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

Pharyngeal observation via transoral endoscopy using a lip cover-type mouthpiece

BACKGROUND AND AIM

Simultaneous and metachronous head and neck cancers are likely to develop in patients with current or previous esophageal cancer. The Valsalva maneuver facilitates the visualization of the hypopharyngeal area during endoscopic observation, but it requires transnasal endoscopy. We developed a novel Valsalva maneuver using transoral endoscopy with a lip cover-type mouthpiece.

METHODS

Between March 2018 and July 2018, 107 patients with current or previous esophageal cancer who were scheduled to undergo upper gastrointestinal endoscopy were included in our pilot study. We performed the Valsalva maneuver using our newly developed mouthpiece and transoral endoscopy in the patients and evaluated the hypopharyngeal region, including the postcricoid area and the posterior wall of the hypopharynx. The outcome measure was procedural success rate, which was graded as "complete," "incomplete," and "none."

RESULTS

Observation of the hypopharyngeal area was "complete" in 81 patients (76%) using the Valsalva maneuver. However, in 25 patients and in 1 patient, observation was "incomplete" and "none," respectively. Seven lesions were newly detected in seven patients during the study period.

CONCLUSIONS

The Valsalva maneuver using transoral endoscopy with a lip cover-type mouthpiece is feasible for the visualization of the postcricoid area and the posterior wall of the hypopharynx. Particularly, this technique would contribute to early detection of head and neck cancers.

Efficacy of Endoscopic Resection and Selective Chemoradiotherapy for Stage I Esophageal Squamous Cell Carcinoma

BACKGROUND & AIMS

Esophagectomy is the standard treatment for stage I esophageal squamous cell carcinoma (ESCC). We conducted a single-arm prospective study to confirm the efficacy and safety of selective chemoradiotherapy (CRT) based on findings from endoscopic resection (ER).

METHODS

We performed a prospective study of patients with T1b (SM1-2) N0M0 thoracic ESCC from December 2006 through July 2012; 176 patients underwent ER. Based on the findings from ER, patients received the following: no additional treatment for patients with pT1a tumors with a negative resection margin and no lymphovascular invasion (group A); prophylactic CRT with 41.4 Gy delivered to locoregional lymph nodes for patients with pT1b tumors with a negative resection margin or pT1a tumors with lymphovascular invasion (group B); or definitive CRT (50.4 Gy) with a 9-Gy boost to the primary site for patients with a positive vertical resection margin (group C). Chemotherapy comprised 5-fluorouracil and cisplatin. The primary end point was 3-year overall survival in group B, and the key secondary end point was 3-year overall survival for all patients. If lower limits of 90% confidence intervals for the primary and key secondary end points exceeded the 80% threshold, the efficacy of combined ER and selective CRT was confirmed.

RESULTS

Based on the results from pathology analysis, 74, 87, and 15 patients were categorized into groups A, B, and C, respectively. The 3-year overall survival rates were 90.7% for group B (90% confidence interval, 84.0%-94.7%) and 92.6% in all patients (90% confidence interval, 88.5%-95.2%).

CONCLUSIONS

In a prospective study of patients with T1b (SM1-2) N0M0 thoracic ESCC, we confirmed the efficacy of the combination of ER and selective CRT. Efficacy is comparable to that of surgery, and the combination of ER and selective CRT should be considered as a minimally invasive treatment option. UMIN-Clinical Trials Registry no.: UMIN000000553.

Clinical benefits from endoscopy screening of esophageal second primary tumor for head and neck cancer patients: Analysis of a hospital-based registry

OBJECTIVES

Esophageal second primary tumors (SPTs) in head and neck cancer (HNC) patients is not uncommon. The impact of image-enhanced endoscopy (IEE) screening for esophageal SPT on the outcome of HNC patients has not been well clarified.

METHODS AND METHODS

Patients with malignancies of the head and neck region and esophagus were recruited from a hospital-based cancer registry between July 2000-December 2016. IEE screening included magnifying endoscopy with narrow-band imaging and chromoendoscopy with Lugol's solution. Biopsied specimens with revised Vienna classification categories 1 and 2 were defined as group I, and those with categories 3 to 5 were defined as group II. The Kaplan-Meier estimate and Cox regression model were used for survival analysis.

RESULTS

Totally 1577 HNC and 501 esophageal cancer patients were enrolled. The 5-year overall survival (OS) rates of stage I/II HNC, stage III/IV HNC and esophageal cancer patients were 58%, 29%, and 8%, respectively (p < 0.01). The 5-year OS rate of HNC patients with negative IEE results was higher than that of HNC patients without IEE screening, followed by IEE screening groups I, II and esophageal cancer patients (44% vs. 39% vs. 35% vs. 11% vs. 8%, respectively, p for trend <0.01). Among advanced HNC patients, those who received IEE screening had a trend of better prognosis than those without screening (5-year OS rate of 31% vs. 28%, p = 0.17).

CONCLUSIONS

IEE screening for esophageal SPTs is helpful in risk stratification and prognosis prediction for HNC patients. Routine IEE screening is recommended in HNC patients.

Artificial intelligence and upper gastrointestinal endoscopy: Current status and future perspective

With recent breakthroughs in artificial intelligence, computer-aided diagnosis (CAD) for upper gastrointestinal endoscopy is gaining increasing attention. Main research focuses in this field include automated identification of dysplasia in Barrett's esophagus and detection of early gastric cancers. By helping endoscopists avoid missing and mischaracterizing neoplastic change in both the esophagus and the stomach, these technologies potentially contribute to solving current limitations of gastroscopy. Currently, optical diagnosis of early-stage dysplasia related to Barrett's esophagus can be precisely achieved only by endoscopists proficient in advanced endoscopic imaging, and the false-negative rate for detecting gastric cancer is approximately 10%. Ideally, these novel technologies should work during real-time gastroscopy to provide on-site decision support for endoscopists regardless of their skill; however, previous studies of these topics remain ex vivo and experimental in design. Therefore, the feasibility, effectiveness, and safety of CAD for upper gastrointestinal endoscopy in clinical practice remain unknown, although a considerable number of pilot studies have been conducted by both engineers and medical doctors with excellent results. This review summarizes current publications relating to CAD for upper gastrointestinal endoscopy from the perspective of endoscopists and aims to indicate what is required for future research and implementation in clinical practice.

Prognostic significance of sarcopenia in patients undergoing esophagectomy for superficial esophageal squamous cell carcinoma

Nononcological prognostic factors in superficial esophageal squamous cell carcinoma (SESCC) patients remain unclear. The aim of this study is to evaluate the relationship between sarcopenia and surgical outcome in patients with SESCC who had undergone definitive surgery. A total of 194 SESCC patients who had undergone thoracic esophagectomy with three-field lymphadenectomy without neoadjuvant therapy at Tokai University Hospital between January 2006 and December 2015 were analyzed retrospectively. Manual tracing using CT imaging was used to measure the cross-sectional areas of the skeletal muscle mass. The cutoff values for the skeletal muscle index used to define sarcopenia were based on the results of a previous study. Twenty-eight patients (14.4%) had sarcopenia, while the remaining 166 patients (85.6%) did not. A multivariate analysis suggested that sarcopenia was an independent risk factor for postoperative pulmonary complications (OR = 3.232, P = 0.026). The overall survival rate and the disease-free survival rate were both significantly worse in the sarcopenia group than in the nonsarcopenia group (P < 0.001). In a multivariate analysis, sarcopenia was an independent prognostic factor affecting overall survival (HR = 7.121, P < 0.001) and disease-free survival (HR = 6.000, P < 0.001). Patients with sarcopenia and lymph node metastasis (n = 18) had a worse outcome than the other patients (P < 0.001). This study suggests that the alleviation of sarcopenia through nutritional support and rehabilitation in SESCC patients scheduled to undergo surgery might help to prevent postoperative pulmonary complications and to improve the long-term outcome.

Prognostic impact of examined lymph node count in pT1N0M0 esophageal cancer: A population-based study

Background

Research on the impact of examined lymph node (ELN) count on node‐negative esophageal cancer (EC) especially pT1N0M0 EC is inadequate. This study was designed to analyze the prognostic impact of ELN count on pT1N0M0 EC.

