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Tayar E, Ladna M, King W, Gupte AR, Paudel B, Sarheed A, Rosasco R, Qumseya BJ. Safety of cold resection of non-ampullary duodenal polyps: Systematic review and meta-analysis. Endosc Int Open 2024; 12:E732-E739. [PMID: 38847013 PMCID: PMC11156513 DOI: 10.1055/a-2306-6535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 03/22/2024] [Indexed: 06/09/2024] Open
Abstract
Background and study aims Endoscopic resection has traditionally involved electrosurgical cautery (hot snare) to resect premalignant polyps. Recent data have suggested superior safety of cold resection. We aimed to assess the safety of cold compared with traditional (hot) resection for non-ampullary duodenal polyps. Methods We performed a systematic review ending in September 2022. The primary outcome of interest was the adverse event (AE) rate for cold compared with hot polyp resection. We reported odds ratios with 95% confidence intervals (CIs). Secondary outcomes included rates of polyp recurrence and post-polypectomy syndrome. We assessed publication bias with the classic fail-safe test and used forest plots to report pooled effect estimates. We assessed heterogeneity using I 2 index. Results Our systematic review identified 1,215 unique citations. Eight of these met inclusion criteria, seven of which were published manuscripts and one of which was a recent meeting abstract. On random effect modeling, cold resection was associated with significantly lower odds of delayed bleeding compared with hot resection. The difference in the odds of perforation (odds ratio [OR] 0.31 [95% confidence interval [CI] 0.05-2.87], P =0.2, I 2 =0) and polyp recurrence (OR 0.75 [95% CI 0.15-3.73], P =0.72, I 2 =0) between hot and cold resection was not statistically significant. There were no cases of post-polypectomy syndrome reported with either hot or cold techniques. Conclusions Cold resection is associated with lower odds of delayed bleeding compared with hot resection for duodenal tumors. There was a trend toward higher odds of perforation and recurrence following hot resection, but this trend was not statistically significant.
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Affiliation(s)
- Elias Tayar
- Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Michael Ladna
- Internal Medicine, University of Florida, Gainesville, United States
| | - William King
- Internal Medicine, University of Florida, Gainesville, United States
| | - Anand R Gupte
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, United States
| | - Bishal Paudel
- Internal Medicine, University of Florida, Gainesville, United States
| | - Ahmed Sarheed
- Internal Medicine, University of Florida, Gainesville, United States
| | - Robyn Rosasco
- Library, Florida State University, Tallahassee, United States
| | - Bashar J. Qumseya
- Gastroenterology, Hepatology, and Nutrition, University of Florida Health, Gainesville, United States
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Uema R, Hayashi Y, Komori M, Shibukawa N, Hayashi N, Horimoto M, Yamada T, Yamamoto M, Hiyama S, Kinoshita K, Ogiyama H, Yamaguchi S, Egawa S, Kanesaka T, Kato M, Yoshii S, Tsujii Y, Keiichiro H, Shinzaki S, Iijima H, Morii E, Takehara T. Non-Pure Intestinal Phenotype as an Indicator of Progression in Sporadic Nonampullary Duodenal Adenomas: A Multicenter Retrospective Cohort Study. Clin Transl Gastroenterol 2024; 15:e00649. [PMID: 37991249 PMCID: PMC10810609 DOI: 10.14309/ctg.0000000000000649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 09/19/2023] [Indexed: 11/23/2023] Open
Abstract
INTRODUCTION We aimed to evaluate the natural course of sporadic nonampullary duodenal adenomas (SNDAs) and determine the risk factors of progression. METHODS We retrospectively analyzed the follow-up outcomes of patients with biopsy-diagnosed SNDA between April 2010 and March 2016 at 13 institutions. All initial biopsy specimens were centrally evaluated. Only those diagnosed with adenomas were included. Mucinous phenotypes were classified into pure intestinal and non-pure intestinal phenotypes. Cumulative incidence rates of carcinoma and tumor enlargement were evaluated. Tumor enlargement was defined as a ≥25% or 5-mm increase in tumor size. RESULTS Overall, 121 lesions were analyzed. Within a median observation period of 32.7 months, 5 lesions were diagnosed as carcinomas; the cumulative 5-year incidence of carcinoma was 9.5%. Male sex ( P = 0.046), initial lesion size ≥10 mm ( P = 0.044), and non-pure intestinal phenotype ( P = 0.019) were significantly associated with progression to carcinoma. Tumor enlargement was observed in 22 lesions, with a cumulative 5-year incidence of 33.9%. Initial lesion size ≥10 mm ( P < 0.001), erythematous lesion ( P = 0.002), high-grade adenoma ( P = 0.002), Ki67 negative ( P = 0.007), and non-pure intestinal phenotype ( P = 0.001) were risk factors of tumor enlargement. In a multivariate analysis, an initial lesion size ≥10 mm ( P = 0.010) and non-pure intestinal phenotype ( P = 0.046) were independent and significant risk factors of tumor enlargement. DISCUSSION Lesion size ≥10 mm and non-pure intestinal phenotype on initial biopsy are risk factors of cancer progression and tumor enlargement in cases with SNDA. Thus, management effectiveness may be improved by focusing on lesion size and the mucinous phenotype.
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Affiliation(s)
- Ryotaro Uema
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoshito Hayashi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Masato Komori
- Department of Gastroenterology, Hyogo Prefectural Nishinomiya Hospital, Nishinomiya, Hyogo, Japan
| | - Narihiro Shibukawa
- Department of Gastroenterology, Daini Osaka Police Hospital, Osaka, Osaka, Japan
| | - Noriko Hayashi
- Department of Gastroenterology, Nishinomiya Municipal Central Hospital, Nishinomiya, Hyogo, Japan
| | - Masayoshi Horimoto
- Department of Gastroenterology, Saiseikai Senri Hospital, Suita, Osaka, Japan
| | - Takuya Yamada
- Department of Gastroenterology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Masashi Yamamoto
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Satoshi Hiyama
- Department of Gastroenterology, Japan Community Health Care Organization Osaka Hospital, Osaka, Osaka, Japan
| | - Kazuo Kinoshita
- Department of Gastroenterology, Otemae Hospital, Osaka, Osaka, Japan
| | - Hideharu Ogiyama
- Department of Gastroenterology, Itami City Hospital, Itami, Hyogo, Japan
| | - Shinjiro Yamaguchi
- Department of Gastroenterology, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Satoshi Egawa
- Department of Internal Medicine, Osaka Police Hospital, Osaka, Osaka, Japan
| | - Takashi Kanesaka
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Osaka, Japan
| | - Minoru Kato
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Shunsuke Yoshii
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoshiki Tsujii
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Honma Keiichiro
- Department of Pathology, Osaka International Cancer Institute, Osaka, Osaka, Japan
- Department of Pathology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
| | - Shinichiro Shinzaki
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hideki Iijima
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Department of Internal Medicine, Osaka Police Hospital, Osaka, Osaka, Japan
| | - Eiichi Morii
- Department of Pathology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
| | - Tetsuo Takehara
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Tanaka I, Hirasawa D, Saito H, Akahira J, Matsuda T. Usefulness of the S-O clip for duodenal endoscopic submucosal dissection: a propensity score-matched study. Clin Endosc 2023; 56:769-777. [PMID: 37524568 PMCID: PMC10665626 DOI: 10.5946/ce.2022.195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/22/2022] [Accepted: 10/08/2022] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND/AIMS Endoscopic submucosal dissection (ESD) for superficial non-ampullary duodenal tumors (SNADETs) is associated with a high rate of en bloc resection. However, the technique for ESD remains challenging. Recent studies have demonstrated the effectiveness of S-O clips in colonic and gastric ESD. We evaluated the efficacy and safety of duodenal ESD using an S-O clip for SNADETs. METHODS Consecutive patients who underwent ESD for SNADETs between January 2011 and December 2021 were retrospectively enrolled. Propensity score matching analysis was used to compare patients who underwent duodenal ESD with the S-O clip (S-O group) and those who underwent conventional ESD (control group). Intraoperative perforation rate was the primary outcome, while procedure time and R0 resection rate were the secondary outcomes. RESULTS After propensity score matching, 16 pairs were created: 43 and 17 in the S-O and control groups, respectively. The intraoperative perforation rate in the S-O group was significantly lower than that in the control group (p=0.033). A significant difference was observed in the procedure time between the S-O and control groups (39±9 vs. 82±30 minutes, respectively; p=0.003). CONCLUSION The S-O clip reduced the intraoperative perforation rate and procedure time, which may be useful and effective in duodenal ESD.
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Affiliation(s)
- Ippei Tanaka
- Department of Gastroenterology, Sendai Kousei Hospital, Sendai, Japan
| | - Dai Hirasawa
- Department of Gastroenterology, Sendai Kousei Hospital, Sendai, Japan
| | - Hiroaki Saito
- Department of Gastroenterology, Sendai Kousei Hospital, Sendai, Japan
| | - Junichi Akahira
- Department of Pathology, Sendai Kousei Hospital, Sendai, Japan
| | - Tomoki Matsuda
- Department of Gastroenterology, Sendai Kousei Hospital, Sendai, Japan
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4
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Zhao Z, Jiao Y, Yang S, Zhou A, Zhao G, Guo S, Li P, Zhang S. Endoscopic diagnosis and treatment of superficial non-ampullary duodenal epithelial tumors: A review. J Transl Int Med 2023; 11:206-215. [PMID: 37662895 PMCID: PMC10474890 DOI: 10.2478/jtim-2023-0102] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023] Open
Abstract
The surface of the small bowel mucosa is covered more than any other section of the digestive canal; however, the overall prevalence of small bowel tumors of the whole gastrointestinal tract is evidently low. Owing to the improvement in endoscopic techniques, the prevalence of small bowel tumors has increased across multiple countries, which is mainly due to an increase in duodenal tumors. Superficial non-ampullary duodenal epithelial tumors (SNADETs) are defined as tumors originating from the non-ampullary region in the duodenum that share similarities and discrepancies with their gastric and colorectal counterparts in the pathogenesis and clinicopathologic characteristics. To date, white light endoscopy (WLE) remains the cornerstone of endoscopic diagnosis for SNADETs. Besides, narrow-band imaging (NBI) techniques and magnifying endoscopy (ME) have been widely used in the clinic and endorsed by multiple guidelines and consensuses for SNADETs' evaluation. Confocal laser endomicroscopy (CLE), endocytoscopy (ECS), and artificial intelligence (AI) are also up-and-coming methods, showing an exceptional value in the diagnosis of SNADETs. Similar to the endoscopic treatment for colorectal polyps, the choices for SNADETs mainly include cold snare polypectomy (CSP), endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and laparoscopic endoscopic cooperative surgery (LECS). However, owing to the narrow lumen, rich vascularity, weak muscle layer, abundant Brunner's gland, and the hardship of endoscope control, the duodenum ranks as one of the most dangerous operating areas in the digestive tract. Therefore, endoscopists must anticipate the difficulties in endoscopic maneuverability, remain aware of the increased risk of complications, and then select the appropriate treatment according to the advantages and disadvantages of each method.
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Affiliation(s)
- Zheng Zhao
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing100050, China
| | - Yue Jiao
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing100050, China
| | - Shuyue Yang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing100050, China
| | - Anni Zhou
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing100050, China
| | - Guiping Zhao
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing100050, China
| | - Shuilong Guo
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing100050, China
| | - Peng Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing100050, China
| | - Shutian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing100050, China
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Yang Q, Liu Z, Sun H, Jiao F, Zhang B, Chen J. A narrative review: narrow-band imaging endoscopic classifications. Quant Imaging Med Surg 2023; 13:1138-1163. [PMID: 36819279 PMCID: PMC9929402 DOI: 10.21037/qims-22-728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 12/11/2022] [Indexed: 01/15/2023]
Abstract
Background and Objective With the development of endoscopic techniques, narrow-band imaging (NBI) has been widely used in the diagnosis of various types of diseases. NBI can detect mucosal lesions at an early stage and different classification strategies have been established to help clinicians in disease diagnosis. However, there is currently no consensus for the classification criteria. This report summarizes the current classifications of diseases using NBI, so as to provide a comprehensive understanding of the various manifestations of mucosal lesions under NBI, and to promote the development of more practical NBI classifications. Methods The PubMed database was searched for English language articles published between January 1994 and November 2021 using the keywords 'narrow band imaging', 'NBI', and 'classification'. Key Content and Findings We systematically summarized the NBI classifications and manifestations of different diseases. The morphology of the mucosa and vessels was used as the basis of most classifications. These classifications are mainly helpful to distinguish benign and malignant tumors and to detect early neoplastic lesions. Conclusions This review summarized existing NBI classifications for different systems. These classifications will be updated as the understanding of diseases increases and new optical techniques become available to better assist doctors in making clinical decisions.
