Assessment of the Diagnostic Performance of Endoscopic Ultrasonography After Conventional Endoscopy for the Evaluation of Esophageal Squamous Cell Carcinoma Invasion Depth

The usefulness of combining narrow-band imaging with magnifying endoscopy and 18F-fluorodeoxyglucose positron emission tomography for predicting the depth of invasion in superficial esophageal squamous cell carcinoma

BACKGROUND

To ascertain the indication of endoscopic resection (ER) for esophageal squamous cell carcinoma (ESCC), accurate preoperative diagnosis of the tumor depth beyond cT1b-SM2 is crucial. This study aimed to assess the efficacy of the combined approach utilizing narrow-band imaging with magnifying endoscopy (NBI-ME) and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) for accurate discrimination of lesions of pT1b-SM2 or deeper.

METHODS

Between 2016 and 2023, we retrospectively enrolled 127 cases (137 lesions) of superficial, treatment-naïve ESCC at Akita University Hospital, involving patients who underwent either ER alone or surgery alone. All patients underwent preoperative NBI-ME and FDG-PET. Preoperative tumor depth was estimated using type B vessels based on NBI-ME and SUVmax based on FDG-PET, and we confirmed the final tumor depth through histopathological evaluation of resected samples. The diagnostic performance of the tests in discriminating pT1b-SM2 or deeper was evaluated in terms of sensitivity, specificity, and accuracy.

RESULTS

Treatment consisted of ER in 97 lesions and surgery in the remaining 40. Fifty-three lesions (44.7%) had pT1b-SM2 or deeper invasion. The sensitivity, specificity, and accuracy of NBI-ME using type B3 vessels were 41.5%, 97.6%, and 75.9%, respectively. For FDG-PET with a cutoff SUVmax of ≥ 2.4, these were 79.2%, 69.0%, and 73.0%, respectively. Combining both tests substantially improved diagnostic performance, with sensitivity, specificity, and accuracy of 83.0%, 89.3%, and 86.9%, respectively.

CONCLUSION

The combination of FDG-PET and NBI-ME offers enhanced diagnostic performance for ESCC with ≥ pT1b-SM2, thereby facilitating a more efficacious preoperative narrowing of the indications for ER of superficial ESCC.

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.

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

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.

Analyzing risk factors and constructing a predictive model for superficial esophageal carcinoma with submucosal infiltration exceeding 200 micrometers

OBJECTIVE

Submucosal infiltration of less than 200 μm is considered an indication for endoscopic surgery in cases of superficial esophageal cancer and precancerous lesions. This study aims to identify the risk factors associated with submucosal infiltration exceeding 200 micrometers in early esophageal cancer and precancerous lesions, as well as to establish and validate an accompanying predictive model.

METHODS

Risk factors were identified through least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression. Various machine learning (ML) classification models were tested to develop and evaluate the most effective predictive model, with Shapley Additive Explanations (SHAP) employed for model visualization.

RESULTS

Predictive factors for early esophageal invasion into the submucosa included endoscopic ultrasonography or magnifying endoscopy> SM1(P<0.001,OR = 3.972,95%CI 2.161-7.478), esophageal wall thickening(P<0.001,OR = 12.924,95%CI,5.299-33.96), intake of pickled foods(P=0.04,OR = 1.837,95%CI,1.03-3.307), platelet-lymphocyte ratio(P<0.001,OR = 0.284,95%CI,0.137-0.556), tumor size(P<0.027,OR = 2.369,95%CI,1.128-5.267), the percentage of circumferential mucosal defect(P<0.001,OR = 5.286,95%CI,2.671-10.723), and preoperative pathological type(P<0.001,OR = 4.079,95%CI,2.254-7.476). The logistic regression model constructed from the identified risk factors was found to be the optimal model, demonstrating high efficacy with an area under the curve (AUC) of 0.922 in the training set, 0.899 in the validation set, and 0.850 in the test set.

CONCLUSION

A logistic regression model complemented by SHAP visualizations effectively identifies early esophageal cancer reaching 200 micrometers into the submucosa.

Endoscopic ultrasound classification for prediction of endoscopic submucosal dissection resectability: PREDICT classification

