images among different esophageal lesions. The proposed CLELNet consists of shared layers and task-specific layers. Shared layers are used to extract common features among different lesions while task-specific layers can complete different tasks. The first two tasks trained by the CLELNet are the classification (task 1) and the segmentation (task 2). We collected a dataset of esophageal endoscopic images from Macau Kiang Wu Hospital for training and testing the CLELNet.

RESULTS

The experimental results showed that the classification accuracy of task 1 was 95.96%, and the Intersection Over Union and the Dice Similarity Coefficient of task 2 were 65.66% and 78.08%, respectively.

CONCLUSIONS

The proposed CLELNet can realize task-incremental learning without forgetting the previous tasks and thus become a useful computer-aided diagnosis system in esophageal lesions analysis.

Efficacy of a new traction method using ring-shaped thread for endoscopic submucosal dissection in the pharynx

BACKGROUND

Endoscopic submucosal dissection (ESD) is a minimally invasive treatment for pharyngeal cancers. However, pharyngeal ESD is sometimes technically challenging because of the narrow and complex space in which to work. Traction is important to complete the procedure efficiently. Here, we report the technical details and efficacy of a new traction method for pharyngeal ESD using ring-shaped thread and grasping forceps.

METHODS

We analyzed pharyngeal ESD performed between January 2016 and March 2021 at our Institute. We designated cases resected using ring-shaped threads "Group R" and those resected without ring-shaped threads as conventional "Group C", and compared the technical outcomes between them. Multivariate analysis and the inverse probability treatment weighting (IPTW) method using propensity scores were adjusted by confounding variables.

RESULTS

We analyzed 89 lesions from 68 patients, of which 46 were in Group R and 43 in Group C. Median procedure time and median dissection speed were significantly shorter in Group R than C (37 min vs. 55 min, and 16.0 mm2/min vs. 7.0 mm2/min, respectively, both P < 0.05). These results were confirmed by both multivariate analysis and after IPTW adjustment. All lesions were resected en bloc, and the complete resection rate was not significantly different between Group R and C (91.3% vs. 79.1%, P = 0.14). There were no treatment-related adverse events in either group.

CONCLUSIONS

The traction method using ring-shaped thread increases the efficiency of pharyngeal ESD. This simple new traction method should be a useful option for pharyngeal ESD.

Multiple Lugol-unstained lesions predict higher cumulative risk of malignance in the esophagus

BACKGROUND AND AIM

The impact of the presence of multiple Lugol-unstained lesions (LULs) in the esophagus on the risk of having severe dysplasia and above (SDA) lesions among asymptomatic individuals is unknown.

METHODS

We collected demographic factors, behavioral variables, and features of LULs from 1073 participants who were biopsied at baseline endoscopic screening in a population-based screening trial, and these individuals were followed over a median time of 7 years. Outcome events were defined as SDA identified at screening, at reexamination, or during follow-up. "Multiple LULs" were defined as ≥ 2 LULs found in the entirety of the esophagus. Multivariable logistic regression models were fitted to assess the effect of "multiple LULs" on the cumulative risk of SDA.

RESULTS

There were 147 SDA cases in the current study. After adjustment for potential risk factors and endoscopic features of LULs, the presence of "multiple LULs" slightly increased the cumulative risk of having SDA with no statistical significance (adjusted odds ratio [OR] = 1.26; 95% confidence interval [CI] [0.85, 1.88]). Further stratified analysis showed that this association was strong among subjects with small LULs (≤ 5 mm) (adjusted OR = 3.29; 95% CI [1.39, 7.79]). However, no such association was observed in subjects with larger LULs (adjusted OR = 0.99; 95% CI [0.63, 1.55], P _interaction  = 0.022).

CONCLUSIONS

The presence of "multiple small LULs (≤ 5 mm)" in chromoendoscopy indicates a higher cumulative risk of having SDA in the esophagus. We recommend biopsies be taken and surveillance be maintained at a more active level in individuals with relatively small but multiple LULs.

Endoscopic Surveillance for Premalignant Esophageal Lesions: A Community-Based Multicenter, Prospective Cohort Study

BACKGROUND & AIMS

Mild and moderate dysplasia are major premalignant lesions of esophageal squamous cell carcinoma (ESCC); however, evidence of the progression risk in patients with these conditions is extremely limited. We aimed to assess the incidence and risk factors for advanced neoplasia in patients with mild-moderate dysplasia.