Methods

Data of resected pT1N0M0 EC patients between 1988 and 2015 were extracted from the United States Surveillance, Epidemiology, and End Results (SEER) database. The association between ELN count and overall survival (OS) or esophageal cancer‐specific survival (ECSS) were investigated. Factors that may predict the outcome were identified using the Kaplan‐Meier method and the Cox proportional‐hazards model.

Results

A total of 906 patients who underwent resection with at least one lymph node (LN) retrieved met our criteria. The cumulative 5‐year OS was 67.6%, while the cumulative 5‐year ECSS was 75.4%. X‐Tile analysis showed that 12 was the optimal cutoff value for ELN count in terms of both OS (χ2 = 28.764, P < 0.0001) and ECSS (χ2 = 15.668, P = 0.0026). A Kaplan‐Meier survival analysis and log‐rank comparison revealed that ELN > 12 was significantly associated with better OS (HR, 0.532; 95% CI, 0.421–0.672; P < 0.001) and ECSS (HR, 0.561; 95% CI, 0.420–0.749; P < 0.001) rates than ELN ≤12. The OS and ECSS benefit of increasing ELN count were also reflected in the multivariate analysis after adjustment for age, sex, race, marital status, location, T stage, tumor size, pathology, and differentiation.

Conclusions

These findings indicated that greater number of ELN count exhibits prognostic significance in pT1N0M0 EC. We recommend more than 12 LNs should be examined in pT1N0M0 EC.

Role of narrow band imaging in the diagnosis of laryngeal lesions: Pilot study from India

INTRODUCTION

Narrow band imaging (NBI) is a new imaging technique developed to improve the diagnostic accuracy of head and neck cancers by depiction of tumor-specific neo-angiogenesis. The purpose of this study was to assess the value of NBI in the diagnosis of laryngeal lesions.

AIM

To assess the sensitivity and specificity of combined white light endoscopy (WLE) and NBI compared with WLE alone in the diagnosis of laryngeal lesions.

SETTINGS AND DESIGN

Prospective study.

MATERIALS AND METHODS

Thirty consecutive patients with various laryngeal lesions scheduled for microlaryngoscopic evaluation underwent WLE followed by NBI. Endoscopic NBI findings were classified into five types (I-V) according to the intraepithelial papillary capillary loop features. Types I-IV are considered benign, whereas type V is considered malignant. The observations were compared with histopathology.

STATISTICAL ANALYSIS

Sensitivity, specificity, and positive and negative predictive values for the diagnosis of malignancy (i.e., invasive carcinoma and carcinoma in situ) by means of NBI with WLE were calculated.

RESULTS

The sensitivity of WLE combined with NBI (100%) was higher than WLE alone (82.6%) in detecting laryngeal cancers. NBI helped in identifying four malignant lesions missed by WLE alone. Two children with respiratory papillomatosis also demonstrated type V pattern, a potential pitfall, leading to an overall positive predictive value of 92% and a negative predictive value of 100%.

CONCLUSION

Combining NBI with WLE increases the sensitivity of detection of laryngeal cancer and its precursor lesions. NBI is also useful in some benign lesions as well as in post-radiotherapy patients.

Failure patterns after adjuvant chemoradiotherapy following endoscopic resection for superficial esophageal squamous cell carcinoma

Background

This study evaluated the locations of lymph node recurrence and their association with irradiation fields used for radiotherapy after adjuvant chemoradiotherapy following endoscopic resection for superficial esophageal squamous cell carcinoma.

Methods

Medical records of 96 consecutive patients with superficial esophageal squamous cell carcinoma who underwent adjuvant chemoradiotherapy following endoscopic resection were reviewed. Computed tomography was used to identify whether nodal recurrences were within the elective nodal irradiation field. The cumulative incidence of recurrence was calculated, accounting for death as a competing risk. Univariate and multivariate analyses identified factors predicting nodal recurrence.

Results

The median follow‐up period was 61 months (range: 6‐137 months). Seven patients (7.3%) developed lymph node recurrence only; two patients (2.1%) developed nodal plus local recurrence. Six of the seven cases without local recurrence involved the elective nodal irradiation field, with five cases involving the recurrent nerve lymph nodes. The 5‐year cumulative incidence of lymph node recurrence was higher for T1b tumors with lymphovascular invasion than for T1a tumors with lymphovascular invasion (17.6% vs 6.2%, P = 0.086; HR: 3.74, 95% CI: 0.80‐17.52, P = 0.094) and T1b tumors without lymphovascular invasion (17.6% vs 3.3%, P = 0.031; HR: 6.78, 95% CI: 0.80‐57.63, P = 0.080).

Conclusions

Lymph node recurrence frequently involved the elective nodal irradiation field, with recurrent nerve lymph nodes being common metastasis sites. The high incidence of nodal recurrence for T1b tumors with lymphovascular invasion highlights a need for new strategies for treating this subset of superficial esophageal squamous cell carcinomas.

Screening for head and neck second primary tumors in patients with esophageal squamous cell cancer: A systematic review and meta-analysis

Background

Esophageal squamous cell carcinomas (ESCCs) are often accompanied by head and neck second primary tumors (HNSPTs). The prognosis of patients with an additional HNSPT is worse compared with patients with only ESCC. Therefore, early detection of HNSPTs may improve the overall outcome of patients with ESCC.

 The purpose of this study was to investigate the yield of endoscopic screening for HNSPTs in patients with primary ESCC.

Methods

We conducted a systematic literature search of all available databases. Studies were included if ESCC patients were endoscopically screened for HNSPT. The primary outcome was the pooled prevalence of HNSPTs.

Results

Twelve studies, all performed in Japan, were included in this systematic review with a total of 6483 patients. The pooled prevalence of HNSPTs was 6.7% (95% confidence interval: 4.9–8.4). The overall heterogeneity was high across the studies (I²= 89.0%, p < 0.001). Most HNSPTs were low stage (85.3%) and located in the hypopharynx (60.3%). The proportion of synchronous (48.2%) and metachronous (51.8%) HNSPTs was comparable.

Conclusion

Based on our results, HNSPT screening could be considered in patients with primary ESCC. All studies were performed in Japan; it is therefore not clear whether this consideration applies to the Western world.

Diagnostic efficacy of dual-focus endoscopy with narrow-band imaging using simplified dyad criteria for superficial esophageal squamous cell carcinoma

BACKGROUND

Our previous studies have shown the diagnostic utility of a newly developed dual-focus endoscope with narrow-band imaging (DF-NBI) and simplified dyad criteria for detection of superficial esophageal squamous cell carcinoma (SESCC). This clinical trial aimed to study the diagnostic efficacy of DF-NBI with dyad criteria for detecting SESCC compared to white light imaging (WLI).

METHODS

This was a single-arm prospective comparative trial. We enrolled 170 consecutive high-risk patients for esophageal squamous cell carcinoma. Patients were initially examined with WLI by one independent endoscopist and then the other performed DF-NBI blinded to the WLI diagnosis to avoid a carry-over effect. Lesions showing proliferation and/or various shapes of intrapapillary capillary loops (IPCL) under DF-NBI (i.e., dyad criteria) were endoscopically diagnosed as SESCC including high-grade intraepithelial neoplasia. The primary endpoint was sensitivity of WLI and DF-NBI for detecting SESCC. The secondary endpoints were the diagnostic performance (i.e., specificity and accuracy) and inter/intra-observer concordance of DF-NBI with dyad criteria.

RESULTS

A total 77 SESCCs were detected. The sensitivity of DF-NBI for SESCC was significantly higher than that of WLI (91% vs. 51%, P < 0.001). The specificity and accuracy of WLI and DF-NBI using dyad criteria were 100% vs. 84%, and 86% vs. 86%, respectively. Various shapes and proliferation of IPCL showed the highest value in inter-observer and intra-observer agreements (κ = 0.77 and 0.82, respectively).

CONCLUSION

DF-NBI combined with dyad criteria may be a promising technique with a high sensitivity for diagnosis of SESCC and high inter/intra-observer agreement.