Background and study aims The safety of endoscopic submucosal dissection (ESD) has been reported, and the risk of lymph node metastasis is low for colorectal cancer if depth of invasion is the only non-curative factor on histological evaluation. ESD is increasingly performed even if submucosal (SM) invasion is suspected. However, reports about endoscopic findings for the criteria to predict ESD resectability remain limited. Endoscopic ultrasound (EUS) can directly visualize the tomographic image of the gastrointestinal wall and may help predict ESD resectability. Therefore, we investigated the possibility of predicting ESD resectability using EUS. Patients and methods We compared the association between EUS findings and pathological results for gastric or colorectal lesions with suspected SM invasion using white light endoscopy between June 2020 and January 2023. EUS findings were grouped based on the status of the underlying the tumor, as follows: Type I, submucosal layer was observed with reproducibility; Type II, submucosal layer not fully visible; and Type III, submucosal layer disrupted and muscularis propria (MP) layer thickened. Results Forty-one gastric cancer and 22 colorectal cancer cases were analyzed. The proportions of pathological VM0 (no tumor exposed on any vertical margin) for ESD-resected specimens were 89% and 33% for Type I and II, respectively, ( P ≤ 0.01). The proportions of cancer involving MP or deeper were significantly higher for Type II/III than for Type I (41% vs 0%, P ≤ 0.01). Conclusions EUS may have an important role in predicting ESD resectability of gastric and colorectal cancers suspected of having SM invasion.

Prediction of the invasion depth of superficial nonampullary duodenal adenocarcinoma

OBJECTIVES

Distinguishing between intramucosal cancer and submucosal invasive cancer is vital for optimal treatment selection for patients with superficial nonampullary duodenal adenocarcinoma (SNADAC); however, standard diagnostic systems for diagnosing invasion depth are as yet undetermined.

METHODS

Of 205 patients with SNADAC who underwent treatment at our institution between 2006 and 2022, 188 had intramucosal cancer and 17 had submucosal invasive cancer. The clinical, endoscopic, and pathological features used in the preoperative diagnosis of invasion depth and the diagnostic performance of endoscopic ultrasonography (EUS) were retrospectively analyzed in 85 patients.

RESULTS

The oral side of the papilla tumor location, protruded or mixed macroscopic type, and moderately-to-poorly differentiated adenocarcinoma based on biopsy specimens were significantly more frequent in submucosal invasive cancer than in intramucosal cancer (88% vs. 48%; 94% vs. 42%; 47% vs. 0%, respectively). From the relationship between the endoscopic features and the submucosal invasive cancer incidence, submucosal invasion risk was stratified as: (i) low-risk (risk, 2%), all lesions located on the anal side of the papilla and superficial macroscopic type on the oral side of the papilla; and (ii) high-risk (risk, 23%), protruded or mixed macroscopic type on the oral side of the papilla. Based on the biopsy specimens, all eight patients with moderately-to-poorly differentiated adenocarcinoma had submucosal invasive cancer. Furthermore, EUS was not associated with invasion depth's diagnostic accuracy improvements.

CONCLUSION

Optimal treatment indications for SNADAC can be selected based on the risk factors of submucosal invasion by tumor location, macroscopic type, and biopsy diagnosis.

18F-fluorodeoxyglucose positron emission tomography/computed tomography parameters are associated with histological outcomes in superficial esophageal squamous cell carcinoma

Endoscopic submucosal dissection is a standard treatment for early esophageal squamous cell carcinoma. However, submucosal or lymphovascular invasion increases the risk of lymph node metastasis. Although 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) parameters are associated with prognosis in patients with advanced esophageal squamous cell carcinoma, the utility of FDG PET/CT in diagnosing superficial esophageal carcinoma remains unclear. This study aimed to investigate the association between FDG PET/CT parameters and histopathological findings in superficial esophageal carcinoma. Fifty-three patients with superficial esophageal cancer who underwent FDG PET/CT scans before undergoing interventions were retrospectively analyzed. The maximal standardized uptake value (SUVmax), metabolic tumor volume, and total lesion glycolysis were significantly higher in the cases with submucosal invasion (T1b) compared with those confined to the muscularis mucosa (T1a). In contrast, classification of intrapapillary capillary loops patterns with magnifying endoscopy did not yield statistical differences between T1a and T1b. Multivariable analysis revealed that SUVmax was the only independent predictor of submucosal and lymphovascular invasion. This study demonstrated that SUVmax may be useful in predicting submucosal and lymphovascular invasion. Thus, the value of SUVmax may guide clinical decision-making in superficial esophageal squamous cell carcinoma.

Novel milestones for early esophageal carcinoma: From bench to bed

Esophageal cancer (EC) is the seventh most common cancer worldwide, and esophageal squamous cell carcinoma (ESCC) accounts for the majority of cases of EC. To effectively diagnose and treat ESCC and improve patient prognosis, timely diagnosis in the initial phase of the illness is necessary. This article offers a detailed summary of the latest advancements and emerging technologies in the timely identification of ECs. Molecular biology and epigenetics approaches involve the use of molecular mechanisms combined with fluorescence quantitative polymerase chain reaction (qPCR), high-throughput sequencing technology (next-generation sequencing), and digital PCR technology to study endogenous or exogenous biomolecular changes in the human body and provide a decision-making basis for the diagnosis, treatment, and prognosis of diseases. The investigation of the microbiome is a swiftly progressing area in human cancer research, and microorganisms with complex functions are potential components of the tumor microenvironment. The intratumoral microbiota was also found to be connected to tumor progression. The application of endoscopy as a crucial technique for the early identification of ESCC has been essential, and with ongoing advancements in technology, endoscopy has continuously improved. With the advancement of artificial intelligence (AI) technology, the utilization of AI in the detection of gastrointestinal tumors has become increasingly prevalent. The implementation of AI can effectively resolve the discrepancies among observers, improve the detection rate, assist in predicting the depth of invasion and differentiation status, guide the pericancerous margins, and aid in a more accurate diagnosis of ESCC.