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Affiliation(s)
- Qingya Yang
- Department of Urology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Zhimei Liu
- Department of Clinical Medicine, Qingdao Medical College, Qingdao University, Qingdao, China
| | - Hui Sun
- Department of Urology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Fangdong Jiao
- Department of Urology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Bing Zhang
- Department of Urology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Jun Chen
- Department of Urology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
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6
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Toya Y, Endo M, Sugai T, Matsumoto T. Current status and perspectives for endoscopic diagnosis of superficial nonampullary duodenal epithelial tumors. Dig Endosc 2023. [PMID: 36626023 DOI: 10.1111/den.14514] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 01/06/2023] [Indexed: 01/11/2023]
Abstract
In recent years, there have been significant advances in the endoscopic resection (ER) procedures of superficial nonampullary duodenal epithelial tumors (SNADETs). A preoperative endoscopic diagnosis is thus deemed necessary in determining the indication for subsequent ER. For the histologic and endoscopic diagnosis of SNADETs, understanding the mucin phenotype is inevitable. Recently, two diagnostic algorithms for the differential diagnosis of SNADETs from nonneoplastic lesions under magnifying endoscopy with narrow-band imaging have been proposed. In addition, various endoscopic approaches have been proposed to differentiate low- and high-grade adenomas/carcinomas, including white light endoscopy, magnifying image-enhanced endoscopy, and endocytoscopy. These methods, however, have not been standardized with respect to the classification of their findings and the validation of their diagnostic accuracy. Moreover, there are still concerns with respect to the histologic criteria required to establish a SNADETs diagnosis. Standardization in the histologic and endoscopic diagnosis of SNADETs is needed.
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Affiliation(s)
- Yosuke Toya
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Masaki Endo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Iwate, Japan.,Kaiunbashi Endoscopy Clinic, Iwate, Japan
| | - Tamotsu Sugai
- Division of Molecular Diagnostic Pathology, Department of Pathology, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Iwate, Japan
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7
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Miura H, Tanaka K, Umeda Y, Ikenoyama Y, Yukimoto H, Hamada Y, Yamada R, Tsuboi J, Nakamura M, Katsurahara M, Horiki N, Nakagawa H. Usefulness of magnifying endoscopy with acetic acid and narrow-band imaging for the diagnosis of duodenal neoplasms: proposal of a diagnostic algorithm. Surg Endosc 2022; 36:8086-8095. [PMID: 35449476 DOI: 10.1007/s00464-022-09239-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 04/02/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND This study aimed to clarify the features of superficial non-ampullary duodenal epithelial tumors (SNADETs) on magnifying endoscopy with narrow-band imaging (M-NBI) and magnifying endoscopy with acetic acid and narrow-band imaging (M-AANBI), and evaluate the efficacy of M-NBI/M-AANBI to distinguish high-grade adenomas or adenocarcinomas (HGA/AC) from low-grade adenomas (LGA). METHODS Clinicopathological data on 62 SNADETs in 58 patients who underwent preoperative M-NBI/M-AANBI and endoscopic resection were retrospectively reviewed. The pathological results were classified into two categories, LGA and HGA/AC. We evaluated microvascular patterns (MVPs) and microsurface patterns (MSPs) observed by M-NBI and MSPs observed by M-AANBI for characterizing LGA and HGA/AC. The kappa value was calculated to assess the interobserver and intraobserver agreements of evaluation of M-AANBI images. RESULTS Pathologically, 38 lesions (61.3%) were LGA and 24 lesions (38.7%) were HGA/AC. HGA/AC tended to have irregular MVP and/or MSP on M-NBI. M-NBI diagnostic performance to distinguish HGA/AC from LGA showed 62.5% sensitivity, 68.4% specificity, and 66.1% accuracy. SNADETs had irregular MSP on M-AANBI. Three irregularity grades (iG) of MSP were observed by M-AANBI as follows: iG1, mild; iG2, moderate; iG3, significant. HGA/AC lesions had a significantly higher rate of iG3 than LGA lesions (p < 0.001). The iG2 was associated with HGA/AC in elevated lesions and LGA in depressed lesions. The diagnostic performance of M-AANBI was as follows: 95.8% sensitivity, 97.4% specificity, and 96.8% accuracy. The diagnostic accuracy of M-AANBI was significantly higher than that of M-NBI (p < 0.001). The kappa value for interobserver agreement on the diagnosis and irregularity grading of M-AANBI images was 0.742 and 0.719, respectively. These data indicate substantial interobserver agreement. Based on the above-mentioned results, we developed a M-AANBI diagnostic algorithm for SNADETs. CONCLUSION The diagnostic algorithm for SNADETs using M-AANBI may be useful for differentiating between LGA and HGA/AC.
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Affiliation(s)
- Hiroshi Miura
- Department of Endoscopy, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Kyosuke Tanaka
- Department of Endoscopy, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Japan.
| | - Yuhei Umeda
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Yohei Ikenoyama
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hiroki Yukimoto
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Yasuhiko Hamada
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Reiko Yamada
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Junya Tsuboi
- Department of Endoscopy, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Misaki Nakamura
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Masaki Katsurahara
- Department of Endoscopy, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Noriyuki Horiki
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hayato Nakagawa
- Department of Endoscopy, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Japan
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Kanzaki H, Horii J, Takenaka R, Nakagawa H, Matsueda K, Tsuzuki T, Kita M, Yamasaki Y, Tanaka T, Iwamuro M, Kawano S, Kawahara Y, Tomoda J, Okada H. Prospective multicenter study of the efficacy and safety of cold forceps polypectomy for ≤ 6-mm non-ampullary duodenal low-grade adenomas. Endosc Int Open 2022; 10:E712-E718. [PMID: 35859656 PMCID: PMC9289977 DOI: 10.1055/a-1793-9439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 12/20/2021] [Indexed: 11/29/2022] Open
Abstract
Background and study aims Because the endoscopic treatment for non-ampullary duodenal adenoma (NADA) has a non-negligible risk of adverse events (AEs), a safe and easy treatment for NADA is desirable. This was a multicenter prospective trial evaluating the efficacy and safety of cold forceps polypectomy (CFP) for diminutive NADAs. Patients and methods This study was prospectively conducted at six general hospitals and one university hospital. The inclusion criteria were histologic and endoscopic diagnosis of low-grade NADA measuring ≤ 6 mm. A second endoscopy was scheduled for 1 month after CFP. After confirmation of the success of CFP, 6-month and 12-month surveillance endoscopies were scheduled. The primary endpoint was the endoscopic and histologic disease disappearance rates at the 12-month endoscopy. Results Thirty-nine lesions from 38 patients were prospectively included. Median tumor size at enrollment was 5 mm (range 3-6 mm). There were four cases of remnant lesions at the second endoscopy, and the lesion disappearance rate of single CFP was 89.7 % (35 /39; 95 % confidence interval (CI), 76.9 %-97.9 %). In three cases, complete removal of the lesion was achieved with a single re-CFP, but one case required four repeat CFPs. The lesion disappearance rate at 12-month endoscopy was 97.4 % (38 /39; 95 %CI, 86.8 %-99.5 %). During the follow-up period, no AEs related to CFP were observed. Conclusions CFP for NADA ≤ 6 mm was safe and effective in this study. This common endoscopic method to remove lesions may be an option for treatment of diminutive NADAs.
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Affiliation(s)
- Hiromitsu Kanzaki
- Department of Gastroenterology, Okayama University Hospital, Okayama,
Japan
| | - Joichiro Horii
- Department of Gastroenterology, Fukuyama Medical Center, Hiroshima,
Japan
| | - Ryuta Takenaka
- Department of Internal Medicine, Tsuyama Central Hospital, Okayama,
Japan
| | - Hiroyuki Nakagawa
- Department of Endoscopy, Hiroshima City Hiroshima Citizens Hospital, Hiroshima,
Japan
| | - Kazuhiro Matsueda
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital,
Okayama, Japan
| | - Takao Tsuzuki
- Department of Internal Medicine, Himeji Red Cross Hospital, Hyogo,
Japan
| | - Masahide Kita
- Department of Gastroenterology, Okayama City Hospital, Okayama,
Japan
| | - Yasushi Yamasaki
- Department of Gastroenterology, Okayama University Hospital, Okayama,
Japan
| | - Takehiro Tanaka
- Department of Pathology, Okayama University Graduate School of Medicine,
Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masaya Iwamuro
- Department of Gastroenterology, Okayama University Hospital, Okayama,
Japan
| | - Seiji Kawano
- Department of Gastroenterology, Okayama University Hospital, Okayama,
Japan
| | - Yoshiro Kawahara
- Department of Practical Gastrointestinal Endoscopy, Okayama University Graduate
School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Jun Tomoda
- Department of Internal Medicine, Akaiwa Medical Association Hospital, Okayama,
Japan
| | - Hiroyuki Okada
- Department of Gastroenterology, Okayama University Hospital, Okayama,
Japan
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9
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Tashima T, Jinushi R, Ishii N, Kawasaki T, Miyaguchi K, Terada R, Nakano Y, Mashimo Y, Ogawa T, Fujita A, Tanisaka Y, Mizuide M, Ryozawa S. Effectiveness of clip-and-thread traction-assisted duodenal endoscopic submucosal dissection: a propensity score-matched study (with video). Gastrointest Endosc 2022; 95:918-928.e3. [PMID: 34979111 DOI: 10.1016/j.gie.2021.12.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/17/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS The indications for endoscopic submucosal dissection (ESD) in superficial nonampullary duodenal epithelial tumors (SNADETs) remain controversial because the procedure is technically challenging. Moreover, the effectiveness of clip-and-thread traction-assisted ESD (TA-ESD) for SNADETs has not been assessed. The aim of the current study was to compare the effectiveness of duodenal TA-ESD and conventional ESD for SNADETs. METHODS SNADETs treated with conventional ESD or TA-ESD between April 2017 and March 2021 at Saitama Medical University International Medical Center were evaluated retrospectively. RESULTS There were 49 cases of conventional ESD and 32 cases of TA-ESD for SNADETs. Using a propensity score-matched design, we selected 26 pairs of cases with conventional ESD and TA-ESD. In the unmatched cohort, patients treated with TA-ESD were characterized by a higher R0 (no tumor identified at the lateral or vertical margins) resection rate (P = .004), more frequent poor submucosal lifting because of fibrosis (P = .014), and shorter follow-up period (P = .0004) than patients treated with conventional ESD. In the propensity score-matched pairs, patients treated with TA-ESD were characterized by a higher rate of R0 resection (P = .021) and a shorter follow-up period (P = .0061). The findings regarding R0 resection rates were confirmed by multivariate logistic regression models, which found a higher odds ratio (OR) for R0 resection in patients who underwent TA-ESD than in patients who underwent conventional ESD both in the unmatched cohort (OR, 17.0; 95% confidence interval, 1.6-178.8; P = .018) and in the propensity score-matched pairs (OR, 26.7; 95% confidence interval, 1.5-460.2; P = .024). CONCLUSIONS Our findings suggest TA-ESD may increase the rate of R0 resection in patients with SNADETs in comparison with conventional ESD.
