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

Clinical backgrounds and outcomes of patients with Barrett's esophageal adenocarcinoma treated via endoscopic submucosal dissection in Kyushu, Japan: A retrospective multicenter cohort study

Objectives

Most esophageal cancers in Japan are squamous cell carcinomas; however, there has been some concern regarding a recent increase in Barrett's esophageal adenocarcinoma (BEA). This study aimed to clarify the clinical characteristics and outcomes of patients treated via endoscopic submucosal dissection (ESD) in Kyushu, including changes over time.

Methods

This multicenter, retrospective, observational study was conducted among 21 institutes situated in Kyushu. Data from patients who underwent ESD for BEA or esophageal squamous cell carcinoma between January 2010 and December 2023 were extracted from the pathology database and reviewed.

Results

The total number of esophageal ESD cases increased from 2299 over the first 7 years to 4009 over the second seven. The incidence of BEA increased from 3.6% (86/2299) over the earlier period to 4.7% (197/4009; p = 0.034) over the latter. We analyzed data from 283 patients (287 lesions). Smaller tumor-sized lesions were detected over the latter period (14.2 ± 11.6 vs. 11.2 ± 9.5 cm2, p = 0.022), significantly reducing treatment times (122.1 ± 81.2 vs. 93.2 ± 53.3 min p < 0.001). The procedure was safe, with low incidence rates, over both the earlier and later periods (respectively), of perforation (0% vs. 1.0%), delayed bleeding (1.2% vs. 2.0%), and pneumonia (4.7% vs. 4.6%).

Conclusion

The proportion of esophageal ESD procedures to treat BEA has increased in Japan's Kyushu region. This procedure has a comparable safety profile to similar ESD procedures used to treat other conditions.

The safety and efficacy of endoscopic submucosal dissection for superficial pharyngeal squamous cell neoplasms: a single-center study in China

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is a mainstream treatment for superficial pharyngeal squamous cell neoplasms (SPSCN) in Japan. There were few reports of it in China, which were small in scale and lack long-term follow-up data. Quality of life (QoL) outcomes of ESD for SPSCN have also not been studied. The aims of this study were to clarify the safety and efficacy of ESD for SPSCN and its outcomes in the Chinese setting.

METHODS

Eighty-four consecutive patients with 145 lesions treated with ESD for SPSCN from January 2014 to August 2022 were enrolled. Their curability, complications, metachronous SPSCN, local recurrence, lymph node metastasis, and overall and disease-specific survival rates were analyzed. The quality of life was measured by MD Anderson Symptom Inventory-Head and Neck (MDASI-HN).

RESULTS

The en-bloc resection rate was 94.5%, and the R0 resection rate was 74.5%. The postoperative adverse event rate was 2.6%. The median follow-up period was 36.28 months. The 3-year rates of metachronous pharyngeal cancer, local recurrence, lymph node metastasis, overall survival, and disease-specific survival were 14.1%, 7.6%, 9.6%, 92.4%, and 98.0%, respectively. The mean symptom composite score and interference score of MDASI-HN were 10.3 and 2.3, respectively.

CONCLUSIONS

In the Chinese setting, pharyngeal ESD achieves curability, safety, and long-term outcomes comparable to those observed in Japan. The postoperative QoL is satisfactory.

Biomarkers for predicting second primary malignancy risk in head and neck squamous cell carcinoma: An integrated molecular perspective

Second primary malignancies (SPMs) threaten long-term survival in head and neck squamous cell carcinoma (HNSCC). Advancing our understanding of the molecular events driving these secondary tumors is essential. This review has explicated molecular drivers of SPM development, including epigenetic alterations such as DNA hypermethylation, genetic polymorphisms affecting detoxification pathways, and shifts in gene and protein expression profiles. Disruptions in the p53 signaling pathway, immune-related pathways, and impairments in glutathione S-transferase-mediated detoxification, emerge as central contributors to SPM risk. Additionally, direct comparisons of tumor specimens with adjacent or distant normal mucosa highlight field cancerization biomarkers, underscoring widespread carcinogen-induced damage. Loss of heterozygosity at chromosome arm 13q, p53 overexpression in tumor-distant epithelia, and proteomic abnormalities in ostensibly healthy mucosa collectively promote a tumor-prone field that encourages the formation of independent secondary tumors. This interplay underscores a multifactorial landscape of SPM pathogenesis, involving genetic susceptibility, environmental exposures, and intricate epigenetic and transcriptomic networks. By recognizing and validating reliable biomarkers, clinicians may pinpoint high-risk patients with greater precision, intervene earlier, and customize follow-up protocols and treatment regimens. Ultimately, translating these insights into routine practice promises a more proactive, individualized approach to preventing SPMs in HNSCC.

Position statement of the World Endoscopy Organization: Role of endoscopy in screening, diagnosis, and treatment of esophageal superficial squamous neoplasiaia

Esophageal squamous cell carcinoma (ESCC) remains a significant global health challenge, being the sixth leading cause of cancer mortality with pronounced geographic variability. The incidence rates range from 125 per 100,000 in northern China to 1-1.5 per 100,000 in the United States, driven by environmental and lifestyle factors such as tobacco and alcohol use, dietary habits, and pollution. Major modifiable risk factors include tobacco and alcohol consumption, with a synergistic risk increase when combined. Nonmodifiable risk factors include previous diagnoses of head and neck squamous cell carcinoma (H&N SCC), achalasia, and prior radiotherapy. Prevention strategies must be tailored to specific regional burdens to efficiently allocate medical and financial resources. Gastrointestinal endoscopy is crucial in reducing ESCC burden through early detection and characterization of neoplastic changes, such as high-grade dysplasia. Early diagnosis significantly improves survival rates, while endoscopic resection of noninvasive dysplasia can prevent ESCC onset, reducing treatment burden for advanced disease. Postresection surveillance can detect high-risk metachronous lesions. Despite these benefits, endoscopic prevention faces challenges, including the lack of high-level evidence supporting its efficacy, opportunity costs, the need for specialized training and techniques, and the requirement for advanced technology investments. This Position Statement from the World Endoscopy Organization (WEO) aims to address these challenges, supplying recommendations for the exploitation of endoscopic resources regarding the possible role of screening, quality, and training for the detection, characterization, resection, and surveillance of ESCC.

Risk factors for pneumonia after endoscopic laryngopharyngeal surgery in cases with prior esophageal cancer treatment

Background and Study Aims

Endoscopic laryngopharyngeal surgery is an effective treatment for superficial laryngopharyngeal cancer, particularly in cases with prior esophageal cancer treatment. Despite its frequent application, reports on the risk factors for postoperative complications are limited. This study aimed to identify the risk factors for pneumonia after endoscopic laryngopharyngeal surgery and to examine the variations in pneumonia incidence among the types of prior esophageal cancer treatment.

Methods

Patients who had a history of esophageal cancer treatment and subsequently underwent endoscopic laryngopharyngeal surgery for superficial pharyngolaryngeal cancer were retrospectively analyzed. We examined the association between postoperative pneumonia and several factors, including number of lesions; diameter of the resected lesion; and type of previous esophageal cancer treatment, such as endoscopic submucosal dissection, chemoradiotherapy, and esophagectomy.

Results

The study included 79 patients who had a mean age of 67.4 years. Postoperative pneumonia occurred in 16.4%. Multivariate analysis showed that the pneumonia incidence significantly increased in cases with multiple lesions (OR 4.794, 95% CI 1.133-20.288, p = 0.033) and larger diameter of the resected lesion (OR 7.047, 95% CI 1.791-27.730, p = 0.005). Importantly, compared with other treatments, prior esophagectomy for esophageal cancer did not increase the pneumonia incidence.

Conclusions

Multiple lesions and larger lesion diameter were the significant predictors of postoperative pneumonia. Moreover, endoscopic laryngopharyngeal surgery can be safely performed even in patients who have previously undergone esophageal cancer surgery, although careful monitoring remains necessary.

Global burden and future trends of head and neck cancer: a deep learning-based analysis (1980-2030)

BACKGROUND

Head and neck cancer (HNC) becomes a vital global health burden. Accurate assessment of the disease burden plays an essential role in setting health priorities and guiding decision-making.

METHODS

This study explores data from the Global Burden of Disease (GBD) 2021 study, involving totally 204 countries during the period from 1980 to 2021. The analysis focuses on age-standardized incidence, mortality, and disability-adjusted life years (DALYs) for HNC. A Transformer-based model, HNCP-T, is used for the prediction of future trends from 2022 to 2030, quantified based on the estimated annual percentage change (EAPC).

RESULTS

The global age-standardized incidence rate (ASIR) for HNC has escalated between 1980 and 2021, with men bearing a higher burden than women. In addition, the burden rises with age and exhibits regional disparities, with the greatest impact on low-to-middle sociodemographic index (SDI) regions. Additionally, the model predicts a continued rise in ASIR (EAPC = 0.22), while the age-standardized death rate (ASDR) is shown to decrease more sharply for women (EAPC = -0.92) than men (EAPC = -0.54). The most rapid increase in ASIR is projected for low-to-middle SDI countries, while ASDR and DALY rates are found to decrease in different degrees across regions.

CONCLUSIONS

The current work offers a detailed analysis of the global burden of HNC based on the GBD 2021 dataset and demonstrates the accuracy of the HNCP-T model in predicting future trends. Significant regional and gender-based differences are found, with incidence rates rising, especially among women and in low-middle SDI regions. Furthermore, the results underscore the value of deep learning models in disease burden prediction, which can outperform traditional methods.