Endoscopic landmarks corresponding to anatomical landmarks for esophageal subsite classification

Objectives

Individual treatment strategies for esophageal cancer have been investigated based on the anatomical subsite classification. Accurate subsite classification based on these anatomical landmarks is thus important. We investigated the suitability of the existing endoscopic classification and explored alternative landmarks for esophageal subsite classification.

Methods

Patients who received endoscopic ultrasonography (and computed tomography scans for surveillance of esophageal cancer treatment or esophageal submucosal tumors were included. Distances between anatomical landmarks, including the inferior cricoid cartilage border, superior border of the sternum, and tracheal bifurcation, were measured using a combination of endoscopic ultrasonography, computed tomography, and other information.

Results

The mean (standard deviation) distances from the superior incisor dentition to the pharynx-esophagus, cervical-upper thoracic esophagus, and upper-middle thoracic esophagus boundaries were 16.9 (1.7), 21.7 (1.9), and 29.0 (1.9) cm, respectively. However, variances in the differences between the mean and individual distances were large (2.8, 3.4, and 3.7, respectively), mainly because of differences in body height. However, variances in the differences between individual distances and novel endoscopic landmarks, including the lower end of the pyriform sinus and lower end of compression of the left main bronchus, were lower (1.7, 1.2, and 0.6, respectively).

Conclusions

Existing indicators of esophageal subsite boundaries were not consistent with anatomical boundaries. Modification of the distance from the superior incisor dentition based on average distances from anatomical landmarks or the use of alternative endoscopic landmarks is recommended to provide more suitable anatomical boundaries.

Curative criteria for endoscopic treatment of oesophageal squamous cell cancer

Endoscopic treatment of early oesophageal squamous cell carcinoma is widely accepted. ESD (Endoscopic Submucosal Dissection), which allows en bloc resection regardless of size, provides resected specimens that facilitate histological evaluation of curability. In the histological investigation, the determination of tumor depth, lymphovascular involvement, and lateral and vertical margins play a great role in the assessment of curability. The diagnosis of lymphovascular invasion, in particular, is enhanced by the addition of immunostaining. The long-term outcome of ESD is comparable to that of oesophagectomy, and ESD may be the first-line treatment for early-stage oesophageal cancer due to its fewer complications. Surveillance after curative resection is also imperative because oesophageal cancer is often characterized by the concept of field cancerization, which results in metachronous multiple primary lesions.

Evaluating the usefulness of considering the size and morphological type of type B2 vessel area based on Japan Esophageal Society classification in estimating tumor invasion depth in superficial esophageal squamous cell carcinomas: study protocol for a prospective observational study (Japan BEES study)

BACKGROUND

Accurate evaluation of tumor invasion depth is essential to determine the appropriate treatment strategy for patients with superficial esophageal cancer. The pretreatment tumor depth diagnosis currently relies on the magnifying endoscopic classification established by the Japan Esophageal Society (JES). However, the diagnostic accuracy of tumors involving the muscularis mucosa (MM) or those invading the upper third of the submucosal layer (SM1), which correspond to Type B2 vessels in the JES classification, remains insufficient. Previous retrospective studies have reported improved accuracy by considering additional findings, such as the size and macroscopic type of the Type B2 vessel area, in evaluating tumor invasion depth. Therefore, this study aimed to investigate whether incorporating the size and/or macroscopic type of the Type B2 vessel area improves the diagnostic accuracy of preoperative tumor invasion depth prediction based on the JES classification.

METHODS

This multicenter prospective observational study will include patients diagnosed with MM/SM1 esophageal squamous cell carcinoma based on the Type B2 vessels of the JES classification. The tumor invasion depth will be evaluated using both the standard JES classification (standard-depth evaluation) and the JES classification with additional findings (hypothetical-depth evaluation) for the same set of patients. Data from both endoscopic depth evaluations will be electronically collected and stored in a cloud-based database before endoscopic resection or esophagectomy. This study's primary endpoint is accuracy, defined as the proportion of cases in which the preoperative depth diagnosis matched the histological depth diagnosis after resection. Outcomes of standard- and hypothetical-depth evaluation will be compared.

DISCUSSION

Collecting reliable prospective data on the JES classification, explicitly concerning the B2 vessel category, has the potential to provide valuable insights. Incorporating additional findings into the in-depth evaluation process may guide clinical decision-making and promote evidence-based medicine practices in managing superficial esophageal cancer.