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Affiliation(s)
- Tomoaki Tashima
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Ryuhei Jinushi
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Naoki Ishii
- Department of Gastroenterology, Tokyo Shinagawa Hospital, Tokyo, Japan
| | - Tomonori Kawasaki
- Department of Pathology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Kazuya Miyaguchi
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Rie Terada
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Yuya Nakano
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Yumi Mashimo
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Tomoya Ogawa
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Akashi Fujita
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Yuki Tanisaka
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Masafumi Mizuide
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Shomei Ryozawa
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
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Iwata K, Kato M, Nakayama A, Kanai T, Yahagi N. Case report: A case of laterally spreading duodenal cancer with slight submucosal invasion accompanied with concurrent lymph nodes metastasis. DEN OPEN 2022; 2:e100. [PMID: 35873515 PMCID: PMC9302270 DOI: 10.1002/deo2.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/14/2022] [Accepted: 01/19/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Kentaro Iwata
- Department of Internal Medicine Division of Gastroenterology and Hepatology Keio University School of Medicine Tokyo Japan
- Division of Research and Development for Minimally Invasive Treatment Cancer Center Keio University School of Medicine Tokyo Japan
| | - Motohiko Kato
- Department of Internal Medicine Division of Gastroenterology and Hepatology Keio University School of Medicine Tokyo Japan
- Division of Research and Development for Minimally Invasive Treatment Cancer Center Keio University School of Medicine Tokyo Japan
| | - Atsushi Nakayama
- Division of Research and Development for Minimally Invasive Treatment Cancer Center Keio University School of Medicine Tokyo Japan
| | - Takanori Kanai
- Department of Internal Medicine Division of Gastroenterology and Hepatology Keio University School of Medicine Tokyo Japan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment Cancer Center Keio University School of Medicine Tokyo Japan
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11
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Kitae H, Dohi O, Naito Y, Yasuda T, Yoshida T, Ishida T, Azuma Y, Matsumura S, Doi T, Hirose R, Inoue K, Yoshida N, Kamada K, Uchiyama K, Ishikawa T, Takagi T, Konishi H, Morinaga Y, Kishimoto M, Itoh Y. Linked Color Imaging and Blue Laser Imaging for the Diagnosis of Superficial Non-Ampullary Duodenal Epithelial Tumors. Dig Dis 2022; 40:693-700. [PMID: 35176739 DOI: 10.1159/000522399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 01/30/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND OBJECTIVE This study aimed to evaluate endoscopic findings using linked color imaging (LCI) and blue laser imaging (BLI) and to determine a diagnostic predictor for duodenal adenocarcinomas. METHODS All consecutive patients who underwent endoscopic resection for superficial non-ampullary duodenal epithelial tumors (SNADETs) between October 2012 and June 2019 were enrolled in this study. Two highly experienced endoscopists investigated six morphological findings using both white light imaging and LCI and three magnifying endoscopic findings using magnifying BLI (M-BLI). RESULTS A total of 90 patients with 110 SNADETs, including 87 adenocarcinomas and 23 adenomas, were analyzed in this study. Among the non-magnifying endoscopic findings, the presence of reddish color, orange color on LCI (orange color sign), lobulation, depression, and marginally white opaque substance were found significantly more frequently in adenocarcinomas than in adenomas (p = 0.015, p < 0.001, p = 0.048, p < 0.001, and p = 0.007, respectively). Among the magnifying endoscopic findings, a mixed microsurface pattern (MSP), irregular MSP, and irregular microvascular pattern were found significantly more frequently in adenocarcinomas than in adenomas (p < 0.001, p < 0.001, and p = 0.002, respectively). In the multivariate analysis of all endoscopic findings associated with adenocarcinoma, orange color sign (odds ratio [OR] 10.46; 95% confidence interval [CI]: 1.42-77.08; p = 0.021), mixed MSP (OR 4.66; 95% CI: 1.02-21.40; p = 0.048), and irregular MSP (OR 13.11; 95% CI: 1.41-121.99; p = 0.024) were independent predictors of adenocarcinoma. CONCLUSIONS The presence of orange color sign on LCI and mixed/irregular MSP on M-BLI were independent diagnostic predictors that were frequently observed in duodenal adenocarcinoma.
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Affiliation(s)
- Hiroaki Kitae
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan,
| | - Osamu Dohi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuji Naito
- Department of Human Immunology and Nutrition Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takeshi Yasuda
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takuma Yoshida
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tsugitaka Ishida
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuka Azuma
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shinya Matsumura
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Toshifumi Doi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Ryohei Hirose
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Ken Inoue
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Naohisa Yoshida
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kazuhiro Kamada
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kazuhiko Uchiyama
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takeshi Ishikawa
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomohisa Takagi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hideyuki Konishi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yukiko Morinaga
- Department of Surgical Pathology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Mitsuo Kishimoto
- Department of Surgical Pathology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.,Department of Pathology, Kyoto City Hospital, Kyoto, Japan
| | - Yoshito Itoh
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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12
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Kim DM, Kim GH, Lee BE, Kim K, Choi KU, Hong SM, Lee MW, Song GA. Histopathologic discrepancies between endoscopic forceps biopsy and endoscopic resection specimens in nonampullary duodenal epithelial tumors. Medicine (Baltimore) 2021; 100:e28307. [PMID: 34941121 PMCID: PMC8701868 DOI: 10.1097/md.0000000000028307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 11/23/2021] [Indexed: 01/05/2023] Open
Abstract
For patients with nonampullary duodenal epithelial tumors (NADETs), endoscopic forceps biopsy results that reflect the final histopathologic results of the entire lesion are indispensable for accurate diagnosis and appropriate treatment modality selection. This study aimed to investigate the histopathologic discrepancies between endoscopic forceps biopsy and endoscopic resection specimens in NADETs and to elucidate the factors contributing to such discrepancies.This retrospective observational study included 105 patients (105 lesions) who underwent endoscopic resection for NADETs at the Pusan National University Hospital between May 2006 and October 2019. NADETs were classified as low-grade intraepithelial neoplasms (LGINs), high-grade intraepithelial neoplasms (HGINs), or adenocarcinomas. Following slide reviews, the histopathologic concordance between endoscopic forceps biopsy and endoscopic resection specimens was assessed for each case.The histopathologic discrepancy rate between endoscopic forceps biopsy and endoscopic resection specimens was 19.0% (20/105 lesions). Among the 20 diagnostically discordant lesions, up- and downgrade of the histopathologic diagnosis occurred in 17 and 3 lesions, respectively. The predominant discrepancies involved upgrades from LGIN to HGIN (n = 14) and upgrades from LGIN to adenocarcinomas (n = 2). The 3 downgraded cases included 2 from LGIN to inflammation and 1 from HGIN to LGIN. In the multivariate analyses, the old age (>67 years) was the only factor significantly associated with histopathologic upgrade (odds ratio 4.553, 95% confidence interval 1.291-15.939; P = .018).Considerable histopathologic discrepancies were observed between endoscopic forceps biopsy and endoscopic resection specimens in NADETs. Older age was significantly associated with these discrepancies.
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Affiliation(s)
- Da Mi Kim
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, South Korea
| | - Gwang Ha Kim
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, South Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Bong Eun Lee
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, South Korea
| | - Kyungbin Kim
- Department of Pathology, Pusan National University College of Medicine, Busan, South Korea
| | - Kyung Un Choi
- Department of Pathology, Pusan National University College of Medicine, Busan, South Korea
| | - Seung Min Hong
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, South Korea
| | - Moon Won Lee
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, South Korea
| | - Geun Am Song
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, South Korea
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13
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Hirose T, Kakushima N, Furukawa K, Furune S, Ishikawa E, Sawada T, Maeda K, Yamamura T, Ishikawa T, Ohno E, Nakamura M, Nishida K, Yokoi T, Kawashima H, Fujishiro M. Endocytoscopy Is Useful for the Diagnosis of Superficial Nonampullary Duodenal Epithelial Tumors. Digestion 2021; 102:895-902. [PMID: 34098561 DOI: 10.1159/000516512] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 03/27/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Endoscopic criteria for the diagnosis of superficial nonampullary duodenal epithelial tumors (SNADETs) are lacking. The aim of this study was to explore the usefulness of endocytoscopy (ECS) in the duodenum. METHODS A total of 77 ECS images stained by methylene blue and 58 images with double staining of methylene blue and crystal violet were obtained from 20 patients. Images were classified into 3 grades based on nuclear and villi atypia: EC A, B, and C. Diagnostic performance of ECS classification to predict histology and interobserver agreement was evaluated. The performance was compared between staining methods and ×520 or ×936 zoom. RESULTS With methylene blue staining, high rates of accuracy, sensitivity, specificity, and positive predictive value (PPV) over 90% were achieved for tumor and nontumor diagnosis as assessed by EC A versus EC B. High rates of accuracy, sensitivity, PPV, and negative predictive value over 90% were achieved for the differentiation between the diagnosis of the Vienna category 3 and 4/5 as assessed by EC B versus C. The accuracy rate of interpreting ECS images with ×936 zoom among 10 endoscopists was 82%, and the interobserver agreement rate was 0.803 (Kendall's coefficient of concordance). In the ×936 zoom group, methylene blue staining was significantly associated with higher accuracy rate (odds ratio 1.76 [1.06-2.92], p value 0.0297). No benefit was observed by double staining. CONCLUSIONS ECS diagnosis with methylene blue provides a high accuracy rate and good interobserver agreement to predict histology of SNADETs.
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Affiliation(s)
- Takashi Hirose
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naomi Kakushima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuhiro Furukawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Satoshi Furune
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Eri Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tsunaki Sawada
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Keiko Maeda
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Takeshi Yamamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuki Nishida
- Biostatistics and Bioinformatics Section, Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan
| | - Takio Yokoi
- Department of Pathology and Laboratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroki Kawashima
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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14
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Muramoto T, Ohata K, Sakai E, Inamoto R, Kurebayashi M, Takayanagi S, Kimoto Y, Suzuki Y, Ishii R, Ono K, Negishi R, Takita M, Minato Y, Ohno A, Chiba H, Hashimoto H, Morikawa T, Matsuhashi N. A new classification for the diagnosis of superficial non-ampullary duodenal epithelial tumors using endocytoscopy: A prospective study. J Gastroenterol Hepatol 2021; 36:3170-3176. [PMID: 34142381 DOI: 10.1111/jgh.15585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 06/08/2021] [Accepted: 06/13/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Although the frequency of endoscopic diagnosis of superficial non-ampullary duodenal epithelial tumors (SNADETs) has been increasing in recent years, no criteria for the endoscopic diagnosis of these tumors have been established yet. The aim of this study was to assess the usefulness of endocytoscopy for diagnosis SNADETs and to establish new criteria. METHODS This prospective study was conducted at the NTT Medical Center Tokyo from May 2019 to July 2020, and a total of 100 consecutive SNADETs were enrolled. All the endocytoscopic images of the lesions and surrounding normal mucosa were classified into three groups according to the degree of structural atypia and the nuclear morphology and size. The endocytoscopic diagnoses using endocytoscopic classification was compared with the final histopathological diagnoses. RESULTS Data of 93 patients with 98 lesions were included in the analysis. The preoperative diagnosis by endocytoscopy coincided with the final histopathological diagnosis in 85 (86.7%) of 98 SNADETs. In addition, the sensitivity and specificity for VCL 4/5 were 87.7% and 85.4%, respectively. In contrast, the accuracy, sensitivity, and specificity of preoperative diagnosis by biopsy were 64.3%, 50.9%, and 82.9%, respectively. Preoperative diagnosis by endocytoscopy showed significantly superior accuracy and sensitivity as compared with preoperative biopsy diagnosis (P < 0.001, respectively). CONCLUSIONS This new classification (endocytoscopic classification) allows prediction of the tumor histopathology in real time, during endocytoscopy without biopsy, and is expected to be of help in determining the appropriate therapeutic strategies for individual cases of SNADETs. (Clinical trial registration number: UMIN000038643.).
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Affiliation(s)
- Takashi Muramoto
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Ken Ohata
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Eiji Sakai
- Department of Gastrointestinal Endoscopy, Yokohama Sakae Kyosai Hospital, Yokohama, Japan
| | - Rin Inamoto
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Marie Kurebayashi
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Syunya Takayanagi
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Yoshiaki Kimoto
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Yuichiro Suzuki
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Rindo Ishii
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Kohei Ono
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Ryoju Negishi
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Maiko Takita
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Yohei Minato
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Akiko Ohno
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Hideyuki Chiba
- Department of Gastroenterology, Omori Red Cross Hospital, Tokyo, Japan
| | | | - Teppei Morikawa
- Department of Diagnostic Pathology, NTT Medical Center Tokyo, Tokyo, Japan
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15
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Yamamura M, Nagami Y, Sakai T, Maruyama H, Ominami M, Fukunaga S, Otani K, Hosomi S, Tanaka F, Taira K, Yamagami H, Tanigawa T, Watanabe T, Fujiwara Y. Safety of Endoscopic Mucosal Resection Using a Bipolar Snare for Superficial Nonampullary Duodenal Epithelial Tumors and the Predictive Factors of Piecemeal Resection. Digestion 2021; 102:682-690. [PMID: 33045711 DOI: 10.1159/000510601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 08/02/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Endoscopic mucosal resection for small superficial nonampullary duodenal epithelial tumors is a noninvasive treatment; however, perforations can occur. Bipolar snares can reduce the risk of perforation due to small tissue damage. Currently, only few studies have reported endoscopic mucosal resection for small superficial nonampullary duodenal epithelial tumors using a bipolar snare and the effect of preoperative findings. OBJECTIVE To investigate (1) resectability and adverse events of endoscopic mucosal resection using a bipolar snare for small superficial nonampullary duodenal epithelial tumors and (2) the predictions of piecemeal resection. METHODS Between 2007 and 2017, 89 patients with 107 lesions underwent endoscopic mucosal resection using a bipolar snare. Among them, 88 lesions of 77 patients were evaluated. The primary outcome was the incidence of en bloc resection and R0 resection and adverse events. Risk factors associated with piecemeal resection, including preoperative lesion findings, were also examined. RESULTS The incidence rates of en bloc and R0 resections were 85.2 and 48.9%, respectively. Neither intraoperative or delayed perforations nor procedure-related mortality was noted. The nonlifting sign after submucosal injection was associated with an increase in piecemeal resection (odds ratio: 20.3, 95% confidence interval: 2.53-162; p = 0.005). CONCLUSION Endoscopic resection for small superficial nonampullary duodenal epithelial tumors can cause perforation; however, endoscopic mucosal resection using a bipolar snare can be a safe treatment option as it does not cause perforations. The nonlifting sign after submucosal injection is a predictive factor for piecemeal resection.
