Schistosomiasis combined with colorectal carcinoma diagnosed based on endoscopic findings and clinicopathological characteristics: a report on 32 cases

AIMS AND BACKGROUND

To improve understanding of the relationship between schistosome-related enteropathy and colorectal carcinoma with particular focus on endoscopic findings and clinicopathological characteristics of colonic schistosomiasis.

MATERIALS AND METHODS

All cases of intestinal schistosomiasis diagnosed at West China Hospital, Chengdu, China, between October 2006 and October 2012 were included in this study. A total of 179 cases of colonic schistosomiasis diagnosed through colonoscopy and pathological examinations were collected for analysis and the demographics, symptoms, endoscopic findings and clinicopathological characteristics were retrospectively evaluated.

RESULTS

Of the 179 colonic schistosomiasis patients, 32 combined with colorectal cancer (CRC) were found, between the ages of 44 and 85 years (24 males, 75%). These 32 lesions were classified as 12 endophytic/ulcerative (37.5%), 10 exophytic/fungating (31.2%), 4 annular (12.5%), 3 giant polypus (9.4%), and 3 IIc (superficial depressed type) (9.4%). The segments of rectum and sigmoid colon were involved in 19 patients (59.4%) and 6 patients (18.8%), respectively. The histopathologic types were classified as follows: 30 well- differentiated adenocarcinomas, one mucinous adenocarcinoma and one poorly differentiated adenocarcinoma. The pathological findings suggest colorectal malignancy with deposited schistosome ova.

CONCLUSIONS

Chronic schistosomal infestation has a probable etiological role in promoting genesis of colorectal neoplasms.

Does chronic ethanol intake cause chronic pancreatitis?: evidence and mechanism

OBJECTIVES

To demonstrate the relationship between prolonged alcohol intake and chronic pancreatitis.

METHODS

Wistar rats were fed diet containing 25% concentration (vol/vol) of ethanol for 6 months. Cholecystokinin (CCK) was quantified by radioimmunoassay. Immunohistochemistry was used to detect alpha-smooth muscle actin, cyclooxygenase 2, and toll-like receptor 4 in rat pancreas. Western-blot was used to quantitatively determine the expression of nuclear factor kappaB and the above inflammatory markers. Pancreatic collagen content was quantified by measuring OH-proline. Superoxide dismutase was measured by colorimetric method.

RESULTS

In contrast to the control group, there was little histological change in pancreatic tissue but obvious ultrastructural changes in acinar cells of the ethanol group. Cholecystokinin, amylase, and lipase were found reduced in the ethanol group. Chronic ethanol intake did not elicit any change in the expression of alpha-smooth muscle actin, cyclooxygenase 2, toll-like receptor 4, nuclear factor kappaB, pancreatic collagen, and superoxide dismutase.

CONCLUSIONS

Long-term alcohol consumption did not cause chronic pancreatitis but impaired exocrine pancreatic function. The mechanism behind it could be associated with decreased output of intestinal CCK and lower concentration of pancreatic CCK. Furthermore, the nonoxidative pathway of ethanol metabolism was probably involved in it.

A phase II study of paclitaxel and nedaplatin as front-line chemotherapy in Chinese patients with metastatic esophageal squamous cell carcinoma

AIM

To evaluate the efficacy and safety of paclitaxel-nedaplatin combination as a front-line regimen in Chinese patients with metastatic esophageal squamous cell carcinoma (ESCC).

METHODS

A two-center, open-label, single-arm phase II study was designed. Thirty-nine patients were enrolled and included in the intention-to-treat analysis of efficacy and adverse events. Patients received 175 mg/m² of paclitaxel over a 3 h infusion on 1 d, followed by nedaplatin 80 mg/m² in a 1 h infusion on 2 d every 3 wk until the documented disease progression, unacceptable toxicity or patient's refusal.

RESULTS

Of the 36 patients assessable for efficacy, there were 2 patients (5.1%) with complete response and 16 patients (41.0%) with partial response, giving an overall response rate of 46.1%. The median progression-free survival and median overall survival for all patients were 7.1 mo (95%CI: 4.6-9.7) and 12.4 mo (95%CI: 9.5-15.3), respectively. Toxicities were moderate and manageable. Grade 3/4 toxicities included neutropenia (15.4%), nausea (10.3%), anemia (7.7%), thrombocytopenia (5.1%), vomiting (5.1%) and neutropenia fever (2.6%).