TRIAL REGISTRATION

This trial was registered in the Clinical Trials Registry of the University Hospital Medical Information Network (UMIN-CTR) under the identifier UMIN000051145, registered on 23/5/2023.

Ensembled CNN with artificial bee colony optimization method for esophageal cancer stage classification using SVM classifier

BACKGROUND

Esophageal cancer (EC) is aggressive cancer with a high fatality rate and a rapid rise of the incidence globally. However, early diagnosis of EC remains a challenging task for clinicians.

OBJECTIVE

To help address and overcome this challenge, this study aims to develop and test a new computer-aided diagnosis (CAD) network that combines several machine learning models and optimization methods to detect EC and classify cancer stages.

METHODS

The study develops a new deep learning network for the classification of the various stages of EC and the premalignant stage, Barrett's Esophagus from endoscopic images. The proposed model uses a multi-convolution neural network (CNN) model combined with Xception, Mobilenetv2, GoogLeNet, and Darknet53 for feature extraction. The extracted features are blended and are then applied on to wrapper based Artificial Bee Colony (ABC) optimization technique to grade the most accurate and relevant attributes. A multi-class support vector machine (SVM) classifies the selected feature set into the various stages. A study dataset involving 523 Barrett's Esophagus images, 217 ESCC images and 288 EAC images is used to train the proposed network and test its classification performance.

RESULTS

The proposed network combining Xception, mobilenetv2, GoogLeNet, and Darknet53 outperforms all the existing methods with an overall classification accuracy of 97.76% using a 3-fold cross-validation method.

CONCLUSION

This study demonstrates that a new deep learning network that combines a multi-CNN model with ABC and a multi-SVM is more efficient than those with individual pre-trained networks for the EC analysis and stage classification.

Development and Validation of PET/CT-Based Nomogram for Preoperative Prediction of Lymph Node Status in Esophageal Squamous Cell Carcinoma

PURPOSE

This study was conducted to predict the lymph node status and survival of esophageal squamous cell carcinoma before treatment by PET-CT-related parameters.

METHODS

From January 2013 to July 2018, patients with pathologically diagnosed ESCC at our hospital were retrospectively enrolled. Completed esophagectomy and two- or three-field lymph node dissections were conducted. Those with neoadjuvant therapy were excluded. The first 65% of patients in each year were regarded as the training set and the last 35% as the test set. Nomogram was constructed by the "rms" package. Five-year, overall survival was analyzed based on the best cutoff value of risk score determined by the "survivalROC" package.

RESULTS

Ultimately, 311 patients were included with 209 in the training set and 102 in the test set. The positive rate of the lymph node in the training set was 36.8% and that in the test set was 32.4%. The C-index of the training set was 0.763 and the test set was 0.766. The decision curve analysis showed that it was superior to the previous methods based on lymph node uptake or long/short axis diameter or axial ratio. Risk score > 0.20 was significantly associated with 5-year, overall survival (p = 0.0015) in all patients.

CONCLUSIONS

The nomogram constructed from PET-CT parameters including primary tumor metabolic length and thickness can accurately predict the risk of lymph node metastasis in ESCC. The risk score calculated by our model accurately predicts the patient's 5-year overall survival.

Diagnostic Performance of Endoscopic Ultrasonography with Water-Filled Balloon Method for Superficial Esophageal Squamous Cell Carcinoma

BACKGROUND

Endoscopic ultrasonography (EUS) is a commonly used tool for preoperative depth diagnosis of superficial esophageal squamous cell carcinoma (ESCC). Probing EUS using the water-filled balloon method is a simple and safe examination.

AIM

The aim of this study was to clarify the diagnostic performance of EUS with the water-filled balloon method for superficial ESCC compared to magnifying narrow-band imaging (ME-NBI).

METHODS

We retrospectively examined 403 lesions in 393 consecutive patients diagnosed with ESCC and evaluated them with ME-NBI and EUS. Clinicopathological findings were collected, and the accuracy of the preoperative diagnosis was compared between ME-NBI and EUS-B. EUS examiners were not blinded to prior ME-NBI results, and EUS results may have been influenced by ME-NBI results.

RESULTS

The pathological tumor depth of the EP/LPM in 152 lesions, MM/SM1 in 130 lesions, and deep submucosa (SM2/SM3) in 121 lesions was examined. The proportion of total lesions with an accurate diagnosis was significantly higher in EUS than in ME-NBI (67.7% versus 62.0%, P = 0.015). When analyzed by clinical depth diagnosis using ME-NBI, the proportion of lesions with an accurate diagnosis was significantly higher for EUS in MM/SM1 (55.7% versus 46.1%, P = 0.033). The sensitivity was significantly higher in EUS for SM2/SM3 lesions (76.0% versus 54.5%, P < 0.001). The accuracy and specificity of EUS, which differentiate MM/SM1 from EP/LPM or SM2/SM3, were significantly higher than those of ME-NBI. The median endoscopic ultrasonography procedure time was approximately 6.5 min.