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Affiliation(s)
- Masafumi Yamamura
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yasuaki Nagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan,
| | - Taishi Sakai
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hirotsugu Maruyama
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masaki Ominami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shusei Fukunaga
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Koji Otani
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shuhei Hosomi
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Fumio Tanaka
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Koichi Taira
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hirokazu Yamagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tetsuya Tanigawa
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Toshio Watanabe
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yasuhiro Fujiwara
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
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16
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Akazawa Y, Ueyama H, Tsuyama S, Ikeda A, Yatagai N, Komori H, Takeda T, Matsumoto K, Matsumoto K, Hashimoto T, Tomita N, Kajiyama Y, Kato M, Yao T, Nagahara A. Endoscopic and Clinicopathological Features of Superficial Non-Ampullary Duodenal Tumor Based on the Mucin Phenotypes. Digestion 2021; 102:663-670. [PMID: 32516774 PMCID: PMC8491506 DOI: 10.1159/000508040] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 04/07/2020] [Indexed: 02/04/2023]
Abstract
AIMS We aimed to clarify the endoscopic/clinicopathological features of superficial non-ampullary duodenal epithelial tumors (SNADETs) based on their mucin phenotypes. METHODS We analyzed 62 SNADET lesions and classified them based on mucin phenotypic expression. Endoscopic and clinicopathological findings were compared according to mucin phenotypes. RESULTS Eleven lesions had the gastric phenotype (GP) and 43 lesions had the intestinal phenotype (IP). All GP lesions were located in the first portion of the duodenum, while most IP lesions (72.1%) were located in the second portion (p < 0.01). Tumor size was significantly larger in the GP than in the IP group (14.4 mm vs. 10.2 mm, p < 0.05). Reddish color (72.7% in GP vs. 37.2% in IP, p < 0.05), type 0-I (72.7% vs. 11.6%, p < 0.01), lobular/granular pattern (81.8% vs. 4.7%, p < 0.01), and category 4/5 in Vienna classification (81.8% vs. 30.2%, p < 0.01) were observed significantly more often in the GP than in the IP group. Regarding findings of magnifying endoscopy with narrow-band imaging (M-NBI), white opaque substance (22.2% in GP vs. 89.7% in IP, p < 0.01) and light blue crest (0% vs. 43.6%, p < 0.05) were significantly less frequently observed in the GP group. Oval-shaped marginal epithelium (66.7% vs. 17.9%, p < 0.01), dense pattern (55.6% vs. 2.6%, p < 0.01), and dilatation of the intervening part (100% vs. 12.8%, p < 0.01) were more frequently observed in the GP group. CONCLUSIONS SNADETs showed distinct endoscopic/clinicopathological features according to the mucin phenotype. Tumor location, coloration, macroscopic type, and endoscopic findings including M-NBI are useful to distinguish the mucin phenotypes of SNADETs.
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Affiliation(s)
- Yoichi Akazawa
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroya Ueyama
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan,*Dr. Hiroya Ueyama, Department of Gastroenterology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo 113-8421 (Japan),
| | - Sho Tsuyama
- Department of Human Pathology, Juntendo University School of Medicine, Tokyo, Japan
| | - Atsushi Ikeda
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Noboru Yatagai
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroyuki Komori
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Tsutomu Takeda
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Kohei Matsumoto
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Kenshi Matsumoto
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Takashi Hashimoto
- Department of Esophageal and Gastroenterological Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Natsumi Tomita
- Department of Esophageal and Gastroenterological Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Yoshiaki Kajiyama
- Department of Esophageal and Gastroenterological Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Motohiko Kato
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Takashi Yao
- Department of Human Pathology, Juntendo University School of Medicine, Tokyo, Japan
| | - Akihito Nagahara
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
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17
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Nanashima A, Tanoue Y, Imamura N, Hiyoshi M, Yano K, Hamada T, Nishida T, Kai K, Suzuki Y, Sato Y, Nakashima K, Hosokawa A, Nagayasu T. Rare resected eight cases of duodenal adenocarcinomas. Int J Surg Case Rep 2021; 86:106384. [PMID: 34507194 PMCID: PMC8433236 DOI: 10.1016/j.ijscr.2021.106384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/16/2021] [Accepted: 09/02/2021] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Duodenal adenocarcinoma is a rare malignancy; recently, it has been found to be accompanied by operative indications. METHODS Nine consecutive rare cases were diagnosed with duodenal carcinoma (DC), in which clinicopathological characteristics were retrospectively examined. Age was ranged over middle-aged males and females. No clinical onset with severe symptoms was observed, and the specific treatment for accompanied diseases or habits was not found. OUTCOMES One case of two T1 stage DCs that underwent pancreas-sparing duodenectomy. Stage II DC was diagnosed in three cases, and stage III DC was diagnosed in four cases. Pancreaticoduodenectomy (PD) mainly occurred in seven patients, and duodenectomy was limited in two patients. All operations were safely performed, and the postoperative course showed no severe morbidity. Histological findings showed R0 resection in eight cases and R1 at the retroperitoneal dissecting part in one case. Five patients with advanced-stage DC underwent adjuvant chemotherapy; however, four patients showed tumor recurrence within 12 months. With additional strong chemotherapy, eight patients survived up to 84 months, and one died of liver metastasis at 43 months after surgery. Three representative cases of mucosal invasion with widespread pancreas-sparing duodenectomy and advanced-stage DC cases undergoing duodenectomy or PD are shown. CONCLUSION In the field of upper digestive tract surgery, duodenal adenocarcinoma and various applications of surgery or adjuvant chemotherapy for long-term survival are important.
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Affiliation(s)
- Atsushi Nanashima
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Japan.
| | - Yukinori Tanoue
- Division of Surgical Oncology, Nagasaki University School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Naoya Imamura
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Japan
| | - Masahide Hiyoshi
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Japan
| | - Koichi Yano
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Japan
| | - Takeomi Hamada
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Japan
| | - Takahiro Nishida
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Japan
| | - Kengo Kai
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Japan
| | - Yasuto Suzuki
- Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, Japan
| | - Yuichiro Sato
- Department of Diagnostic Pathology, University of Miyazaki Hospital, 5200 Kihara, Kiyotake, Miyazaki 889-1692, Japan
| | - Koji Nakashima
- Department of Clinical Oncology, University of Miyazaki Hospital, 5200 Kihara, Kiyotake, Miyazaki 889-1692, Japan
| | - Ayumu Hosokawa
- Department of Clinical Oncology, University of Miyazaki Hospital, 5200 Kihara, Kiyotake, Miyazaki 889-1692, Japan
| | - Takeshi Nagayasu
- Division of Surgical Oncology, Nagasaki University School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
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18
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Tanaka Y, Fujii S, Oiwa Y, Kusaka T, Shibuya S, Kokuryu H. Efficacy of Magnifying Narrow Band Imaging with Acetic Acid Spray in Diagnosing Superficial Non-Ampullary Duodenal Epithelial Tumors. Digestion 2021; 102:572-579. [PMID: 32846421 DOI: 10.1159/000509854] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 06/28/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS The aim of the present study was to evaluate the efficacy of magnifying narrow band imaging with acetic acid spray (MA-NBI) in differentiating category 4/5 lesions from category 3 lesions of superficial non-ampullary duodenal epithelial tumors (SNADETs) as per Vienna Classification and to compare the diagnostic performances of both MA-NBI and magnifying narrow band imaging (M-NBI). METHODS We retrospectively identified 60 resected SNADETs (31 category 3 lesions and 29 category 4/5 lesions) in 60 patients who underwent M-NBI and MA-NBI preoperatively. We evaluated vascular and surface patterns using M-NBI and MA-NBI for characterizing category 3 and 4/5 lesions. The surface pattern was classified as tubular, villous, or mix structure using MA-NBI. In addition, lesions with disorganized and unclear structures with irregular margins that can be clearly recognized by MA-NBI were defined as irregular surface structures. RESULTS For MA-NBI, category 4/5 lesions had a significantly higher mix structure rate and higher irregular surface structure rate than category 3 lesions (62 vs. 16%, p < 0.001, and 86 vs. 19%, p < 0.001, respectively). The diagnostic accuracy of MA-NBI using mix and irregular surface structures for identifying category 4/5 lesions was as follows: sensitivity, 62/86%; specificity, 84/77%; positive predictive value, 78/78%; negative predictive value, 70/86%; and accuracy, 73/82%. The diagnostic accuracy of MA-NBI using irregular surface structure was significantly higher than that of M-NBI (p < 0.05). CONCLUSION MA-NBI may be useful in differentiating between category 3 and category 4/5 lesions of SNADETs.
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Affiliation(s)
- Yasuyuki Tanaka
- Department of Gastroenterology and Hepatology, Kyoto Katsura Hospital, Kyoto, Japan,
| | - Shigehiko Fujii
- Department of Gastroenterology and Hepatology, Kyoto Katsura Hospital, Kyoto, Japan
| | - Yoko Oiwa
- Department of Gastroenterology and Hepatology, Kyoto Katsura Hospital, Kyoto, Japan
| | - Toshihiro Kusaka
- Department of Gastroenterology and Hepatology, Kyoto Katsura Hospital, Kyoto, Japan
| | | | - Hiroyuki Kokuryu
- Department of Gastroenterology and Hepatology, Kyoto Katsura Hospital, Kyoto, Japan
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19
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Matsueda K, Uedo N, Kitamura M, Iwagami H, Shichijo S, Maekawa A, Kanesaka T, Takeuchi Y, Higashino K, Ishihara R. Pre-ampullary location and size ≥10 mm are independent predictors for high-grade superficial non-ampullary duodenal epithelial tumors. J Gastroenterol Hepatol 2021; 36:1605-1613. [PMID: 33125738 DOI: 10.1111/jgh.15317] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/28/2020] [Accepted: 10/24/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIM The incidence of identified superficial non-ampullary duodenal epithelial tumors (SNADETs) has been increasing with recent advances in endoscopic diagnosis. Nevertheless, the clinical features of SNADETs with malignant potential remain unclear. The aim of the present study was to clarify the clinical characteristics of high-grade SNADETs. METHODS A total of 328 SNADETs that had been endoscopically or surgically resected between January 2013 and April 2019 were identified from an endoscopic and pathological database. Clinical characteristics were compared between mucosal low-grade neoplasm (n = 154) and mucosal high-grade neoplasm/submucosal carcinoma (HGN/SMC, n = 174). RESULTS In univariate analysis, tumor size, pre-ampullary tumor location, red color, and rough/nodular surface were significantly associated with HGN/SMC. In multivariate analysis (odds ratio [95% confidence interval]), large (≥10 mm) tumor size (odds ratio: 4.5, 95% confidence interval: 2.6-7.7, P < 0.001) and pre-ampullary tumor location (odds ratio: 2.1, 95% confidence interval: 1.3-3.5, P = 0.004) were independent predictors for HGN/SMC. Analysis of histological phenotypes revealed that the proportion of tumors that were HGN/SMC was much greater for gastric-type tumors (21/23 lesions, 91%) than for intestinal-type tumors (150/302 lesions, 50%) (P < 0.001) and that all gastric-type tumors were located in the pre-ampullary portion. CONCLUSIONS Pre-ampullary location and large tumor size are independent predictors for HGN/SMC SNADETs. Pre-ampullary tumor location is significantly associated with gastric histological phenotype. These findings may help in decision making for endoscopic treatment, active indication for pre-ampullary tumor or tumor ≥10 mm, and understanding the pathophysiology of SNADETs.