CONCLUSION

The combination of paclitaxel and nedaplatin is active and well tolerated as a first-line therapy for patients with metastatic ESCC.

Prevention of severe acute pancreatitis with octreotide in obese patients: a prospective multi-center randomized controlled trial

OBJECTIVES

To evaluate the efficacy of octreotide in preventing severe acute pancreatitis (SAP) in obese patients.

METHODS

A prospective multi-center partly randomized control trial was conducted in patients with mild acute pancreatitis (AP). Nonobese patients received conventional management (nonobese-C, n = 82), whereas obese patients (body mass index ≥ 25 kg/m(2)) were randomized into 2 groups: obese-C (n = 79), who received conventional management, and obese-C+O (n = 82), who received conventional management plus intravenous infusion of octreotide, 50 μg/h for 72 hours.

RESULTS

The risk ratio and relative risk reduction in the development of SAP in the obese-C+O group were 0.27 (95% confidence interval, 0.10-0.69) and 0.73 (95% confidence interval, 0.31-0.90), respectively. The number of cases developing local complications in the obese-C+O group was significantly smaller than that in the obese-C group: 4.9% vs 19%, P = 0.006. The plasma level of somatostatin in the obese-C+O group was significantly higher than that in the obese-C group: 165.5 ± 42.6 vs 112.1 ± 24.86 pg/mL, P < 0.05. Supplement of octreotide also accompanied with reduction in plasma levels of tumor necrosis factor α and IL-6.

CONCLUSIONS

Intravenous administration of octreotide (50 μg/h) for 72 hours in the early stage of AP could prevent the development of SAP effectively in obese patients by raising plasma somatostatin to a normal level and reducing circulating cytokines.

Standing-type magnetically guided capsule endoscopy versus gastroscopy for gastric examination: multicenter blinded comparative trial

AIM

To compare feasibility and safety after gastrointestinal checkup by standing-type magnetically controlled capsule endoscopy (SMCE) and conventional gastroscopy.

METHODS

This was a prospective multicenter, blinded study that compared SMCE with gastroscopy in patients from April 2018 to July 2018. All patients first underwent SMCE and then subsequently had gastroscopy with i.v. anesthesia. We calculated the compliance rates of gastric lesion detection by SMCE using gastroscopy as the standard. Capsule retention rate, incidence of adverse events, and patient satisfaction were documented throughout the study.

RESULTS

One hundred and sixty-one patients who completed SMCE and gastroscopy were included in the analysis. Positive compliance rate among SMCE and gastroscopy was 92.0% (95% CI: 80.77%-97.78%). Negative compliance rate was 95.5% (89.80%, 98.52%). Moreover, overall compliance rate was 94.41% (89.65%, 97.41%). Sixty-four pathological outcomes were identified. Of these 64 outcomes, 50 were detected by both procedures. The gastroscopy method neglected seven findings (such as five erosions, one polyp, and one ulcer). Furthermore, SMCE also overlooked seven lesions (i.e. one erosion, two polyps, one atrophy, and three submucosal tumors). Capsule retention or related adverse events were not reported.

CONCLUSION

Standing-type magnetically controlled capsule endoscopy provides equivalent agreement with gastroscopy and may be useful for screening of gastric illnesses without any anesthesia.

Preoperative NLR and PLR in the middle or lower ESCC patients with radical operation

Neutrophil lymphocyte ratio (NLR) and platelet lymphocyte ratio (PLR) had been analysed in many kind of tumours, but its role of predict the oesophageal squamous cell carcinoma (ESCC) patients' prognosis was not reach a consensus. Relationship between NLR, PLR and ESCC located in the middle or lower segment was evaluated. 317 patients with ESCC who underwent attempted curative oesophagectomy were analysed in this study. 157 and 98 patients had elevated NLR and PLR respectively (NLR >3.3 and PLR >150). The median overall survival time (OS) and disease-free survival (DFS) was 34.1 and 19.2 months respectively. Multivariate analysis found PLR >150 (P = 0.018, HR 1.426, 95%CI 1.063-1.912) accompanied by male, lymphatic metastases, tumour size more than 3 cm, tumour located at middle segment and poor differentiation were associated with significantly worse DFS. Meanwhile, gender, lymphatic metastases, tumour location and differentiation along with PLR >150 (P = 0.003, HR 1.595, 95% CI 1.172-2.170) and NLR>3.3 (P = 0.039, HR 1.367, 95% CI 1.015-1.840) were all independent prognostic factors for OS. Preoperative NLR and PLR might be used as predictive factors in patients with ESCC. For DFS, elevated PLR compared to NLR may have an advantage to indicate poor prognosis.