METHODS

This prospective cohort study included patients with mild-moderate dysplasia from 9 regions in rural China. These patients were identified from a community-based ESCC screening program conducted between 2010 and 2016 and were offered endoscopic surveillance until December 2021. We estimated the incidence of advanced esophageal neoplasia, including severe dysplasia, carcinoma in situ, or ESCC, and identified potential risk factors using the Cox regression model.

RESULTS

The 1183 patients with mild-moderate dysplasia were followed up over a period of 6.95 years. During follow-up evaluation, 88 patients progressed to advanced neoplasia (7.44%), with an incidence rate of 10.44 per 1000 person-years. The median interval from the progression of mild-moderate dysplasia to advanced neoplasia was 2.39 years (interquartile range, 1.58-4.32 y). A total of 74.47% of patients with mild-moderate dysplasia experienced regression to nondysplasia, and 18.09% showed no lesion progression. Patients with mild-moderate dysplasia who had a family history of esophageal cancer and were age 55 years and older showed 97% higher advanced neoplasia yields than all patients with mild-moderate dysplasia.

CONCLUSIONS

In a country with a high incidence of ESCC, patients with mild-moderate dysplasia showed an overall risk of advanced neoplasia progression of 1.04% per year. Patients with mild-moderate dysplasia would be recommended for endoscopic surveillance during the first 2 to 3 years.

Impact of linked color imaging and blue laser imaging on the diagnosis of esophageal squamous cell carcinoma in iodine unstained areas

The pink color sign in iodine unstained areas is useful to differentiate esophageal squamous cell carcinoma (ESCC) from other lesions. However, some ESCCs have obscure color findings which affect the ability of endoscopists to differentiate these lesions and determine the resection line. Using white light imaging (WLI), linked color imaging (LCI) and blue laser imaging (BLI), 40 early ESCCs were retrospectively evaluated using images before and after iodine staining. Visibility scores for ESCC by expert and non-expert endoscopists were compared using these three modalities and color differences measured for malignant lesions and surrounding mucosa. BLI had the highest score and color difference without iodine staining. Each determination with iodine was much higher than without iodine regardless of the modality. With iodine, ESCC mainly appeared pink, purple and green using WLI, LCI and BLI, respectively and visibility scores determined by non-experts and experts were significantly higher for LCI (both p < 0.001) and BLI (p = 0.018 and p < 0.001) than for WLI. The score with LCI was significantly higher than with BLI among non-experts (p = 0.035). With iodine, the color difference using LCI was twice that with WLI and one with BLI was significantly larger than with WLI (p < 0.001). These greater tendencies were found regardless of location, depth of cancer or intensity of pink color using WLI. In conclusion, areas of ESCC unstained by iodine were easily recognized using LCI and BLI. Visibility of these lesions is excellent even by non-expert endoscopists, suggesting that this method is useful to diagnose ESCC and determine the resection line.

Oncologic significance of lymphovascular invasion in patients with superficial esophageal squamous cell carcinoma reaching the muscularis mucosae or with slight invasion of the submucosa

BACKGROUND

The clinicopathological features and the distribution of lymph node metastasis in patients with T1a-MM and T1b-SM1 superficial esophageal squamous cell carcinoma remain unclear; therefore, the optimal treatment strategy is still controversial.

METHODS

One hundred and ninety-one patients who had undergone a thoracic esophagectomy with 3-field lymphadenectomy and who were pathologically confirmed to have thoracic superficial esophageal squamous cell carcinoma that had reached the T1a-MM or T1b-SM1 stage were retrospectively reviewed. Risk factors of lymph node metastasis, the distribution of lymph node metastasis, and long-term outcomes were evaluated.

RESULTS

A multivariate analysis revealed that lymphovascular invasion was the only independent risk factor of lymph node metastasis (odds ratio: 6.410, P < .001). Patients with primary tumors in the middle thoracic region had lymph node metastasis in all 3 fields, whereas patients with primary tumors in the upper or lower thoracic region did not have distant lymph node metastasis. The frequencies of neck (P = .045) and abdominal (P < .001) lymph node metastasis were significantly higher in lymphovascular invasion-positive patients than those in lymphovascular invasion-negative patients in all cohort. MM/lymphovascular invasion-positive patients with middle thoracic tumors had lymph node metastasis spread from the neck to the abdomen. SM1/lymphovascular invasion-negative patients with middle thoracic tumors did not have lymph node metastasis in the abdominal region. The SM1/pN+ group had a significantly poorer overall survival and relapse-free survival than the other groups.

