Association of multiple Lugol-voiding lesions with synchronous and metachronous esophageal squamous cell carcinoma in patients with head and neck cancer

Clinicopathological characteristics of abnormal micro-lesions at the oro-hypopharynx detected by a magnifying narrow band imaging system

BACKGROUND

Narrow band imaging (NBI) with magnifying endoscopy (NBI-ME) allows the detection of abnormal micro-lesions smaller than 5 mm in diameter in the oro-hypopharynx that could not be visualized previously. The purpose of the present study was to clarify the clinicopathological characteristics of abnormal micro-lesions of the oro-hypopharynx detected by NBI-ME.

METHODS

Of the 62 lesions detected by NBI-ME, 40 abnormal micro-lesions in 37 patients were removed by endoscopic treatment and were pathologically evaluated. We reviewed the medical records of patients with these lesions and investigated the relationship between NBI-ME findings and pathological findings.

RESULTS

Pathological examination revealed the following: high-grade intraepithelial neoplasia (HGIN) in nine (23%) lesions, low-grade intraepithelial neoplasia (LGIN) in 22 (55%), pharyngitis in seven (18%) and papilloma in two (5%). Two NBI-ME findings, high microvascular density (MVD) and a brownish area (BA), were recognized more frequently as the grade of malignancy advanced. The likelihood ratio (confidential interval) for having HGIN in the patients with both MVD and BA was 13 (3.62-127).

CONCLUSIONS

The pathological diagnosis of abnormal micro-lesions ranged from pharyngitis to HGIN. High MVD and BA may be important findings for grading the malignancy of abnormal micro-lesions.

Concomitantly elevated serum matrix metalloproteinases 3 and 9 can predict survival of synchronous squamous cell carcinoma of the upper aero-digestive tract

Matrix metalloproteinases (MMPs) are elevated in patients with squamous cell carcinoma (SCC) over either the head and neck (HNSCC) or the esophagus (ESCC). Synchronous SCC with both HNSCC and ESCC predispose to worse survival. This study tested if serum MMP levels correlate with clinical features and predict survival for HNSCC, ESCC, and synchronous SCC. One hundred and thirty patients with SCCs in upper aero-digestive tract (70 ESCC, 20 HNSCC, and 40 synchronous SCC) and 74 healthy controls were assessed for serum MMP-3, -7, and -9 titers by enzyme-linked immunosorbent assay. The titers were validated to their correlations to clinical features and survival rates of the different SCC groups. Patients with SCCs had significantly higher serum MMP-3, -7, and -9 titers than the controls (P < 0.001) but there was no difference among the three SCC groups. Based on the optimal MMP cut-off values by ROC curve, elevated MMP-3 and MMP-9, but not MMP-7, correlated with distant metastasis and poor survival (P < 0.05). Concomitantly elevated MMP-3 (>14 ng/mL) and MMP-9 (>329.3 ng/mL) independently correlated with poor two-year survival (P = 0.002, by log rank test). Cox regression confirmed that such concomitant elevation was superior to the tumor stage of either ESCC or HNSCC in predicting survival for synchronous SCC. Serum MMPs are elevated in SCC of the upper aero-digestive tract. Especially for synchronous SCC, concomitantly elevated MMP-3 and MMP-9 levels serve as better biomarkers to predict prognosis than TNM staging of ESCC or HNSCC.

Role of narrow band imaging for diagnosis of early-stage esophagogastric cancer: current consensus of experienced endoscopists in Asia-Pacific region

In Asian countries, squamous cell carcinoma is the most common type of esophageal cancer, and the incidence of gastric cancer remains have plateaued. To synthesize current information and to illustrate its clinical benefit of narrow band imaging (NBI) for diagnosis of superficial esophageal squamous carcinoma (SESCC) and early gastric cancer (EGC), a consensus conference was held by a panel of nine experts from Asian-Pacific countries. The expert's agreement suggested importance of interpretation of both vascular architecture and surface structure of the lesions and proper processor settings for endoscopic images. Zoom endoscopy was not regarded as absolutely necessary for detection of SESCC, but magnifying observation provided valuable information for characterization of detected lesions in the esophagus and the stomach. In general, NBI is useful for detection and characterization of SESCC, whereas it is beneficial mainly for characterization of EGC. Chromoendoscopy was found to be still worthwhile in certain situations, such as determination of the extent of SESCC by Lugol's staining, or detection and delineation of EGC by indigo carmine. NBI could replace chromoendoscopy in routine examination because it is easy to use and adds much information to conventional WLI, but it cannot eliminate chromoendoscopy when we make a final diagnosis for treatment decision-making. Consequently, the benefit of NBI or magnifying NBI is specific for the organ and the purpose of the examination, thus optimum indication and usage should be understood for maximum clinical benefit.

Lugol-voiding lesions are an important risk factor for a second primary squamous cell carcinoma in patients with esosphageal cancer or head and neck cancer

OBJECTIVES

Lugol-voiding lesions (LVLs), detected by chromoendoscopy using iodine dye in patients with esophageal squamous cell carcinoma (EC) or head and neck squamous cell carcinoma (HNC), are associated with a second primary carcinoma in the other organ. We undertook a cross-sectional and retrospective cohort study to assess the risk for second primary carcinomas according to the severity of LVLs, on the basis of their number and size.

METHODS

A total of 1,060 patients with only EC, only HNC, or both EC and HNC (EC+HNC) underwent esophageal endoscopic examination between January 1994 and January 2010. The patients were classified according to the number of LVLs in an endoscopic visual field and the size of the largest LVLs. Factors associated with the second primary EC or HNC were analyzed.

RESULTS

Univariate analysis showed that a larger number and size of LVLs increased the risk for synchronous and early metachronous second primary cancer (P value for trend <0.0001). Multivariate analysis showed that a number of LVLs ≥20 (EC+HNC vs. only HNC, odds ratio (OR)=15.7; EC+HNC vs. only EC, 3.5) and a size ≥10 mm (EC+HNC vs. only HNC, OR=3.1; EC+HNC vs. only EC, 3.2) were independent risk factors for synchronous and early metachronous second primary cancer. A larger number of LVLs was a risk factor for metachronous EC and HNC, and a size ≥10 mm was a risk factor for late metachronous EC.