Artificial intelligence-assisted esophageal cancer management: Now and future

Esophageal cancer poses diagnostic, therapeutic and economic burdens in high-risk regions. Artificial intelligence (AI) has been developed for diagnosis and outcome prediction using various features, including clinicopathologic, radiologic, and genetic variables, which can achieve inspiring results. One of the most recent tasks of AI is to use state-of-the-art deep learning technique to detect both early esophageal squamous cell carcinoma and esophageal adenocarcinoma in Barrett's esophagus. In this review, we aim to provide a comprehensive overview of the ways in which AI may help physicians diagnose advanced cancer and make clinical decisions based on predicted outcomes, and combine the endoscopic images to detect precancerous lesions or early cancer. Pertinent studies conducted in recent two years have surged in numbers, with large datasets and external validation from multi-centers, and have partly achieved intriguing results of expert's performance of AI in real time. Improved pre-trained computer-aided diagnosis algorithms in the future studies with larger training and external validation datasets, aiming at real-time video processing, are imperative to produce a diagnostic efficacy similar to or even superior to experienced endoscopists. Meanwhile, supervised randomized controlled trials in real clinical practice are highly essential for a solid conclusion, which meets patient-centered satisfaction. Notably, ethical and legal issues regarding the black-box nature of computer algorithms should be addressed, for both clinicians and regulators.

Coexpression of periostin and EGFR in patients with esophageal squamous cell carcinoma and their prognostic significance

BACKGROUND

Both periostin (PN) and epidermal growth factor receptor (EGFR) can predict the prognosis of several carcinomas alone. However, coexpression of PN and EGFR in esophageal squamous cell carcinoma (ESCC) still remains unknown. We aimed to clarify their relationship with clinicopathological factors and prognostic significance of their coexpression in ESCC.

PATIENTS AND METHODS

In this single-center retrospective study, immunohistochemistry was performed to evaluate the expression of PN and EGFR in ESCC and paracarcinomatous tissues of 83 patients. The quantitative expression levels of PN and EGFR were examined in two ESCC and tumor-adjacent tissues. The levels of PN and EGFR expression were correlated with clinicopathological parameters by the χ (2) or Kruskal-Wallis method. Spearman's rank correlation test was performed to determine the relationship between PN and EGFR expression levels. Kaplan-Meier and Cox regression analyses were used to detect the prognostic factors of disease-free survival (DFS) and overall survival (OS).

RESULTS

The high expression of PN protein in ESCC tissues was significantly associated with tumor length (P=0.044), differentiation grade (P=0.003), venous invasion (P=0.010), invasion depth (P=0.007), lymphatic metastasis (P=0.000), and tumor stage (P=0.000). The high expression of EGFR protein in ESCC tissues was only significantly related to lymphatic metastasis (P=0.000), invasion depth (P=0.022), and tumor stage (P=0.000). Kaplan-Meier analysis showed that high expression of PN was closely correlated to reduced OS (P=0.000) and DFS (P=0.000), which was consistent with EGFR expression. Cox regression analysis identified PN and EGFR as independent poor prognostic factors of OS and DFS in the ESCC patients (P<0.05). Moreover, the risk of death for the ESCC patients with low expression of two biomarkers and high expression of single biomarker was 0.243 times (P=0.000) and 0.503 times (P=0.030), respectively, than that for patients with high expression of two biomarkers.

CONCLUSION

PN and EGFR are related to miscellaneous clinicopathologic characteristics. Coexpression of PN and EGFR is more closely to be of predictive value on ESCC development and progression, which may offer a novel and potential target strategy for ESCC treatment in the future.

Artificial intelligence for detecting superficial esophageal squamous cell carcinoma under multiple endoscopic imaging modalities: A multicenter study

BACKGROUND AND AIM

Diagnosis of esophageal squamous cell carcinoma (ESCC) is complicated and requires substantial expertise and experience. This study aimed to develop an artificial intelligence (AI) system for detecting superficial ESCC under multiple endoscopic imaging modalities.

METHODS

Endoscopic images were retrospectively collected from West China Hospital, Sichuan University as a training dataset and an independent internal validation dataset. Images from other four hospitals were used as an external validation dataset. The AI system was compared with 11 experienced endoscopists. Furthermore, videos were collected to assess the performance of the AI system.