Histopathologic discrepancies between endoscopic forceps biopsy and endoscopic resection specimens in superficial esophageal squamous neoplasms

BACKGROUND AND AIM

Endoscopic forceps biopsy results that reflect the final pathologic results of an entire lesion are essential for making accurate diagnoses and appropriate therapeutic decisions for patients with superficial esophageal squamous neoplasms (SESNs). This study investigated the histopathologic discrepancies between endoscopic forceps biopsy and endoscopic resection specimens to elucidate the factors contributing to such discrepancies.

METHODS

This retrospective observational study involved 77 patients (84 lesions) who underwent endoscopic resections for SESNs, between January 2005 and August 2017, at the Pusan National University Hospital. The SESNs were classified as low-grade intraepithelial neoplasms (LGINs), high-grade intraepithelial neoplasms (HGINs), or squamous cell carcinomas (SCCs). Following slide reviews, the histopathologic concordance between endoscopic forceps biopsy and endoscopic resection specimens was assessed, in each case.

RESULTS

The histopathologic discrepancy rate between the endoscopic forceps biopsy and endoscopic resection specimens was 34.5% (29/84 lesions). Among the 29 diagnostically discordant lesions, upgrades and downgrades of the histopathologic diagnoses occurred for 27 and 2 lesions, respectively. The predominant discrepancies results in lesion upgrades from HGIN to SCC (n = 21) and from LGIN to SCC (n = 5). The two downgraded cases included one from SCC to HGIN and one from HGIN to LGIN. Multivariate analyses identified two factors that were significantly associated with the histopathologic discrepancies: upper esophageal location (odds ratio, 7.743; 95% confidence interval, 1.031-58.174; P = 0.047) and tumor area per biopsy ≥ 158.6 mm2 /biopsy (odds ratio, 5.933; 95% confidence interval, 1.051-44.483; P = 0.044).

CONCLUSION

Histopathologic discrepancies were observed between endoscopic forceps biopsy and endoscopic resection specimens in patients with SESNs. Tumor location and tumor area/biopsy were both significantly associated with the discrepancies.

Detection of hypopharyngeal cancer (Tis, T1 and T2) by ENT physicians vs gastrointestinal endoscopists

OBJECTIVES

Hypopharyngeal cancer is typically detected at a late stage by ear, nose, and throat (ENT) physicians, when the prognosis is poor. We evaluated how hypopharyngeal cancer (Tis, T1 and T2) were detected by ENT physicians and gastrointestinal endoscopists (GEs) according to the detection reasons.

MATERIALS AND METHODS

A total of 109 consecutive patients with hypopharyngeal cancer (Tis, T1 and T2) who received treatment in our institution from January 2014 to February 2018 was enrolled. The detection detail of hypopharyngeal cancer lesions by ENT physicians and GEs, tumor size and location, and the characteristics of the lesions missed by ENT physicians and GEs were reviewed retrospectively.

RESULTS

Twenty seven and 82 of 109 (24.8% and 75.2%) patients were detected by ENT physicians and GEs, respectively. The most frequent original reasons for ENT physicians and GEs were both pharyngeal discomfort screening and examination of swollen neck lymph nodes (12 of 27, 44.4% for each) and pre-treatment or follow-up screening for esophageal cancer (25 of 82, 30.5%), respectively. Among the 13 cases of upper gastrointestinal tract screening of the head-and-neck cancer other than pharyngeal cancer detected by GEs, 11 (84.6%) were missed by ENT physicians. In contrast, among the 25 cases of pre-treatment screening of the esophageal cancer detected by GEs, 12 (48%) were missed by other GEs just before the consultation from other institutions.

CONCLUSIONS

The percentage of detection of hypopharyngeal cancer (especially, Tis and T1) by ENT physicians is low. A careful examination of the pharynx should be conducted by GEs.

Outcomes of endoscopic submucosal dissection for early oesophageal squamous cell neoplasia at a Western centre

Background and aims

Endoscopic submucosal dissection is the reference treatment for early oesophageal squamous cell carcinoma. However, data from Western centres are scarce.

Methods

We conducted a retrospective study from a prospectively collected database at a tertiary care centre in France. All consecutive patients undergoing endoscopic submucosal dissection for oesophageal squamous cell carcinoma were included. The main outcome was the curative resection rate. Secondary outcomes were en-bloc resection rates, histologically complete resection rates, morbidity, recurrence-free and overall survival.

Results

Fifty-six cases of oesophageal squamous cell carcinoma (49 patients; mean age 61.5 ± 10 years; 36 men) were included. En-bloc, histologically complete and curative resection rates were 98%, 86% and 71%, respectively. Fifteen (30%) patients received an additional treatment after endoscopic submucosal dissection, nine treated by chemoradiotherapy, four by surgery and two by further endoscopic submucosal dissection. Within a mean follow-up of 21 ± 15 months, recurrences occurred in 14 (29%) patients (four local, eight metachronous and three distant recurrences). Eight patients died during follow-up, of which two (4%) patients died from oesophageal squamous cell carcinoma. Factors significantly associated with mortality in this series were: moderate or poor differentiation of oesophageal squamous cell carcinoma (p = 0.02) and recurrence of oesophageal squamous cell carcinoma (p = 0.028).

Conclusion

Moderately or poorly differentiated cancer is a major prognostic factor and should probably be taken into account when indicating an additional treatment after endoscopic submucosal dissection. Close endoscopic follow-up is essential considering the high recurrence rate.

HPV-related oropharyngeal cancer: a review on burden of the disease and opportunities for prevention and early detection

The incidence of oropharyngeal cancer (OPC) related to infection with human papillomavirus (HPV) is rising, making it now the most common HPV-related malignancy in the United States. These tumors present differently than traditional mucosal head and neck cancers, and those affected often lack classic risk factors such as tobacco and alcohol use. Currently, there are no approved approaches for prevention and early detection of disease, thus leading many patients to present with advanced cancers requiring intense surgical or nonsurgical therapies resulting in significant side effects and cost to the health-care system. In this review, we outline the evolving epidemiology of HPV-related OPC. We also summarize the available evidence corresponding to HPV-related OPC prevention, including efficacy and safety of the HPV vaccine in preventing oral HPV infections. Finally, we describe emerging techniques for identifying and screening those who may be at high risk for developing these tumors.

The Characteristics of Blue Laser Imaging and the Application in Diagnosis of Early Digestive Tract Cancer

Background:

The blue laser imaging is a kind of new endoscopic system, sending 2 different wavelengths of laser.

Result:

It can observed that the gastrointestinal mucosa shallow capillaries and mucosal surface microstructure are shown in bright and high resolution images, thus being helpful to the diagnosis of early digestive tract cancer. It has unique advantages compared with the existing technique. This article reviewed the application of blue laser imaging in diagnosis of early gastrointestinal carcinoma.

A clinically translatable hyperspectral endoscopy (HySE) system for imaging the gastrointestinal tract

Hyperspectral imaging (HSI) enables visualisation of morphological and biochemical information, which could improve disease diagnostic accuracy. Unfortunately, the wide range of image distortions that arise during flexible endoscopy in the clinic have made integration of HSI challenging. To address this challenge, we demonstrate a hyperspectral endoscope (HySE) that simultaneously records intrinsically co-registered hyperspectral and standard-of-care white light images, which allows image distortions to be compensated computationally and an accurate hyperspectral data cube to be reconstructed as the endoscope moves in the lumen. Evaluation of HySE performance shows excellent spatial, spectral and temporal resolution and high colour fidelity. Application of HySE enables: quantification of blood oxygenation levels in tissue mimicking phantoms; differentiation of spectral profiles from normal and pathological ex vivo human tissues; and recording of hyperspectral data under freehand motion within an intact ex vivo pig oesophagus model. HySE therefore shows potential for enabling HSI in clinical endoscopy.

New Diagnostic Approach for Esophageal Squamous Cell Neoplasms Using Linked Color Imaging and Blue Laser Imaging Combined with Iodine Staining

A 62-year-old man with a flat early esophageal cancer was referred for endoscopic treatment. White light imaging revealed a pale red lesion, whereas linked color imaging (LCI) and blue laser imaging (BLI) yielded purple and brown images, respectively. Iodine staining demonstrated a large unstained area with a homogenous but very weak pink-color sign. This area appeared more clearly as purple and green on LCI and BLI, respectively; however, a different colored portion was observed at the 4 o’clock position inside the iodineunstained area. Histopathology findings of the resected specimen revealed squamous intraepithelial neoplasia at the 4 o’clock position and an esophageal squamous cell carcinoma in the remaining iodine-unstained area. LCI and BLI combined with iodine staining produce characteristic images that overcomes the pink-color sign, reflecting the histological features of a flat esophageal neoplasm. This new method is useful for detailed evaluation of early flat squamous cell neoplasms.