CONCLUSIONS

The severity of LVLs in patients with HNC or EC closely correlated with a second primary carcinoma in the other organ. Patients with LVLs must be followed closely for development of a second primary carcinoma.

Secondary prevention of esophageal squamous cell carcinoma in areas where smoking, alcohol, and betel quid chewing are prevalent

Esophageal cancer is ranked as the sixth most common cause of cancer death worldwide and has a substantial effect on public health. In contrast to adenocarcinoma arising from Barrett's esophagus in Western countries, the major disease phenotype in the Asia-Pacific region is esophageal squamous cell carcinoma which is attributed to the prevalence of smoking, alcohol, and betel quid chewing. Despite a multidisciplinary approach to treating esophageal cancer, the outcome remains poor. Moreover, field cancerization reveals that esophageal squamous cell carcinoma is closely linked with the development of head and neck cancers that further sub-optimize the treatment of patients. Therefore, preventive strategies are of paramount importance to improve the prognosis of this dismal disease. Since obstacles exist for primary prevention via risk factor elimination, the current rationale for esophageal cancer prevention is to identify high-risk groups at earlier stages of the disease, and encourage them to get a confirmatory diagnosis, prompt treatment, and intensive surveillance for secondary prevention. Novel biomarkers for identifying specific at-risk populations are under extensive investigation. Advances in image-enhanced endoscopy do not just substantially improve our ability to identify small precancerous or cancerous foci, but can also accurately predict their invasiveness. Research input from the basic sciences should be translated into preventive measures in order to decrease the disease burden of esophageal cancer.

Endoscopic submucosal dissection is superior to conventional endoscopic resection as a curative treatment for early squamous cell carcinoma of the esophagus (with video)

BACKGROUND

Endoscopic submucosal dissection (ESD) was originally developed in Japan for en bloc resection of gastric neoplasms.

OBJECTIVE

To clarify whether the novel ESD procedure is feasible and gives results that justify the pursuit of integrated minimally invasive procedures aimed at curing early squamous cell carcinoma of the esophagus (SCCE).

DESIGN

Retrospective cohort study.

SETTING

A single-institution trial by experienced endoscopists.

PATIENTS

This study involved 300 consecutively enrolled patients with SCCE (Tumor, Nodes, Metastasis classification T1, N0) who underwent either EMR (n = 184) or ESD (n = 116) from March 1994 to July 2007.

INTERVENTION

The patients underwent endoscopic resection and then were followed by periodic endoscopy for 8 to 174 months (mean 65 months).

MAIN OUTCOME MEASUREMENTS

Resectability, cure rates, complications, disease-free survival of the two groups, and risk factors for local recurrence were explored.

RESULTS

En bloc resection and the local recurrence rate were significantly better in the ESD group (P = .0009 and .065, respectively). The frequency of perforation was not significantly different between the two groups (P = .68). Four independent risk factors for local recurrence were identified by the Cox regression model: EMR, deep cancer invasion, upper esophagus location, and family history of esophageal cancer. Radical cure is mostly obtained by successful endoscopic retreatment of local recurrence after previous endoscopic resection. Disease-free survival was significantly better with ESD.

LIMITATIONS

The study's retrospective nature prevents definitive conclusions.

CONCLUSIONS

We provide evidence that ESD gives a higher cure rate and is safer than conventional endoscopic resection when applied to early SCCE. ESD warrants prospective comparative studies with conventional endoscopic resection.

Gastric mucosal changes caused by Lugol's iodine solution spray: endoscopic features of 64 cases on screening esophagogastroduodenoscopy

AIM

To clarify the endoscopic mucosal change of the stomach caused by Lugol's iodine solution spray on screening esophagogastroduodenoscopy (EGD).

METHODS

Sixty-four consecutive patients who underwent EGD for esophageal squamous cell carcinoma screening were included in this study. The records for these patients included gastric mucosa findings before and after Lugol's iodine solution was sprayed. The endoscopic findings of the greater curvature of the gastric body were retrospectively analyzed based on the following findings: fold thickening, exudates, ulcers, and hemorrhage.

RESULTS

Mucosal changes occurred after Lugol's solution spray totally in 51 patients (80%). Fold thickening was observed in all 51 patients (80%), and a reticular pattern of white lines was found on the surface of the thickened gastric folds found in 28 of the patients (44%). Exudates were observed in 6 patients (9%).

CONCLUSION

The gastric mucosa could be affected by Lugol's iodine; the most frequent endoscopic finding of this effect is gastric fold thickening, which should not be misdiagnosed as a severe gastric disease.

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

PURPOSE

Most of the esophageal squamous cell carcinomas (ESCCs) and cancers of the head and neck (H&N) region are diagnosed at later stages. To achieve better survival, early detection is necessary. We compared the real-time diagnostic yield of superficial cancer in these regions between conventional white light imaging (WLI) and narrow band imaging (NBI) in high-risk patients.

PATIENTS AND METHODS

In a multicenter, prospective, randomized controlled trial, 320 patients with ESCC were randomly assigned to primary WLI followed by NBI (n = 162) or primary NBI followed by WLI (n = 158) in a back-to-back fashion. The primary aim was to compare the real-time detection rates of superficial cancer in the H&N region and the esophagus between WLI and NBI. The secondary aim was to evaluate the diagnostic accuracy of these techniques.

RESULTS

NBI detected superficial cancer more frequently than did WLI in both the H&N region and the esophagus (100% v 8%, P < .001; 97% v 55%, P < .001, respectively). The sensitivity of NBI for diagnosis of superficial cancer was 100% and 97.2% in the H&N region and the esophagus, respectively. The accuracy of NBI for diagnosis of superficial cancer was 86.7% and 88.9% in these regions, respectively. The sensitivity and accuracy were significantly higher using NBI than WLI in both regions (P < .001 and P = .02 for the H&N region; P < .001 for both measures for the esophagus, respectively).

CONCLUSION

NBI could be the standard examination for the early detection of superficial cancer in the H&N region and the esophagus.