RESULTS

A total of 53 933 images from 2621 patients and 142 videos from 19 patients were used to develop and validate the AI system. In the internal and external validation datasets, the performance of the AI system under all or different endoscopic imaging modalities was satisfactory, with sensitivity of 92.5-99.7%, specificity of 78.5-89.0%, and area under the receiver operating characteristic curves of 0.906-0.989. The AI system achieved comparable performance with experienced endoscopists. Regarding superficial ESCC confined to the epithelium, the AI system was more sensitive than experienced endoscopists on white-light imaging (90.8% vs 82.5%, P = 0.022). Moreover, the AI system exhibited good performance in videos, with sensitivity of 89.5-100% and specificity of 73.7-89.5%.

CONCLUSIONS

We developed an AI system that showed comparable performance with experienced endoscopists in detecting superficial ESCC under multiple endoscopic imaging modalities and might provide valuable support for inexperienced endoscopists, despite requiring further evaluation.

Cell apoptosis control using BMP4 and noggin embedded in a polyelectrolyte multilayer film

Programmed cell death (apoptosis) is a genetically regulated process of cell elimination essential during development. During development, programmed cell death is involved in the specific shaping of organs, in the elimination of cells having achieved their program, and in regulating the number of cells to differentiate. Tooth development includes these three aspects and was used here as a model to study the control of apoptosis. Bone morphogenetic proteins (BMPs) are currently considered as playing a major role in signaling apoptosis. This apoptosis could be stopped by treatments with a BMP antagonist ("Noggin"). We selected a model system made by a layer-by-layer approach using poly-L-glutamic acid (PlGA) and poly-L-lysine (PlL) films into which BMP4 and/or Noggin have been embedded. Our results indicate that in situ control of apoptosis during tooth differentiation mediated by both BMP4 and Noggin embedded in a polyelectrolyte multilayer film is possible. We show here for the first time that in the presence of BMP4 and Noggin embedded in a multilayered film, we can induce or inhibit cell death in tooth differentiation, and conserve their biological effects.

Open peroral endoscopic myotomy for the treatment of achalasia: a case series of 82 cases

During peroral endoscopic myotomy (POEM), creation of the tunnel is highly technically demanding and mucosal injury is one of the most common potential complications. We explored a method without a submucosal tunnel, which we call open peroral endoscopic myotomy (O-POEM). This study aimed to assess the feasibility and safety of O-POEM. O-POEM was performed on 82 patients with achalasia. Treatment success was defined as an Eckardt score of less than or equal to 3 after the myotomy. Adverse events including operative and postoperative adverse events were recorded. Treatment success and procedure-related adverse events were analyzed. After a median follow-up of 18 months (range: 6-26 months), the treatment success (Eckhart score ≤3) was achieved in 96.3% of cases (mean score pre- vs. post-treatment (7.4 vs. 1.8); P < 0.001) with a recurrence of 3 cases. Ten patients (12.2%) had adverse events consisting of 2 cases of mediastinitis, 1 case of post-O-POEM bleeding, 1 case of subcutaneous emphysema, 6 cases of pleural effusion. Two cases of mediastinitis required intraprocedural drainage, and other patients were managed by endoscopy and conservative medical treatment. There were no deaths. No patients required surgical conversion. Clinical reflux occurred in 15.9% of patients (13/82). O-POEM was reliable and effective for the treatment of achalasia. In addition, O-POEM might be a better option for patients with severe submucosal fibrosis.

CD4 + CD25high regulatory T cell numbers and FOXP3 mRNA expression in patients with advanced esophageal cancer before and after chemotherapy

We evaluated the changes in CD4 + CD25(high) regulatory T (Treg) cells and FOXP3 mRNA expression in patients with advanced esophageal cancer as well as its clinical significance. For this purpose, the frequencies of peripheral blood Treg cells in 68 patients with advanced esophageal cancer and 40 healthy controls were determined by flow cytometry, and FOXP3 mRNA expression in Treg cells of 40 patients was determined by RT-PCR. The data show that Treg cell numbers were significantly higher (P < 0.01) in esophageal cancer patients (1.82 ± 0.54% of CD4 + T cells) as compared with healthy controls (1.52 ± 0.70% of CD4(+) T cells). Treg cell numbers in the patients were significantly higher (P < 0.05) before chemotherapy (1.82 ± 0.54% of CD4 + T cells) than after chemotherapy (1.66 ± 0.58% of CD4 + T cells). Expression of the FOXP3 mRNA in the patients was significantly lower (P < 0.05) after chemotherapy (0.266 ± 0.028% of CD4 + T cells) than before chemotherapy (0.318 ± 0.027% of CD4 + T cells). It was, therefore, concluded that Treg cell numbers as well as FOXP3 mRNA expression in advanced esophageal cancer patients were significantly decreased after chemotherapy. Notably, FOXP3 gene may thus be involved in regulating the numbers and function of Treg cells in advanced esophageal cancer patients receiving chemotherapy.