Current status of esophageal endoscopy including the evaluation of smoking and alcohol consumption in Japan: an analysis based on the Japan endoscopy database

PURPOSE

The aim was to investigate the current status of esophageal endoscopy, including the evaluation of smoking and alcohol consumption, in Japan.

METHODS

A total of 47,441 patients who underwent 69,748 sessions of esophageal endoscopy were registered in the Japan Endoscopy Database between January 2015 and March 2017. The study variables were as follows: (1) methods for monitoring the esophagus and the time required for monitoring and (2) the status of smoking and alcohol consumption in patients with esophageal cancer and head and neck cancer.

RESULTS

Image-enhanced endoscopy was performed in 10.6%, Lugol chromoendoscopy in 4.1%, and magnifying endoscopy in 3.2%. The mean time required for gastrointestinal endoscopy was 10 min 58 s. The mean examination times in patients with or without monitoring of the head and neck were 10 min 51 s and 11 min 13 s, respectively. In 57.0% of the patients with esophageal cancer, the head and neck were monitored at the time of gastrointestinal endoscopy. The proportion of current smokers (esophageal cancer: 16.8-4.7%; head and neck cancer: 24.3-9.3%) and addicted drinkers (esophageal cancer: 52.3-40.8%; head and neck cancer: 50.2-47.3%) were lower at the second or subsequent endoscopy than at the initial endoscopy.

CONCLUSIONS

The new strategy for esophageal endoscopy has led to an evolutionary change in Japan. The patients with esophageal cancer and head and neck cancer who underwent a second or subsequent endoscopy had lower incidences of smoking and alcohol consumption, although the incidences remained high.

Utility of linked color imaging for endoscopic diagnosis of early gastric cancer

BACKGROUND

Linked color imaging (LCI) is a method of endoscopic imaging that emphasizes slight differences in red mucosal color.

AIM

To evaluate LCI in diagnostic endoscopy of early gastric cancer and to compare LCI and pathological findings.

METHODS

Endoscopic images were obtained for 39 patients (43 lesions) with early gastric cancer. Three endoscopists evaluated lesion recognition with white light imaging (WLI) and LCI. Color values in Commission Internationale de l'Eclairage (CIE) 1976 L*a*b* color space were used to calculate the color difference (ΔE) between cancer lesions and non-cancer areas. After endoscopic submucosal dissection, blood vessel density in the surface layer of the gastric epithelium was evaluated pathologically. The identical region of interest was selected for analyses of endoscopic images (WLI and LCI) and pathological analyses.

RESULTS

LCI was superior for lesion recognition (P < 0.0001), and ΔE between cancer and non-cancer areas was significantly greater with LCI than WLI (29.4 vs 18.6, P < 0.0001). Blood vessel density was significantly higher in cancer lesions (5.96% vs 4.15%, P = 0.0004). An a* cut-off of ≥ 24 in CIE 1976 L*a*b* color space identified a cancer lesion using LCI with sensitivity of 76.7%, specificity of 93.0%, and accuracy of 84.9%.

CONCLUSION

LCI is more effective for recognition of early gastric cancer compared to WLI as a result of improved visualization of changes in redness. Surface blood vessel density was significantly higher in cancer lesions, and this result is consistent with LCI image analysis.

Usefulness of narrow band imaging with magnifying endoscopy for the differential diagnosis of cancerous and noncancerous laryngeal lesions

BACKGROUND

We evaluated the accuracy of endoscopic findings observed by narrow band imaging (NBI) combined with magnifying gastrointestinal endoscopy (GIE) for the differential diagnosis of cancerous and noncancerous laryngeal lesions.

METHODS

A total of 166 vocal cord lesions for which good images were obtained on NBI with magnifying GIE were evaluated with respect to the following 6 variables: macroscopic type, tumor location, color, white coat, keratinization, and abnormal microvessels.

RESULTS

Multivariate analysis showed that white coat (odds ratio [OR], 2.95, P = 0.05), keratosis (OR, 3.14, P = 0.02) and abnormal microvessels (OR, 31.1, P < 0.0001) were significantly related to laryngeal cancer. In the diagnosis of laryngeal cancer, the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of abnormal microvessels were 84.4%, 88.6%, 91%, 80.5%, and 86.1%, respectively.

CONCLUSION

The abnormal microvessels on NBI combined with magnifying GIE are useful for the differential diagnosis of laryngeal lesions.

Endoscopic findings corresponding to multiple Lugol-voiding lesions in the esophageal background mucosa

BACKGROUND AND AIM

Multiple Lugol-voiding lesions (LVLs) on Lugol chromoendoscopy can predict the development of metachronous multiple cancers in the esophagus and the head and neck regions. However, Lugol chromoendoscopy sometimes causes adverse events such as chest pain and discomfort. We therefore investigated the endoscopic findings on narrow band imaging (NBI) or blue laser imaging (BLI) that correspond to the presence of multiple LVLs in patients with esophageal squamous cell carcinoma.

METHODS

First, we investigated the NBI/BLI findings corresponding to individual small LVLs (one-to-one correspondence). Second, we investigated the association between the grade of multiple LVLs and the five endoscopic findings, including multiple foci of dilated vessels (MDV), multiple small brownish areas without microvascular irregularity, and a nonuniform color tone.

RESULTS

One-to-one correspondence of endoscopic findings was analyzed in 106 small LVLs. The main findings matched with small LVLs were a focus of dilated vessels (44 lesions), a small brownish area (17 lesions), and a small brownish area with a focus of dilated vessels (19 lesions). The relationship between multiple LVLs and each finding assessed by NBI/BLI was assessed in 155 patients. Multivariate logistic regression indicated that the presence of MDV was the only finding independently associated with multiple LVLs (P < 0.01).

CONCLUSIONS

The presence of MDV in the noncancerous background esophageal mucosa was significantly associated with multiple LVLs. This pilot study demonstrates that MDV has the potential to be a new risk factor for the development of metachronous multiple esophageal squamous cell carcinoma.

An Asian consensus on standards of diagnostic upper endoscopy for neoplasia

BACKGROUND

This is a consensus developed by a group of expert endoscopists aiming to standardise the preparation, process and endoscopic procedural steps for diagnosis of early upper gastrointestinal (GI) cancers.

METHOD

The Delphi method was used to develop consensus statements through identification of clinical questions on diagnostic endoscopy. Three consensus meetings were conducted to consolidate the statements and voting. We conducted a systematic literature search on evidence for each statement. The statements were presented in the second consensus meeting and revised according to comments. The final voting was conducted at the third consensus meeting on the level of evidence and agreement.

RESULTS

Risk stratification should be conducted before endoscopy and high risk endoscopic findings should raise an index of suspicion. The presence of premalignant mucosal changes should be documented and use of sedation is recommended to enhance detection of superficial upper GI neoplasms. The use of antispasmodics and mucolytics enhanced visualisation of the upper GI tract, and systematic endoscopic mapping should be conducted to improve detection. Sufficient examination time and structured training on diagnosis improves detection. Image enhanced endoscopy in addition to white light imaging improves detection of superficial upper GI cancer. Magnifying endoscopy with narrow-band imaging is recommended for characterisation of upper GI superficial neoplasms. Endoscopic characterisation can avoid unnecessary biopsy.

CONCLUSION

This consensus provides guidance for the performance of endoscopic diagnosis and characterisation for early gastric and oesophageal neoplasia based on the evidence. This will enhance the quality of endoscopic diagnosis and improve detection of early upper GI cancers.