CONCLUSION

The present study revealed that lymphovascular invasion was associated with not only the frequency of lymph node metastasis, but also the distribution of lymph node metastasis. It also suggested that superficial esophageal squamous cell carcinoma patients with T1b-SM1 and lymph node metastasis had a significantly poorer outcome than those with T1a-MM and lymph node metastasis.

A prospective evaluation of postoperative swallowing function and dysphagia following endoscopic laryngopharyngeal surgery

BACKGROUND

Endoscopic laryngopharyngeal surgery (ELPS) is a minimally invasive transoral surgery for superficial pharyngeal and laryngeal cancer, but dysphagia occasionally occurs post-treatment. We investigated dysphagia following ELPS and its risk factors.

METHODS

Of the 145 patients who underwent ELPS, 92 were evaluated in this study using the Hyodo score, Functional Outcome Swallowing Scale, Eating Assessment Tool-10 along with the total scores for the three items of the method of intake, time, and food preoperatively and on postoperative 1, 3, and 6 months. We examined the 6-month trends of these values. Furthermore, the fasting period post-surgery, the need for swallowing rehabilitation by a speech therapist, and postoperative pneumonia episodes were set as outcomes reflecting the short-term swallowing function. We determined the associations between these outcomes and patient background factors.

RESULTS

Postoperatively, the Hyodo score worsened at 1 month but recovered at 3 months. The Hyodo scores of all patients who underwent postcricoid ELPS did not worsen. The diameter of the resected specimen (DRS) was significantly associated with the need for swallowing rehabilitation and postoperative fasting time. A DRS ≥ 35 mm was considered the threshold for the need of swallowing rehabilitation, postoperative pneumonia, and prolonged postoperative fasting time.

CONCLUSION

ELPS exerts a temporal and limited impact on the swallowing function, which recovers within 3 months in every swallowing evaluation. This necessitates additional care during the treatment of patients with mucosal defects ≥ 35 mm, owing to the significant association between the DRS and short-term swallowing function.

Usefulness of Endoscopy for the Detection and Diagnosis of Primary Esophageal Motility Disorders and Diseases Relating to Abnormal Esophageal Motility

Esophagogastroduodenoscopy (EGD) is performed to rule out organic diseases in the diagnosis of esophageal motility disorders (EMDs). Abnormal endoscopic findings can be observed during EGD, which indicate the presence of EMDs. Several endoscopic findings at both the esophagogastric junction and esophageal body that are related to EMDs have been reported. Gastroesophageal reflux disease (GERD) and eosinophilic esophagitis (EoE) could be detected during EGD, and these diseases are often associated with abnormal esophageal motility. Image-enhanced endoscopy (IEE) could improve the detection of these diseases during EGD. Although no report has been published previously on the potential usefulness of IEE in the endoscopic diagnosis of EMDs, IEE can be used to detect disorders that can be associated with abnormal esophageal motility.

A narrative review: narrow-band imaging endoscopic classifications

Background and Objective

With the development of endoscopic techniques, narrow-band imaging (NBI) has been widely used in the diagnosis of various types of diseases. NBI can detect mucosal lesions at an early stage and different classification strategies have been established to help clinicians in disease diagnosis. However, there is currently no consensus for the classification criteria. This report summarizes the current classifications of diseases using NBI, so as to provide a comprehensive understanding of the various manifestations of mucosal lesions under NBI, and to promote the development of more practical NBI classifications.

Methods

The PubMed database was searched for English language articles published between January 1994 and November 2021 using the keywords 'narrow band imaging', 'NBI', and 'classification'.

Key Content and Findings

We systematically summarized the NBI classifications and manifestations of different diseases. The morphology of the mucosa and vessels was used as the basis of most classifications. These classifications are mainly helpful to distinguish benign and malignant tumors and to detect early neoplastic lesions.