Overexpression of cyclooxygenase-2 in noncancerous liver tissue increases the postoperative recurrence of hepatocellular carcinoma in patients with hepatitis B virus-related cirrhosis

BACKGROUND

Many previous studies have evaluated the histopathological features of tumours as risk factors for postoperative recurrence in hepatitis B virus (HBV)-associated hepatocellular carcinoma (HCC). However, there have been few large studies investigating the relationship between cyclooxygenase-2 (COX-2) expression in noncancerous regions of the liver and postoperative recurrence in the remnant liver, especially in HBV-related HCC.

OBJECTIVE

To evaluate the significance of COX-2 expression levels in noncancerous liver regions as a prognostic indicator of HCC in patients with HBV-related cirrhosis.

METHODS

A total of 124 patients who underwent curative resection for HCC were reviewed retrospectively. Immunohistochemistry was used to evaluate the expression of COX-2 in noncancerous liver tissue. Clinicopathological variables were compared between patients with high COX-2 expression (n=58 [COX-2-positive group]) and patients with low COX-2 expression (n=66; [COX-2-negative group]). Univariate and multivariate analyses were performed to identify factors that affected disease recurrence.

RESULTS

There was a significant correlation between COX-2 expression and alanine aminotransferase levels and vascular invasion. The recurrence-free survival rates in the COX-2-positive group were significantly lower than the rates in the COX-2-negative group. On multivariate analysis, the overexpression of COX-2 in noncancerous liver regions was found to be an unfavourable prognostic indicator for the recurrence of HCC.

CONCLUSIONS

The results of the current study suggest that overexpression of COX-2 in noncancerous liver regions is an independent and significant indicator predictive of early recurrence of HCC in patients with HBV-related cirrhosis.

Fatal lactic acidosis and hypoglycemia in a patient with relapsed natural killer/T-cell lymphoma

Presented here is the first reported case of natural killer (NK)/T-cell lymphoma associated with lactic acidosis (LA) and hypoglycemia. LA and hypoglycemia are rare complications of non-Hodgkin's lymphoma. A 28-year-old male patient with NK/T-cell lymphoma had a relapse after 14 mo of initial remission and was admitted to the hospital because of altered mental status. He developed severe LA (pH, 7.17; lactate, 11.2 mmol/L) and hypoglycemia (42 mg/dL) that was resistant to sodium bicarbonate and glucose infusions. A very brief partial remission was achieved after a cycle of vincristine, dexamethasone, and L-asparaginase was given, but the disease recurred quickly after chemotherapy was discontinued and the patient did not respond to additional chemotherapy. The patient expired at 47 d after relapse. An extensive review of the literature reveals that only 2 of 28 patients have achieved complete remission, and more than 75% of patients died within 1 mo. Furthermore, 90% of previously reported cases had liver involvement. The case described here indicates that non-Hodgkin's lymphoma-induced LA portends a poor prognosis.

Association between periostin and epithelial-mesenchymal transition in esophageal squamous cell carcinoma and its clinical significance

The present study aimed to investigate the association between periostin (POSTN), epithelial cadherin (E-cad) and vimentin (Vim) expression levels in esophageal squamous cell carcinoma (ESCC) tissues, and its clinicopathological significance. A total of 58 patients with esophageal cancer were enrolled. Immunohistochemistry was performed to quantify the expression levels of POSTN, E-cad and Vim. E-cad expression was reduced in ESCC tissue, which was associated with severe tumor node metastasis (TNM) stage (P<0.001), lymphatic metastasis (P<0.001) and vascular invasion (P=0.026). Conversely, Vim expression was found to be increased in ESCC tissues, and had associations with TNM stage (P=0.039) and lymphatic metastasis (P=0.039). POSTN overexpression observed in ESCC cells was associated with attenuation of E-cad expression (P<0.001) and elevated expression levels of Vim (P<0.001). Additionally, significant correlations between the overexpression of POSTN in ESCC cells and clinicopathological variables including TNM staging (P=0.009), degree of differentiation (P<0.001), lymphatic metastasis (P=0.009) and vascular invasion (P=0.002) were verified. Multivariate analysis revealed that overexpression of POSTN in ESCC cancer cells is able to predict the poor prognosis of patients independently of overall survival (P=0.022) and disease free survival (P=0.019). The preliminary findings of the present study demonstrate that POSTN is involved in the epithelial-mesenchymal transition of ESCC cells, and may therefore be a predictive factor for tumor invasion and metastasis, as well as an indicator of poor prognosis for patients with ESCC.