CONCLUSIONS

EUS with the water-filled balloon method is a safe and straightforward method that can be performed on lesions clinically diagnosed as MM/SM1 using ME-NBI. We retrospectively reviewed lesions in patients diagnosed with ESCC and evaluated them using magnifying endoscopy with narrow-band imaging (ME-NBI) and endoscopic ultrasound using the water-filled balloon method (EUS-B). We conclude that EUS-B can increase the diagnostic accuracy.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Endoscopic resection for local residual or recurrent cancer after definitive chemoradiotherapy or radiotherapy for esophageal squamous cell carcinoma

Chemoradiotherapy (CRT) and radiotherapy (RT) are treatment options for esophageal squamous cell carcinoma (ESCC), but local residual/recurrent cancer after CRT/RT is a major problem. Endoscopic resection (ER) is an effective treatment option for local residual/recurrent cancer. To ensure the efficacy of ER, complete removal of endoscopically visible lesions with cancer-free vertical margins is desired. This study aimed to identify the endoscopic parameters associated with the complete endoscopic removal of local residual/recurrent cancer. In this single-center, retrospective study, we used a prospectively maintained database to identify esophageal lesions that were diagnosed as local residual/recurrent cancer after CRT/RT and treated by ER between January 2012 and December 2019. We evaluated the associations of endoscopic R0 resection with findings on conventional endoscopy and endoscopic ultrasonography (EUS). In total, 98 lesions (83 cases) were identified from our database. The rate of endoscopic R0 resection was higher for flat lesions (100% versus 77%, P = 0.00014). EUS was performed for 24 non-flat lesions, and endoscopic R0 resection was achieved for 94% of lesions with an uninterrupted fifth layer. Flat lesions on conventional endoscopy and lesions with an uninterrupted fifth layer on EUS are good candidates for ER.

Analysis of white-light imaging-based features predictive for determination of lesion depths of superficial flat esophageal squamous cell carcinoma: a retrospective multicenter study from China

OBJECTIVES

Endoscopic diagnosis of invasion depth of superficial esophageal squamous cell carcinoma (SESCC) by white-light imaging (WLI) modality remains difficult. This study aims to clarify WLI-based features which are predictive for invasion depth of SESCC.

METHODS

A two-phase study was performed by enrolling 1288 patients with 1396 SESCC lesions. Endoscopic appearances, clinical characteristics and post-operative pathological outcomes were collected and reviewed. The association between lesion features and invasion depth were analyzed. A predictive nomogram was constructed for prediction of invasion depth.

RESULTS

Among 1396 lesions in derivation and validation cohort, 1139 (81.6%), 194 (13.9%) and 63 (4.5%) lesions were diagnosed as lesions confined into the intraepithelium or the lamina propria mucosa (T1a-EP/LPM), lesions invading the muscularis mucosa (T1a-MM) or superficial submucosa (T1b-SM1) and tumor with moderate invasion into the submucosa or deeper submucosal invasion (≥ T1b-SM2), respectively. Lesion length > 2 cm (p < 0.001), wider circumferential extension (p < 0.001, 0.002 and 0.048 for > 3/4, 1/2-3/4 and 1/4-1/2 circumferential extension, respectively), surface unevenness (p < 0.001 for both type 0-IIa/0-IIc lesions and mixed type lesions), spontaneous bleeding (p < 0.001), granularity (p < 0.001) and nodules (p < 0.001) were identified as significant factors predictive for lesion depth. A nomogram based on these factors was constructed and the values of area under the Receiver Operating Characteristics curve were 0.89 and 0.90 in the internal and external patient cohort.

CONCLUSIONS

Our study provides six WLI-based morphological features predicting for lesion depth of SESCC. Our findings will make endoscopic evaluation of invasion depth for SESCC more convenient by assessing these profiles.

Endoscopic submucosal dissection versus esophagectomy for t1 esophageal squamous cell carcinoma: a propensity score-matched analysis

BACKGROUND

Endoscopic submucosal dissection (ESD) has been a preferred treatment option for superficial esophageal squamous cell carcinoma (SESCC).

OBJECTIVES

To compare the outcomes of ESD and esophagectomy in the treatment of SESCC, especially for lesions invading muscularis mucosa or submucosa (pT1a-MM/T1b).

DESIGN

We retrospectively analyzed data from patients with SESCC who underwent ESD or esophagectomy between 2015 and 2021.

METHODS

After propensity score matching, overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS), and treatment-related events were compared between the ESD and esophagectomy groups. Furthermore, we performed a Cox regression analysis to identify factors associated with survival.