Linked color imaging improves the endoscopic visibility of gastric mucosal cancers

Background and study aims  As a newly developed endoscopy technique, linked color imaging (LCI) provides very bright images with enhanced color tones. With the objective of improving the detection rate of gastric mucosal cancers, which are often difficult to detect, we examined the utility of LCI from the viewpoint of visibility. Patients and methods  The current study used 100 consecutive gastric mucosal cancers ≤ 20 mm in diameter. For each lesion, we selected one endoscopic image acquired by white-light imaging (WLI), blue-laser imaging (BLI) -bright, and LCI modes. Four endoscopists interpreted the images; using a previously reported scale, we scored the visibility level on a scale of 1 - 4. Results  The mean (± SD) visibility scores were 2.54 ± 1.10 for WLI, 3.02 ± 1.07 for BLI-bright, and 3.28 ± 0.97 for LCI. The score was significantly higher for BLI-bright compared with WLI ( P  < .001) and again higher for LCI compared with BLI-bright ( P  < .001). For the experts, the scores for BLI-bright and LCI were similar, but both were significantly higher than the score for WLI. For the trainees, there was no significant difference between the WLI and BLI-bright scores, but LCI score was significantly higher than those for WLI and BLI-bright scores. With regard to clinical characteristics, LCI particularly enhanced visibility of normochromic, flat and depressed lesions, which had the lowest visibility scores of all three modalities compared with those of the other lesions. Conclusion  LCI increased visibility and may contribute to early detection of gastric mucosal cancers.

Efficacy of endoscopic treatment on patients with severe dysplasia/carcinoma in situ of esophageal squamous cell carcinoma: A prospective cohort study

Objective

To explore the natural history of severe dysplasia/carcinoma in situ (SD/CIS) patients and to evaluate the efficacy of endoscopic treatment to SD/CIS patients.

Methods

Between January 2005 and December 2009, a population-based prospective screening program on esophageal squamous cell carcinoma (ESCC) was performed in Linzhou, China, with endoscopic screening plus iodine staining. All the eligible histologically confirmed SD/CIS patients were followed up through the door-to-door follow-up and local cancer registry. The endpoint was diagnosed as ESCC or the December 31st, 2016. Kaplan-Meier survival analysis and Log-rank test were used to compare the survival rates among treated and untreated patients.

Results

A total of 175 SD/CIS patients were enrolled and grouped by whether they received endoscopic treatment. Eleven-year cumulative incidence rates for untreated and treated SD/CIS patients were 10.7% [95% confidence interval (95% CI): 6.9−16.1] and 3.2% (95% CI: 1.4−7.0), respectively. The ESCC incidence free survival rate, and all-cause incidence and mortality free survival rates were all significantly higher in the treated patientsvs. untreated patients (P=0.043, P=0.008 and P=0.015, respectively). The ESCC mortality free survival rate showed no significant differences between the two groups (P=0.847).

Conclusions

The cumulative incidence rate of SD/CIS patients to ESCC was much lower than previously reported. The Kaplan-Meier survival analysis showed that endoscopic treatment could increase the ESCC and all-cause disease-free survival rates of SD/CIS patients significantly.

Clinical and translational advances in esophageal squamous cell carcinoma

Esophageal squamous cell carcinoma (ESCC) is among the most deadly forms of human malignancy characterized by late stage diagnosis, metastasis, therapy resistance and frequent recurrence. Clinical management of ESCC remains challenging and the disease presently lacks approved targeted therapeutics. However, emerging data from recent clinical and translational investigations hold great promise for future progress toward improving patient outcomes in this deadly disease. Here, we review current clinical perspectives in ESCC epidemiology, pathophysiology, and clinical care, highlighting recent advances with potential to impact ESCC prevention, diagnosis and management. We further provide an overview of recent translational investigations contributing to our understanding of the molecular mechanisms underlying ESCC development, progression and therapy response, including insights gained from genetic studies and various murine model systems. Finally, we discuss future perspectives in the clinical and translational realms, along with remaining hurdles that must be overcome to eradicate ESCC.

Outcomes of Endoscopic Submucosal Dissection vs Esophagectomy for T1 Esophageal Squamous Cell Carcinoma in a Real-World Cohort

BACKGROUND & AIMS

Esophagectomy is the standard treatment for early-stage esophageal squamous cell carcinoma (EESCC), but patients who undergo this procedure have high morbidity and mortality. Endoscopic submucosal dissection (ESD) is a less-invasive procedure for treatment of EESCC, but is considered risky because this tumor frequently metastasizes to the lymph nodes. We aimed to directly compare outcomes of patients with EESCC treated with ESD vs esophagectomy.

METHODS

We performed a retrospective cohort study of patients with T1a-m2/m3, or T1b EESCCs who underwent ESD (n = 322) or esophagectomy (n = 274) from October 1, 2011 through September 31, 2016 at Zhongshan Hospital in Shanghai, China. The primary outcome was all-cause mortality at the end of follow up (minimum of 6 months). Secondary outcomes included operation time, hospital stay, cost, perioperative mortalities/severe non-fatal adverse events, requirement for adjuvant therapies, and disease-specific mortality and cancer recurrence or metastasis at the end of the follow up period.

RESULTS

Patients who underwent ESD were older (mean 63.5 years vs 62.3 years for patients receiving esophagectomy; P = .006) and a greater proportion was male (80.1% vs 70.4%; P = .006) and had a T1a tumor (74.5% vs 27%; P = .001). A lower proportion of patients who underwent ESD had perioperative mortality (0.3% vs 1.5% of patients receiving esophagectomy; P = .186) and non-fatal severe adverse events (15.2% vs 27.7%; P = .001)-specifically lower proportions of esophageal fistula (0.3% of patients receiving ESD vs 16.4% for patients receiving esophagectomy; P = .001) and pulmonary complications (0.3% vs 3.6%; P = .004). After a median follow-up time of 21 months (range, 6-73 months), there were no significant differences between treatments in all-cause mortality (7.4% for ESD vs 10.9%; P = .209) or rate of cancer recurrence or metastasis (9.1% for ESD vs 8.9%; P = .948). Disease-specific mortality was lower among patients who received ESD (3.4%) vs patients who patients who received esophagectomy (7.4%) (P = .049). In Cox regression analysis, depth of tumor invasion was the only factor associated with all-cause mortality (T1a-m3 or deeper vs T1a-m2: hazard ration, 3.54; P = .04).

CONCLUSION

In a retrospective study of patients with T1am2/m3 or T1b EESCCs treated with ESD (n = 322) or esophagectomy (n = 274), we found lower proportions of patients receiving ESD to have perioperative adverse events or disease specific mortality after a median follow up time of 21 months. We found no difference in overall survival or cancer recurrence or metastasis in patients with T1a or T1b ESCCs treated with ESD vs esophagectomy.

Narrow-Band Imaging: Clinical Application in Gastrointestinal Endoscopy

Narrow-band imaging is an advanced imaging system that applies optic digital methods to enhance endoscopic images and improves visualization of the mucosal surface architecture and microvascular pattern. Narrow-band imaging use has been suggested to be an important adjunctive tool to white-light endoscopy to improve the detection of lesions in the digestive tract. Importantly, it also allows the distinction between benign and malignant lesions, targeting biopsies, prediction of the risk of invasive cancer, delimitation of resection margins, and identification of residual neoplasia in a scar. Thus, in expert hands it is a useful tool that enables the physician to decide on the best treatment (endoscopic or surgical) and management. Current evidence suggests that it should be used routinely for patients at increased risk for digestive neoplastic lesions and could become the standard of care in the near future, at least in referral centers. However, adequate training programs to promote the implementation of narrow-band imaging in daily clinical practice are needed. In this review, we summarize the current scientific evidence on the clinical usefulness of narrow-band imaging in the diagnosis and characterization of digestive tract lesions/cancers and describe the available classification systems.

Linked Color Imaging and Blue Laser Imaging for Upper Gastrointestinal Screening

White light imaging (WLI) may not reveal early upper gastrointestinal cancers. Linked color imaging (LCI) produces bright images in the distant view and is performed for the same screening indications as WLI. LCI and blue laser imaging (BLI) provide excellent visibility of gastric cancers in high color contrast with respect to the surrounding tissue. The characteristic purple and green color of metaplasias on LCI and BLI, respectively, serve to increase the contrast while visualizing gastric cancers regardless of a history of Helicobacter pylori eradication. LCI facilitates color-based recognition of early gastric cancers of all morphological types, including flat lesions or those in an H. pylori-negative normal background mucosa as well as the diagnosis of inflamed mucosae including erosions. LCI reveals changes in mucosal color before the appearance of morphological changes in various gastric lesions. BLI is superior to LCI in the detection of early esophageal cancers and abnormal findings of microstructure and microvasculature in close-up views of upper gastrointestinal cancers. Excellent images can also be obtained with transnasal endoscopy. Using a combination of these modalities allows one to obtain images useful for establishing a diagnosis. It is important to observe esophageal cancers (brown) using BLI and gastric cancers (orange) surrounded by intestinal metaplasia (purple) and duodenal cancers (orange) by LCI.