Conclusions

This review summarized existing NBI classifications for different systems. These classifications will be updated as the understanding of diseases increases and new optical techniques become available to better assist doctors in making clinical decisions.

Intraoperative Imaging Techniques to Improve Surgical Resection Margins of Oropharyngeal Squamous Cell Cancer: A Comprehensive Review of Current Literature

Inadequate resection margins in head and neck squamous cell carcinoma surgery necessitate adjuvant therapies such as re-resection and radiotherapy with or without chemotherapy and imply increasing morbidity and worse prognosis. On the other hand, taking larger margins by extending the resection also leads to avoidable increased morbidity. Oropharyngeal squamous cell carcinomas (OPSCCs) are often difficult to access; resections are limited by anatomy and functionality and thus carry an increased risk for close or positive margins. Therefore, there is a need to improve intraoperative assessment of resection margins. Several intraoperative techniques are available, but these often lead to prolonged operative time and are only suitable for a subgroup of patients. In recent years, new diagnostic tools have been the subject of investigation. This study reviews the available literature on intraoperative techniques to improve resection margins for OPSCCs. A literature search was performed in Embase, PubMed, and Cochrane. Narrow band imaging (NBI), high-resolution microendoscopic imaging, confocal laser endomicroscopy, frozen section analysis (FSA), ultrasound (US), computed tomography scan (CT), (auto) fluorescence imaging (FI), and augmented reality (AR) have all been used for OPSCC. NBI, FSA, and US are most commonly used and increase the rate of negative margins. Other techniques will become available in the future, of which fluorescence imaging has high potential for use with OPSCC.

Differences in color between early gastric cancer and cancer-suspected non-cancerous mucosa on linked color imaging

Background and study aims  Linked color imaging (LCI) can enhance the original color of each area and may useful to detect tumorous lesions during esophagogastroduodenoscopy. However, LCI may also enhance cancer-suspected non-cancerous regional color change. We conducted a retrospective image analysis to investigate the color characteristics of early gastric cancer (EGC) and cancer-suspected non-cancerous mucosa (CSM) in LCI. Methods  LCI images of both EGC and CSM were retrospectively collected from the database of the institution. Fifteen endoscopists individually judged each image as EGC or CSM. The color difference between the inside and outside of the lesions was measured by CIE-Lab analysis in both groups and compared. Results  A total of 245 LCI images of EGC (169) and CSM (76) were extracted and randomly lined for image collection. The test by the endoscopists showed accuracy, sensitivity, and specificity of 64.0 %, 63.7 %, and 64.0 %, respectively. Although the color difference between EGC and CSM was almost the same (12.5 vs. 12.9, not significant), each parameter of ΔL (bright: -0.3 vs. -2.7, P  < 0.001), Δa (Reddish: 7.2 vs. 9.6, P  = 0.004), and Δb (Yellowish: 6.4 vs. 3.8, P  < 0.001) was significantly different in the groups. The color feature of both positive ΔL and Δb to EGC showed accuracy, sensitivity, and specificity of 54.7 %, 39.6 %, 88.2%, respectively. Conclusions  The total color difference was almost the same between EGC and CSM; however, their color tones were different on linked color imaging. Although the color characteristics of EGC had high specificity, they also had low sensitivity.

Endoscopic submucosal dissection using an ultrathin endoscope for superficial pharyngeal cancer: a prospective feasibility study (with video)

Background and study aims  Endoscopic submucosal dissection (ESD) of pharyngeal cancers with conventional endoscopes often is difficult, not only because of the narrow working space, but also because endoscope maneuverability in the pharynx is poor due to interference from the endotracheal tube and/or hyoid bone. However, we hypothesized that those problems could possibly be resolved by use of an ultrathin endoscope for ESD of superficial pharyngeal cancer. The aim of this prospective interventional study was to investigate the feasibility of ESD for superficial pharyngeal cancer using an ultrathin endoscope. Patients and methods  This feasibility study was conducted at NTT Medical Center Tokyo between June 2020 and September 2021, and data from a total of 20 consecutively superficial pharyngeal cancers were analyzed. The primary outcome measure was the R0 resection rate. The ESD completion rate, en bloc resection rate, procedure time, and frequency of intraoperative and postoperative adverse events (AEs) were also evaluated as secondary outcome measures. Results  Data from 16 patients with 20 lesions were included in the analysis. All of the lesions were successfully resected by ultrathin endoscope ESD, and the en bloc and R0 resection rates were 100 % and 85.0 % (17/20), respectively; the procedure time was 37.8 ± 28.2 minutes. No intraoperative or postoperative AEs were encountered in any cases. Conclusions  ESD using an ultrathin endoscope is feasible for superficial pharyngeal cancers and has potential to be a safe and effective treatment option for these cancers.