Characteristics of esophageal squamous cell carcinomas and lugol-voiding lesions in patients with head and neck squamous cell carcinoma

BACKGROUND

The relationship between esophageal squamous cell carcinoma (ESCC) and Lugol-voiding lesions (LVLs) in patients with head and neck squamous cell carcinoma (HNSCC) is unclear.

AIM

To investigate the characteristics of ESCC and the relationship between ESCC and LVLs in patients with HNSCC.

METHODS

Between 2003 and 2006, 157 patients with primary HNSCC underwent Lugol chromoendoscopy at the Hiroshima University Hospital, Hiroshima, Japan. Of the patients, 135 were followed up for more than 6 months. We retrospectively analyzed the incidence of synchronous and metachronous ESCC and cumulative proportions of patients without metachronous ESCC with or without multiple LVLs.

RESULTS

Synchronous and metachronous ESCC were detected in 17 of 157 (10.8%) and 9 of 135 (6.7%) patients, respectively. The incidence of synchronous and metachronous ESCC was significantly higher in patients with LVLs compared with the incidence in those without LVLs [13 of 32 (40.6%) vs. 4 of 125 (3.2%), P<0.0001 and 8 of 19 (42.1%) vs. 1 of 116 (0.9%), P<0.0001, respectively]. Cumulative proportions of patients without metachronous ESCC were significantly lower in patients with multiple LVLs compared with that in those without multiple LVLs (P<0.0001).

CONCLUSIONS

Patients who had HNSCC, especially those with multiple LVLs in the esophagus, should be followed with close endoscopic observation with Lugol chromoendoscopy.

Narrow-band imaging endoscopy with magnification is useful for detecting metachronous superficial pharyngeal cancer in patients with esophageal squamous cell carcinoma

BACKGROUND AND AIMS

Head and neck cancers, especially pharyngeal cancers, as well as esophageal cancers frequently coexist either synchronously or metachronously, but most cases of pharyngeal cancer are detected at an advanced stage resulting in poor prognosis. The aim of this study is to evaluate the effectiveness of using narrow-band imaging (NBI) endoscopy with magnification for early detection of pharyngeal cancer on patients following their treatment for esophageal squamous cell carcinoma (SCC).

METHODS

This case series was conducted at the National Cancer Center Hospital in Tokyo between April and October 2005 and included 424 consecutive patients for surveillance endoscopy who had previously undergone chemoradiotherapy (CRT) and/or surgery for esophageal SCC. Observation of the pharyngeal region was randomly conducted on 91 patients using NBI endoscopy with magnification (NBI group) and 333 patients using conventional white light endoscopy (control group).

RESULTS

The detection rate for pharyngeal cancer was significantly higher using NBI endoscopy with magnification (10.9%; 10/91) compared with conventional endoscopy (1.2%; 4/333) (P < 0.0001). In particular, the detection rate in CRT patients was significantly higher in the NBI group (12.9%; 7/54) than the control group (0.5%; 1/191) (P < 0.0001). In addition, diagnostic sensitivity, specificity, accuracy, positive predictive value and negative predictive value for the NBI group were 100% (10/10), 97.5% (79/81), 97.8% (89/91), 83.3% (10/12) and 100% (79/79), respectively.

CONCLUSION

NBI endoscopy with magnification is a promising technique for detecting superficial pharyngeal cancer at an early stage in patients previously treated for esophageal SCC.

Narrow-band imaging provides reliable screening for esophageal malignancy in patients with head and neck cancers

OBJECTIVES

The narrow-band imaging (NBI) system is a novel technology that enhances the visualization of microvasculature and mucosal patterns. The aim of this study was to assess the reliability of the NBI system for esophageal cancer screening in patients with head and neck cancers.

METHODS

A total of 142 patients with head and neck squamous cell carcinoma (SCC) were examined by NBI endoscopy, followed by Lugol chromoendoscopy between April 2006 and June 2008 at the Okayama University Hospital, Okayama, Japan. Detection of SCC and high-grade intraepithelial neoplasia (HGIN) was conducted.

RESULTS

The median age of the patients was 64 years (range: 29-86 years), and approximately three-fourths of all the patients were male. In total, 21 superficial lesions in 16 patients were detected by NBI endoscopy. Of these, 4 lesions were diagnosed histologically as SCC and 11 lesions as HGIN. An additional 22 Lugol-voiding lesions >or=5 mm were detected in 19 patients by Lugol chromoendoscopy. Although 1 of these lesions was diagnosed as HGIN, 21 lesions were diagnosed as low-grade intraepithelial neoplasia or lesions without atypical findings. The sensitivity of NBI endoscopy for detecting esophageal SCC and HGIN was 90.9% (95% confidence interval (CI), 58.7-99.8), specificity was 95.4% (95% CI, 90.3-98.3), and accuracy was 95.1% (95% CI, 90.1-98.0).

CONCLUSIONS

NBI seems to be useful and reliable for screening for esophageal SCC in patients with head and neck cancers.

Long-term outcomes of endoscopic submucosal dissection for superficial esophageal squamous cell neoplasms

BACKGROUND

The long-term outcomes of endoscopic submucosal dissection (ESD) for superficial esophageal squamous cell neoplasms (ESCNs) have not been evaluated to date.

OBJECTIVE

Assess the long-term outcomes of ESD for ESCNs from our consecutive cases.

DESIGN AND SETTING

Retrospective study from a single institution.

PATIENTS AND INTERVENTION

From January 2002 to July 2008, 107 superficial ESCNs in 84 patients were treated by ESD. The enrolled patients were divided into 2 groups based on the lesion with the deepest invasion in each patient: group A, intraepithelial neoplasm or invasive carcinoma limited to the lamina propria mucosa and group B, invasive carcinoma deeper than the lamina propria mucosa.

MAIN OUTCOME MEASUREMENTS

Rates of en bloc resection, complete resection, and complication were evaluated as short-term outcomes. Overall survival, cause-specific survival, and postoperative stricture rates were evaluated as long-term outcomes.