Differences in upper gastrointestinal neoplasm detection rates based on inspection time and esophagogastroduodenoscopy training

Background and study aims  Esophagogastroduodenoscopy (EGD) has utility in early detection of upper gastrointestinal (UGI) neoplasms. However, previous studies report shorter inspection times and inexperienced endoscopists contribute to overlooking gastric neoplasms. We investigated neoplasm detection rates according to inspection time and extent of EGD training. Patients and methods  In this retrospective observational study, we reviewed routine EGDs for 3,925 consecutive cases between October 2014 and March 2015. We divided the endoscopists into three groups based on median inspection time during EGD without undergoing biopsy. Using cut-off median inspection times of 7 and 10 minutes, three, five, and eight endoscopists were classified into the fast, moderate, and slow groups, respectively. We compared detection rates according to inspection time and the extent of EGD training. Results  The median inspection time among all endoscopists was 9.3 minutes (range, 6.6 - 12.0 min). The detection rate for UGI neoplasms was as follows: fast group, 3.6%; moderate group, 3.3 %; and slow group, 3.1 % ( P  = 0.807). The median inspection time was significantly shorter among the intensive training ≥ 1-year group than among the < 1-year group (< 1-year: median 6.3 min; range 8.2 - 13.9 min, ≥ 1-year: median 8.9 min; range 6.4 - 11.4 min, P  < 0.001). The detection rate for UGI neoplasms was significantly higher among the intensive training ≥ 1-year group than among the < 1-year group (< 1-year: 2.2 %; ≥ 1-year: 3.7 %, OR = 1.65, 95 % CI: 1.02 - 2.68, P  = 0.041). Conclusions  There was no association between inspection times and neoplasm detection rates. The quality of EGD, as measured by neoplasm detection rates, may be improved by ≥ 1-year of intensive training.

Recent Topics and Perspectives on Esophageal Cancer in Japan

Despite recent advances in multidisciplinary treatment strategy, outcomes of esophageal cancer treatment still remain unsatisfactory. There are two histologic subtypes of esophageal cancer, namely, squamous cell carcinoma and adenocarcinoma, and these subtypes turned out to be genetically separate diseases. I focused on nine topics among the cancer's epidemiology, diagnosis, and treatment, and reviewed the literature. Although the number of patients with esophageal cancer has been continuously increasing, the cause of esophageal cancer is evident in a substantial proportion of patients, and public education may be able to decrease its incidence. Early detection and less invasive treatment will improve the outcome of patients. Minimally invasive esophagectomy decreased surgical invasiveness and improved short-term outcomes in the clinical trials. Centralization of patients to high-volume centers and introduction of multidisciplinary perioperative care bundle may further improve the outcome of patients undergoing esophagectomy. Although no targeting agent has shown efficacy in patients with esophageal cancer, immune checkpoint blockades are promising, and the results of phase III trials are awaited.

Narrow Band Imaging-guided resection of oral cavity cancer decreases local recurrence and increases survival

PURPOSE

Overall local recurrence of oral squamous cell carcinoma (OSCC) is estimated at 20%. Incomplete primary tumour excision contributes to localised postsurgical recurrence of OSCC. The purpose of this study was to report on patient outcomes following resection of OSCC using Narrow Band Imaging (NBI).

MATERIALS AND METHODS

Patients with OSCC requiring resection were visualised under conventional white light (WL) then NBI using an Olympus NBI ENF-VQ nasendoscope with CLV-180 light source and processor (Olympus Medical Systems, Tokyo, Japan). OSCC tissue was resected to the NBI-defined surgical margins, and patients followed for a minimum of 5 years postsurgery to assess local recurrence rate (LRR) and disease-free survival (DFS).

RESULTS

Of the 20 patients recruited for this study, one patient (5%) declined follow-up. At the latest follow-up period (up to 7 years postsurgery), 14 of 19 patients (73.68%) were alive with no recurrence. Two patients (10.53%) had died from metastatic disease with no local recurrence, one patient (5.26%) had died from disease with local recurrence, and two patients (10.53%) had died disease-free from other causes. In total, 16 of 19 patients (84.21%) who were followed for a minimum of 5 years were still alive and had not developed local recurrence. Only one patient developed local recurrence. Five-year DFS was 84.21% and LRR was 5.26%.

CONCLUSION

Resection to NBI-defined margins improves survival rates and decreases recurrence rates of OSCC compared to traditional methods and should be adopted as the new gold standard for determining mucosal surgical margins for treatment of oral cavity cancer. These promising results have set the scene for a multicentred randomised controlled trial comparing NBI to WL currently underway.

Utility of narrow band imaging in the diagnosis of middle turbinate head edema

PURPOSE

Middle turbinate head edema has recently been found to have high specificity for diagnosis of inhalant allergy. However, subtle mucosal edema can be difficult to appreciate under white light endoscopy. Narrow band imaging (NBI) has the potential to demonstrate edema by identifying reduced mucosal vascularity and improve sensitivity for the detection of mucosal edema. Narrow band imaging was assessed to determine its utility in objectifying mucosal edema.

MEATERIALS AND METHODS

A cross-sectional diagnostic study was performed on patients with edematous mucosa of the middle turbinate head. Under traditional white light endoscopy, areas of edematous mucosa were identified. Using NBI, these areas were compared to areas of normal mucosa on the middle turbinate head. NBI images of these same areas were then converted to grey scale and a vascularity index was created by pixel analysis and brightness in Fiji Image J software (Wisconsin, US).

RESULTS

Thirty-three middle turbinates were assessed (age 42.4 ± 12.5, 42.4% female). NBI discriminated between areas identified under white light endoscopy as edematous and normal (158.2 ± 48.4 v 96.9 ± 32.7 p < 0.01). Receiver operating curve (ROC) analysis suggested a threshold of 115 brightness units to define endoscopically visible edematous mucosa with sensitivity 70% and specificity 79% (ROC AUC, p = 0.85).

CONCLUSIONS

NBI can differentiate edematous from normal mucosa. The potential for an objective measure of mucosal edema may assist research efforts and may provide a more sensitive tool for subtle mucosal inflammatory changes.

Technical feasibility and oncologic safety of diagnostic endoscopic resection for superficial esophageal cancer

BACKGROUND AND AIMS

Active use of endoscopic resection (ER) for cM3-SM2 esophageal cancer may enable sufficient extent of esophageal resection and help determine the need for lymph node dissection based on histopathologic findings. However, ER preceding esophagectomy may have an adverse impact on outcomes. This study was designed to determine the technical feasibility and oncologic safety of diagnostic ER.

METHODS

A single-institution retrospective cohort study was performed between July 2008 and June 2014. During this period, 135 consecutive patients with clinical T1a-M3N0M0, T1b-SM1N0M0, and T1b-SM2N0M0 primary esophageal cancer were referred to our division. Eight patients who underwent chemoradiotherapy as primary treatment were excluded because of inadequate pathologic findings. Based on oncologic and physical factors, we categorized the remaining 127 patients into 2 groups: primary esophagectomy (n = 54) and primary ER (n = 73).

RESULTS

In all 127 patients, the 3-year overall survival (OS) and disease-free survival (DFS) rates were 95.7% and 87.6%, respectively. No adverse event requiring surgical intervention was observed after ER. Diagnostic ER had no negative impact on surgical outcomes, DFS, and OS after esophagectomy. Fourteen patients (19.2%) of those who received primary ER underwent curative resection, whereas 11 (20.4%) who had pT1a disease, no lymphovascular invasion, and no pathologic lymph node metastasis underwent primary esophagectomy.