Endoscopic Laryngopharyngeal Surgery Combined with Endoscopic Submucosal Dissection as a Treatment Option for Superficial Hypopharyngeal Cancer with Suspected Synchronous Lymph Node Metastasis

We report 4 cases of hypopharyngeal cancer preoperatively suspected with synchronous lymph node metastases. Pathologic lymph node metastasis was confirmed in three of the four cases. All 4 cases underwent endoscopic laryngopharyngeal surgery (ELPS) combined with endoscopic submucosal dissection (ESD) and subsequent lymph node dissection as an optional treatment rather than the standard treatment. Peroral resection for primary site was selected because of the expected decline in quality of life (QoL) after radical surgery. Among 4 patients, one developed local recurrence; however, the other three remained recurrence-free and survived without any additional treatment. Furthermore, the patient who developed local recurrence had a recurrence-free survival for more than 5 years, with additional chemoradiation therapy. No disorders in speech, swallowing, or breathing was observed during the follow-up period. ELPS combined with ESD is generally indicated for laryngopharyngeal cancer without synchronous lymph node metastasis. However, this can be a treatment option for patients may wish to preserve a greater QoL after treatment. In the future, when more data on the results and long-term prognosis of this treatment are accumulated, it may be possible to discuss its validity further.

Effect of anesthesia assistance on the detection rate of precancerous lesions and early esophageal squamous cell cancer in esophagogastroduodenoscopy screening: A retrospective study based on propensity score matching

Background

Esophagogastroduodenoscopy (EGD) screening is vital for the early diagnosis of esophageal squamous cell cancer (ESCC). However, improvement in the detection rate of precancerous lesions and early ESCC with anesthesia assistance (AA) has not yet been investigated. This retrospective study aimed to evaluate the effect of AA on the detection rate of precancerous lesions and early ESCC in patients undergoing EGD screening and identify risk factors affecting the detection rate.

Methods

We reviewed patients' electronic medical records who underwent EGD screening between May 2019 and August 2020. Patients were divided into two groups based on whether they received AA: those in Group A underwent EGD screening with AA, and patients in Group O underwent EGD screening without AA. Propensity score matching (PSM) was used to account for differences in baseline characteristics. Detection rates of precancerous lesions and early ESCC were compared between the two groups following PSM. Binary logistic regression was used to identify risk factors affecting the detection rate.

Results

The final analysis included 21,835 patients (Group A = 13,319, Group O = 8,516) from 28,985 patients who underwent EGD screening during the study period. Following PSM, 6009 patients remained in each group for analysis. There was no significant difference in the detection rate of precancerous lesions and early ESCC between Groups A and O (1.1% vs. 0.8%, p > 0.05). Binary logistic regression showed that age (50-59 years, 60-69 years and 70-79 years), higher endoscopist seniority, high-definition (HD) endoscopy, narrow-band imaging (NBI), and number of endoscopic images were all independent risk factors that affected the detection rate of precancerous lesions and early ESCC.

Conclusion

There was no statistically significant difference in the detection rate of precancerous lesions and early ESCC between patients who underwent EGD screening with and without AA. All independent risk factors that affected the detection rate of precancerous lesions and early ESCC included the following: age (50-59 years, 60-69 years and 70-79 years), higher endoscopist seniority, HD endoscopy, NBI, and number of endoscopic images. Endoscopists should consider all these factors as much as possible when performing EGD screening.

A novel intelligent chromo capsule endoscope for the diagnosis of neoplastic lesions in the gastrointestinal tract

Background

Chromoendoscopy has not been fully integrated into capsule endoscopy. This study aimded to develop and validate a novel intelligent chromo capsule endoscope (ICCE).