Artificial intelligence-aided optical biopsy improves the diagnosis of esophageal squamous neoplasm

BACKGROUND

Early detection of esophageal squamous neoplasms (ESN) is essential for improving patient prognosis. Optical diagnosis of ESN remains challenging. Probe-based confocal laser endomicroscopy (pCLE) enables accurate in vivo histological observation and optical biopsy of ESN. However, interpretation of pCLE images requires histopathological expertise and extensive training. Artificial intelligence (AI) has been widely applied in digestive endoscopy; however, AI for pCLE diagnosis of ESN has not been reported.

AIM

To develop a pCLE computer-aided diagnostic system for ESN and assess its diagnostic performance and assistant efficiency for nonexpert endoscopists.

METHODS

The intelligent confocal laser endomicroscopy (iCLE) system consists of image recognition (based on inception-ResNet V2), video diagnosis, and quality judgment modules. This system was developed using pCLE images and videos and evaluated through image and prospective video recognition tests. Patients between June 2020 and January 2023 were prospectively enrolled. Expert and non-expert endoscopists and the iCLE independently performed diagnoses for pCLE videos, with histopathology as the gold standard. Thereafter, the non-expert endoscopists performed a second assessment with iCLE assistance.

RESULTS

A total of 25056 images from 2803 patients were selected for iCLE training and validation. Another 2442 images from 226 patients were used for testing. iCLE achieved a high accuracy of 98.3%, sensitivity of 95.3% and specificity of 98.8% for diagnosing ESN images. A total of 2581 patients underwent upper gastrointestinal pCLE examination and were prospectively screened; 54 patients with suspected ESN were enrolled. Overall, 187 videos from 67 lesions were assessed by iCLE, three nonexpert and three expert endoscopists. iCLE achieved a high accuracy, sensitivity and specificity of 90.9%, 92.0%, and 90.2%, respectively. Compared to experts, iCLE showed significantly higher sensitivity (92.0% vs 80.4%; P < 0.001) and negative predictive value (94.4% vs 87.7%; P = 0.003). With iCLE assistance, nonexpert endoscopists showed significant improvements in accuracy (from 83.6% to 88.6%) and sensitivity (from 76.0% to 89.8%).

CONCLUSION

iCLE system demonstrated high diagnostic performance for ESN. It can assist nonexpert endoscopists in improving the diagnostic efficiency of pCLE for ESN and has the potential for reducing unnecessary biopsies.

Impact of preceding treatment for head and neck squamous cell carcinoma on synchronous superficial esophageal squamous cell carcinoma

BACKGROUND

Patients with esophageal squamous cell carcinoma (ESCC) frequently develop synchronous head and neck squamous cell carcinoma (HNSCC). With advances in endoscopic technology and widespread screening of synchronous cancers, the detection of synchronous HNSCC and superficial ESCC (SESCC) is increasing. We aimed to evaluate the impact of preceding HNSCC treatment on synchronous SESCC.

METHODS

This single-center retrospective study enrolled patients with synchronous HNSCC and SESCC who were treated between January 2010 and December 2023. Tumor size and depth of SESCC before and after HNSCC treatment were evaluated. The factors associated with SESCC progression were investigated.

RESULTS

Of the 299 patients with synchronous HNSCC and SESCC, 134 who underwent preceding HNSCC treatment with follow-up esophagogastroduodenoscopy (EGD) for SESCC were evaluated. Chemoradiotherapy was the most common treatment for HNSCC (56.0%), followed by surgery (17.2%), radiotherapy (14.9%), local resection (7.5%), and chemotherapy (4.5%). The tumor size of SESCC increased after HNSCC treatment in 18 patients (13.4%). Multivariate analysis revealed that an EGD interval of ≥ 120 days was significantly associated with increased tumor size in SESCC (odds ratio, 6.64; 95% confidence interval, 1.91-23.1). Tumor regrowth was observed in 70.6% of SESCCs that shrank with HNSCC treatment, mostly within six months. Tumor depth aggravation was rare (2.2%), but progression to advanced ESCC was observed in two patients.

CONCLUSIONS

Timely endoscopic follow-up, preferably within 120 days, is crucial for managing synchronous SESCC after HNSCC treatment to prevent tumor progression. Tumor regrowth should be monitored when SESCC shrinks with HNSCC treatment.

Impact of HPV status on oropharyngeal cancer detection via gastrointestinal endoscopy: a retrospective study

BACKGROUND

Gastrointestinal endoscopy (GIE) performed by gastroenterologists is essential for the early detection of pharyngeal cancer. Human papillomavirus (HPV) is a significant cause of oropharyngeal squamous cell carcinoma (OPSCC). However, the prevalence of HPV-related OPSCC detected by GIE remains unclear.

AIM

This study aims to evaluate the differences in detection rates, patient characteristics, and treatment approaches between HPV-positive and HPV-negative OPSCCs, with a focus on the role of GIE in early diagnosis.

METHODS

We retrospectively analyzed 207 OPSCCs from 2018 to 2022, where HPV infection was diagnosed by p16 immunohistochemistry. We compared detection modalities and evaluated the proportion of lesions detected by GIE in both p16-positive and p16-negative cases.

RESULTS

Out of the 207 patients, 92 (44.4%) were p16-positive. p16-positive cases had significantly lower rates of alcohol use, smoking, and history of esophageal or head/neck squamous cell carcinoma (all p < 0.001). Only 4.3% of p16-positive cases were detected by GIE, compared to 44.3% of p16-negative cases (p < 0.001). In addition, p16-positive patients were often diagnosed at advanced stages and underwent transoral resection less frequently (2.2% vs. 31.3%, p < 0.001). In cT1 cases, GIE and laryngoscopy revealed that p16-positive lesions were typically protruding and white to normal-colored, while p16-negative lesions were predominantly flat and erythematous.

CONCLUSIONS

HPV-related OPSCC cases are rarely detected by GIE, and few cases are treated with minimally invasive transoral resection. These findings highlight the need for enhanced detection strategies for HPV-positive OPSCC.

Development of Deep Learning-Based Virtual Lugol Chromoendoscopy for Superficial Esophageal Squamous Cell Carcinoma

BACKGROUND

Lugol chromoendoscopy has been shown to increase the sensitivity of detection of esophageal squamous cell carcinoma (ESCC). We aimed to develop a deep learning-based virtual lugol chromoendoscopy (V-LCE) method.

METHODS

We developed still V-LCE images for superficial ESCC using a cycle-consistent generative adversarial network (CycleGAN). Six endoscopists graded the detection and margins of ESCCs using white-light endoscopy (WLE), real lugol chromoendoscopy (R-LCE), and V-LCE on a five-point scale ranging from 1 (poor) to 5 (excellent). We also calculated and compared the color differences between cancerous and non-cancerous areas using WLE, R-LCE, and V-LCE.

RESULTS

Scores for the detection and margins were significantly higher with R-LCE than V-LCE (detection, 4.7 vs. 3.8, respectively; p < 0.001; margins, 4.3 vs. 3.0, respectively; p < 0.001). There were nonsignificant trends towards higher scores with V-LCE than WLE (detection, 3.8 vs. 3.3, respectively; p = 0.089; margins, 3.0 vs. 2.7, respectively; p = 0.130). Color differences were significantly greater with V-LCE than WLE (p < 0.001) and with R-LCE than V-LCE (p < 0.001) (39.6 with R-LCE, 29.6 with V-LCE, and 18.3 with WLE).

CONCLUSIONS

Our V-LCE has a middle performance between R-LCE and WLE in terms of lesion detection, margin, and color difference. It suggests that V-LCE potentially improves the endoscopic diagnosis of superficial ESCC.

Current status and perspectives of esophageal cancer: a comprehensive review

Esophageal cancer (EC) continues to be a significant global health concern, with two main subtypes: esophageal squamous cell carcinoma and esophageal adenocarcinoma. Prevention and changes in etiology, improvements in early detection, and refinements in the treatment have led to remarkable progress in the outcomes of EC patients in the past two decades. This seminar provides an in-depth analysis of advances in the epidemiology, disease biology, screening, diagnosis, and treatment landscape of esophageal cancer, focusing on the ongoing debate surrounding multimodality therapy. Despite significant advancements, EC remains a deadly disease, underscoring the need for continued research into early detection methods, understanding the molecular mechanisms, and developing effective treatments.

[Thinking out of the tube: endoscopic findings in oral cavity, pharynx and larynx during flexible esophagogastroduodenoscopy]

During a flexible esophagogastroduodenoscopy (EGD), the oral cavity and significant regions of the pharynx (oropharynx, hypopharynx), as well as the larynx, can usually be examined with a high resolution. Numerous benign and malignant findings of considerable clinical relevance can occur in this region of the digestive tract, which can be inspected during a gastroscopy and treated subsequently. Remarkably, head and neck tumors represent a heterogeneous group of malignant diseases and account for ca. 4 % of cancers diagnosed in men in Germany.This review presents benign and malignant findings assessed during routine endoscopy in the oral cavity, pharynx and larynx discussing them in the context of an extensive literature review.Common benign and malignant findings in the oral cavity, oropharynx, hypopharynx and larynx are easy to diagnose visually with a reasonable amount of additional time and histological confirmation is possible in selected cases. We describe a proposal for a structured examination procedure.Careful routine inspection of the oral cavity, oropharynx, hypopharynx and larynx during gastroscopy can reveal pathological findings and diagnose them at an early stage, especially in people at risk, but also in the general population.