RESULTS

The rates of en bloc resection and complete resection were 100% and 88%, respectively. Perforation accompanied by mediastinal emphysema was observed in 4 (4%) patients. No patient experienced massive bleeding. During the median observation of 632 days (range 8-2358), 15 (18%) patients experienced benign esophageal stricture with dysphagia, which was successfully managed by balloon dilation for a median of 2 sessions (range 1-20). One patient had local recurrence 6 months after ESD. In 2 patients with intramucosal invasive carcinomas in the muscularis mucosa, distant metastases were observed 9 and 18 months after ESD. During the observation period, 3 patients died of esophageal carcinoma. The 5-year cause-specific survival rates of groups A and B were 100% and 85%, respectively.

LIMITATIONS

This was a retrospective study with a relatively short follow-up and a small number of patients from a single institution.

CONCLUSION

This long-term follow-up study revealed that ESD is a potentially curative treatment for superficial ESCNs. There were substantial risks of perforation and stricture that were successfully managed endoscopically.

Treatment results of radiotherapy for carcinoma of the cervical esophagus

The methods and results of treatment for cancer of the cervical esophagus differ from those for cancer of the thoracic esophagus. Our objective was to retrospectively review the outcome for cervical esophageal cancer patients treated with radiotherapy. Twenty-seven patients with carcinoma of the cervical esophagus treated with definitive radiotherapy from 1988 to 2002 were enrolled in the study. Clinical stage (UICC 1997) was stage I in five, II in six, III in 12 and IV in four. Concurrent head and neck malignancy was found in six patients (22%). The mean radiation dose was 66 Gy. Concurrent chemotherapy (cisplatin and 5-fluorouracil) was performed in 23 patients. The actuarial overall survival rates at 1, 3 and 5 years were 55.6%, 37.9% and 37.9%, respectively, with a median survival of 13.9 months. In the patients with stage I, the 3-year and 5-year survival rates were 75% and 75%, respectively. With univariate analysis, only two of the possible prognostic factors were found to actually influence survival: performance status (p < 0.01) and tumor length (p < 0.01). The survival of patients with cervical esophageal cancer remains poor. It is thought that organ preservation is possible by definitive chemoradiation for early cancer.

Prospective study of early detection of pharyngeal superficial carcinoma with the narrowband imaging laryngoscope

BACKGROUND

The newly developed narrowband imaging (NBI) gastrointestinal endoscope makes possible the detection of superficial carcinoma in the oropharynx and hypopharynx, which is difficult with the conventional laryngoscope. Here, we investigated whether the combined use of laryngoscope with NBI allows the detection of superficial carcinoma in this region.

METHODS

A total of 51 superficial, histologically confirmed lesions in 29 patients were studied. The quality of visualization of superficial carcinoma in the oropharynx and hypopharynx using the NBI-equipped laryngoscope was evaluated in comparison with the results by conventional laryngoscopy.

RESULTS

The NBI laryngoscope provided better detection of the irregular microvascular pattern of carcinoma than the conventional laryngoscope (p <.05) and better visualization of the demarcation line (p <.05), and thus significantly better visualization of the lesions.

CONCLUSION

The NBI laryngoscope may play an important role in the diagnosis and treatment of superficial carcinoma in the oropharynx and hypopharynx.

Lugol chromoendoscopy combined with brush cytology in patients at risk for esophageal squamous cell carcinoma

BACKGROUND AND STUDY AIMS

Patients with achalasia or malignancies of the head and neck are at increased risk for esophageal squamous cell carcinoma. The discussion of a screening and surveillance program is controversial. The aim of the present study was to determine the diagnostic potential of Lugol chromoendoscopy combined with brush cytology to diagnose esophageal squamous cell carcinoma and high-grade dysplasia. Secondly, the benefit of additional biomarkers was investigated.

PATIENTS AND METHODS

A total of 61 patients (21 patients with achalasia and 40 patients with malignancies of the head and neck) were included. Chromoendoscopy with 1.2% Lugol iodine solution with targeted biopsies and brush cytology processed by digital image cytometry (DICM) and fluorescence in situ hybridization (FISH) from unstained lesions (USLs) and stained mucosa were performed.

RESULTS

Six of the 61 patients had USLs ≥2 cm. Four patients had high-grade dysplasia (HGD) or carcinoma in situ (CIS). One patient with HGD and one patient with CIS were detected only after Lugol chromoendoscopy. The sensitivity and specificity for detected HGD or CIS in USLs ≥2 cm were 100% and 96.5%. No dysplasia was found in USLs <2 cm. DNA ploidy by DNA cytometry and p53 loss of heterozygosity (LOH) by fluorescence in situ hybridization showed no additional impact on diagnostic accuracy.

CONCLUSIONS

Lugol chromoendoscopy enhances the detection rate of high-risk lesions with dysplasia or carcinoma in situ in large unstained lesions. Biomarkers such as aneuploidy and p53 LOH from brush cytology were not of additional benefit in this setting.

Chromoendoscopy

Chromoendoscopy involves the use of stains or dyes during endoscopy to improve the visualization and characterization of the gastrointestinal mucosa. Its main clinical application is the detection of dysplasia or early cancer of the gastrointestinal tract in individuals with pre-malignant conditions or hereditary and environmental factors that predispose them to cancer. The utility of chromoendoscopy has been mostly studied in squamous cell carcinoma of the esophagus, Barrett's esophagus, gastric cancer, colorectal polyps, and chronic ulcerative colitis. Although chromoendoscopy has been shown to be feasible and safe, several limitations have prevented its widespread use in endoscopy. Despite this, chromoendoscopy remains a useful adjunct to standard white light endoscopy in the visualization of mucosal lesions, which may potentially improve tissue diagnosis and impact patient care.

Transnasal endoscopy with narrow-band imaging and Lugol staining to screen patients with head and neck cancer whose condition limits oral intubation with standard endoscope (with video)

BACKGROUND

Early detection of esophageal cancer in patients with head and neck cancers may alter treatment planning and improve survival. However, standard endoscopic screening is not feasible for some patients with tumor-related airway compromise or postirradiation trismus.

OBJECTIVE

To evaluate a novel, sequential approach by integrating ultrathin endoscopy with narrow-band imaging and Lugol chromoendoscopy.

DESIGN

Cross-sectional study.

SETTING

Single center in Taiwan.

PATIENTS

Forty-four consecutive patients with transoral difficulty screened for synchronous or metachronous esophageal cancer.