Methods

The ICCE has two modes: a white-light imaging (WLI) mode and an intelligent chromo imaging (ICI) mode. The performance of the ICCE in observing colors, animal tissues, and early gastrointestinal (GI) neoplastic lesions in humans was evaluated. Images captured by the ICCE were analysed using variance of Laplacian (VoL) values or image contrast evaluation.

Results

For color observation, conventional narrow-band imaging endoscopes and the ICI mode of the ICCE have similar spectral distributions. Compared with the WLI mode, the ICI mode had significantly higher VoL values for animal tissues (2.154 ± 1.044 vs 3.800 ± 1.491, P = 0.003), gastric precancerous lesions and early gastric cancers (2.242 ± 0.162 vs 6.642 ± 0.919, P < 0.001), and colon tumors (3.896 ± 1.430 vs 11.882 ± 7.663, P < 0.001), and significantly higher contrast for differentiating tumor and non-tumor areas (0.069 ± 0.046 vs 0.144 ± 0.076, P = 0.005). More importantly, the sensitivity, specificity, and accuracy of the ICI mode for early GI tumors were 95.83%, 91.67%, and 94.64%, respectively, which were significantly higher than the values of the WLI mode (78.33% [P < 0.001], 77.08% [P = 0.01], and 77.98% [P < 0.001], respectively).

Conclusions

We successfully integrated ICI into the capsule endoscope. The ICCE is an innovative and useful tool for differential diagnosis based on contrast-enhanced images and thus has great potential as a superior diagnostic tool for early GI tumor detection.

Endoscopic Diagnosis of Eosinophilic Esophagitis: Basics and Recent Advances

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated inflammatory disease, characterized by esophageal dysfunction and intense eosinophil infiltration localized in the esophagus. In recent decades, EoE has become a growing concern as a major cause of dysphagia and food impaction in adolescents and adults. EoE is a clinicopathological disease for which the histological demonstration of esophageal eosinophilia is essential for diagnosis. Therefore, the recognition of the characteristic endoscopic features with subsequent biopsy are critical for early definitive diagnosis and treatment, in order to prevent complications. Accumulating reports have revealed that EoE has several non-specific characteristic endoscopic findings, such as rings, furrows, white exudates, stricture/narrowing, edema, and crepe-paper esophagus. These findings were recently unified under the EoE endoscopic reference score (EREFS), which has been widely used as an objective, standard measurement for endoscopic EoE assessment. However, the diagnostic consistency of those findings among endoscopists is still inadequate, leading to underdiagnosis or misdiagnosis. Some endoscopic findings suggestive of EoE, such as multiple polypoid lesions, caterpillar sign, ankylosaurus back sign, and tug sign/pull sign, will aid the diagnosis. In addition, image-enhanced endoscopy represented by narrow band imaging, endocytoscopy, and artificial intelligence are expected to render endoscopic diagnosis more efficient and less invasive. This review focuses on suggestions for endoscopic assessment and biopsy, including recent advances in optical technology which may improve the diagnosis of EoE.

Updates in narrow-band imaging for colorectal polyps: Narrow-band imaging generations, detection, diagnosis, and artificial intelligence

Narrow-band imaging (NBI) is an optical digital enhancement method that allows the observation of vascular and surface structures of colorectal lesions. Its usefulness in the detection and diagnosis of colorectal polyps has been demonstrated in several clinical trials and the diagnostic algorithms have been simplified after the establishment of endoscopic classifications such as the Japan NBI Expert Team classification. However, there were issues including lack of brightness in the earlier models, poor visibility under insufficient bowel preparation, and the incompatibility of magnifying endoscopes in certain endoscopic platforms, which had impeded NBI from becoming standardized globally. Nonetheless, NBI continued its evolution and the newest endoscopic platform launched in 2020 offers significantly brighter and detailed images. Enhanced visualization is expected to improve the detection of polyps while universal compatibility across all scopes including magnifying endoscopy will promote the global standardization of magnifying diagnosis. Therefore, knowledge related to magnifying colonoscopy will become essential as magnification becomes standardly equipped in future models, although the advent of computer-aided diagnosis and detection may greatly assist endoscopists to ensure quality of practice. Given that most endoscopic departments will be using both old and new models, it is important to understand how each generation of endoscopic platforms differ from each other. We reviewed the advances in the endoscopic platforms, artificial intelligence, and evidence related to NBI essential for the next generation of endoscopic practice.