Utilizing Narrow Band Imaging for Early Detection of Recurrence in Follow-Up Patients with Head and Neck Squamous Cell Carcinoma Treated with Curative Intent Using Radiotherapy/Chemo-Radiotherapy: Enhancing Detection and Patient Outcomes

Head and Neck squamous cell carcinoma (HNSCC) is one of the most common cancer in developing countries. Most of the patients present with advanced disease and requires rigorous treatment. Routine follow up of the patient is required to detect any recurrence which will substantially affect overall survival of the patient. Narrow Band Imaging is one of the advanced endoscopic modalities which can be used for assessment of the patients during follow-up along with White light examination (WLE) and WB PETCT. An observational study to determine the efficacy and diagnostic accuracy of NBI in early detection of recurrence in follow-up patients with HNSCC was conducted comparing it with WLE, WB-PETCT and HPE. 60 patients who received definitive radiotherapy /Chemoradiotherapy (RT/CRT) for HNSCC were followed up for a period of 12 months with WLE, NBI, WB PETCT and was compared with HPE. NBI demonstrated higher sensitivity (95.45%) and specificity (97.37%) compared to WLE, which had sensitivity and specificity of 77.27% and 92.11%, respectively. NBI also had superior diagnostic accuracy (96.67%) versus white light (86.67%).WB-PETCT had sensitivity of 95.45% and specificity of 92.11% with a diagnostic accuracy of 93.33% for detecting local recurrences. NBI is a more sensitive and accurate tool for detecting early recurrences in HNSCC post RT/CRT, improving patient outcomes through timely intervention. Proper training and standardized interpretation protocols are essential for maximizing its clinical utility.

Laryngeal Carcinoma Characteristics Associated with Positive Margins and Endoscopic Understaging

Background/Objectives: The study aims to analyse the factors associated with positive margins and endoscopic understaging in laryngeal carcinoma. It also aims to assess the diagnostic accuracy of Narrow Band Imaging (NBI) in comparison to White Light Endoscopy (WLE) and other diagnostic methods. Methods: In this retrospective comparative cohort analysis, 206 patients who underwent endoscopic laser surgery for T1 and T2a glottic squamous cell carcinoma between 1 January 2016 and 30 April 2023 were included. The data were collected from endoscopy, CT, histopathology, and NBI images. Statistical analysis was performed and associations between variables were analysed using binary logistic regression and receiver operating characteristic analysis. Results: The types of cordectomy performed included type III (51 patients), type IV (40 patients), and type VI (23 patients). Positive margins were found in 14.01% of patients, with significant correlations observed between positive margins and bilateral laryngeal carcinoma, right-sided laryngeal carcinoma, higher clinical and histopathologic T categories, and higher NBI grade. Endoscopic understaging versus histopathologic T category correlated with various factors, including cordectomy type, tumour size, and clinical T category. The NBI findings correlated with positive margins but did not correlate with endoscopic understaging. Conclusions: The study highlights several clinical and pathological factors associated with positive margins and endoscopic understaging in laryngeal carcinoma. NBI demonstrated high diagnostic accuracy, correlating with histopathological results and serving as an independent predictive factor for positive margins. Recognizing these factors is crucial for improving preoperative assessments, refining treatment strategies, and enhancing patient care.

Characteristics of multiple esophageal squamous cell carcinomas detected in the surveillance after endoscopic resection

BACKGROUND AND STUDY AIM

Endoscopic resection (ER) of esophageal squamous cell carcinoma (ESCC) is an organ-preserving treatment; however, heterochronic carcinomas are often encountered. Most patients are treated using ER; however, for some, this is inadequate and requires additional treatment. We sought to identify the characteristics and frequency of lesions at high risk of metastasis during surveillance based on Lugol-voiding lesion (LVL) grading and esophagogastroduodenoscopy (EGD) intervals.

METHODS

Of the 1301 patients who underwent ER, 956 underwent surveillance EGD at our hospital for at least 1 year (median, 59 months). We analyzed identified multiple ESCCs to reveal the characteristic of high-metastasis-risk lesions, which was defined ESCC with submucosal or lymphovascular invasion.

RESULTS

In the 956 patients, 444 multiple ESCCs were identified in 216 patients and the cumulative incidence of multiple ESCCs was 15.4% and 22.9% at 3 and 5 years, respectively, while for high-risk lesions, it was 1.0% and 1.8%. The risk factors for high-metastasis-risk lesions were being female (odds ratio (OR):5.58, 95% confidence interval (CI):1.96-15.9), lesions located in the cervical/upper thoracic esophagus (OR: 4.81, 95% CI:1.80-12.8), and the presence of submucosal tumor (SMT)-like marginal elevation (OR:65.4, 95% CI:11.0-390). No significant differences in the frequency of high-risk lesions were found based on LVL grade at any EGD intervals.

CONCLUSION

During endoscopic surveillance, attention should be given to the cervical/upper thoracic esophagus and lesions with SMT-like marginal elevation. The frequency of high-metastasis-risk lesions was not different by LVL grade or EGD intervals.

Evaluating the discrepancies between evidence-based and community standard practices in the endoscopic diagnosis of esophageal squamous cell carcinoma: a survey study

BACKGROUND

The practice of endoscopic diagnosis of esophageal squamous cell carcinoma (ESCC) often diverges from evidence-based standards due to various factors, including inadequate dissemination of evidence or a mismatch between evidence and real-world contexts. This survey aimed to identify discrepancies between evidence-based standard practices and community standard practices for ESCC among endoscopists.

METHODS

An online survey targeting endoscopists who perform upper gastrointestinal endoscopy at least weekly was conducted to collect data on clinical practices related to ESCC diagnosis. The survey, comprising 20 questions, was disseminated through multiple professional networks. Descriptive statistical analysis and logistic regression were performed to analyze the data.

RESULTS

Data from 819 endoscopists were included in the analyses. Notably, a significant proportion employed narrow-band imaging/blue-laser imaging over iodine staining, and preferences varied based on risk assessment for ESCC. In total, 64.0% of endoscopists primarily used iodine solution at a concentration of 1% or less, while 96.5% of endoscopists performed an observation of the oral cavity and the pharynx when conducting upper gastrointestinal endoscopies on individuals at high risk of ESCC. The surveillance interval for metachronous multiple ESCCs was most commonly every 6 months, followed by every 12 months. In addition, most physicians conducted surveillance of metastatic recurrence at 6-month intervals.

CONCLUSIONS

This survey highlights significant gaps between evidence-based and community standard practices in the endoscopic diagnosis of ESCC. These findings underscore the need for enhanced dissemination of evidence-based guidelines and consideration of real-world clinical contexts to bridge these gaps and optimize patient care.

Prospects for Narrow Band Imaging Magnification Endoscopy in Oral Lesions: Recommendations from Oral and Maxillofacial Surgeons and a Gastroenterologist

Narrow band imaging (NBI) magnification endoscopy for the diagnosis of early-stage oral cavity-related cancer and precancerous lesions can recognize oral lesions as brownish areas, and can observe intraepithelial papillary capillary loops (IPCLs) in the mucosa and submucosa to make a qualitative diagnosis of the lesion and highlight the mucosal surface microstructure to facilitate appropriate diagnosis and early treatment. IPCLs are classified from Type 0 to IV: Type 0 is normal mucosa or no blood vessels observed, e.g., in keratinization; Type I is mainly normal mucosa; Type II is mainly inflammatory sites or non-malignant lesions; Type III is mainly precancerous or suspected malignant lesions; and Type IV is cancerous or malignant lesions. NBI magnification endoscopy is a useful noninvasive method for identifying the malignant transformation of oral potentially malignant disorders (OPMDs). Oral lesions classified as IPCL Type II or higher are atypical epithelial or oral squamous cell carcinoma (OSCC); oral biopsy is recommended for early and accurate diagnosis, and is an indicator of the appropriate biopsy site in the follow-up for OPMDs. In the future, the accuracy of NBI magnification endoscopy for malignant transformation of OPMDs and OSCC will be further confirmed.

Current Status and Future Directions of Research on Artificial Intelligence in Nasopharyngolaryngoscopy

BACKGROUND

The nasopharyngolaryngoscopy (NPL) has emerged as a valuable tool for detecting early cases of head and neck cancers. However, misdiagnoses and missed diagnoses are still common phenomena. The expertise of examining physicians often serves as the primary limiting factor, leading to issues such as incomplete visualization, imprecise identification, and unclear vision. Over recent years, the application of artificial intelligence (AI) in medical imaging, particularly in the realm of gastrointestinal endoscopy, has instigated revolutionary changes in site quality control, lesion identification, and report generation. However, there remains a lack of standardized guidelines for the proper application of NPL across various countries.

SUMMARY

In this paper, we set our sights on reviewing the current clinical applications and summarizing the primary shortcomings of NPL. In addition, we encapsulate the progress of AI application within gastrointestinal endoscopy and NPL. Drawing from real-world clinical practice, we propose future directions and prospects for AI research in NPL. We firmly believe that the pace of clinical application of AI in NPL will accelerate significantly in the near future.