MAIN OUTCOME MEASUREMENTS

Sensitivity, specificity, and accuracy in the detection of mucosal high-grade neoplasia or invasive cancer.

RESULTS

Fifty-four endoscopic interpretations were obtained, and 11 mucosal high-grade neoplasia and 7 invasive cancers were confirmed by histology. The mean examination time was 19.4 minutes (range 7.9-35.2 minutes), and all patients tolerated the procedure well. Sensitivity, specificity, and accuracy (with 95% CI) were 55.6% (95% CI, 33.5%-75.6%), 97.2% (95% CI, 85.8%-99.3%), and 83.3% (95% CI, 71.2%-90.9%), respectively, for standard endoscopy; 88.9% (95% CI, 66.9%-96.6%), 97.2% (95% CI, 85.8%-99.3%), and 94.4% (95% CI, 84.9%-97.9%), respectively, with the adjunct of narrow-band imaging; and 88.9% (95% CI, 66.9%-96.6%), 72.2% (95% CI, 55.9%-84.1%), and 77.8% (95% CI, 64.9%-86.8%), respectively, with the adjunct of Lugol chromoendoscopy. When we integrated all interpretations on the basis of the sequential approach, the estimated probability of false-negative findings was 1.2% (95% CI, 0.1%-4.6%).

LIMITATIONS

Inherent shortcomings of ultrathin endoscopy, such as its resolution, light source, and lack of magnification.

CONCLUSIONS

The use of ultrathin endoscopy in a sequential approach for multimodal detection is feasible in patients with transoral difficulty and substantially increases the detection rate of synchronous or metachronous neoplasms.

Quantitative analysis of the color change after iodine staining for diagnosing esophageal high-grade intraepithelial neoplasia and invasive cancer

BACKGROUND

Despite its high sensitivity for detecting esophageal cancer, chromoendoscopy with iodine staining has low specificity and requires many biopsy specimens, which is undesirable. Dramatic color change after iodine staining (initially whitish yellow and then pink 2 to 3 minutes later) has come to be recognized as the pink-color sign in cancerous lesions.

OBJECTIVE

The aim of the present study was to verify the accuracy of the pink-color sign for diagnosing esophageal squamous neoplasms by a quantitative analysis.

DESIGN

A quantitative analysis of endoscopic images was performed by using prospectively pooled data.

SETTING

A cancer referral center.

PATIENTS

From December 2003 to September 2005, consecutive patients who underwent a procedure by an experienced endoscopist and had iodine-unstained lesions measuring 5 to 20 mm in diameter without obvious protrusions or ulcers were prospectively enrolled.

MAIN OUTCOME MEASUREMENTS

The diagnostic ability of the quantitative assessment of the color change at 2 minutes after iodine staining (late phase) was investigated by using a receiver operating characteristic analysis.

RESULTS

A total of 45 iodine-unstained lesions in 32 patients were included in the study. Among these, 22 of 23 pink-color-positive lesions were diagnosed as high-grade intraepithelial neoplasias or invasive cancers, whereas 19 of 22 pink-color-negative lesions were diagnosed as nonneoplastic lesions or low-grade intraepithelial neoplasias. The area under the receiver operating characteristic curve was 0.94, indicating excellent validity of the test. A sensitivity of 88% and specificity of 95% were obtained.

LIMITATIONS

Single-center retrospective analysis.

CONCLUSIONS

We verified the accuracy of the pink-color sign for diagnosing esophageal squamous neoplasms by a quantitative analysis.

Advances in endoscopic imaging of the esophagus

The introduction of flexible fiberoptic endoscopy in the 1960s was a major step forward in the diagnosis and management of various esophageal disorders. Since then, there has been steady progress in the development of novel gastrointestinal endoscopy techniques. Magnification and high-resolution endoscopy, chromoendoscopy, narrow-band imaging, autofluorescence imaging, and confocal laser endomicroscopy are some of the recent advances that have shown promise in the diagnosis of squamous cell carcinoma, gastroesophageal reflux disease, Barrett's esophagus, and adenocarcinoma of the esophagus. The purpose of this review is to summarize the recent advances in endoscopic imaging of the esophagus and their practical application for the gastroenterologist.

Novel imaging modalities in the detection of oesophageal neoplasia

The prognosis of oesophageal neoplasia is dependent on the stage of the disease at the time of detection. Early lesions have an excellent prognosis in contrast to more advanced stages that usually have a dismal prognosis. Therefore, the early detection of these lesions is of the utmost importance. In recent years, several new techniques have been introduced to improve the endoscopic detection of early lesions. The most important improvement, in general, has been the introduction of high-resolution/high-definition endoscopy into daily clinical practice. The value of superimposing techniques such as chromoendoscopy, narrow band imaging and computed virtual chromoendoscopy onto high-resolution/high-definition endoscopy will have to be proven in randomised cross-over trials comparing these techniques with standard techniques. Important future adjuncts to white-light endoscopy serving as 'red-flag' techniques for the detection of early neoplasia may be broad field functional imaging techniques such as video autofluorescence endoscopy. In addition, real-time histopathology during endoscopy has become possible with endocytoscopy and confocal endomicroscopy. The clinical value of these techniques needs to be ascertained in the coming years.

Local recurrence of large squamous-cell carcinoma of the esophagus after endoscopic resection

BACKGROUND

A new technique, endoscopic submucosal dissection (ESD), which uses specially developed endoscopic knives, was recently developed for en bloc resection of large lesions. Despite increasing indications for endoscopic resection (ER), there are limited data available regarding the outcome of ER for lesions 20 mm or more in diameter.

OBJECTIVE

To investigate the risk factors for local recurrence.

DESIGN

Retrospective cohort study.

SETTING

A cancer-referral center.

PATIENTS

Seventy patients, who presented between September 1994 and April 2006, with a total of 78 lesions that measured 20 mm or more in diameter.

MAIN OUTCOME MEASUREMENT

Local recurrence rate after ER was assessed.