RESULTS

OS and DSS were significantly higher in the ESD group (n = 508) than that in the esophagectomy group (n = 466). After matching, 404 patients (202 per group) were included in the study. No significant differences were found between the ESD and esophagectomy groups in OS (p = 0.566), RFS (p = 0.586), and DSS (p = 0.912). The ESD group showed less blood loss, shorter procedure duration and hospital stay, lower hospital cost, and fewer adverse events. However, a lower R0 resection rate was observed in the ESD group compared to the esophagectomy group. Subgroup analysis showed comparable survival outcomes between the two groups. In Cox regression analysis, age was the independent factor associated with OS.

CONCLUSION

In the treatment of SESCC, ESD showed sufficient safety and advantages. Even for pT1a-MM/pT1b SESCC, ESD may be an alternative treatment to esophagectomy.

Study of preoperative diagnostic modalities in Chinese patients with superficial esophageal squamous cell carcinoma

BACKGROUND

Endoscopic ultrasonography (EUS) and magnifying endoscopy (ME) reliably determine indications for endoscopic resection in patients with superficial esophageal squamous cell carcinoma (SESCC). ME is widely accepted for predicting the invasion depth of superficial esophageal cancer with satisfying accuracy. However, the addition of EUS is controversial.

AIM

To evaluate the diagnostic efficiency of ME vs EUS for invasion depth prediction and investigate the influencing factors in patients with SESCC to determine the best diagnostic model in China.

METHODS

We retrospectively analyzed patients with suspected SESCC who completed both ME and EUS and then underwent endoscopic or surgical resection at Sun Yat-Sen University Cancer Center between January 2018 and December 2021. We evaluated and compared the diagnostic efficiency of EUS and ME according to histological results, and investigated the influencing factors.

RESULTS

We included 152 lesions from 144 patients in this study. The diagnostic accuracies of ME and EUS in differentiating invasion depth were not significantly different (73.0% and 66.4%, P = 0.24); both demonstrated moderate consistency with the pathological results (ME: kappa = 0.58, 95% confidence interval [CI]: 0.48-0.68, P < 0.01; EUS: kappa = 0.46, 95%CI: 0.34-0.57, P < 0.01). ME was significantly more accurate in the diagnosis of high-grade intraepithelial (HGIN) or carcinoma in situ (odds ratio [OR] = 3.62, 95%CI: 1.43-9.16, P = 0.007) subgroups. Using a miniature probe rather than conventional EUS can improve the accuracy of lesion depth determination (82.3% vs 49.3%, P < 0.01). Less than a quarter of circumferential occupation and application of a miniature probe were independent risk factors for the accuracy of tumor invasion depth as assessed by EUS (< 1/4 circumferential occupation: OR = 3.07, 95%CI: 1.04-9.10; application of a miniature probe: OR = 5.28, 95%CI: 2.41-11.59, P < 0.01). Of the 41 lesions (41/152, 27.0%) that were misdiagnosed by ME, 24 were corrected by EUS (24/41, 58.5%).

CONCLUSION

Preoperative diagnosis of SESCC should be conducted endoscopically using white light and magnification. In China, EUS can be added after obtaining patient consent. Use of a high-frequency miniature probe or miniature probe combined with conventional EUS is preferable.

Management of Superficial Esophageal Squamous Cell Carcinoma and Early Gastric Cancer following Non-Curative Endoscopic Resection

According to the European and Japanese guidelines, additional treatment is recommended for cases of superficial esophageal squamous cell carcinoma (ESCC) and early gastric cancer (EGC) that do not meet the curability criteria for endoscopic resection (ER), i.e., non-curative ER, owing to the risk of lymph node metastasis (LNM). However, the rates of LNM in such cases were relatively low (e.g., 8% for EGC). Several recent advances have been made in this field. First, pathological risk stratification for metastatic recurrence following non-curative ER without additional treatment was developed for both superficial ESCC and EGC. Second, the pattern of metastatic recurrence and prognosis after recurrence following non-curative ER without additional treatment was found to be considerably different between superficial ESCC and EGC. Third, a combination of ER and selective chemoradiotherapy was developed as a minimally invasive treatment method for clinical T1b-SM ESCC. These findings may help clinicians decide the treatment strategy for patients following non-curative ER; however, for optimal therapeutic decision-making in such patients, it is also important to predict the prognosis other than SESCC or EGC and impaired quality of life. Thus, a novel algorithm that considers these factors, as well as metastatic recurrence, should be developed.