KEY MESSAGES

Incomplete examination coverage, failure to detect and diagnose lesions, and poor image quality happens in the current use of NPL. Currently, NPL examinations lack third-party supervision and quality control. AI application has achieved great advancements in gastrointestinal endoscopy concerning endoscopic quality control, lesion identification, and standardized reporting. While AI-related research in NPL is still in its nascent stages, it shows substantial potential for clinical application and endoscopic training. The interaction of AI into NPL examinations is potential and inevitable in the era of big data.

Feasibility of endoscopic resection for superficial laryngopharyngeal cancer after radiotherapy

BACKGROUND AND AIM

We aimed to elucidate the feasibility of endoscopic resection (ER) for salvage and metachronous lesions following chemoradiotherapy (CRT) and radiotherapy (RT) for laryngopharyngeal cancer.

METHODS

Consecutive patients who underwent ER for superficial laryngopharyngeal cancer between March 2005 and September 2022 were retrospectively reviewed and stratified into salvage (16 patients, 16 lesions), metachronous (18 patients, 27 lesions), and naïve RT (217 patients, 306 lesions) groups. Salvage lesions were residual or local recurrent after CRT, and metachronous lesions were second primary lesions in the irradiated field following complete response. Short-term outcomes were evaluated, including R0 resection, en bloc resection, procedure time, adverse events, local recurrence rate, and clinical course.

RESULTS

The en bloc resection rates were 88%, 93%, and 88%; R0 resection rates were 50%, 52%, and 56%; procedure times were 25, 27, and 25 min, in the salvage, metachronous, and naïve RT groups, none of which were significantly different among the three groups. Although adverse event rates tended to be higher in the salvage and metachronous groups than in the naïve RT group, the differences were not significant (18%, 15%, and 8%). The cumulative local recurrence rates at 2 years were 21%, 13%, and 6%, significantly higher in the salvage group than in the naïve RT group. The local control rates with ER alone were 94%, 93%, and 97%; none were significantly different among the three groups.

CONCLUSION

ER for salvage and metachronous superficial lesions can be safely performed, suggesting its acceptability as a minimally invasive treatment.

Advanced Esophageal Endoscopy

Recent advancements in endoscopy, including high-definition imaging, virtual chromoendoscopy, and optical magnification, have enhanced our ability to visualize and diagnose certain esophageal diseases. Innovative endoscopic tools and procedures have been developed to broaden the scope of therapeutic options for treating patients with various esophageal conditions. This comprehensive review aims to elucidate the esophageal anatomy and major disorders from an endoscopist's perspective and explore recent advances in endoscopic treatment.

Risk of stricture after endoscopic submucosal dissection in the cervical esophagus and efficacy of local steroid injection for stricture prevention (with video)

BACKGROUND AND AIMS

There is a high incidence of stricture after endoscopic submucosal dissection (ESD) for cervical esophageal cancer. We aimed to elucidate the risk factors for stricture and to evaluate the efficacy of steroid injection for stricture prevention in the cervical esophagus.

METHODS

We retrospectively analyzed 100 patients who underwent ESD for cervical esophageal cancer to (1) identify the factors associated with stricture among patients who did not receive steroid injection, and (2) compare the incidence of stricture between patients with and without steroid injection.

RESULTS

Among 48 patients who did not receive steroid injection, there were significant differences in tumor size (P = .026), resection time (P = .028), and circumferential extent of the mucosal defect (P = .005) between patients with stricture (n = 5) and without stricture (n = 43). Compared with patients without steroid injection, patients with steroid injection had a significantly lower incidence of stricture when the post-ESD mucosal defect was <3/4 and ≥1/2 (40% versus 8%; P = .039). For the patients with a post-ESD mucosal defect of ≥3/4 (n = 13), local steroid injection was performed for all of them, and 6 (46%) developed stricture.

CONCLUSIONS

Patients who underwent ≥1/2 circumferential resection were at high risk of cervical esophageal stricture. Steroid injection had a stricture prevention effect in patients with <3/4 and ≥1/2 circumferential resection, but seemed to be insufficient in preventing stricture in patients with ≥3/4 circumferential resection.

Characteristics of Esophageal Squamous Cell Carcinomas Based on Circumferential Localization

BACKGROUND AND AIM

In terms of their longitudinal positioning, esophageal squamous cell carcinoma (ESCC) commonly arises in the middle segment of the esophagus. However, limited attention has been given to the circumferential aspect. This study aimed to investigate the prevalence and characteristics of ESCC lesions resected via endoscopic submucosal dissection (ESD), taking into consideration both longitudinal and circumferential positions.

METHODS

We retrospectively evaluated 193 ESD-resected ESCC lesions and compared the occurrence rate of ESCC development and the degree of histopathological invasion across various circumferential and longitudinal positions. We scrutinized lesion characteristics by location, with a particular focus on the proportion of early-stage small lesions in each site.

RESULTS

Regarding lesion location, 27 were situated on the anterior wall, 62 on the left, 66 on the posterior, and 38 on the right. Among the four circumferential positions, the anterior wall group had the smallest median tumor size. Additionally, the anterior wall group had the highest proportions of lesions with invasion depths limited to the epithelial layer and sizes < 10 mm, at 44.4% and 25.9%, respectively. Furthermore, a significant difference was noted among the four circumferential positions with respect to the proportion of ESCC lesions satisfying both criteria, with the highest proportion observed in the anterior wall group (p = 0.049).

CONCLUSIONS

Our findings suggest that while ESCC occurrence on the anterior wall is less frequent, these lesions may present as small lesions with superficial invasion depths.

Is blue light imaging without magnification satisfactory as screening for esophageal squamous cell carcinoma? Post-hoc analysis of multicenter randomized controlled trial

OBJECTIVES

Narrow light observation is currently recommended as an alternative to Lugol chromoendoscopy (LCE) to detect esophageal squamous cell carcinoma (ESCC). Studies revealed little difference in sensitivity between the two modalities in expert settings; however, these included small numbers of cases. We aimed to determine whether blue light imaging (BLI) without magnification is satisfactory for preventing misses of ESCC.

METHODS

This was a post-hoc analysis of a multicenter randomized controlled trial targeting patients at high risk of ESCC in expert settings. In this study, BLI without magnification followed by LCE was performed. The evaluation parameters included: (i) the diagnostic abilities of ESCC; (ii) the endoscopic characteristics of lesions with diagnostic differences between the two modalities; and (iii) the color difference between cancerous and noncancerous areas in BLI and LCE.

RESULTS

This study identified ESCC in 49 of 699 cases. Of these cases, nine (18.4%) were missed by BLI but detected by LCE. In per-patient analysis, the sensitivity of BLI was lower than that of LCE following BLI (83.7% vs. 100.0%; P = 0.013), whereas the specificity and accuracy of BLI were higher (88.2% vs. 81.2%; P < 0.001 and 87.8% vs. 82.5%; P < 0.001, respectively). No significant endoscopic characteristics were identified, but the color difference was lower in BLI than in LCE (21.4 vs. 25.1; P = 0.003).

CONCLUSION

LCE following BLI outperformed BLI in terms of sensitivity in patients with high-risk ESCC. Therefore, LCE, in addition to BLI, would still be required in screening esophagogastroduodenoscopy even by expert endoscopists.

Correlation of Narrow Band Imaging Patterns with Histopathology Reports in Head and Neck Lesions

Introduction

Head and neck malignancies are associated with poor prognosis and poor quality-of-life if detected late. Narrow-Band-Imaging(NBI) is one of the important tools, which helps in detecting these lesions earlier. By using narrow-wavelength(400-550 nm) it enhances the mucosal and submucosal vascularity against the pale mucosal background which helps us detecting benign, pre-malignant and malignant lesions.

Objective

The objective of this study was to evaluate the accuracy of NBI in the diagnosis of various mucosal lesions of head and neck region and its correlation with the histopathology reports.

Materials and Methods

This was a prospective diagnostic study conducted between June 2020 - June 2022 where 118 patients(oral cavity-28, laryngeal-87,and hypopharyngeal-3) who fulfilled the inclusion and exclusion criteria were recruited. All-118-patients underwent NBI endoscopy under local/general anaesthesia followed by biopsies from the most suspicious-areas. Type of vascular-pattern noted from NBI and their respective histopathological reports were correlated.

Results

The mean age was 53.28 ± 1.24 years ranging from 16 to 88 years. The sensitivity, specificity, Positive-Predictive-Value(PPV) and Negative-Predictive-Value(NPV) in detecting benign lesions were 100%, 90%, 74% and 100% respectively. The sensitivity, specificity, PPV and NPV in detecting premalignant lesions were 70%, 92%, 56% and 96% respectively. The sensitivity, specificity, PPV and NPV in detecting malignant lesions were 83%,97.5%, 98.5% and 97.5% respectively. NBI has a strong association with the histopathological reports, which is statistically significant(p-value < 0.001).

Conclusion

NBI has high specificity and negative predictive value in detecting and classifying various mucosal lesions of head-neck region. Its findings had a strong correlation with histopathological reports.