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Affiliation(s)
- Katsunori Matsueda
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Noriya Uedo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Masanori Kitamura
- Department of Diagnostic Pathology and Cytology, Osaka International Cancer Institute, Osaka, Japan
| | - Hiroyoshi Iwagami
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Satoki Shichijo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Akira Maekawa
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Takashi Kanesaka
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yoji Takeuchi
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Koji Higashino
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Ryu Ishihara
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
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20
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Fang Y, Ding X. Current status of endoscopic diagnosis and treatment for superficial non-ampullary duodenal epithelial tumors. Scand J Gastroenterol 2021; 56:604-612. [PMID: 33730963 DOI: 10.1080/00365521.2021.1900384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Though superficial non-ampullary duodenal epithelial tumors (SNADETs) have been traditionally considered rare, there is a growing detection under the development and widespread of endoscopic techniques in recent times. Many case studies have revealed early manifestations of lesions through advanced endoscopic technology, however, because of the low incidence of duodenal tumors and challenges in diagnosing, the preoperative diagnosis criteria have not been established so far. In spite of this, recently the increasing detection rate of early duodenal epithelial lesions enhances the demand for minimally invasive treatment as well. The most suitable therapeutic endoscopic modality to remove duodenal lesions should be selected according to the size, location and histological invasive depth of duodenal lesions. Nevertheless, due to the special anatomical structure of the duodenum, the incidence of complications is much higher than in any other part of the digestive tract. To prevent these adverse events prophylactically, a few novel strategies have been applied effectively after resection. This review describes the current status of preoperative endoscopic diagnosis and endoscopic resection approaches, as well as countermeasures for avoiding procedure-related complications.
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Affiliation(s)
- Yi Fang
- The Medical School, Ningbo University, Ningbo, China.,The Gastroenterology Department, Ningbo First Hospital, Ningbo, China
| | - Xiaoyun Ding
- The Gastroenterology Department, Ningbo First Hospital, Ningbo, China
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21
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Vanbiervliet G, Moss A, Arvanitakis M, Arnelo U, Beyna T, Busch O, Deprez PH, Kunovsky L, Larghi A, Manes G, Napoleon B, Nalankilli K, Nayar M, Pérez-Cuadrado-Robles E, Seewald S, Strijker M, Barthet M, van Hooft JE. Endoscopic management of superficial nonampullary duodenal tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:522-534. [PMID: 33822331 DOI: 10.1055/a-1442-2395] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
1: ESGE recommends that all duodenal adenomas should be considered for endoscopic resection as progression to invasive carcinoma is highly likely.Strong recommendation, low quality evidence. 2: ESGE recommends performance of a colonoscopy, if that has not yet been done, in cases of duodenal adenoma.Strong recommendation, low quality evidence. 3: ESGE recommends the use of the cap-assisted method when the location of the minor and/or major papilla and their relationship to a duodenal adenoma is not clearly established during forward-viewing endoscopy.Strong recommendation, moderate quality evidence. 4: ESGE recommends the routine use of a side-viewing endoscope when a laterally spreading adenoma with extension to the minor and/or major papilla is suspected.Strong recommendation, low quality evidence. 5: ESGE suggests cold snare polypectomy for small (< 6 mm in size) nonmalignant duodenal adenomas.Weak recommendation, low quality evidence. 6: ESGE recommends endoscopic mucosal resection (EMR) as the first-line endoscopic resection technique for nonmalignant large nonampullary duodenal adenomas.Strong recommendation, moderate quality evidence. 7: ESGE recommends that endoscopic submucosal dissection (ESD) for duodenal adenomas is an effective resection technique only in expert hands.Strong recommendation, low quality evidence. 8: ESGE recommends using techniques that minimize adverse events such as immediate or delayed bleeding or perforation. These may include piecemeal resection, defect closure techniques, noncontact hemostasis, and other emerging techniques, and these should be considered on a case-by-case basis.Strong recommendation, low quality evidence. 9: ESGE recommends endoscopic surveillance 3 months after the index treatment. In cases of no recurrence, a further follow-up endoscopy should be done 1 year later. Thereafter, surveillance intervals should be adapted to the lesion site, en bloc resection status, and initial histological result. Strong recommendation, low quality evidence.
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Affiliation(s)
- Geoffroy Vanbiervliet
- Department of Digestive Endoscopy, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Alan Moss
- Department of Endoscopic Services, Western Health, Melbourne, Australia.,Department of Medicine - Western Health, Melbourne Medical School, The University of Melbourne, Victoria, Australia
| | - Marianna Arvanitakis
- Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Urban Arnelo
- Department of Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Torsten Beyna
- Department of Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Nordrhein-Westfalen, Germany
| | - Olivier Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Pierre H Deprez
- Gastroenterology and Hepatology Department, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Lumir Kunovsky
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianpiero Manes
- Aziende Socio Sanitaria Territoriale Rhodense, Gastroenterology, Garbagnate Milanese, Italy
| | - Bertrand Napoleon
- Service de Gastroentérologie, Hôpital Privé Jean Mermoz, Ramsay Générale de Santé, Lyon, France
| | - Kumanan Nalankilli
- Department of Endoscopic Services, Western Health, Melbourne, Australia.,Department of Medicine - Western Health, Melbourne Medical School, The University of Melbourne, Victoria, Australia
| | - Manu Nayar
- Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Enrique Pérez-Cuadrado-Robles
- Department of Gastroenterology, Georges-Pompidou European Hospital, AP-HP Centre - Université de Paris, Paris, France
| | - Stefan Seewald
- Center of Gastroenterology Centre, Klinik Hirslanden, Zurich, Switzerland
| | - Marin Strijker
- Department of Gastroenterology, Hôpital Nord, Assistance publique des hôpitaux de Marseille, Marseille, France
| | - Marc Barthet
- Department of Gastroenterology, Hôpital Nord, Assistance publique des hôpitaux de Marseille, Marseille, France
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, The Netherlands
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22
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Yoshida M, Yabuuchi Y, Kakushima N, Kato M, Iguchi M, Yamamoto Y, Kanetaka K, Uraoka T, Fujishiro M, Sho M. The incidence of non-ampullary duodenal cancer in Japan: The first analysis of a national cancer registry. J Gastroenterol Hepatol 2021; 36:1216-1221. [PMID: 33002211 DOI: 10.1111/jgh.15285] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/20/2020] [Accepted: 09/25/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Although duodenal cancer is rare, no epidemiological research on this disease has been conducted in Asian countries. We aimed to elucidate the incidence and clinical features of duodenal cancer in Japan using a large-scale national database. METHODS Data of patients with primary duodenal cancer diagnosed from January 1, 2016, to December 31, 2016, were extracted from the Japanese national cancer registry. Excluding malignant neoplasm of the Vater's ampulla, we calculated the incidence among the population as a crude number of patients with duodenal cancer divided by the total Japanese population in 2016. We performed multivariate analyses using logistic regression models to identify risk factors for advanced cancer, defined as metastatic cancer or local invasion to adjacent organs. RESULTS Data on 3005 patients were included. The incidence of duodenal cancer was 23.7 per 1 000 000 person-years. In total, 56.4% of cases were detected at the localized stage. In the localized cancer group, endoscopic resection was more frequently performed (48.0%), whereas in the advanced cancer group, surgery and chemotherapy were the major treatment options (39.3% and 41.5%, respectively). Multivariate analyses identified age ≥80 years (odds ratio [OR], 1.489; 95% confidence interval [CI], 1.113-1.992; P = 0.007), incidental detection (OR, 2.325; CI, 1.623-3.331; P < 0.0001), and precise examination for symptomatic patients (OR, 10.561; CI, 7.416-15.042; P < 0.0001) as independent risk factors for advanced cancer. CONCLUSIONS Our study revealed the incidence of duodenal cancer in Japan. However, localized cancer was the major tumor stage at detection, resulting in a high rate of endoscopic resection.
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Affiliation(s)
- Masao Yoshida
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Japan
| | - Yohei Yabuuchi
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Japan
| | - Naomi Kakushima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Motohiko Kato
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Mikitaka Iguchi
- Department of Gastroenterology, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yorimasa Yamamoto
- Department of Gastroenterology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Kengo Kanetaka
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Toshio Uraoka
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Nara, Japan
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23
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Large duodenal pyloric gland adenoma successfully resected by endoscopic submucosal dissection. Clin J Gastroenterol 2021; 14:538-541. [PMID: 33661443 DOI: 10.1007/s12328-021-01367-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 02/22/2021] [Indexed: 02/07/2023]
Abstract
A 71-year-old woman was given a barium meal examination as part of a workup for recurring melena and iron deficiency anemia (IDA), and it revealed a large duodenal polyp measuring 60 mm in diameter. Subsequent upper gastrointestinal endoscopy showed a large pedunculated polyp in the duodenal bulb. Magnifying endoscopy with narrow-band imaging (NBI) showed that the lesion consisted of a regular enlarged intervening part between crypts of the epithelium that resembled gastric mucosa. Although the lesion was suspected of being benign, it was resected by endoscopic submucosal dissection (ESD) to prevent the progression of the IDA. The pathology examination revealed the proliferation of mildly irregular-shaped or dilated glands lined by cuboidal cells and low columnar cells in the submucosa. The gastric glands were immunohistochemically positive for MUC6, suggesting pyloric gland differentiation. The lesion was covered by a foveolar-type epithelium, and we made a diagnosis of pyloric gland adenoma (PGA). PGAs are most common in the stomach, and they are rare in the duodenum, where endoscopic treatment is technically challenging. Here we report a case of large duodenal PGA successfully resected by ESD. Since part of PGAs has been reported to be associated with adenocarcinoma, minimally invasive treatment strategies are desirable to reduce the risk of progression to carcinoma.
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24
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Yamasaki Y, Uedo N. Stop taking routine biopsy specimens for the diagnose of a duodenal adenoma! Endosc Int Open 2021; 9:E470-E471. [PMID: 33655051 PMCID: PMC7895647 DOI: 10.1055/a-1339-1089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Yasushi Yamasaki
- Department of Gastroenterology, Okayama University Hospital, Okayama, Japan
| | - Noriya Uedo
- Department of Gastrointestinal oncology, Osaka International Cancer Institute, Osaka, Japan
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25
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Ishii R, Ohata K, Sakai E, Takita M, Minato Y, Muramoto T, Hashimoto H, Morikawa T, Matsuhashi N. Simple scoring system for the diagnosis of superficial non-ampullary duodenal epithelial tumors. Dig Endosc 2021; 33:399-407. [PMID: 32506480 DOI: 10.1111/den.13762] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/25/2020] [Accepted: 05/28/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS Differentiating superficial non-ampullary duodenal epithelial tumors (SNADETs) that harbor malignant potential is important. We developed a simple scoring system and investigated whether it enables the differentiation of low-grade adenoma and high-grade adenoma/adenocarcinoma. PATIENTS AND METHODS We retrospectively enrolled 197 consecutive patients with 207 SNADETs who underwent endoscopic resection at NTT Medical Center Tokyo between March 2016 and May 2019. Endoscopic findings were compared between Vienna Classification (VCL) C3 and C4/5 lesions. A multivariate logistic regression analysis was performed to develop a scoring system to identify VCL C4/5 lesions. The efficacy of our scoring system was elucidated among five novice and five expert endoscopists. RESULTS Of 207 SNADETs, 66 and 141 lesions were pathologically diagnosed as VCL C3 and C4/5. A multivariate logistic regression analysis identified a tumor diameter of 10-19 mm (OR, 3.81; 95% CI, 1.02-14.2; P = 0.04), a tumor diameter ≥20 mm (OR, 95.2; 95% CI, 10.4-871.0; P < 0.001), a red color (OR, 14.5; 95% CI, 3.55-59.6; P < 0.001), the presence of irregular surface pattern (OR, 12.4; 95% CI, 3.00-51.4; P < 0.001), and the presence of irregular vessel pattern (OR, 13.7; 95% CI, 4.03-46.6; P < 0.001) as independent significant predictors of VCL C4/5. Considering these results, we developed a scoring system. Using an appropriate cutoff value, the diagnostic accuracy, sensitivity and specificity were calculated as 92%, 95% and 93%. The average diagnostic accuracy did not differ between novice and expert endoscopists (86% vs 87%, P = 0.76). CONCLUSIONS Our scoring system was useful for differentiating VCL C3 and C4/5 lesions. UMIN Clinical Trials (No. 000039063).