Endoscopic imaging modalities for diagnosing the invasion depth of superficial esophageal squamous cell carcinoma: a systematic review

Endoscopic diagnosis of the invasion depth of superficial esophageal squamous cell carcinoma (ESCC) is an important determinant of the treatment strategy. The three endoscopic imaging modalities commonly used to predict the invasion depth of superficial ESCC in Japan are non-magnifying endoscopy (non-ME), magnifying endoscopy (ME), and endoscopic ultrasonography (EUS). However, which of these three modalities is most effective remains unclear. We performed a systematic review of the literature to compare the diagnostic accuracy of the three modalities for prediction of the invasion depth of superficial ESCC. We used Medical Subject Heading terms and free keywords to search the PubMed, Cochrane Central, and Ichushi databases to identify direct comparison studies published from January 2000 to August 2020. The results of direct comparison studies were used to compare the diagnostic accuracy of each modality. The primary outcome was defined as the proportion of overdiagnosis of pT1b-SM2/3 cancers, and the main secondary outcome was the proportion of underdiagnosis of pT1b-SM2/3 cancers. Other secondary outcomes were the sensitivity and specificity values of the modalities. Four articles were finally selected for qualitative evaluation. Although ME showed no significant advantages over non-ME in terms of sensitivity and specificity, it had a slightly lower proportion of overdiagnosis. EUS had sensitivity and specificity similar to those of non-ME and ME, but EUS had a higher proportion of overdiagnosis. Non-ME and ME are useful for the diagnosis of cancer invasion depth. EUS may increase overdiagnosis, and caution is required in determining its indications.

Efficacy of Digestive Endoscope Based on Artificial Intelligence System in Diagnosing Early Esophageal Carcinoma

Objective

To explore the efficacy of digestive endoscopy (DEN) based on artificial intelligence (AI) system in diagnosing early esophageal carcinoma.

Methods

The clinical data of 300 patients with suspected esophageal carcinoma treated in our hospital from January 2018 to January 2020 were retrospectively analyzed; among them, 198 were diagnosed with esophageal carcinoma after pathological examination, and 102 had benign esophageal lesion. An AI system based on convolutional neural network (CNN) was adopted to assess the DEN images of patients with early esophageal carcinoma. A total of 200 patients (148 with early esophageal carcinoma and 52 with benign esophageal lesion) were selected as the learning group for the Inception V3 image classification system to learn; and the rest 100 patients (50 with early esophageal carcinoma and 50 with benign esophageal lesion) were included in the diagnosis group for the Inception V3 system to assist the narrow-band imaging (NBI) with diagnosis. The diagnosis results from Inception V3-assisted NBI were compared with those from imaging physicians, and the diagnostic efficacy diagram was drawn.

Results

The diagnosis rate of AI-NBI was significantly faster than that of physician diagnosis (0.02 ± 0.01 vs. 5.65 ± 0.32 s (mean rate of two physicians), P < 0.001); between AI-NBI diagnosis and physician diagnosis, no statistical differences in sensitivity (90.0% vs. 92.0%), specificity (92.0% vs. 94.0%), and accuracy (91.0% vs. 93.0%) were observed (P > 0.05); and according to the ROC curves, AUC (95% CI) of AI-NBI diagnosis = 0.910 (0.845-0.975), and AUC (95% CI) of physician diagnosis = 0.930 (0.872-0.988).

Conclusion

CNN-based AI system can assist NBI in screening early esophageal carcinoma, which has a good application prospect in the clinical diagnosis of early esophageal carcinoma.

Positive predictive value of the clinical diagnosis of T1a-epithelial/lamina propria esophageal cancer depends on lesion size

OBJECTIVES

Endoscopic resection (ER) is a minimally invasive treatment for esophageal squamous cell carcinoma (ESCC). However, stricture may develop after ER for widespread lesions. Application of ER is justified if these cancers are pathological T1a-epithelial/lamina propria (pEP/LPM) cancers that can be cured by ER. We conducted a study to clarify the association between pathological invasion depth and lesion size or circumference in clinical (c) EP/LPM cancers.

METHODS

From our database, we identified patients diagnosed with cEP/LPM ESCC via endoscopic examination who underwent endoscopic or surgical tumor resection. The accuracy of the cEP/LPM ESCC diagnosis was determined by histologically diagnosing cancer invasion depth as a reference standard.

RESULTS

Between January 2015 and December 2019, 1271 cancer patients were diagnosed with cEP/LPM ESCC, of which 1195 (94.0%) were correctly diagnosed with pEP/LPM cancer. The positive predictive value (PPV) classified according to lesion sizes of ≤25, 26-49, and ≥50 mm was 95.8% (981/1024 lesions), 89.7% (191/213 lesions), and 67.6% (23/34 lesions), respectively. PPV according to the circumferential extent of <3/4, ≥3/4, and <1, and whole was 94.6% (1164/1230 lesions), 75.0% (24/32 lesions), and 77.8% (7/9 lesions), respectively. In multivariate analysis, the PPV of cEP/LPM ESCC was significantly associated with lesion size (P < 0.001) and male sex.