Surveillance for metachronous cancers after endoscopic resection of esophageal squamous cell carcinoma

The literature pertaining to surveillance following treatment for esophageal squamous cell carcinoma (SCC) was reviewed and summarized, encompassing the current status and future perspectives. Analysis of the standardized mortality and incidence ratios for these cancers indicates an elevated risk of cancer in the oral cavity, pharynx, larynx, and lungs among patients with esophageal SCC compared to the general population. To enhance the efficacy of surveillance for these metachronous cancers, risk stratification is needed. Various factors, including multiple Lugol-voiding lesions, multiple foci of dilated vascular areas, young age, and high mean corpuscular volume, have been identified as predictors of metachronous SCCs. Current practice involves stratifying the risk of metachronous esophageal and head/neck SCCs based on the presence of multiple Lugol-voiding lesions. Endoscopic surveillance, scheduled 6-12 months post-endoscopic resection, has demonstrated effectiveness, with over 90% of metachronous esophageal SCCs treatable through minimally invasive modalities. Narrow-band imaging emerges as the preferred surveillance method for esophageal and head/neck SCC based on comparative studies of various imaging techniques. Innovative approaches, such as artificial intelligence-assisted detection systems and radiofrequency ablation of high-risk background mucosa, may improve outcomes in patients following endoscopic resection.

Prospective multicenter trial of the cryoballoon ablation system for superficial esophageal squamous cell carcinoma on post-endoscopic resection scars: a CRYO-SCAR study (EPOC1902)

BACKGROUND AND AIMS

Endoscopic resection is a minimally invasive treatment for superficial esophageal squamous cell carcinoma (SESCC). Post-endoscopic resection scars complicate en-bloc resection, even with advanced techniques, such as endoscopic submucosal dissection. The cryoballoon ablation system (CBAS) effectively manages Barrett's esophagus but has limited evidence in SESCC treatment, particularly on post-endoscopic resection scars. This study aimed to evaluate the efficacy and safety of the CBAS for treating SESCC on post-endoscopic resection scars.

METHODS

This prospective study was conducted at 2 tertiary referral centers in Japan in patients endoscopically diagnosed with T1a SESCC on the post-endoscopic resection scar. Focal CBAS was used for cryoablation, with specific criteria for lesion selection and treatment method. The primary endpoint was the rate of local complete response (L-CR) of the primary lesion 48 weeks after the first cryoablation as evaluated by an independent central evaluation committee.

RESULTS

From October 2020 to October 2021, 15 patients with 17 lesions underwent cryoablation, with 2 requiring repeat cryoablation. The L-CR rate for primary and all lesions evaluated by the central evaluation committee was 100%. The endoscopist's evaluation was consistent with these results. The median procedure time was 9 minutes. Eight patients experienced no pain, and the highest pain score reported on a numeric rating scale from 1 to 10 was 3. The technical success rate was 94.7% (18/19). Throughout the median follow-up period of 14.3 months, recurrences, deaths, or severe treatment-related adverse events were not reported.

CONCLUSIONS

CBAS is a potentially safe and effective approach for SESCC on post-endoscopic resection scars and represents an encouraging alternative to traditional endoscopic treatments. (Clinical trial registration numbers: NCT03097666 and jRCT1080225331.).

Role of narrow band imaging in detecting recurrence in patients of squamous cell carcinoma larynx and hypopharynx who underwent radiotherapy/chemo-radiotherapy

Background

Narrow band imaging (NBI) is an emerging modality that enhances the accuracy of detection of head and neck malignancies by visualisation of aberrant neoangiogenesis in malignant tissue using narrow bandwidth light in blue and green spectrum. The purpose of this study was to assess the role of NBI in detecting recurrence in patients with Squamous cell carcinoma larynx and hypopharynx who have undergone Radiotherapy/Chemoradiotherapy (RT/CTRT). The aim of the study was to (a) determine the role of NBI in follow-up of patients with carcinoma of larynx and hypopharynx previously treated with radiotherapy or chemotherapy, (b) determine the role of NBI as the initial investigatory tool of choice in detecting local recurrence and compare with other modalities like fibreoptic laryngoscopy (FOL), Magnetic Resonance Imaging (MRI) and Positron Emission Tomography- Computed Tomography (PETCT).

Methods

Prospective multicentric study at ENT departments of tertiary care centres in Delhi, Bangalore and Pune in India was conducted from Jan 2019 to Sep 2022. Thirty-four consecutive patients diagnosed as squamous cell carcinoma (SCC) larynx/hypopharynx who underwent chemo/radiotherapy were scheduled for NBI 12 weeks after completion of therapy with FOL and PETCT/MRI and followed up 03 monthly for 02 years. NBI/FOL/PETCT or MRI and Histopathological Examination (HPE) were compared.

Results

NBI was found to be 100% sensitive and 96% specific with a positive predictive value of 85% and negative predictive value of 100% respectively with a diagnostic accuracy of 97%.

Conclusion

NBI along with FOL increases the sensitivity of detection of recurrence in patients of laryngeal/hypopharyngeal cancer post-chemo/radiotherapy.

Clinical Implications of Circulating Tumor Cells in Patients with Esophageal Squamous Cell Carcinoma: Cancer-Draining Blood Versus Peripheral Blood

Circulating tumor cells (CTCs) in cancer-draining veins have diagnostic and prognostic value. However, studies on esophageal squamous cell carcinoma (ESCC) are limited. This study aimed to compare CTCs obtained from different sampling sites (peripheral vein vs. cancer-draining azygos vein) and to investigate their association with the clinicopathological characteristics of ESCC patients. Blood samples were collected preoperatively from both veins in 40 ESCC patients at Pusan National University Hospital from June 2020 to April 2022. CTCs were detected using a centrifugal microfluidic method with fluid-assisted separation. CTCs and TWIST (+) CTCs were detected more frequently in the azygos vein blood than in the peripheral vein blood; however, the difference was not statistically significant (85.0% [34/40] vs. 77.5% [31/40], p = 0.250 and 82.5% [33/40] vs. 75.0% [30/40], p = 0.586, respectively). CTC and TWIST (+) CTC counts were significantly higher in the azygos vein blood than in the peripheral vein blood (7 vs. 3, p < 0.001, and 6 vs. 2, p < 0.001, respectively). CTCs and TWIST (+) CTCs from peripheral and azygos veins showed no association with clinicopathological characteristics. Further large-scale studies are needed to clarify their role as predictive biomarkers for prognosis and chemotherapy responses in ESCC patients.

Endoscopic detection and diagnostic strategies for minute gastric cancer: A real-world observational study

BACKGROUND

Minute gastric cancers (MGCs) have a favorable prognosis, but they are too small to be detected by endoscopy, with a maximum diameter ≤ 5 mm.

AIM

To explore endoscopic detection and diagnostic strategies for MGCs.

METHODS

This was a real-world observational study. The endoscopic and clinicopathological parameters of 191 MGCs between January 2015 and December 2022 were retrospectively analyzed. Endoscopic discoverable opportunity and typical neoplastic features were emphatically reviewed.

RESULTS

All MGCs in our study were of a single pathological type, 97.38% (186/191) of which were differentiated-type tumors. White light endoscopy (WLE) detected 84.29% (161/191) of MGCs, and the most common morphology of MGCs found by WLE was protruding. Narrow-band imaging (NBI) secondary observation detected 14.14% (27/191) of MGCs, and the most common morphology of MGCs found by NBI was flat. Another three MGCs were detected by indigo carmine third observation. If a well-demarcated border lesion exhibited a typical neoplastic color, such as yellowish-red or whitish under WLE and brownish under NBI, MGCs should be diagnosed. The proportion with high diagnostic confidence by magnifying endoscopy with NBI (ME-NBI) was significantly higher than the proportion with low diagnostic confidence and the only visible groups (94.19% > 56.92% > 32.50%, P < 0.001).

CONCLUSION

WLE combined with NBI and indigo carmine are helpful for detection of MGCs. A clear demarcation line combined with a typical neoplastic color using nonmagnifying observation is sufficient for diagnosis of MGCs. ME-NBI improves the endoscopic diagnostic confidence of MGCs.

Administration of oral prednisolone to prevent esophageal stricture after balloon-type radiofrequency ablation for ultralong-segment esophageal neoplasia

BACKGROUND AND AIMS

Endoscopic radiofrequency ablation (RFA) has shown good efficacy and safety in eradicating flat-type early esophageal squamous cell neoplasia (ESCN). However, post-RFA stricture is still a major concern, especially when treating ultralong-segment ESCNs. The aim of this study was to investigate the efficacy and safety of oral prednisolone to prevent post-RFA stricture.

METHODS

We prospectively enrolled 48 patients treated with balloon-type RFA who had Lugol-unstained or mosaic-like flat-type ESCNs with an expected treatment area of >10 cm. Oral prednisolone was started at a dose of 30 mg/day on the third day after RFA and continued for 4 weeks. The results were compared with an historical control group of 25 patients who received RFA without oral steroids. The primary endpoint was the frequency of post-RFA stricture. Secondary endpoints were the number of balloon dilation sessions and adverse event rate.

RESULTS

No significant differences were found in the worst pathology grade at baseline and length of unstained lesions between the 2 groups. The complete response rates after 1 session of RFA were 73% and 72%, respectively. Compared with the control group, the oral prednisolone group had a significantly lower stricture rate (4% [2/48 patients] vs 44% [11/25 patients]; P < .0001) and a lower number of balloon dilation sessions (median, 0 [range, 0-4] vs 6 [range, 0-10]). Two cases of asymptomatic candida esophagitis occurred in the study group, but no severe adverse effects.

CONCLUSIONS

Oral prednisolone may offer a useful and safe preventive option for post-RFA stricture in ultralong ESCNs. (Clinical trial registration number: NCT05768282.).