Risk factors for distal migration of biliary plastic stents and related duodenal injury

BACKGROUND

The risk factors of duodenal injury from distal migrated biliary plastic stents remain uncertain. The aim of this study was to determine the risk factors of distal migration and its related duodenal injury in patients who underwent placement of a single biliary plastic stent for biliary strictures.

METHODS

We retrospectively reviewed all patients with biliary strictures who underwent endoscopic placement of a single biliary plastic stent from January 2006 to October 2017.

RESULTS

Two hundred forty-eight patients with 402 endoscopic retrograde cholangiopancreatography procedures were included. The incidence of distal migration was 6.2%. The frequency of duodenal injury was 2.2% in all cases and 36% in cases with distal migration. Benign biliary strictures (BBS), length of the stent above the proximal end of the stricture (> 2 cm), and duration of stent retention (< 3 months) were independently associated with distal migration (p = 0.018, p = 0.009, and p = 0.016, respectively). Duodenal injury occurred more commonly in cases with larger angle (≥ 30°) between the distal end of the stent and the centerline of the patient's body (p = 0.018) or in cases with stent retention < 3 months (p = 0.031).

CONCLUSIONS

The risk factors of distal migration are BBS and the length of the stent above the proximal end of the stricture. The risk factor of duodenal injury due to distal migration is large angle (≥ 30°) between the distal end of the stent and the centerline of the patient's body. Distal migration and related duodenal injury are more likely to present during the early period after biliary stenting.

Genetic polymorphisms of ERCC1 and their effects on the efficacy of cisplatin-based chemotherapy in advanced esophageal carcinoma

The aim of this study was to investigate the relationship between the ERCC1-C8092A, ERCC1-C19007T and GSTP1-A105G genetic polymorphisms and the curative effect of cisplatin-based chemotherapy in advanced esophageal carcinoma. A total of 256 pathologically confirmed advanced esophageal carcinoma patients were given regimens of cisplatin and 5-fluorouracil. Clinical evaluations were obtained from 241 patients who completed the therapy. The remission rate of patients with ERCC1-C8092A, A/C or A/A was higher compared to that of patients with C/C (51.75 vs. 29.59%, P<0.01). Progression-free survival of patients with ERCC1-C8092A, A/C or A/A was longer compared to that of patients with C/C (7.5 months vs. 4.5 months, P<0.0001). The C19007T and GSTP1-A105G genetic polymorphisms were not positively correlated with remission rates and progression-free survival of patients. In conclusion, the ERCC1-C8092A genetic polymorphism may be correlated with the efficacy of cisplatin-based chemotherapy in cases of advanced esophageal carcinoma. Further studies with a larger sample size are needed for tailored chemotherapy treatment of advanced esophageal carcinoma.

Effect of an artificial intelligence-assisted system on endoscopic diagnosis of superficial oesophageal squamous cell carcinoma and precancerous lesions: a multicentre, tandem, double-blind, randomised controlled trial

BACKGROUND

Despite the usefulness of white light endoscopy (WLE) and non-magnified narrow-band imaging (NBI) for screening for superficial oesophageal squamous cell carcinoma and precancerous lesions, these lesions might be missed due to their subtle features and interpretation variations among endoscopists. Our team has developed an artificial intelligence (AI) system to detect superficial oesophageal squamous cell carcinoma and precancerous lesions using WLE and non-magnified NBI. We aimed to evaluate the auxiliary diagnostic performance of the AI system in a real clinical setting.