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Affiliation(s)
- Rindo Ishii
- Divisions of, Division of, Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Ken Ohata
- Divisions of, Division of, Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Eiji Sakai
- Divisions of, Division of, Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Maiko Takita
- Divisions of, Division of, Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Yohei Minato
- Divisions of, Division of, Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Takashi Muramoto
- Divisions of, Division of, Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | | | - Teppei Morikawa
- Division of, Diagnostic Pathology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Nobuyuki Matsuhashi
- Divisions of, Division of, Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
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26
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Kakushima N, Yoshida M, Takizawa K, Yabuuchi Y, Kawata N, Kishida Y, Ito S, Imai K, Hotta K, Ishiwatari H, Matsubayashi H, Ono H. White light and/or magnifying endoscopy with narrow band imaging for superficial nonampullary duodenal epithelial tumors. Scand J Gastroenterol 2021; 56:211-218. [PMID: 33417531 DOI: 10.1080/00365521.2020.1866062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM A reliable optical diagnosis of superficial nonampullary duodenal epithelial tumors (SNADETs) to guide optimal treatment strategy is lacking. The aim of this study was to simulate the treatment outcomes based on optical diagnosis using white light imaging (WLI) or magnifying endoscopy with narrow band imaging (MNBI) and to evaluate the method to extract optimal lesions suitable for cold snare polypectomy (CSP) or not. METHODS We created a decision tree model using WLI and MNBI diagnosis for ideal treatment for SNADETs. Optical diagnoses of Vienna category 3 lesions (C3), category 4/5 (C4/5) were defined based on the WLI scoring system or the MNBI pattern diagnosis. Ideal treatments were CSP for C3 < 10mm, and endoscopic mucosal resection, endoscopic submucosal dissection or surgery for lesions ≥10mm or C4/5. Ideal treatment results based on optical diagnosis were analyzed according to actual pathological results. RESULTS A total of 218 lesions with pre-operative diagnosis of SNADETs were included for analysis. Percentage of ideal treatment for C3 < 10mm based on WLI or MNBI or both was 88%, 83% and 97%. When WLI and MNBI diagnoses predicted the same histology, the specificity, positive predictive value and accuracy were significantly higher than those of WLI or MNBI alone (p < .05). CONCLUSIONS A decision tree model using lesion diameter, WLI scoring and MNBI pattern diagnosis is hypothetically useful to select ideal lesions for CSP among SNADETs. Optical diagnosis using both WLI and MNBI is more useful than WLI or MNBI alone.
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Affiliation(s)
- Naomi Kakushima
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Shizuoka, Japan.,Department of Gastroenterology & Hepatology, Nagoya University Graduate School of Medicine, Showaku, Nagoya, Japan
| | - Masao Yoshida
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Shizuoka, Japan
| | - Kohei Takizawa
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Shizuoka, Japan
| | - Yohei Yabuuchi
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Shizuoka, Japan
| | - Noboru Kawata
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Shizuoka, Japan
| | - Yoshihiro Kishida
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Shizuoka, Japan
| | - Sayo Ito
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Shizuoka, Japan
| | - Kenichiro Imai
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Shizuoka, Japan
| | - Kinichi Hotta
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Shizuoka, Japan
| | | | | | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Nagaizumi, Shizuoka, Japan
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Tsuji S, Doyama H, Tsuyama S, Dejima A, Nakashima T, Wakita S, Kito Y, Nakanishi H, Yoshida N, Katayanagi K, Minato H, Yao T, Yao K. Does previous biopsy lead to cancer overdiagnosis of superficial non-ampullary duodenal epithelial tumors? Endosc Int Open 2021; 9:E58-E65. [PMID: 33403237 PMCID: PMC7775803 DOI: 10.1055/a-1293-7487] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 09/28/2020] [Indexed: 02/07/2023] Open
Abstract
Background and study aims We aimed to evaluate the diagnostic performance of magnifying endoscopy with narrow-band imaging (M-NBI) in superficial non-ampullary duodenal epithelial tumors (SNADETs) regarding the absence or presence of biopsy before M-NBI diagnosis. Patients and methods Clinicopathological data were retrospectively reviewed for 99 SNADETs from 99 patients who underwent endoscopic resection. The 99 tumors were divided into the non-biopsy group (32 lesions not undergoing biopsy before M-NBI examination) and the biopsy group (67 lesions undergoing biopsy before M-NBI examination). We investigated the correlation between the M-NBI diagnosis and the histopathological diagnosis of the SNADETs in both groups. Results According to the modified revised Vienna classification, 31 tumors were classified as category 3 (C3) (low-grade adenoma) and 68 as category 4/5 (C4/5) (high-grade adenoma/cancer). The accuracy, sensitivity, and specificity of preoperative M-NBI diagnoses in the non-biopsy group vs the biopsy group were 88 % (95 % confidence interval: 71.0 - 96.5) vs 66 % (51.5 - 75.5), P = 0.02; 95 % (77.2 - 99.9) vs 89 % (76.4 - 96.4), P = 0.39; and 70 % (34.8 - 93.3) vs 14 % (3.0 - 36.3), P < 0.01, respectively. Notably, in the biopsy group, the specificity of M-NBI in SNADETs was low at only 14 % because we over-diagnosed most C3 lesions as C4/5. M-NBI findings might have been compromised by the previous biopsy procedure itself. Conclusions In the non-biopsy group, the accuracy of M-NBI in SNADETs was excellent in distinguishing C4/5 lesions from C3. The M-NBI findings in SNADETs should be evaluated while carefully considering the influence of a previous biopsy.
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Affiliation(s)
- Shigetsugu Tsuji
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Hisashi Doyama
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Sho Tsuyama
- Department of Human Pathology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Akihiro Dejima
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Takashi Nakashima
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Shigenori Wakita
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Yosuke Kito
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Hiroyoshi Nakanishi
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Naohiro Yoshida
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Kazuyoshi Katayanagi
- Department of Diagnostic Pathology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Hiroshi Minato
- Department of Diagnostic Pathology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Takashi Yao
- Department of Human Pathology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Kenshi Yao
- Department of Endoscopy, Fukuoka University Chikushi Hospital, Fukuoka, Japan
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Linked color imaging can improve the visibility of superficial non-ampullary duodenal epithelial tumors. Sci Rep 2020; 10:20667. [PMID: 33244140 PMCID: PMC7691495 DOI: 10.1038/s41598-020-77726-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 11/17/2020] [Indexed: 11/09/2022] Open
Abstract
The current study aimed to evaluate the efficacy of linked color imaging (LCI) in improving the visibility of superficial non-ampullary duodenal epithelial tumors (SNADETs). We prospectively evaluated 44 consecutive patients diagnosed with SNADETs. Three trainees and three experts assessed the visibility scores of white light imaging (WLI), LCI, and blue laser imaging-bright (BLI-b) for SNADETs, which ranged from 1 (not detectable without repeated cautious examination) to 4 (excellent visibility). In addition, the L* a* b* color values and color differences (ΔE*) were evaluated using the CIELAB color space system. For SNADETs, the visibility scores of LCI (3.53 ± 0.59) were significantly higher than those of WLI and BLI-b (2.66 ± 0.79 and 3.41 ± 0.64, respectively). The color differences (ΔE*) between SNADETs and the adjacent normal duodenal mucosa in LCI mode (19.09 ± 8.33) were significantly higher than those in WLI and BLI-b modes (8.67 ± 4.81 and 12.92 ± 7.95, respectively). In addition, the visibility score of SNADETs and the color differences in LCI mode were significantly higher than those in WLI and BLI-b modes regardless of the presence of milk white mucosa (MWM). LCI has potential benefits, and it is considered a promising clinical modality that can increase the visibility of SNADETs regardless of the presence of MWM.This study was registered at the University Hospital Medical Information Network (UMIN000028840).
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29
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Toya Y, Endo M, Oizumi T, Akasaka R, Yanai S, Kawasaki K, Nakamura S, Eizuka M, Fujita Y, Uesugi N, Ishida K, Sugai T, Matsumoto T. Diagnostic algorithm of magnifying endoscopy with crystal violet staining for non-ampullary duodenal epithelial tumors. Dig Endosc 2020; 32:1066-1073. [PMID: 31997426 DOI: 10.1111/den.13640] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 01/21/2020] [Accepted: 01/27/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Little is known about the usefulness of magnifying endoscopy with crystal violet staining (ME-CV) for the diagnosis of duodenal tumors. We assessed the ability of ME-CV to distinguish Vienna classification (VCL) category 4/5 (C4/5) from category 3 (C3) non-ampullary duodenal epithelial tumors (NADETs). METHODS A total of 76 NADETs were studied. We retrospectively analyzed the diagnostic values of the white light endoscopy (WLE) scoring system and the ME-CV algorithm with receiver operating characteristic (ROC) curves, and three endoscopists calculated the sensitivity, specificity, accuracy, and the area under the curve (AUC) of each. The diagnostic values were tested among NADETs overall and among subgroups of tumors with gastric, gastrointestinal or intestinal mucin phenotypes. Inter-observer agreement of the diagnostic results was also calculated. RESULTS According to the VCL, 54 lesions (71.1%) were regarded as C3 and 22 lesions (28.9%) as C4/5. The sensitivity, specificity, accuracy and AUC of ME-CV were higher than those of the WLE scoring system (63.6 vs 54.5, 85.2 vs 75.9, 78.9 vs 69.7, 0.744 vs 0.652, respectively). Inter-observer agreements of the WLE scoring system and ME-CV were both moderate (kappa 0.45 and 0.41). ME-CV had higher sensitivity, specificity, accuracy and AUC than those of the WLE scoring system among the gastric and intestinal phenotypes of NADETs. CONCLUSIONS ME-CV is appropriate for the diagnosis of C4/5 and C3 NADETs.
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Affiliation(s)
- Yosuke Toya
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Masaki Endo
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Iwate, Japan.,Kaiunbashi Endoscopy Clinic, Iwate, Japan
| | - Tomofumi Oizumi
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Risaburo Akasaka
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Shunichi Yanai
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Keisuke Kawasaki
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Shotaro Nakamura
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Makoto Eizuka
- Molecular Diagnostic Pathology, Pathology, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Yasuko Fujita
- Molecular Diagnostic Pathology, Pathology, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Noriyuki Uesugi
- Molecular Diagnostic Pathology, Pathology, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Kazuyuki Ishida
- Molecular Diagnostic Pathology, Pathology, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Tamotsu Sugai
- Molecular Diagnostic Pathology, Pathology, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Iwate, Japan
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Ota R, Sawada T, Tsuyama S, Sasaki Y, Suzuki H, Kaizaki Y, Hasatani K, Yamamoto E, Nakanishi H, Inagaki S, Tsuji S, Yoshida N, Doyama H, Minato H, Nakamura K, Kasashima S, Kubota E, Kataoka H, Tokino T, Yao T, Minamoto T. Integrated genetic and epigenetic analysis of cancer-related genes in non-ampullary duodenal adenomas and intramucosal adenocarcinomas. J Pathol 2020; 252:330-342. [PMID: 32770675 PMCID: PMC7693035 DOI: 10.1002/path.5529] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 07/20/2020] [Accepted: 07/28/2020] [Indexed: 12/24/2022]
Abstract
The molecular and clinical characteristics of non‐ampullary duodenal adenomas and intramucosal adenocarcinomas are not fully understood because they are rare. To clarify these characteristics, we performed genetic and epigenetic analysis of cancer‐related genes in these lesions. One hundred and seven non‐ampullary duodenal adenomas and intramucosal adenocarcinomas, including 100 small intestinal‐type tumors (90 adenomas and 10 intramucosal adenocarcinomas) and 7 gastric‐type tumors (2 pyloric gland adenomas and 5 intramucosal adenocarcinomas), were investigated. Using bisulfite pyrosequencing, we assessed the methylation status of CpG island methylator phenotype (CIMP) markers and MLH1. Then using next‐generation sequencing, we performed targeted exome sequence analysis within 75 cancer‐related genes in 102 lesions. There were significant differences in the clinicopathological and molecular variables between small intestinal‐ and gastric‐type tumors, which suggests the presence of at least two separate carcinogenic pathways in non‐ampullary duodenal adenocarcinomas. The prevalence of CIMP‐positive lesions was higher in intramucosal adenocarcinomas than in adenomas. Thus, concurrent hypermethylation of multiple CpG islands is likely associated with development of non‐ampullary duodenal intramucosal adenocarcinomas. Mutation analysis showed that APC was the most frequently mutated gene in these lesions (56/102; 55%), followed by KRAS (13/102; 13%), LRP1B (10/102; 10%), GNAS (8/102; 8%), ERBB3 (7/102; 7%), and RNF43 (6/102; 6%). Additionally, the high prevalence of diffuse or focal nuclear β‐catenin accumulation (87/102; 85%) as well as mutations of WNT pathway components (60/102; 59%) indicates the importance of WNT signaling to the initiation of duodenal adenomas. The higher than previously reported frequency of APC gene mutations in small bowel adenocarcinomas as well as the difference in the APC mutation distributions between small intestinal‐type adenomas and intramucosal adenocarcinomas may indicate that the adenoma–carcinoma sequence has only limited involvement in duodenal carcinogenesis. © 2020 The Authors. The Journal of Pathology published by John Wiley & Sons, Ltd. on behalf of The Pathological Society of Great Britain and Ireland.