Endoscopic Artificial Intelligence for Image Analysis in Gastrointestinal Neoplasms

BACKGROUND

Artificial intelligence (AI) using deep learning systems has recently been utilized in various medical fields. In the field of gastroenterology, AI is primarily implemented in image recognition and utilized in the realm of gastrointestinal (GI) endoscopy. In GI endoscopy, computer-aided detection/diagnosis (CAD) systems assist endoscopists in GI neoplasm detection or differentiation of cancerous or noncancerous lesions. Several AI systems for colorectal polyps have already been applied in colonoscopy clinical practices. In esophagogastroduodenoscopy, a few CAD systems for upper GI neoplasms have been launched in Asian countries. The usefulness of these CAD systems in GI endoscopy has been gradually elucidated.

SUMMARY

In this review, we outline recent articles on several studies of endoscopic AI systems for GI neoplasms, focusing on esophageal squamous cell carcinoma (ESCC), esophageal adenocarcinoma (EAC), gastric cancer (GC), and colorectal polyps. In ESCC and EAC, computer-aided detection (CADe) systems were mainly developed, and a recent meta-analysis study showed sensitivities of 91.2% and 93.1% and specificities of 80% and 86.9%, respectively. In GC, a recent meta-analysis study on CADe systems demonstrated that their sensitivity and specificity were as high as 90%. A randomized controlled trial (RCT) also showed that the use of the CADe system reduced the miss rate. Regarding computer-aided diagnosis (CADx) systems for GC, although RCTs have not yet been conducted, most studies have demonstrated expert-level performance. In colorectal polyps, multiple RCTs have shown the usefulness of the CADe system for improving the polyp detection rate, and several CADx systems have been shown to have high accuracy in colorectal polyp differentiation.

KEY MESSAGES

Most analyses of endoscopic AI systems suggested that their performance was better than that of nonexpert endoscopists and equivalent to that of expert endoscopists. Thus, endoscopic AI systems may be useful for reducing the risk of overlooking lesions and improving the diagnostic ability of endoscopists.

Outcomes of repeated endoscopic submucosal dissection for superficial Esophageal squamous cell carcinoma on endoscopic resection scar

BACKGROUND

Endoscopic submucosal dissection (ESD) can be performed for superficial esophageal cancer. However, performing ESD for superficial esophageal cancer on a previous endoscopic resection scar may be difficult.

METHODS

We compared the outcomes between ESD for superficial esophageal cancers on previous endoscopic resection scar (group A) and that for naïve lesions (group B). The study included outcomes of ESD, cumulative incidence of local failure, and predictors of the occurrence of local failure in ESD patients with squamous cell carcinoma (SCC). The outcome variables evaluated were en bloc resection rates, procedure times, adverse events, and overall survival rates.

RESULTS

Overall, 220 lesions were extracted (groups A and B: 23 and 197 lesions, respectively). In groups A and B, the complete resection rates were 60.9 and 92.9% (P < 0.001), and the mean procedure times were 79 and 68 min (P = 0.15), respectively. The perforation rates in groups A and B were 4.3 and 1% (P = 0.28). The 1-year cumulative local failure rates were 22 and 1% (P < 0.001), respectively. In the multivariate Cox proportional hazards analysis, superficial esophageal SCC on a previous endoscopic resection scar was a strong predictor of local failure (hazard ratio = 21.95 [3.99-120.80], P < 0.001). The 3-year overall survival rates in groups A and B were 95 and 93% (P = 0.99), respectively.

CONCLUSIONS

Repeated ESD on scar is an option for treating superficial esophageal SCC with an acceptable rate of adverse events. Because of the low complete resection rate and high local failure compared with conventional ESD, strict endoscopic follow-up is required after repeated esophageal ESD.

Optical enhancement mode 2 improves the detection rate of gastric neoplastic lesion in high-risk populations: A multicenter randomized controlled clinical study

OBJECTIVES

Detection of early neoplastic lesions is crucial for improving the survival rates of patients with gastric cancer. Optical enhancement mode 2 is a new image-enhanced endoscopic technique that offers bright images and can improve the visibility of neoplastic lesions. This study aimed to compare the detection of neoplastic lesions with optical enhancement mode 2 and white-light imaging (WLI) in a high-risk population.

METHODS

In this prospective multicenter randomized controlled trial, patients were randomly assigned to optical enhancement mode 2 or WLI groups. Detection of suspicious neoplastic lesions during the examinations was recorded, and pathological diagnoses served as the gold standard.

RESULTS

A total of 1211 and 1219 individuals were included in the optical enhancement mode 2 and WLI groups, respectively. The detection rate of neoplastic lesions was significantly higher in the optical enhancement mode 2 group (5.1% vs. 1.9%; risk ratio, 2.656 [95% confidence interval, 1.630-4.330]; p < 0.001). The detection rate of neoplastic lesions with an atrophic gastritis background was significantly higher in the optical enhancement mode 2 group (8.6% vs. 2.6%, p < 0.001). The optical enhancement mode 2 group also had a higher detection rate among endoscopists with different experiences.

CONCLUSIONS

Optical enhancement mode 2 was more effective than WLI for detecting neoplastic lesions in the stomach, and can serve as a new method for screening early gastric cancer in clinical practice.

CLINICAL REGISTRY

United States National Library of Medicine (https://www.

CLINICALTRIALS

gov), ID: NCT040720521.

Time trend analysis of rare cancer incidence 2011-2018: Nationwide population-based cancer registries in Japan

Rare cancers collectively account for a significant proportion of the overall cancer burden in Japan. We aimed to describe and examine the incidence of each rare cancer and the temporal changes using the internationally agreed rare cancer classification. Cancer cases registered in regional population-based cancer registries from 2011 to 2015 and the National Cancer Registry (NCR) from 2016 to 2018 were classified into 18 families, 68 Tier-1 cancer groupings, and 216 single cancer entities based on the RARECAREnet list. Crude incidence rates and age-standardized incidence rates (ASR) were calculated for Tier-1 and Tier-2 cancers. The annual percent change and the 95% and 99% confidence limits for annual ASR for each of the 68 Tier-1 cancers were estimated using the log-linear regression of the weighted least squares method. The differences in ASRs between 2011 and 2018 were evaluated as an absolute change. A total of 5,640,879 cases were classified into Tier-1 and Tier-2 cancers. The ASRs of 18 out of 52 Tier-1 cancers in the rare cancer families increased, whereas the ASR for epithelial tumors of gallbladder decreased. The ASRs of 6 out of the 16 Tier-1 cancers in the common cancer families increased, whereas those of epithelial tumors of stomach and liver decreased. There was no significant change in the incidence of the other 40 Tier-1 cancers. The incidence of several cancers increased due to the dissemination of diagnostic concepts, improved diagnostic techniques, changes in coding practice, and the initiation of the NCR.

Surveillance esophagogastroduodenoscopy using linked color imaging and narrow-band imaging: A multicenter randomized controlled trial

BACKGROUND AND AIM

There has been no report on a direct comparison between linked color imaging (LCI) and second-generation narrow-band imaging (2G-NBI) for surveillance of epithelial neoplasms in the upper gastrointestinal tract (UGIT). The aim of this study was to verify the superiority of LCI to 2G-NBI for surveillance esophagogastroduodenoscopy and to clarify how each endoscopic system should be used.

METHODS

This study was conducted as an open-label, two-arm-parallel (1:1), multicenter, randomized controlled trial at six institutions. Patients aged 20-85 years with a treatment history of epithelial neoplasms in the UGIT were recruited. Patients were assigned to a 2G-NBI group and an LCI group, and esophagogastroduodenoscopy was performed with primary image-enhanced endoscopy followed by white light imaging (WLI). The primary endpoint was the detection rate of one or more epithelial neoplasms in the primary image-enhanced endoscopy. A WLI-detected epithelial neoplasm was defined as a lesion that was detected in only WLI.

RESULTS

A total of 372 patients in the 2G-NBI group and 378 patients in the LCI group were analyzed. Epithelial neoplasms in the UGIT were detected by 2G-NBI in 18 patients (4.6%) and were detected by LCI in 20 patients (5.3%) (P = 0.87). WLI-detected epithelial neoplasms were in 11 patients in the 2G-NBI group (3.0%) and in 1 patient in the LCI group (0.27%) (P = 0.003).

CONCLUSIONS

Linked color imaging did not show superiority to 2G-NBI for the detection of epithelial neoplasms. Also, the percentage of WLI-detected epithelial neoplasms in primary NBI was significantly higher than that in primary LCI.

Methylation analysis of DCC gene in saliva samples is an efficient method for non-invasive detection of superficial hypopharyngeal cancer

BACKGROUND

Advances in upper gastrointestinal endoscopic technology have enabled early detection and treatment of hypopharyngeal cancer. However, in-depth pharyngeal observations require sedation and are invasive. It is important to establish a minimally invasive and simple evaluation method to identify high-risk patients.

METHODS

Eighty-seven patients with superficial hypopharyngeal cancer and 51 healthy controls were recruited. We assessed the methylation status of DCC, PTGDR1, EDNRB, and ECAD, in tissue and saliva samples and verified the diagnostic accuracy by methylation analyses of their promoter regions using quantitative methylation-specific PCR.

RESULTS

Significant differences between cancer and their surrounding non-cancerous tissues were observed in the methylation values of DCC (p = 0.003), EDNRB (p = 0.001), and ECAD (p = 0.043). Using receiver operating characteristic analyses of the methylation values in saliva samples, DCC showed the highest area under the curve values for the detection of superficial hypopharyngeal cancer (0.917, 95% confidence interval = 0.864-0.970), compared with those for EDNRB (0.680) and ECAD (0.639). When the cutoff for the methylation values of DCC was set at ≥0.163, the sensitivity to detect hypopharyngeal cancer was 82.8% and the specificity was 90.2%.