METHODS

We did a multicentre, tandem, double-blind, randomised controlled trial at 12 hospitals in China. Eligible patients were aged 18 years or older and underwent sedated upper gastrointestinal endoscopy for screening, investigation of gastrointestinal symptoms, or surveillance. Patients were randomly assigned (1:1) to either the AI-first group or the routine-first group using a computerised random number generator. Patients, pathologists, and statistical analysts were masked to group assignment, whereas endoscopists and research assistants were not. The same endoscopist at each centre did tandem upper gastrointestinal endoscopy for each eligible patient on the same day. In the AI-first group, the endoscopist did the first examination with the assistance of the AI system and the second examination without it. In the routine-first group, the order of examinations was reversed. The primary outcome was the miss rate of superficial oesophageal squamous cell carcinoma and precancerous lesions, calculated on a per-lesion and per-patient basis. All analyses were done on a per-protocol basis. This trial is registered with the Chinese Clinical Trial Registry (ChiCTR2100052116) and is completed.

FINDINGS

Between Oct 19, 2021, and June 8, 2022, 5934 patients were randomly assigned to the AI-first group and 5912 to the routine-first group, of whom 5865 and 5850 were eligible for analysis. Per-lesion miss rates were 1·7% (2/118; 95% CI 0·0-4·0) in the AI-first group versus 6·7% (6/90; 1·5-11·8) in the routine-first group (risk ratio 0·25, 95% CI 0·06-1·08; p=0·079). Per-patient miss rates were 1·9% (2/106; 0·0-4·5) in AI-first group versus 5·1% (4/79; 0·2-9·9) in the routine-first group (0·37, 0·08-1·71; p=0·40). Bleeding after biopsy of oesophageal lesions was observed in 13 (0·2%) patients in the AI-first group and 11 (0·2%) patients in the routine-first group. No serious adverse events were reported by patients in either group.

INTERPRETATION

The observed effect of AI-assisted endoscopy on the per-lesion and per-patient miss rates of superficial oesophageal squamous cell carcinoma and precancerous lesions under WLE and non-magnified NBI was consistent with substantial benefit through to a neutral or small negative effect. The effectiveness and cost-benefit of this AI system in real-world clinical settings remain to be further assessed.

FUNDING

National Natural Science Foundation of China, 1·3·5 project for disciplines of excellence, West China Hospital, Sichuan University, and Chengdu Science and Technology Project.

TRANSLATION

For the Chinese translation of the abstract see Supplementary Materials section.

Hybrid Dry Powders for Rapid Sealing of Gastric Perforations under an Endoscope

Effective wound sealing is key to prevent postoperative complications arising from gastric endoscopic submucosal dissection (ESD). Accurate delivery of the adhesive to wet and dynamic tissues and rapid action of the adhesive onsite should be considered for endoscopic operation. A hybrid dry powder (HDP) strategy, characterized by decoupling of powder gelation and tissue adhesion, for rapid sealing of wet tissues is presented. HDPs carrying oppositely charged polyelectrolytes become a hydrogel layer over the target tissue by absorbing the surrounding water and forming strong electrostatic interactions between heterogeneous components. Strong adhesion is realized through hydrogen bonding between the adhesive component, poly(acrylic acid), and the tissue. Wet tissue adhesion can be achieved in a few seconds (adhesion strength of ∼30 kPa to porcine skin). Notably, the HDP-assembled hydrogel can maintain a low swelling rate and resist degradation in acidic aqueous environments (pH 1). Furthermore, HDPs can be delivered to target tissues by spraying via an endoscope. The results of in vivo experiments indicate that healing of gastric ESD perforations by sealing with the powder-assembled hydrogel is as effective as that by sealing with clips. This strategy is expected to facilitate the development of fast-acting hydrogel-based adhesives for endoscopic operation.

Endoscopic submucosal dissection with additional radiotherapy in the treatment of T1a esophageal squamous cell cancer: randomized controlled Trial

BACKGROUND

Endoscopic submucosal dissection (ESD) is effective for treating T1a early esophageal squamous cell carcinoma (ESCC). However, occasional recurrences are inevitable. This trial was designed to clarify the efficacy of combining ESD with additional radiotherapy in the treatment of T1a ESCC.

METHODS

Between January 2015 and September 2018, patients with early ESCC (T1aN0M0) following ESD were randomly assigned (1:1) to the radiotherapy group or non-radiotherapy group. Patients in the radiotherapy group received a median radiation dose of 59.4 Gy within 2 months after ESD. In the non-radiotherapy group, patients underwent regular follow-up only. Recurrence-free survival, cancer-specific survival, overall survival, and complications were evaluated.