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Affiliation(s)
- Ryosuke Ota
- Division of Translational and Clinical Oncology, Cancer Research Institute, Kanazawa University, Kanazawa, Japan
| | - Takeshi Sawada
- Division of Translational and Clinical Oncology, Cancer Research Institute, Kanazawa University, Kanazawa, Japan.,Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Sho Tsuyama
- Department of Human Pathology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Yasushi Sasaki
- Division of Biology, Department of Liberal Arts and Sciences, Center for Medical Education, Sapporo Medical University, Sapporo, Japan
| | - Hiromu Suzuki
- Department of Molecular Biology, Sapporo Medical University, Sapporo, Japan
| | - Yasuharu Kaizaki
- Department of Pathology, Fukui Prefectural Hospital, Fukui, Japan
| | - Kenkei Hasatani
- Department of Gastroenterology, Fukui Prefectural Hospital, Fukui, Japan
| | - Eiichiro Yamamoto
- Department of Molecular Biology, Sapporo Medical University, Sapporo, Japan
| | - Hiroyoshi Nakanishi
- Division of Translational and Clinical Oncology, Cancer Research Institute, Kanazawa University, Kanazawa, Japan
| | - Satoko Inagaki
- Department of Advanced Research in Community Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Shigetsugu Tsuji
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Naohiro Yoshida
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Hisashi Doyama
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Hiroshi Minato
- Department of Pathology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Keishi Nakamura
- Department of Gastroenterological Surgery, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Satomi Kasashima
- Department of Clinical Laboratory Science, Kanazawa University, Kanazawa, Japan
| | - Eiji Kubota
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hiromi Kataoka
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takashi Tokino
- Department of Medical Genome Sciences, Research Institute for Frontier Medicine, Sapporo Medical University, Sapporo, Japan
| | - Takashi Yao
- Department of Human Pathology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Toshinari Minamoto
- Division of Translational and Clinical Oncology, Cancer Research Institute, Kanazawa University, Kanazawa, Japan
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31
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Successful endoscopic mucosal resection for non-ampullary duodenal signet-ring cell carcinoma. Clin J Gastroenterol 2020; 13:1102-1110. [PMID: 32654096 DOI: 10.1007/s12328-020-01173-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/22/2020] [Indexed: 01/05/2023]
Abstract
We present a case of non-ampullary duodenal signet-ring cell carcinoma treated by endoscopic mucosal resection. The patient is a 61-year-old male with a history of coronary artery bypass grafting, hypertension, dyslipidemia, and diabetes mellitus complicated by end-stage renal disease requiring peritoneal dialysis who presented for routine endoscopic screening. A 9 mm protruding mass was found in the second part of the duodenum, proximal to the ampulla of Vater. Biopsy of the mass revealed proliferation of signet-ring cells with vacuolated foamy cytoplasm and displaced ovoid nuclei, consistent with signet-ring cell carcinoma. We performed endoscopic mucosal resection and achieved margin-free resection without complications. No recurrence was seen during the 24 months of follow-up. Duodenal signet-ring cell carcinoma is a rare entity most commonly occurring in the ampulla of Vater. This is the first report of successful endoscopic mucosal resection for early non-ampullary duodenal signet-ring cell carcinoma.
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32
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Kuroki K, Sanomura Y, Oka S, Yorita N, Kurihara M, Mizumoto T, Yoshifuku Y, Arihiro K, Tanaka S, Chayama K. Clinical outcomes of endoscopic resection for superficial non-ampullary duodenal tumors. Endosc Int Open 2020; 8:E354-E359. [PMID: 32118107 PMCID: PMC7035028 DOI: 10.1055/a-0998-3708] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 02/05/2019] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Because superficial non-ampullary duodenal epithelial tumors (SNADETs) are relatively rare, studies evaluating the outcomes of endoscopic resection (ER) for SNADETs are limited. Therefore, this study aimed to evaluate the clinical validity of ER for SNADETs. Patients and methods The study participants included 163 consecutive patients (108 men; mean age, 61.5 ± 11.3 years) with 171 SNADETs, excluding patients with familial adenomatous polyposis resected by ER, at Hiroshima University Hospital between May 2005 and September 2016. Clinicopathological features and the outcomes of ER for 171 cases were retrospectively analyzed. Additionally, the prognosis of 135 patients with more than 12 months' follow-up was analyzed. Results Mean diameter of SNADETs was 10.7 ± 7.2 mm. Most of the SNADET cases were classified as category 3 (71 %, 121/171), but some were category 5 (2 %, 3/171). En bloc resection rates were 93 % (146/157), 100 % (7/7), and 86 % (6/7) in endoscopic mucosal resection (EMR), polypectomy, and in endoscopic submucosal dissection (ESD) cases, respectively. Complete resection rates were 90 % (141/157), 100 % (7/7), and 71 % (5/7) in EMR, polypectomy, and ESD cases, respectively. Emergency surgery was performed in two patients with intraoperative perforation and in two with delayed perforation without artificial ulcer bed closure after ER. Since endoscopic closure of ulcer by clipping was performed, delayed perforation has not occurred. Local recurrence occurred in 1.2 %, but no metastasis to lymph nodes or other organs occurred after ER. No patient died of primary SNADETs. Conclusion Our data supported the clinical validity of ER for SNADETs. However, delayed perforation should be given much attention.
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Affiliation(s)
- Kazutaka Kuroki
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Yoji Sanomura
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan,Corresponding author Yoji Sanomura, MD, PhD Department of Endoscopy, Hiroshima University Hospital1-2-3 Kasumi, Minami-kuHiroshima 734-8551Japan+81-82-257-5939
| | - Shiro Oka
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Naoki Yorita
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Mio Kurihara
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Takeshi Mizumoto
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Yoshikazu Yoshifuku
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Koji Arihiro
- Department of Anatomical Pathology, Hiroshima University Hospital, Hiroshima, Japan
| | - Shinji Tanaka
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
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Yoshida M, Shimoda T, Abe M, Kakushima N, Kawata N, Takizawa K, Ono H, Sugino T. Clinicopathological characteristics of non-ampullary duodenal tumors and their phenotypic classification. Pathol Int 2019; 69:398-406. [PMID: 31328367 DOI: 10.1111/pin.12829] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 05/22/2019] [Indexed: 12/14/2022]
Abstract
The tumorigenesis of non-ampullary duodenal epithelial tumors (NADETs) might be different between the oral and anal sides of Vater's papilla. We conducted an immunohistological review to elucidate the clinicopathological features according to the tumor location and phenotypic classification. A review of an institutional database identified 121 patients with 125 superficial NADETs. NADETs were histologically evaluated and classified into the intestinal or gastric type based on immunohistochemical analysis. Clinicopathological factors were compared based on the tumor location and phenotype. Logistic regression analysis was performed to identify independent predictors for gastric-type NADETs. According to location analysis, the mucin phenotype was significantly different (oral side, intestinal-type 64.8%, gastric-type 35.3%; anal side, intestinal-type 87.3%, gastric-type 12.7%; P < 0.01). Although the incidence of adenoma was significantly predominant in the intestinal type (75.3%), most gastric-type NADETs were cancerous (64.3%). Notably, most gastric-type NADETs were adenocarcinomas even when the tumor size was ≤0 mm. In multivariate analysis, tumor location on the oral side (odds ratio [OR], 4.42), villous structure (OR, 6.44), and low tumor gland density (OR, 9.49) were independent predictors of gastric-type tumors. Gastric-type NADETs significantly differ from intestinal-type NADETs in terms of tumor location, morphology, and biology.
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Affiliation(s)
- Masao Yoshida
- Division of Pathology, Shizuoka Cancer Center, Shizuoka, Japan.,Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | | | - Masato Abe
- Division of Pathology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Naomi Kakushima
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Noboru Kawata
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kohei Takizawa
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Takashi Sugino
- Division of Pathology, Shizuoka Cancer Center, Shizuoka, Japan
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Kakushima N, Yoshida M, Yamaguchi Y, Takizawa K, Kawata N, Tanaka M, Kishida Y, Ito S, Imai K, Hotta K, Ishiwatari H, Matsubayashi H, Sasaki K, Ono H. Magnified endoscopy with narrow-band imaging for the differential diagnosis of superficial non-ampullary duodenal epithelial tumors. Scand J Gastroenterol 2019; 54:128-134. [PMID: 30638088 DOI: 10.1080/00365521.2018.1557740] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM Differentiation of low-grade adenoma (Vienna category 3, C3) and high-grade adenoma/carcinoma (C4/5) among superficial non-ampullary duodenal epithelial tumors (SNADETs) using magnified endoscopy with narrow-band imaging (MNBI) is not established. The aim of this study is to clarify the diagnostic ability of MNBI to differentiate between C3 and C4/5 among SNADETs. METHODS A total of 585 MNBI images taken from 156 SNADETs were evaluated in a test and validation phase. In the test phase, MNBI patterns were extracted based on the combination of surface structure and vasculature. Comparison between MNBI patterns and histology was performed to establish diagnostic criteria to differentiate between C3 and C4/5. In the validation phase, the accuracy and interobserver agreement of the diagnostic criteria were assessed. RESULTS Four MNBI patterns (network, disappeared, white opaque substance and intrastructural vessels) with distinctive histological features were selected. The median number of MNBI patterns observed among C3 and C4/5 differed with significance (1 vs 2, p < .01). The pattern of disappeared was suggestive of C4/5. Diagnosis of C4/5 by using the criteria of 2 or more MNBI patterns or presence of disappeared pattern revealed a sensitivity of 76%, specificity of 63% and accuracy of 72%. Interobserver agreement of recognizing MNBI patterns was moderate (kappa 0.59). CONCLUSION Diagnosis based on MNBI patterns is useful to differentiate between C3 and C4/5 lesions among SNADETs.
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Affiliation(s)
- Naomi Kakushima
- a Division of Endoscopy , Shizuoka Cancer Center , Shizuoka , Japan
| | - Masao Yoshida
- a Division of Endoscopy , Shizuoka Cancer Center , Shizuoka , Japan
| | | | - Kohei Takizawa
- a Division of Endoscopy , Shizuoka Cancer Center , Shizuoka , Japan
| | - Noboru Kawata
- a Division of Endoscopy , Shizuoka Cancer Center , Shizuoka , Japan
| | - Masaki Tanaka
- a Division of Endoscopy , Shizuoka Cancer Center , Shizuoka , Japan
| | | | - Sayo Ito
- a Division of Endoscopy , Shizuoka Cancer Center , Shizuoka , Japan
| | - Kenichiro Imai
- a Division of Endoscopy , Shizuoka Cancer Center , Shizuoka , Japan
| | - Kinichi Hotta
- a Division of Endoscopy , Shizuoka Cancer Center , Shizuoka , Japan
| | | | | | - Keiko Sasaki
- b Division of Pathology , Shizuoka Cancer Center , Shizuoka , Japan
| | - Hiroyuki Ono
- a Division of Endoscopy , Shizuoka Cancer Center , Shizuoka , Japan
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35
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Toya Y, Endo M, Akasaka R, Urushikubo J, Gonai T, Asakura K, Yanai S, Kawasaki K, Eizuka M, Uesugi N, Nakamura S, Sugai T, Matsumoto T. Clinicopathological Features and Magnifying Chromoendoscopic Findings of Non-Ampullary Duodenal Epithelial Tumors. Digestion 2018; 97:219-227. [PMID: 29428955 DOI: 10.1159/000485505] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 11/16/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS We aimed to investigate an association between clinicopathological features, including immunohistochemical mucin phenotypes, and magnifying chromoendoscopic findings with crystal violet staining (ME-CV) in non-ampullary duodenal epithelial tumors (NADETs). METHODS A total of 55 patients with NADET were divided into 3 groups by mucin phenotype: intestinal, gastrointestinal, or gastric. ME-CV findings were classified into 4 patterns: convoluted, leaf-like, reticular/sulciolar, and pinecone. The clinicopathological features and ME-CV findings were compared among the mucin phenotypes. RESULTS Tumors of the gastric type were located in the duodenal bulb (p < 0.001), and contained pyloric gland adenoma (p < 0.001) more frequently than the other types. White-light endoscopy indicated that milk-white mucosa was less frequent in tumors of the gastric type than in those of the gastrointestinal type (p = 0.006) and the intestinal type (p < 0.001). ME-CV findings were significantly different between the gastric type and the other type (p = 0.028). Totally, 5 of 8 tumors of the gastric type manifested a pinecone pattern, 4 of which were compatible with pyloric gland adenoma. CONCLUSIONS The endoscopic findings of NADETs differ according to mucin phenotype. A pinecone pattern under ME-CV may be characteristic of NADETs of the gastric type, especially pyloric gland adenoma.