CONCLUSIONS

DCC methylation in saliva samples could be a non-invasive and efficient tool for early detection of hypopharyngeal cancer in high-risk patients.

Efficacy of endoscopic surveillance for pharyngeal mucosa during endoscopic resection for pharyngeal carcinoma: a multicenter prospective study

INTRODUCTION

Since patients with pharyngeal squamous cell carcinoma (SCC) often have multiple pharyngeal lesions, evaluation of pharyngeal lesions before endoscopic resection (ER) is important. However, detailed endoscopic observation of the entire pharyngeal mucosa under conscious sedation is difficult. We examined the usefulness of endoscopic surveillance with narrow band imaging (NBI) and lugol staining for detection of pharyngeal sublesions during ER for pharyngeal SCC under general anesthesia (endoscopic surveillance during treatment; ESDT).

METHODS

From January 2021 through June 2022, we examined 78 patients who were diagnosed with superficial pharyngeal SCC and underwent ER. They underwent the ESDT and for patients who were diagnosed with new lesions of pharyngeal SCC or high-grade dysplasia (HGD) that were not detected in the endoscopic examination before treatment, ER were performed simultaneously for new lesions and the main lesions. The primary endpoint of this study was the detection rate of new lesions of pharyngeal SCC or HGD in the ESDT.

RESULTS

Fifteen of the 78 patients were diagnosed as having undetected new pharyngeal lesions in the ESDT and 10 (12.8%) (95% CI 6.9-22.2%) were histopathologically confirmed to have new lesions of pharyngeal SCC or HGD. Among the 13 lesions of SCC or HGD, 8 were found by NBI observation; however, 5 were undetectable using NBI but detectable by lugol staining. All of the 13 lesions had endoscopic findings of pink color sign on lugol staining.

CONCLUSIONS

Endoscopic surveillance for pharyngeal sublesions during ER for pharyngeal SCC is feasible and useful.

Topic highlight on texture and color enhancement imaging in gastrointestinal diseases

Olympus Corporation developed texture and color enhancement imaging (TXI) as a novel image-enhancing endoscopic technique. This topic highlights a series of hot-topic articles that investigated the efficacy of TXI for gastrointestinal disease identification in the clinical setting. A randomized controlled trial demonstrated improvements in the colorectal adenoma detection rate (ADR) and the mean number of adenomas per procedure (MAP) of TXI compared with those of white-light imaging (WLI) observation (58.7% vs 42.7%, adjusted relative risk 1.35, 95%CI: 1.17-1.56; 1.36 vs 0.89, adjusted incident risk ratio 1.48, 95%CI: 1.22-1.80, respectively). A cross-over study also showed that the colorectal MAP and ADR in TXI were higher than those in WLI (1.5 vs 1.0, adjusted odds ratio 1.4, 95%CI: 1.2-1.6; 58.2% vs 46.8%, 1.5, 1.0-2.3, respectively). A randomized controlled trial demonstrated non-inferiority of TXI to narrow-band imaging in the colorectal mean number of adenomas and sessile serrated lesions per procedure (0.29 vs 0.30, difference for non-inferiority -0.01, 95%CI: -0.10 to 0.08). A cohort study found that scoring for ulcerative colitis severity using TXI could predict relapse of ulcerative colitis. A cross-sectional study found that TXI improved the gastric cancer detection rate compared to WLI (0.71% vs 0.29%). A cross-sectional study revealed that the sensitivity and accuracy for active Helicobacter pylori gastritis in TXI were higher than those of WLI (69.2% vs 52.5% and 85.3% vs 78.7%, respectively). In conclusion, TXI can improve gastrointestinal lesion detection and qualitative diagnosis. Therefore, further studies on the efficacy of TXI in clinical practice are required.

Efficacy and safety of the water pressure method for endoscopic submucosal dissection in superficial pharyngeal cancer

Background and study aims Superficial pharyngeal cancers can be cured with transoral surgery (TOS), which preserves organ function and quality of life. Pharyngeal endoscopic submucosal dissection (ESD) is challenging to perform because of limited maneuverability and complex anatomical features. The water pressure method (WPM) is useful for natural traction techniques during ESD and is potentially useful for pharyngeal ESD. This study aimed to investigate the short-term outcomes of WPM-ESD for pharyngeal lesions. Patients and methods Therapeutic outcomes of patients who underwent WPM-ESD for pharyngeal lesions at Keio University between May 2019 and February 2022 were retrospectively analyzed. Results Twenty-one pharyngeal lesions treated with WPM-ESD were analyzed. Three lesions were located in the oropharynx and 18 in the hypopharynx. All ESD procedures were performed under general anesthesia. The endoscopic en bloc resection rate was 100%. The median procedure time was 15 minutes (range 4-45 minutes). All patients were successfully extubated on the day of ESD. No serious adverse events (AEs) related to WPM-ESDs were observed. None of the patients required nasogastric intubation, percutaneous endoscopic gastrostomy, or tracheotomy. The median fasting time and hospital stay were 2 days (range 2-5 days) and 6 days (range 6-10 days), respectively. All the histological results indicated squamous cell carcinoma. The complete histologic resection rate was 76.2%. Conclusions WPM-ESD achieved a high en bloc resection rate and short procedure time without serious AEs. Thus, it may be a useful treatment for pharyngeal lesions.

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

The Japan Gastroenterological Endoscopy Society (JGES) held four serial symposia between 2021 and 2022 on state-of-the-art issues related to advanced diagnostic endoscopy of the upper gastrointestinal tract. This review summarizes the four core sessions and presents them as a conference report. Eleven studies were discussed in the 101st JGES Core Session, which addressed the challenges and prospects of upper gastroenterological endoscopy. Ten studies were also explored in the 102nd JGES Core Session on advanced upper gastrointestinal endoscopic diagnosis for decision-making regarding therapeutic strategies. Moreover, eight studies were presented during the 103rd JGES Core Session on the development and evaluation of endoscopic artificial intelligence in the field of upper gastrointestinal endoscopy. Twelve studies were also discussed in the 104th JGES Core Session, which focused on the evidence and new developments related to the upper gastrointestinal tract. The endoscopic diagnosis of upper gastrointestinal diseases using image-enhanced endoscopy and AI is one of the most recent topics and has received considerable attention. These four core sessions enabled us to grasp the current state-of-the-art in upper gastrointestinal endoscopic diagnostics and identify future challenges. Based on these studies, we hope that an endoscopic diagnostic system useful in clinical practice is established for each field of upper gastrointestinal endoscopy.

Artificial intelligence-based diagnosis of the depth of laryngopharyngeal cancer

OBJECTIVE

Transoral surgery (TOS) is a widely used treatment for laryngopharyngeal cancer. There are some difficult cases of setting the extent of resection in TOS, particularly in setting the vertical margins. However, positive vertical margins require additional treatment. Further, excessive resection should be avoided as it increases the risk of bleeding as a postoperative complication and may lead to decreased quality of life, such as dysphagia. Considering these issues, determining the extent of resection in TOS is an important consideration. In this study, we investigated the possibility of accurately diagnosing the depth of laryngopharyngeal cancer using radiomics, an image analysis method based on artificial intelligence (AI).

METHODS

We included esophagogastroduodenoscopic images of 95 lesions that were pathologically diagnosed as squamous cell carcinoma (SCC) and treated with transoral surgery at our institution between August 2009 and April 2020. Of the 95 lesions, 54 were SCC in situ, and 41 were SCC. Radiomics analysis was performed on 95 upper gastrointestinal endoscopic NBI images of these lesions to evaluate their diagnostic performance for the presence of subepithelial invasion. The lesions in the endoscopic images were manually delineated, and the accuracy, sensitivity, specificity, and area under the curve (AUC) were evaluated from the features obtained using least absolute shrinkage and selection operator analysis. In addition, the results were compared with the depth predictions made by skilled endoscopists.

RESULTS

In the Radiomics study, the average cross-validation was 0.833. The mean AUC for cross-validation calculated from the receiver operating characteristic curve was 0.868. These results were equivalent to those of the diagnosis made by a skilled endoscopist.

CONCLUSION

The diagnosis of laryngopharyngeal cancer depth using radiomics analysis has potential clinical applications. We plan to use it in actual surgery in the future and prospectively study whether it can be used for diagnosis.

Routine image-enhanced endoscopic surveillance for metachronous esophageal squamous cell neoplasms in head and neck cancer patients

BACKGROUND

Esophageal squamous cell neoplasms (ESCNs) are common second primary tumors in patients with head and neck cancer. Image-enhanced endoscopy (IEE) with Lugol chromoendoscopy or magnifying narrow-band imaging both increase the detection of early ESCNs. No evidence-based ESCN surveillance program for head and neck cancer patients without a history of synchronous ESCNs exists. We aimed to evaluate the performance of an IEE surveillance program with magnifying narrow-band imaging endoscopy and Lugol chromoendoscopy.

METHODS

From April 2016, we routinely used IEE with magnifying narrow-band imaging and Lugol chromoendoscopy to evaluate patients with head and neck cancer history. All patients who were negative for ESCNs at the first surveillance endoscopy and received at least 2 IEEs through December 2019 were included. Demographic profiles, clinical data, cancer characteristics, IEE results and pathology reports were analyzed.