RESULTS

70 patients completed the per-protocol treatment. Three patients in the non-radiotherapy group experienced intraluminal mucosal recurrence compared with none in the radiotherapy group. No local lymph node or distant metastases occurred in either group. The 3-year cumulative recurrence-free survival was 100 % in the radiotherapy group and 85.3 % in the non-radiotherapy group (P = 0.04; hazard ratio 0.08, 95 % confidence interval [CI] 0.01 - 0.86). However, there was no significant difference in RFS between the treatments within the T1a invasion subgroups (P > 0.05). No patient died in either group. Mucosal defects of more than three-quarters of the esophageal circumference were positively correlated with stenosis (P < 0.01; odds ratio 23.26, 95 %CI 4.04 - 133.86). No severe radiation toxicities were recorded.

CONCLUSIONS

Radiotherapy after ESD might be a safe and effective optional therapeutic strategy to prevent recurrence of T1a ESCC.

Clinical efficacy of chemotherapy combined with verapamil in metastatic colorectal patients

In order to determine the clinical efficacy and adverse reactions of chemotherapy and verapamil infusion through a target artery to treat colorectal cancer patients with metastasis after failure with previous conventional treatments. Patients with metastatic colon cancer (n = 36) received an infusion of verapamil, interleukin-2, oxaliplatin (or hydroxy camptothecin or irinotecan hydrochloride), fluorouracil and calcium folinate through target artery using the Seldinger puncture technique. From the second day of infusion, the patients were treated with fluorouracil and calcium folinate via systematic intravenous injection for 2-3 days. Efficacy was evaluated after at least two treatment courses. The objective response including complete or partial response was 58.3% in the 36 patients; clinical benefit rate, evaluated by Karnofsky Performance Status score was 91.7%; by weight was 83.3%; by the amount of painkiller consumed was 80.6%. No patient experienced side effects associated with heart function. Post-treatment, the P-R period, Q-T period, QRS, and heart rate were not significantly different than before treatment. Liver function was significantly improved. Side effects of chemotherapy were minor in comparison to those observed with intravenous chemotherapy. Infusion of verapamil and chemotherapy directly into pelvic tumor tissue can increase treatment efficacy and has been shown to be a relatively safe technique.

Detection and Treatment of Helicobacter pylori: Problems and Advances

Helicobacter pylori (H. pylori) infection is chronic and etiologically linked to gastric cancer (GC) derived from gastric epithelium. The potential mechanism is complex, covering chronic inflammation, epithelial senescence, NF-κB activation, the cytotoxin-associated gene A protein translocation, and related abnormal signaling pathways. In clinical practice, the test-and-treat strategy, endoscopy-based strategy, and (family-based) screen-and-treat strategy are recommended to detect H. pylori and prevent GC. It has been demonstrated that the decreasing annual incidence of GC is largely attributable to the management of H. pylori. This study reviews the current clinical practice of H. pylori on the detection and eradication, alternative treatment strategies, and related problems and advances, and hopes to contribute to the better clinical management of H. pylori.

Artificial intelligence for diagnosing microvessels of precancerous lesions and superficial esophageal squamous cell carcinomas: a multicenter study

BACKGROUND

Intrapapillary capillary loop (IPCL) is an important factor for predicting invasion depth of esophageal squamous cell carcinoma (ESCC). The invasion depth is closely related to the selection of treatment strategy. However, diagnosis of IPCLs is complicated and subject to interobserver variability. This study aimed to develop an artificial intelligence (AI) system to predict IPCLs subtypes of precancerous lesions and superficial ESCC.

METHODS

Images of magnifying endoscopy with narrow band imaging from three hospitals were collected retrospectively. IPCLs subtypes were annotated on images by expert endoscopists according to Japanese Endoscopic Society classification. The performance of the AI system was evaluated using internal and external validation datasets (IVD and EVD) and compared with that of the 11 endoscopists.

RESULTS

A total of 7094 images from 685 patients were used to train and validate the AI system. The combined accuracy of the AI system for diagnosing IPCLs subtypes in IVD and EVD was 91.3% and 89.8%, respectively. The AI system achieved better performance than endoscopists in predicting IPCLs subtypes and invasion depth. The ability of junior endoscopists to diagnose IPCLs subtypes (combined accuracy: 84.7% vs 78.2%, P < 0.0001) and invasion depth (combined accuracy: 74.4% vs 67.9%, P < 0.0001) were significantly improved with AI system assistance. Although there was no significant differences, the performance of senior endoscopists was slightly elevated.

CONCLUSIONS

The proposed AI system could improve the diagnostic ability of endoscopists to predict IPCLs classification of precancerous lesions and superficial ESCC.