CONCLUSIONS

Between January 2015 and December 2019, 1271 cancer patients were diagnosed with cEP/LPM ESCC, of which 1195 (94.0%) were correctly diagnosed with pEP/LPM cancer. The PPV of cEP/LPM ESCC was related to lesion size. Treatment should be determined considering the high risk of cancer invasion into the muscularis mucosa or deeper in cEP/LPM cancers with a lesion size of ≥50 mm.

Anal Intraepithelial Neoplasia: Precursor of Anal Squamous Cell Carcinoma

Anal squamous cell carcinoma (SCC) is rare, but it has been commonly detected as an invasive cancer. The standard treatment for anal SCC was surgical resection. However, recent medical advances have enabled the standard treatment to be chemoradiotherapy. Anal intraepithelial neoplasia (AIN) is a premalignant lesion of SCC. The screening test for AIN and human papilloma virus vaccine are important for the following high-risk patients: patients positive for human immunodeficiency virus and men who have sexual intercourse with men. Although cytology can be easily applied for a screening test, the false-negative rate for AIN is high. Instead, high-resolution anoscopy (HRA) has been gaining attention as a promising screening method for high-risk patients. Investigations comparing characteristic findings of HRA with the histology of AIN have demonstrated that HRA is a highly specific test for AIN. Magnifying or image-enhanced endoscopies are also routinely used for colonoscopy, as they allow detailed observations at higher magnifications than those of HRA. Hence, these endoscopic modalities can be applied for assessing AIN. Ablation therapies or topical medications are available as the local treatment for AIN. Although endoscopic submucosal dissection is considered to be feasible to remove AIN, it has a technical difficulty to approach endoscopically invisible areas. Hence, this technique may be useful to resect AIN localized in the endoscopically visible areas, when the localization is confirmed via targeted biopsy.

Current status of endoscopic detection, characterization and staging of superficial esophageal squamous cell carcinoma

BACKGROUND

This review focuses on the current status of endoscopic detection, characterization and tumour category staging of oesophagealsquamous cell carcinoma.

DETECTION

The diagnostic yield of white-light imaging is limited and narrow-band imaging has demonstrated a better performance for detecting oesophageal cancer. Narrow-band imaging has also shown similar sensitivity and superior specificity to iodine staining.

CHARACTERIZATION

Accurate differentiation between cancerous and non-cancerous lesions can be achieved by magnifying narrow-band imaging or iodine staining with confirmation of a pink-colour sign. A per-patient analysis of a randomized study showed similar sensitivities, specificities and overall accuracies of magnifying narrow-band imaging and iodine staining of 82.2%, 95.1% and 91.2%, and 80.5%, 94.3% and 90.5%, respectively.

TUMOUR-STAGING

The diagnostic capability of endoscopic ultrasonography after conventional and narrow-band imaging in terms of tumour depth was evaluated in a multicentre prospective study. Endoscopic ultrasonography did not significantly improve the accuracy for distinguishing between mucosal or submucosal microinvasive cancer and deeper cancers from 72.9 to 74.0%, suggesting that additional endoscopic ultrasonography did not improve the diagnostic accuracy. In addition, endoscopic ultrasonography increased the incidence of overdiagnosis, defined as a diagnosis of cancer depth greater than the actual depth, by 6.6%. The risk of overdiagnosis by endoscopic ultrasonography was reconfirmed in two systematic reviews.

CONCLUSIONS

Narrow-band imaging is currently considered as the standard modality for the detection and characterization of oesophageal cancer. The risk of overdiagnosis should be considered when applying endoscopic ultrasonography for the evaluation of tumour invasion depth of superficial oesophageal squamous cell carcinoma.

Endoscopic Diagnosis and Treatment of Superficial Esophageal Squamous Cell Cancer: Present Status and Future Perspectives

This review provides information regarding the preoperative examinations, indications for endoscopic resection (ER), and curability assessment in subjects with superficial esophageal squamous cell carcinoma (SCC). Narrow-band imaging (NBI) is a more sensitive modality for detecting esophageal cancer than conventional observation, and esophageal observation using NBI is thus recommended for the detection of superficial esophageal cancer. It is also important to adjust the volume of air in the esophagus during observation. Workup by non-magnifying followed by magnifying endoscopy is a common process for diagnosing the invasion depth of superficial esophageal SCCs in Japan. Endoscopic ultrasonography carries a risk of overdiagnosis, and its routine use is therefore not recommended. The Japanese endoscopic submucosal dissection/endoscopic mucosal resection guidelines for esophageal cancer considered the indications for ER based on the results of studies focusing on clinical MM/SM1 cancers, and concluded that clinical MM/SM1 carcinomas, except circumferential carcinoma, were an indication for ER. The curative effect of ER should be assessed based on histologic examination of the resected specimens. ER should be conducted based on a thorough understanding of the preoperative diagnosis, indication, curability, and additional treatment of esophageal SCC.