RESULTS

A total of 178 patients were included. Only 4 patients (2.2%) developed metachronous ESCNs during follow-up, all of whom received curative resection treatment. The interval for the development of metachronous ESCNs was 477 to 717 days. In multivariate Firth logistic regression and Kaplan‒Meier survival curve analysis, Lugol's voiding lesion type C had an increased risk of esophageal cancer development (adjusted odds ratio = 15.71; 95% confidence interval, 1.33-185.87, p = 0.029). Eight patients died during the study period, and none of them had metachronous ESCNs.

CONCLUSIONS

IEE with magnifying narrow-band imaging and Lugol chromoendoscopy is an effective surveillance program in head and neck cancer patients without a history of ESCNs. Annual surveillance can timely detect early ESCNs with low ESCN-related mortality.

Multiple foci of dilated vessels as a new predictor of metachronous esophageal cancer

OBJECTIVES

Prediction of the risk of esophageal squamous cell carcinoma (SCC) by endoscopic findings without iodine staining, which is irritating to the esophagus, would be beneficial. In a previous retrospective study, we found that multiple foci of dilated vascular areas (MDV) of the esophageal mucosa, seen in narrow-band imaging (NBI)/blue laser imaging (BLI), are associated with iodine-unstained lesions and, thus, may be a predictor of esophageal SCC. This prospective study aimed to investigate the association between MDV and metachronous esophageal SCC.

METHODS

Patients with a history of endoscopic resection for esophageal SCC were included in the study. First, evaluation of the MDV using NBI or BLI was conducted during the initial endoscopy. The patients were then monitored for metachronous esophageal SCC by endoscopic surveillance. The association between the number of MDV and incidence of metachronous esophageal SCC was investigated.

RESULTS

From February 2018 to May 2019, 206 patients were enrolled and 201 patients were included in the analysis. Patients were followed up until October 2022. The median (interquartile range) endoscopic follow-up period was 1260 (1105-1348) days. The incidence of metachronous esophageal SCC at 2 years was 7.1% in patients with MDV ≤4 and 13.9% in patients with MDV ≥5 (P < 0.01). In the multivariate analysis, MDV was an independent predictor of metachronous esophageal SCC, with an odds ratio (95% confidence interval) of 2.37 (1.06-5.31).

CONCLUSION

Multiple foci of dilated vascular area is a useful predictor for stratifying the risk of metachronous esophageal SCC.

Global burden of head and neck cancers from 1990 to 2019

Head and neck cancer (HNC) exerts a significant healthcare burden worldwide. Insufficient data impedes a comprehensive understanding of its global impact. Through analysis of the 2019 Global Burden of Disease (GBD) database, our secondary investigation unveiled a surging global incidence of HNC, yet a decline in associated mortality and disability-adjusted life years (DALYs) owing to enhanced prognosis. Particularly noteworthy is the higher incidence of escalation among females compared to males. Effective resource allocation, meticulous control of risk factors, and tailored interventions are imperative to curtail mortality rates among young individuals afflicted with HNC in underprivileged regions, as well as in elderly individuals grappling with thyroid cancer.

Feasibility and efficacy of endoscopy with blue laser imaging for the detection and diagnosis of cardia polyps: A single-center randomized controlled study

OBJECTIVE

To compare the detection rate and diagnostic accuracy of cardia polyps using endoscopy with blue laser imaging (BLI) and white-light imaging (WLI).

METHODS

Patients were randomly divided into the BLI group and WLI group according to the endoscopic procedures. BLI followed by WLI was conducted in the BLI group, whereas WLI followed by BLI examination was conducted in the WLI group. The number, size, microstructure, and microvascular patterns of cardia polyps detected were recorded. Biopsy of the polyps was then performed.

RESULTS

The detection rate of cardia polyps in the BLI group was higher than that in the WLI group (7.87% vs 4.22%, P = 0.018). The rate of overlooked lesions in the BLI group was lower than in the WLI group (0.64% vs 3.38%, P = 0.003). The diagnostic coincidence rate between magnifying BLI and histopathology was 88.16%. The sensitivity, specificity, positive predictive value and negative predictive value for the diagnosis of neoplastic lesions by magnifying endoscopy with BLI were 90.91%, 87.69%, 55.56%, and 98.28%, respectively. The most remarkable patterns for predicting inflammatory polyps were the prolonged and fine network patterns (sensitivity 71.43%, specificity 93.75%). Small round combined with honeycomb patterns were the most common among fundic gland polyps (sensitivity 80.00%, specificity 98.48%). Neoplastic lesions presented as villous or ridge-like combined with core vascular or unclear pattern for both microvascular and microstructure patterns.

CONCLUSION

BLI is more effective than WLI in the detection and diagnosis of cardia polyps, and magnifying endoscopy with BLI may help diagnose such lesions.

Impact of non-obese metabolic dysfunction-associated fatty liver disease on risk factors for the recurrence of esophageal squamous cell carcinoma treated with endoscopic submucosal dissection: A multicenter study

AIM

Metabolic dysfunction is a risk factor for esophageal squamous cell carcinoma (ESCC). We investigated the impact of the recently proposed metabolic dysfunction-associated fatty liver disease (MAFLD) and its subtypes on ESCC recurrence after endoscopic treatment.

METHODS

This multicenter observational cohort study enrolled consecutive patients newly diagnosed with ESCC after endoscopic treatment. Patients were classified into MAFLD or non-MAFLD groups. The MAFLD group was further classified into non-obese and obese MAFLD groups with a body mass index cutoff value of 25 kg/m2 . The impact of MAFLD on the recurrence of ESCC was evaluated using a decision tree algorithm and random forest analysis.

RESULTS

A total of 147 patients (average age 69 years; male : female, 127:20; observational period, 2.4 years) were enrolled. The 1-, 3-, and 5-year recurrence rates were 2.0%, 21.1%, and 33.7%, respectively. Independent risk factors for the recurrence of ESCC were MAFLD (HR 2.2812; 95% confidence interval 1.0497-4.9571; p = 0.0373), drinking status, and smoking status. Metabolic dysfunction-associated fatty liver disease was identified as the second most important classifier for recurrence, followed by drinking status. The cumulative incidence of ESCC recurrence was higher in the MAFLD group than in the non-MAFLD group. In a subanalysis, the cumulative incidence of recurrence was significantly higher in the non-obese than in the obese MAFLD group among abstainers/non-drinkers. Directed acyclic graphs revealed that MAFLD directly contributes to ESCC recurrence.

CONCLUSIONS

MAFLD was independently and directly associated with ESCC recurrence after endoscopic treatment; a high recurrence rate was observed in patients with non-obese MAFLD. Metabolic dysfunction-associated fatty liver disease may identify patients at high risk for ESCC recurrence.

Subsite-specific trends in mid- and long-term survival for head and neck cancer patients in Japan: A population-based study

Advances in diagnostic techniques and treatment modalities have impacted head and neck cancer (HNC) prognosis, but their effects on subsite-specific prognosis remain unclear. This study aimed to assess subsite-specific trends in mid- and long-term survival for HNC patients diagnosed from 1993 to 2011 using data from population-based cancer registries in Japan. We estimated the net survival (NS) for HNC by subsite using data from 13 prefectural population-based cancer registries in Japan. Changes in survival over time were assessed by multivariate excess hazard model of mortality. In total, 68,312 HNC patients were included in this analysis. We observed an overall improvement in 5-year NS for HNC patients in Japan. However, survival varied among subsites of HNC, with some, such as naso-, oro- and hypopharyngeal cancers, showing significant improvement in both 5- and 10-year NS, whereas others such as laryngeal cancer showed only a slight improvement in 5-year NS and no significant change in 10-year NS after adjustment for age, sex and stage. In conclusion, the study provides insights into changing HNC survival by site at the population level in Japan. Although advances in diagnostic techniques and treatment modalities have improved survival, these improvements are not shared equally among subsites.

Novel endoscopic duodenal observation protocol based on Seven Pictures Rule for detecting duodenal neoplasms during esophagogastroduodenoscopy: Prospective observational study

OBJECTIVES

No protocol for esophagogastroduodenoscopic examination of the duodenum has been established. We examined the feasibility and ability to detect neoplasms of a novel duodenal examination protocol.

METHODS

This was a two-facility, prospective, observational study. Our protocol, the Seven Pictures Rule (7PR), requires pictures of the following seven locations: anterior and posterior to the bulb, area of and contralateral to the superior duodenal angle, area of and contralateral to the ampulla, and the transverse duodenum. The primary outcome was rate of completion of 7PR. Secondary outcomes were overall rates of detecting neoplasms, rates of detecting neoplasms for each location, examination time, and completion rates for standard or ultrathin endoscopes.

RESULTS

There were 1549 participants. The 7PR completion rate was 81.1% and the detection rates of overall neoplasms, adenomas, and carcinomas were 0.84%, 0.71%, and 0.06%, respectively. The area in which most neoplasms was detected was contralateral to the ampulla (69.2%), and the fewest the transverse duodenum (0%). Mean duration of duodenal examination was 53.1 s. Completion rates for standard vs. ultrathin were 84.4% (1077/1276) vs. 65.6% (179/273) (P < 0.01), respectively.

CONCLUSIONS

Seven Pictures Rule is acceptable for duodenal examination and a potential quality indicator.