CONCLUSIONS

Diagnostic ER for cM3-SM2 esophageal cancer with or without subsequent esophagectomy was feasible and safe, not only from a surgical perspective but also an oncologic perspective. Approximately 20% of cM3-SM2N0M0 patients can potentially avoid undergoing additional treatment including esophagectomy using diagnostic ER.

Laryngeal dysplasia and narrow band imaging: Secondary analysis of published data supports the role in patient follow-up

BACKGROUND

Clinicians have recognised the role of narrow band imaging (NBI) in the management of head and neck cancer in several studies. However, a recent systematic review was unable to pool the data on diagnostic efficacy in this setting owing to the heterogeneity in the published data.

METHODS

Secondary analysis of data, utilising Bayes' theorem, from meta-analyses and randomised trials.

RESULTS

In patients with a histological diagnosis of mild dysplasia who show no abnormalities on NBI, the post-test probability of malignancy is estimated to be 2.3%, compared to 10.3% with conventional white light imaging (WLI). For severe dysplasia, similar post-test probabilities after NBI and WLI are estimated to be 8.0% and 29.7%, respectively. Post-test probabilities in this setting indicate the chance of missing malignancy following a negative NBI or WLI in patients who undergo no further intervention. This study also provides a nomogram designed for use in this setting.

CONCLUSIONS

This study identifies the evidence base for use of NBI in the follow-up for laryngeal dysplasia.

Detection of aberrant crypt foci with image-enhanced endoscopy

Background and study aims  Conventional detection of aberrant crypt foci (ACF) with dye-spraying and magnifying observation is labor- and skill-intensive. We performed a prospective non-inferiority study to investigate the utility of image-enhanced endoscopy (IEE) for detection of ACF. Patients and methods  Patients with a history of colorectal neoplasm were eligible. The number of ACF in the lower rectum was counted first using IEE magnification with narrow-band imaging (NBI) or blue-laser imaging (BLI), and subsequently using the methylene blue method. The primary endpoint was the ACF detection rate with IEE, i. e., the number of ACF detected with IEE relative to the number of ACF detected with methylene blue. The secondary endpoints were bowel preparation time, ACF detection time, and the detection rate with NBI or BLI. Results  A total of 40 patients were enrolled (NBI 20 and BLI 20). The overall detection rate for ACF with IEE was 81.7 % (503/616; 95 %CI 78.8 - 84.6 %), meeting the primary endpoint. The detection rate for ACF with BLI (84.9 %, 258/304) was significantly higher than with NBI (78.5 %, 245/312; P  < 0.05). Both bowel preparation time and ACF detection time were significantly shorter with IEE versus the methylene blue method ( P  < 0.01, respectively). The detection rates for dysplastic and non-dysplastic ACF with IEE were 84.4 % (27/32) and 80.3 % (469/584), respectively. Conclusion  IEE is able to detect ACF during colonoscopy with sensitivity non-inferior to that of the conventional methylene blue method. IEE is simpler than the methylene blue method and is therefore a potentially useful new tool for ACF detection.

Transoral endoscopic examination of head and neck region

Transoral endoscopy with narrow band imaging (NBI) is useful for early detection of head and neck (HN) cancer. However, the lateral and anterior walls of the oropharynx, postcricoid area, and posterior wall of the hypopharynx are difficult to observe using transoral endoscopy. Advanced cancers in these regions may be missed even when NBI is used. This report highlights a method of transoral endoscopic examination of the HN region. For observation of the oral cavity and oropharynx, it is important to observe these regions without using a mouthpiece. Wide opening of the mouth facilitates observation of the oral cavity and oropharynx. Moreover, visibility of the oropharynx, including the anterior wall, is dramatically improved, when the patient positions the tongue forward and says 'aaah.' This technique also facilitates observation of the dorsum of the tongue, which is difficult to observe from a tangential view when using a mouthpiece. To observe the hypopharynx, the Valsalva maneuver is very useful. Patient cooperation is important when observing the HN region thoroughly to gain clear endoscopic views. Narcotic drugs, such as pethidine hydrochloride, are ideal for conscious sedation and reduce the gag reflex while still allowing patient cooperation. From the oral cavity to the hypopharynx, including the lateral and anterior walls of the oropharynx, postcricoid area, and posterior wall of the hypopharynx, most of the HN region can be observed during routine examination using transoral endoscopy without any special devices.

Endoscopic submucosal dissection for superficial esophageal cancer

Endoscopic submucosal dissection (ESD) has evolved into a viable treatment modality for superficial esophageal cancer. ESD offers a distinct advantage given the ability to perform en bloc resection enabling accurate histopathologic assessment. Data from published literature has established ESD as the preferred option in the treatment of superficial squamous cell carcinoma with complete resection rates of 78-100%, and a low rate recurrence of 0-2.6%. En bloc resection for esophageal SCC is curative for tumors with M1 (intrapethelial) or M2 (invasion into the lamina propria) involvement with no lymphovascular invasion. Tumors that contain lymphovascular invasion or submucosal invasion greater than 200 μm should be treated as advanced carcinomas due to the increased risk of lymph node metastasis. In contrast, the role of ESD in Barrett's esophagus is more limited due to the high rate of efficacy of EMR. A randomized control trial comparing EMR and ESD strategies found a higher R0 resection rate for ESD, but no significant difference in complete remission from neoplasia at 3 month follow up. Endoscopic ultrasound (EUS) has a limited role in the evaluation of superficial esophageal cancer. Alternatively, detailed endoscopic assessment along with magnification endoscopy or narrow band imaging, may provide greater utility than EUS. The most common adverse events of ESD in the esophagus include perforation and stricture. Perforation can often be managed by defect closure along with non-operative conservative management. Steroid administration with either topical or local injection can be effective management in stricture prevention. Continued refinement of ESD technique and innovation will overcome some of the current limitations of ESD and enable curative resection of superficial esophageal cancer as an alternative to invasive surgery.

Diagnostic Accuracy of Magnifying Endoscopy with Narrow Band Imaging and Its Diagnostic Value for Invasion Depth Staging in Esophageal Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis

BACKGROUND AND GOALS

This study aimed to investigate the diagnostic accuracy of magnifying endoscopy with narrow band imaging (ME-NBI) and determine its value for invasion depth staging in esophageal squamous cell carcinoma.

METHODS

We searched the PubMed, Embase, and Cochrane Library databases and found relevant studies published up to December 2016. Quality Assessment of Diagnostic Accuracy Studies 2 was used to evaluate the quality of the studies. We calculated sensitivity, specificity, and positive and negative likelihood values from forest plots and determined summary receiver operating characteristic (sROC) curves for ME-NBI diagnostic accuracy analysis.

RESULTS

Ten studies met our criteria and were selected for this meta-analysis. A total of 1,033 patients underwent ME-NBI, and 207 of these patients received a diagnosis of staging mucosal or submucosal invasion. The pooled sensitivity, specificity, and positive and negative likelihood values of ME-NBI for the diagnostic rate were 0.90 (95% CI, 0.71-0.97), 0.90 (95% CI, 0.80-0.95), 6.74 (95% CI, 3.52-712.89), and 0.20 (95% CI, 0.10-0.42), respectively. The area under the curve (AUC) was 0.95 for all studies.

CONCLUSIONS

ME-NBI provides a high diagnostic rate in evaluating the esophagus to diagnose squamous cell carcinoma. In the differentiation for invasion depth staging, ME-NBI was demonstrated to be superior to white light endoscopy and had a similar diagnostic rate compared with HF-EUS. However, HF-EUS had high positive likelihood values for invasion depth staging, suggesting that HF-EUS is a reliable method for confirming invasion depth staging.

Narrow band imaging for risk stratification of glottic cancer within leukoplakia

BACKGROUND

This study investigates relevance of narrow band imaging (NBI) in stratifying risk of malignant transformation within leukoplakia.

METHODS

We conducted a prospective analysis that included 62 patients with 91 changes of leukoplakia on vocal folds. The NBI was obtained before microsurgery. Categorization of the lesion as benign was made when vessels of surrounding epithelium were classified as type I, II, or IV according to Ni classification. If there were visualized intraepithelial papillary capillary loops of type V, the lesion was classified as malignant. Results were compared to the histopathological diagnosis.