RESULTS

At a median follow-up of 32 months (range 12-121 months), there were 12 local recurrences (15.4%). There was no significant association between local recurrence and multiple iodine-voiding lesions, tumor size, or tumor location. The number of resections and the resection method, however, were significantly associated with local recurrence. There was no recurrence of lesions treated by en bloc resection. Lesions resected in 5 or more pieces had a significantly higher recurrence rate than lesions resected in 2 to 4 pieces. Lesions treated by EMR had a significantly higher recurrence rate than lesions treated by ESD.

LIMITATIONS

Single-center retrospective analysis.

CONCLUSIONS

Esophageal squamous-cell carcinoma that measured 20 mm or more in diameter should be resected en bloc by ESD. Lesions treated by resection in 5 or more pieces have a higher risk for local recurrence.

Endoscopic diagnosis of early squamous neoplasia of the esophagus with iodine staining: high-grade intra-epithelial neoplasia turns pink within a few minutes

BACKGROUND AND AIM

The ability to detect early squamous neoplasia of the esophagus can be enhanced considerably by iodine staining during endoscopic examination; however, there has been no study on distinguishing high-grade intra-epithelial squamous neoplasia from low-grade dysplasia by endoscopic examination. We assumed that high-grade intra-epithelial neoplasia could be identified as iodine-unstained areas more distinct and reddish than low-grade dysplasia after the brown color of iodine solution has faded, because there is almost no remaining glycogen-containing epithelium in high-grade intra-epithelial neoplasia.

METHODS

Seventy-nine patients who were found to have demarcated iodine-unstained areas (0.5 cm to 1.5 cm at widest part, 121 lesions in total) were studied. After a target lesion was found, the lesion was observed for about 3 min and its discoloration was evaluated. If a light-pink part appeared in the iodine-unstained area, the lesion was regarded as being positive for pink color. If no light-pink part was observed in the lesion within 3 min, the lesion was regarded as being negative for pink color.

RESULTS

Thirty-four (87.2%) of the 39 lesions diagnosed as pink-color positive were histologically confirmed to be high-grade intra-epithelial squamous neoplasia or squamous cell carcinoma, whereas only three (3.7%) of the 82 lesions diagnosed as negative for pink color were histologically confirmed to be high-grade intra-epithelial squamous neoplasia (P < 0.0001). Using the pink-color sign as a diagnostic index for high-grade intra-epithelial squamous neoplasia and squamous cell carcinoma, sensitivity was 91.9% and specificity was 94.0%.

CONCLUSION

By using the pink-color sign for endoscopic diagnosis, accurate diagnosis without endoscopic biopsy for iodine-unstained areas was possible.

American Gastroenterological Association (AGA) Institute technology assessment on image-enhanced endoscopy

This document presents the official recommendations of the American Gastroenterological Association (AGA) Institute Technology Assessment on "Image-Enhanced Endoscopy." It was approved by the Clinical Practice and Economics Committee on August 3, 2007, and by the AGA Institute Governing Board September 27, 2007.

Potential and present limitation of endocytoscopy in the diagnosis of esophageal squamous-cell carcinoma: a multicenter ex vivo pilot study

BACKGROUND

Endocytoscopy enables the in vivo observation of cellular nuclei in the GI tract. However, potential and present limitations of endocytoscopy have not been elucidated in detail.

OBJECTIVE

To investigate whether endocytoscopic images of cancerous and normal squamous cells in the esophagus correspond with horizontal histology of the mucosal surface.

DESIGN

An ex vivo pilot study.

SETTING

Multiple academic institutions.

MATERIALS

Endoscopically or surgically resected human esophagus obtained between May 2006 and July 2006.

INTERVENTIONS

Endocytoscopic observation was performed on small areas of cancerous lesions and corresponding normal squamous cells. Biopsy specimens were then retrieved from the areas scanned to make horizontal histologic sections.

MAIN OUTCOME MEASUREMENTS

Comparison of the images obtained by endocytoscopy and histology and comparison of the mean numbers of the total nuclei per endocytoscopic image obtained in cancerous and normal areas.

RESULTS

Twenty-seven esophageal squamous-cell carcinomas were acquired and evaluable pairs of an endocytoscopic image and a histological picture were obtained at 12 cancerous and 14 normal areas that showed similar morphologies between them. The mean (+/-SD) numbers of the total nuclei per image were 129+/-14.8 at the normal area and 550+/-66.5 at the cancerous area, respectively, which were significantly different between groups (P<.0001).

LIMITATIONS

Only a comparison of cancerous and normal squamous cells in the esophagus at the ex vivo setting.

CONCLUSIONS

Although endocytoscopic images closely correlated with conventional histology in the esophagus, appropriate preconditioning to constantly obtain sufficient image quality and universal criteria for endocytoscopic diagnosis of various diseases are essential before clinical application.

Early squamous cell carcinoma of the oesophagus: the Japanese viewpoint

In Japan, more than 90% of oesophageal malignancies are squamous cell carcinomas, and superficial and early carcinomas now account for about 40% and 20%, respectively, of all oesophageal carcinomas. Definition of early carcinoma has changed on the basis of new data. As of 2007, early carcinoma is defined as intramucosal carcinoma with or without metastasis. In the subclassification based on depth of cancer invasion, m1 and m2 carcinomas have no metastasis and are considered curable by endoscopic mucosal resection alone, whereas < 10% of m3 carcinomas and about 20% of sm1 carcinomas have lymph node metastasis. The relationship between various pathological findings and the incidence of lymph node metastasis has been reviewed. High-grade squamous dysplasia (squamous cell carcinoma in situ in Japan) requires surgical or endoscopic removal. Very minute carcinomas have recently been detected by magnifying endoscopy and/or narrowband imaging. Endocytoscopy could replace biopsy histopathological examination for diagnosis of oesophageal squamous cell carcinoma, and endocytoscopic diagnosis and endoscopic therapy may be performed simultaneously. As a result of advances in the development of endoscopes, pathologists are now expected to diagnose very minute lesions, < 1 mm in size, in the oesophagus.

[A review of the clinical application of dyes in gastrointestinal chromoendoscopy, and their magistral formulation]

OBJECTIVE

To review the drug compounding of dyes employed in chromoendoscopy, and their clinical effectiveness.