RESULTS

The NBI assessment classified 75 lesions (82.4%) as benign and 16 (17.6%) as malignant. Histopathological results revealed the diagnosis of no dysplastic changes or low grade dysplasia in 77 cases (84.6%). Another 14 cases (15.4%) occurred with high-grade dysplasia, carcinoma in situ, and invasive cancer. Sensitivity, specificity, and accuracy of NBI in predicting malignancy within leukoplakia were 100%, 97.4%, and 97.8%, respectively. The kappa index was 0.92 (95% confidence interval 81.1%-100%).

CONCLUSION

The noninvasive procedure of an NBI endoscopy may be recommended as an accurate method in predicting the risk of malignant transformation within the vocal fold leukoplakia and, therefore, would be useful in the clinic for planning the patient's therapy.

A retrospective study of treatment for curative synchronous double primary cancers of the head and neck and the esophagus

OBJECTIVE

Curative synchronous double primary cancers of the head and neck and the esophagus (CSC-HE) are frequently detected, but a standard treatment remains to be established. We studied the clinical course to explore appropriate treatment strategies.

METHODS

We retrospectively studied consecutive 33 patients who had CSC-HE. The disease stage was classified into 4 groups: group A, early head and neck cancer (HNC) and early esophageal cancer (EC); group B, early HNC and advanced EC; group C, advanced HNC and early EC; and group D, advanced HNC and advanced EC. As induction chemotherapy, the patients received 3 courses of TPF therapy (docetaxel 75mg/m² on day 1, cisplatin 75mg/m² on day 1, and 5-fluorouracil 750mg/m² on days 1-5) at 3-week intervals. The clinical courses and treatment outcomes were studied according to the disease stage of CSC-HE.

RESULTS

The disease stage of CSC-HE was group A in 1 patient (3%), group B in 9 patients (27.3%), group C in 3 patients (9.1%), and group D in 20 patients (60.6%). The median follow-up was 26months, and the 2-year overall survival rate was 67.4%. In groups A, B, and C, the 2-year overall survival rate was 83.3%. In group D, the 2-year overall survival rate was 62.6%. Ten of 20 patients in group D received induction chemotherapy with TPF, and 6 patients were alive and disease free at the time of this writing.

CONCLUSION

The treatment outcomes of patients with CSC-HE were relatively good. TPF induction chemotherapy might be an effective treatment for patients with advanced HNC and advanced EC.

Development of Image-enhanced Endoscopy of the Gastrointestinal Tract: A Review of History and Current Evidences

Endoscopy imaging of the gastrointestinal (GI) tract has evolved tremendously over the last few decades. Key milestones in the development of endoscopy imaging include the use of various dyes for chromoendoscopy, the application of optical magnification in endoscopy, the introduction of high-definition image capturing and display technology and the application of altered illuminating light to achieve vascular and surface enhancement. Aims of this review paper are to summarize the development and evolution of modern endoscopy imaging and in particular, imaged-enhanced endoscopy (IEE), to promote appropriate usage, and to guide future development of good endoscopy practice. A search of PubMed database was performed to identify articles related to IEE of the GI tract. Where appropriate, landmark trials and high-quality meta-analyses and systematic reviews were used in the discussion. In this review, the developments and evolutions in endoscopy imaging and in particular, IEE, were summarized into discernible eras and the literature evidence with regard to the strengths and weaknesses in term of their detection and characterization capability in each of these eras were discussed. It is in the authors' opinion that IEE is capable of fairly good detection and accurate characterization of various GI lesions but such benefits may not be readily reaped by those who are new in the field of luminal endoscopy. Exposure and training in making confident diagnoses using these endoscopy imaging technologies are required in tandem with these new developments in order to fully embrace and adopt the benefits.

In-vivo optical imaging in head and neck oncology: basic principles, clinical applications and future directions

Head and neck cancers become a severe threat to human's health nowadays and represent the sixth most common cancer worldwide. Surgery remains the first-line choice for head and neck cancer patients. Limited resectable tissue mass and complicated anatomy structures in the head and neck region put the surgeons in a dilemma between the extensive resection and a better quality of life for the patients. Early diagnosis and treatment of the pre-malignancies, as well as real-time in vivo detection of surgical margins during en bloc resection, could be leveraged to minimize the resection of normal tissues. With the understanding of the head and neck oncology, recent advances in optical hardware and reagents have provided unique opportunities for real-time pre-malignancies and cancer imaging in the clinic or operating room. Optical imaging in the head and neck has been reported using autofluorescence imaging, targeted fluorescence imaging, high-resolution microendoscopy, narrow band imaging and the Raman spectroscopy. In this study, we reviewed the basic theories and clinical applications of optical imaging for the diagnosis and treatment in the field of head and neck oncology with the goal of identifying limitations and facilitating future advancements in the field.

Rapid detection of superficial head and neck squamous cell carcinoma by topically spraying fluorescent probe targeting dipeptidyl peptidase-IV

BACKGROUND

A fluorescent probe glutamylprolyl hydroxymethyl rhodamine green (EP-HMRG), which becomes fluorescent after cleavage by dipeptidyl peptidase-IV (DPP-IV), has been reported to be useful for the detection of esophageal cancer. Thus, we investigated whether head and neck squamous cell carcinoma (HNSCC) can be detected by spraying EP-HMRG.

METHODS

Fluorescence imaging of 17 cases of HNSCCs resected using endoscopic or surgical resection was performed ex vivo after spraying EP-HMRG, and then the fluorescence intensity of the tumors and normal mucosa were measured.

RESULTS

Iodine-voiding lesions became fluorescent within a few minutes after the application of EP-HMRG in 12 resected tumors without a history of radiotherapy but this was not observed in the normal mucosa. Fluorescence intensity in tumor lesions was significantly higher than normal lesions. However, 5 other tumors that developed after radiotherapy did not have sufficient contrast against normal mucosa.

CONCLUSION

Fluorescence imaging with EP-HMRG would be useful for rapid detection of superficial HNSCC without a history of radiotherapy.

Prediction of esophageal stricture in patients given locoregional triamcinolone injections immediately after endoscopic submucosal dissection

BACKGROUND AND AIM

Esophageal endoscopic submucosal dissection (ESD) to resect widespread lesions has increased the incidence of strictures, and some patients develop strictures despite receiving prophylactic locoregional triamcinolone injections. The present study evaluated the predictive factors for esophageal stricture formation in patients given prophylactic triamcinolone injections after ESD.

METHODS

This was a retrospective observational study. Of 552 consecutive patients who underwent ESD, those who received prophylactic triamcinolone injections immediately after ESD were enrolled. Primary outcome was predictive factors for esophageal stricture formation in patients given prophylactic triamcinolone injections.

RESULTS

We evaluated 101 en bloc resections involving 144 lesions in 96 patients. Strictures occurred following 17 (16.8%) resections. Wider circumferential mucosal defect (odds ratio [OR] 2.42, 95% confidence interval [CI]: 1.01-5.80; P = 0.048) was an independent predictive factor for stricture development. Cut-off value associated with stricture formation was five-sixths of the circumferential mucosal defect. Propensity analysis determined that frequency of esophageal strictures increased in patients with circumferential mucosal defects of more than five-sixths compared with those less than five-sixths (OR = 5.70, 95% CI: 1.61-20.18; P = 0.007).

CONCLUSION

Resections involving circumferential mucosal defects of more than five-sixths increased the likelihood of stricture formation in patients given prophylactic locoregional triamcinolone injections after esophageal ESD.

Combined transoral-transhyoid endoscopic approach for hypopharyngeal cancer

Endoscopic transoral surgery for hypopharyngeal cancer is an effective treatment option to avoid invasive open surgery or chemoradiation. Here we describe the case of a 66-year-old patient with cT2N0M0 pyriform sinus cancer whom we treated using a transoral-transhyoid endoscopic approach. Using this approach, a transhyoid route was created in addition to the transoral route and used to extirpate the tumor. En bloc resection of the tumor was completed without difficulty. A combined transoral-transhyoid approach is a useful surgical option for treatment of selected patients with hypopharyngeal cancer. This technique is straightforward to perform and can be used as a backup technique in endoscopic transoral surgery. Also, more complicated lesions can be resected by this approach than by a single-route transoral approach.