METHOD

A literature search in Medline, Cochrane Library, and Micromedex was carried out with the term chromoendoscopy as a keyword, and the search was then repeated for each dye found in association with the term endoscopy. A number of monographs, scientific journals, and references quoted in selected papers were also reviewed. Papers collected were then classified according to their methodology.

RESULTS

Ninety-six references were found, their original article being recovered for only 57 of these - 13 clinical trials, 21 case series, and 11 reviews. References were found for 7 dyes. Main indications, evidence of effectiveness, administration route, and drug formulation are described for each dye.

CONCLUSIONS

The number of papers involved is high, but their accessibility is limited. Evidence is overall scarce, but high in cases such as methylene blue for Barrett s esophagus, lugol in the detection of esophageal carcinoma, and indigo carmine for colonic hyperplastic polyp differentiation. Drug compounding is rather simple, but scarcely developed.

Laryngoscopic detection of pharyngeal carcinoma in situ with narrowband imaging

OBJECTIVES

Narrowband imaging (NBI) is a novel optical technique that enhances the diagnostic capability of endoscopes in characterizing tissues by using narrow-bandwidth filters in a video endoscope system. The purposes of this study were to verify the effectiveness of the NBI system in conducting endoscopic screening at the oropharynx and the hypopharynx.

METHODS

This study was conducted between July 2005 and August 2005. During this period, 217 consecutive patients with esophageal cancer underwent endoscopic screening of the oropharynx and the hypopharynx with the NBI system at the Department of Otolaryngology, Keiyukai Sapporo Hospital.

RESULTS

Among 217 patients, 6 superficial lesions, at the oropharynx (n = 1) and at the hypopharynx (n = 5), were discovered with the NBI system. On conventional electroendoscopic view, four of six lesions could be hardly recognized because of its small diameter measuring 5 mm or less. The NBI view was more beneficial in recognizing the superficial lesions than conventional electroendoscopic view. Endoscopic mucosal resection was performed for all six patients under general anesthesia in the operation room. The histologic examination exhibited a histologically proven squamous cell carcinoma (SCC) in situ. In our series, the NBI system might improve the sensitivity by about twofold over the conventional method.

CONCLUSION

NBI may play an important role in the diagnosis of SCCs of the oropharynx and hypopharynx.

Endoscopic detection of early upper GI cancers

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

Cribado del carcinoma escamoso de esófago en población de riesgo

Together with adenocarcinoma, epidermoid esophageal carcinoma is the most clinically important neoplasm of the esophagus. Because of the low incidence of epidermoid esophageal carcinoma in the general population, strategies for its early diagnosis are not a priority compared with other neoplasms. However, because survival is low when the disease is diagnosed in symptomatic patients (less than 20% at 5 years), methods for its early diagnosis should be investigated. The use of cytology or Lugol chromoendoscopy in countries with a high incidence of epidermoid carcinoma or in individuals at increased risk (mainly alcoholics and smokers) has allowed early diagnosis and potentially curative treatment, substantially increasing life expectancy in this group of patients. These results should stimulate the evaluation and eventual implementation of programs to achieve early diagnosis and therefore greater survival in patients with epidermoid esophageal carcinoma in Western countries.

p53 immunoexpression: an aid to conventional methods in the screening of precursor lesions of squamous esophageal cancer in patients at high-risk?

INTRODUCTION

Squamous cell carcinoma of the esophagus (SCCE) is diagnosed late and carries a poor prognosis. Lugol chromoendoscopy (LC) has being shown a useful tool in the management of patients at high risk for SCCE. Biomarkers such as p53 protein expression may be present in the esophageal mucosa long before esophageal symptoms or lesions appear and may aid in early diagnosis. This study was carried out to investigate the p53 immunoexpression in esophageal mucosa of smokers and alcohol consumers and study its relationship with different degrees of histological findings and the role of LC to detect areas that express p53.

METHODS

Group 1: One hundred and eighty-two asymptomatic subjects at high risk for SCCE (consumption of more than 80 g of ethanol and 10 cigarettes/day for at least 10 years). Group 2: Twenty healthy volunteers who neither smoked nor consumed alcohol. Both groups underwent upper GI endoscopy plus LC, with biopsies of the esophageal mucosa. Expression of p53 protein was compared to histological findings.

RESULTS

Group 1: There was 25/182 (14%) Lugol's unstained areas. p53 protein was expressed in a stepwise fashion according to the severity of the histological findings: normal mucosa (12/103 or 12%), mild esophagitis (6/43 or 14%), moderate esophagitis (4/18 or 22%), severe esophagitis (1/3 or 33%), low-grade dysplasia (4/11 or 36%), high-grade dysplasia (2/2 or 100%) and squamous cell carcinoma (2/2 or 100%) (p=0.001). Nine in 25 (36%) patients with Lugol's unstained areas and 22/157 (14%) with normal appearing Lugol's stained mucosa expressed p53. Group 2: There was no Lugol unstained areas. The histological analysis and immunohistochemistry for p53 were normal with the exception of two patients that presented mild esophagitis and expressed p53. Unstained areas were 3.5 times (95% CI: 1.2-9.6) more likely to express p53 then stained ones. Alcoholics/smokers were 1.9 (95% CI: 0.4-8) times more likely to express p53 than non-alcoholics/non smokers.

CONCLUSIONS

In this study, we find an association between histological alterations, p53 expression and Lugol's unstained areas. It may point to a higher risk for SCCE. Smokers and alcohol drinkers with normal mucosa or chronic esophagitis that express p53 protein may represent an unrecognized sub-group of individuals that may benefit from surveillance or intervention.

Risk of multiple squamous cell carcinomas both in the esophagus and the head and neck region

While multiple squamous cell carcinomas are often observed in the esophagus and the head and neck region and confound us about the favorable treatments, the reason why some patients are more likely to develop multiple cancers remains obscure. We statistically analyzed clinical factors in 203 patients with newly diagnosed squamous cell carcinoma, to assess the risk of multiple cancers for the establishment of an effective prevention and screening programs. Widespread epithelial oncogenic alterations were assessed as multiple lugol-voiding lesions (multiple LVL) using lugol chromoendoscopy. Genetic polymorphisms of alcohol dehydrogenase type 3 (ADH3) and aldehyde dehydrogenase type 2 (ALDH2) were identified by PCR-restriction fragment length polymorphism analysis. Forty patients had synchronous multiple cancers and the remaining 163 had solitary cancer. Presence of multiple LVL was the only independent risk factor for multiple cancers [relative risk (RR) = 67; 95%CI, 15-310]. Multiple LVL was observed in only smoking drinkers. Among them, a multivariate analysis demonstrated that the ALDH2 deficiency allele (RR = 5.7; 95%CI, 2.8-11.6) and the slow metabolizing ADH3 allele (RR = 1.9; 95%CI, 1.1-7.9) were the independent risk factors for multiple LVL. Combination of these alleles lead to increase the risk of multiple LVL. In conclusion, an episode of multiple LVL is a remarkable high risk for multiple cancers both at the esophagus and the head and neck region. The interaction between drinking and the ALDH2 deficiency allele increases the risk. In addition, the slow metabolizing ADH3 allele enhances the risk. Prohibiting the use of alcohol and early detection of cancer are strongly recommended for such individuals.

Local recurrence of squamous-cell carcinoma of the esophagus after EMR

BACKGROUND

Multicentric squamous dysplasia is frequent in the esophagus and can be visualized by chromoendoscopy (Lugol's solution) as multiple Lugol-voiding lesions (LVLs). Although EMR commonly is used to treat superficial esophageal cancer, new lesions can arise and incomplete resection can result in residual disease. Little is known about the risk factors for local recurrence or the appropriate treatment for recurrent lesions.

METHODS

A total of 116 consecutive patients with a total of 165 esophageal squamous-cell carcinomas were studied retrospectively. Follow-up examination by means of chromoendoscopy (Lugol's solution) and biopsies was performed every 3 months during the first year after EMR and every 6 months thereafter. Lesions were defined as a local recurrence when cancer was detected at the site of the EMR scar. Risk factors associated with local recurrence were investigated by using logistic analysis.

RESULTS

At a median follow-up of 35 months (range 12-110 months), local recurrence was detected for 33 (20%) of 165 lesions. Of the patient-related factors, multivariate logistic analysis showed that multiple LVLs (OR 3.1: 95% CI[1.1, 8.5]; p = 0.03) was an independent risk factor for local recurrence after EMR. The cumulative local recurrence rates at 3 years in patients with multiple LVLs and those without multiple LVLs were 39% and 14% (p < 0.01), respectively. All of the recurrent lesions except two could be removed by EMR, which was not associated with any serious complication. The remaining two patients had chemoradiotherapy. Overall cause-specific survival at 3 years was 100%.

CONCLUSIONS

Patients with multiple LVLs are at risk of local recurrence after EMR. Although careful long-term endoscopic follow-up is needed for such patients, EMR is potentially curative for recurrent lesions.

Chromoendoscopy and magnification endoscopy for diagnosing esophageal cancer and dysplasia

Based on preliminary reports, the use of chromoendoscopy and magnification endoscopy appears to be a valuable adjunct to standard endoscopy for the detection and classification of metaplastic and dysplastic lesions of the esophagus. Ideally, the use of this technique would enable the endoscopist to rule in or out the presence of intestinal metaplasia and dysplastic/cancerous epithelium by obtaining only a minimal number of targeted biopsy specimens--or potentially taking no biopsies at all, which could transform upper endoscopy into a much more effective screening and surveillance tool. There are several problems with the use of chromoendoscopy and magnification endoscopy in the esophagus. This technique is operator-dependent (ie, dependent on the skill and experience of the endoscopist). Studies reporting the accuracy of chromoendoscopy remain mixed, especially for Barrett's esophagus and dysplasia, which is likely explained by differences in techniques and materials used in the investigations. Staining within the esophagus is often patchy and uneven. Poor spraying technique can exaggerate irregular uptake by the mucosa. There is a high false-positive rate when staining gastric-type epithelium or in the setting of inflammation. Areas of dysplasia or cancer might take up stain in an irregular manner or might not stain at all. Magnification only allows the endoscopist to observe small areas of mucosa at a time, increasing the overall difficulty of the procedure and procedure length. Currently, the greatest body of literature exists concerning the use of Lugol's solution for the diagnosis of squamous cell dysplasia/carcinoma of the esophagus and methylene blue for diagnosing Barrett's esophagus. If used consistently by practicing physicians, the accuracy of biopsies could be improved. If endoscopic ablative therapy for high-grade dysplasia and early carcinoma (eg, photodynamic therapy and endoscopic mucosal resection) becomes accepted, sensitive methods of detecting residual metaplastic or dysplastic epithelium after ablation will be needed to help guide additional endoscopic therapy. Chromoendoscopy and magnification endoscopy could prove helpful in this setting. Further research in this field needs to be performed. As a first step, a uniform classification system for staining and magnification patterns should be devised. Future studies could then be performed using consistent terminologies. More controlled investigations with larger numbers of patients must be performed before tissue staining and magnification endoscopy become a part of day-to-day endoscopic practice. Lugol's chromoendoscopy is a simple technique for the detection of synchronous squamous dysplasia and cancer, but a substantial amount of work remains to be performed for the validation of chromoendoscopy for the detection of Barrett's esophagus and dysplasia. The ultimate aim of chromoendoscopy and magnification endoscopy in the esophagus is to show improved outcomes (ie, early detection of cancer and improved survival). These goals have not yet been realized and will require welldesigned studies in the future.

A case of simultaneous primary carcinomas of the tongue

Reports of multiple primary cancers are increasing, but simultaneous primary cancers are not frequently reported especially originated in the same organ. We encountered a 71-year-old female who had two simultaneous carcinomas at both edges of the tongue. Histologically, the carcinoma of the right edge was a well-differentiated squamous cell carcinoma, while that on the left edge was a moderately-differentiated squamous cell carcinoma. No other tumors were detected on other examinations, including gallium-67 scintigraphy, CT scan of the chest, upper gastrointestinal fiberscopy and so on. She underwent surgical treatment without other induction treatments such as radiotherapy and chemotherapy. Her postoperative radiotherapy and chemotherapy were also uneventful because of her age. Fourteen-month follow-up revealed neither recurrence nor metastasis.