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Affiliation(s)
- Yosuke Toya
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Masaki Endo
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Japan.,Kaiunbashi Endoscopy Clinic, Morioka, Japan
| | - Risaburo Akasaka
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Jun Urushikubo
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Takahiro Gonai
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Kensuke Asakura
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Shunichi Yanai
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Keisuke Kawasaki
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Makoto Eizuka
- Division of Molecular Diagnostic Pathology, Department of Pathology, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Noriyuki Uesugi
- Division of Molecular Diagnostic Pathology, Department of Pathology, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Shotaro Nakamura
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Tamotsu Sugai
- Division of Molecular Diagnostic Pathology, Department of Pathology, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Japan
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Toba T, Inoshita N, Kaise M, Nomura K, Kuribayashi Y, Tanaka M, Yamashita S, Furuhata T, Kikuchi D, Matsui A, Mitani T, Iizuka T, Hoteya S. Clinicopathological features of superficial non-ampurally duodenal epithelial tumor; gastric phenotype of histology correlates to higher malignant potency. J Gastroenterol 2018; 53:64-70. [PMID: 28321513 DOI: 10.1007/s00535-017-1327-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 03/01/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Superficial non-ampullary duodenal epithelial tumors (SNADETs) are relatively rare, but they are now being detected more frequently due to advances in endoscopic technology. Nevertheless, the pathological nature of SNADETs remains unclear and a management strategy for these tumors has not been established. METHODS To elucidate the clinicopathological features, we conducted a retrospective analysis of 138 endoscopically resected SNADETs. Lesions were classified into two groups by histological grade according to the Vienna classification: category 3 (71 lesions, 51.4%) and category 4/5 (67 lesions, 48.6%). RESULTS Compared with category 3 lesions, category 4/5 lesions were significantly more common in elderly patients (p < 0.001) and had a significantly larger tumor diameter (p = 0.001). Immunohistochemical analysis showed that category 4/5 lesions expressed MUC5AC (p = 0.002), MUC6 (p < 0.001), and p53 (p = 0.003) significantly more frequently and expressed CD10 (p = 0.002) and CDX2 (p = 0.029) significantly less frequently. Multivariate regression analysis showed that advanced age (p < 0.001), MUC6 expression (p = 0.001), and p53 expression (p = 0.004) were independent risk factors for a classification of category 4/5. In addition, advanced age (p = 0.010) and MUC5AC expression (p = 0.011) were identified as risk factors for lesions classified as category 4.2 (noninvasive carcinoma) or higher. All category 5 lesions expressed MUC5AC. CONCLUSIONS The gastric phenotype of MUC5AC and MUC6 may be linked to the malignant potential of SNADETs.
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Affiliation(s)
- Takahito Toba
- Department of Gastroenterology, Toranomon Hospital, Tokyo, 105-8470, Japan. .,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, 143-8541, Japan.
| | - Naoko Inoshita
- Department of Pathology, Toranomon Hospital, Tokyo, 105-8470, Japan
| | - Mitsuru Kaise
- Department of Gastroenterology, Toranomon Hospital, Tokyo, 105-8470, Japan
| | - Kosuke Nomura
- Department of Gastroenterology, Toranomon Hospital, Tokyo, 105-8470, Japan
| | | | - Masami Tanaka
- Department of Gastroenterology, Toranomon Hospital, Tokyo, 105-8470, Japan
| | - Satoshi Yamashita
- Department of Gastroenterology, Toranomon Hospital, Tokyo, 105-8470, Japan
| | - Tsukasa Furuhata
- Department of Gastroenterology, Toranomon Hospital, Tokyo, 105-8470, Japan
| | - Daisuke Kikuchi
- Department of Gastroenterology, Toranomon Hospital, Tokyo, 105-8470, Japan
| | - Akira Matsui
- Department of Gastroenterology, Toranomon Hospital, Tokyo, 105-8470, Japan
| | - Toshifumi Mitani
- Department of Gastroenterology, Toranomon Hospital, Tokyo, 105-8470, Japan
| | - Toshiro Iizuka
- Department of Gastroenterology, Toranomon Hospital, Tokyo, 105-8470, Japan
| | - Shu Hoteya
- Department of Gastroenterology, Toranomon Hospital, Tokyo, 105-8470, Japan
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Hocke M, Braden B, Jenssen C, Dietrich CF. Present status and perspectives of endosonography 2017 in gastroenterology. Korean J Intern Med 2018; 33:36-63. [PMID: 29161800 PMCID: PMC5768548 DOI: 10.3904/kjim.2017.212] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 06/16/2017] [Indexed: 12/13/2022] Open
Abstract
Endoscopic ultrasound has become an essential tool in modern gastroenterology and abdominal surgery. Compared with all other endoscopic methods, it has the most potential for innovation and its future looks bright. Thus, we compiled this summary of established and novel applications of endoscopic ultrasound methods to inform the reader about what is already possible and where future developments will lead in improving patient care further. This review is structured in four parts. The first section reports on developments in diagnostic endoscopic ultrasound, the second looks at semi-invasive endoscopic ultrasound, and the third discusses advances in therapeutic endoscopic ultrasound. An overview on the future prospects of endoscopic ultrasound methods concludes this article.
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Affiliation(s)
- Michael Hocke
- Internal Medicine II, Helios Hospital Meiningen, Germany
| | - Barbara Braden
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK
| | | | - Christoph F. Dietrich
- Medical Department 2, Caritas Hospital Bad Mergentheim, Bad Mergentheim, Germany
- Correspondence to Christoph F. Dietrich, M.D. Medical Department 2, Caritas Hospital Bad Mergentheim, Uhlandstraße 7, Bad Mergentheim 97980, Germany Tel: +49-7931-582201 Fax: +49-7931-582290 E-mail:
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Kakushima N, Yoshida M, Iwai T, Kawata N, Tanaka M, Takizawa K, Ito S, Imai K, Hotta K, Ishiwatari H, Matsubayashi H, Ono H, Sasaki K. A simple endoscopic scoring system to differentiate between duodenal adenoma and carcinoma. Endosc Int Open 2017; 5:E763-E768. [PMID: 28791326 PMCID: PMC5546900 DOI: 10.1055/s-0043-113567] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 05/31/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Diagnosis of nonampullary duodenal low grade adenoma (Vienna classification category 3, VCL 3) and high grade adenoma/carcinoma (VCL 4 or higher) is important for clinical management decisions. However, there are no criteria based on which endoscopic diagnosis can differentiate between VCL3 and VCL4 or higher. This study aimed to establish simple diagnostic criteria to differentiate between VCL3 and VCL4 or higher. PATIENTS AND METHODS This retrospective study included patients with superficial nonampullary duodenal epithelial tumors (NADETs) who underwent tumor resection between June 2004 and November 2016 at a single cancer center hospital. Using patient demographics and endoscopic findings from 2004 to 2013, variables related to the final histology of VCL4 or higher were analyzed, and a predictive model was developed. Validation analysis was performed on patients treated between 2014 and 2016. RESULTS A total of 150 lesions in 134 patients were included. Lesion diameter, reddish color, depression, heterogeneous or no nodularity, and mixed or depressed macroscopic types were significantly predictive of VCL4 or higher. A predictive score model was developed and a score of 3 points was defined as an appropriate cutoff for predicting VCL4 or higher. In the validation analysis, the accuracy rate of VCL4 or higher diagnosis was 86 % when the score was ≥ 3 points. Scores between patients with VCL3 and VCL4 or higher were significantly different ( P = 0.0004). CONCLUSIONS A simple and useful endoscopic scoring system was developed to preoperatively differentiate between VCL3 and VCL4 or higher among superficial NADETs.
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Affiliation(s)
- Naomi Kakushima
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
- Corresponding author Naomi Kakushima MD, PhD Division of EndoscopyShizuoka Cancer Center1007 ShimonagakuboNagaizumiSuntougunShizuoka 4118777Japan+81-55-9895692
| | - Masao Yoshida
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Tomohiro Iwai
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Noboru Kawata
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Masaki Tanaka
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kohei Takizawa
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Sayo Ito
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kenichiro Imai
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kinichi Hotta
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | | | | | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Keiko Sasaki
- Division of Pathology, Shizuoka Cancer Center, Shizuoka, Japan
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Kinoshita S, Nishizawa T, Ochiai Y, Uraoka T, Akimoto T, Fujimoto A, Maehata T, Goto O, Kanai T, Yahagi N. Accuracy of biopsy for the preoperative diagnosis of superficial nonampullary duodenal adenocarcinoma. Gastrointest Endosc 2017; 86:329-332. [PMID: 28003118 DOI: 10.1016/j.gie.2016.12.007] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 12/04/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic biopsy sampling for the diagnosis of duodenal adenocarcinoma is not perfect. We investigated the accuracy of biopsy specimen diagnoses of superficial nonampullary duodenal epithelial tumors (NADETs). METHODS Clinicopathologic data were retrospectively reviewed for 95 superficial NADETs from 95 patients who underwent endoscopic resection. Preoperative diagnoses based on biopsy specimens were compared with histologic diagnoses of resected specimens. RESULTS Among the 21 lesions with biopsy specimen diagnoses of carcinoma, 12 (57.1%) were histologically diagnosed as adenomas after resection. Among the 74 lesions with biopsy specimen diagnoses of adenoma, 15 (20.3%) were histologically diagnosed as carcinomas after resection. The duodenal biopsy specimen predicted final histologic diagnoses of carcinoma with a sensitivity of 37.5% (95% CI, 18.8-59.4), specificity of 83.1% (95% CI, 72.3-91.0), accuracy of 71.6% (95% CI, 61.4-80.4), positive predictive value of 42.9% (95% CI, 21.8-66.0), and negative predictive value of 79.7% (95% CI, 68.8-88.2). Among 61 cases considered suitable for EMR, treatment modality was converted from EMR to endoscopic submucosal dissection because of the nonlifting sign in 15 cases (24.6%). CONCLUSIONS The accuracy of duodenal biopsy sampling was relatively low. Duodenal biopsy sampling may induce unexpected fibrosis. New endoscopic modalities that can improve preoperative diagnosis yield of NADETs are eagerly awaited.
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Affiliation(s)
- Satoshi Kinoshita
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan; Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan; Division of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Toshihiro Nishizawa
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan; Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yasutoshi Ochiai
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Toshio Uraoka
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan; Division of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Teppei Akimoto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan; Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Ai Fujimoto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Tadateru Maehata
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Osamu Goto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
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Comparison of endoscopic ultrasonography and magnifying endoscopy for assessment of the invasion depth of shallow gastrointestinal neoplasms: a systematic review and meta-analysis. Surg Endosc 2017; 31:4923-4933. [PMID: 28547665 DOI: 10.1007/s00464-017-5596-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 05/11/2017] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To conduct a meta-analysis to provide accurate evidence regarding the preferred diagnostic method, magnifying endoscopy (ME) or endoscopic ultrasonography (EUS), for assessment of the depth of invasion of the gastrointestinal neoplasms. METHODS PubMed, EMBASE, Ovid Medline, and the Cochrane Library databases were searched for studies published between January 1946 and October 2016, regarding the use of EUS and ME to assess the invasion depth of gastrointestinal cancers. The quality of diagnostic studies was evaluated using the QUADAS2 instrument. The Meta-DiSc software (version 1.4) was used for meta-analysis of the pooled data regarding the diagnostic accuracy of EUS and ME of the invasion depth of gastrointestinal neoplasms. RESULTS Our meta-analysis included the data of 754 patients with gastrointestinal cancers contributed by seven prospective studies. All studies were of high quality (QUADAS2). The receiver operating characteristic (ROC) planes were not observed in shoulder and arm forms for either EUS or ME, with Spearman's correlation coefficients of -0.821 and 0.234 for EUS and ME, respectively. The p values of the diagnostic odds ratio for EUS and ME were 0.0038 and 0.0131, respectively. The sensitivity and specificity of EUS for the diagnosis of the depth of invasion of gastrointestinal cancers were 0.75 (95% CI 0.69-0.81) and 0.84 (95% CI 0.79-0.88), respectively. In comparison, the sensitivity and specificity for ME were 0.74 (95% CI 0.67-0.69) and 0.85 (95% CI 0.80-0.89), respectively. The values of area under the summary ROC (SROC) curves for EUS and ME were 0.8499 and 0.8757, respectively, with a non-significant Z value between EUS and MR (0.296 < 1.96). CONCLUSIONS Both EUS and ME provide a comparable performance for judging the depth of invasion of gastrointestinal neoplasms. However, there is heterogeneity between studies contributed by non-threshold effects.
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Mitsuishi T, Hamatani S, Hirooka S, Fukasawa N, Aizawa D, Hara Y, Dobashi A, Goda K, Fukuda T, Saruta M, Urashima M, Ikegami M. Clinicopathological characteristics of duodenal epithelial neoplasms: Focus on tumors with a gastric mucin phenotype (pyloric gland-type tumors). PLoS One 2017; 12:e0174985. [PMID: 28376132 PMCID: PMC5380350 DOI: 10.1371/journal.pone.0174985] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 03/18/2017] [Indexed: 12/16/2022] Open
Abstract
Objective Epithelial tumors less commonly occur in the duodenum than in the stomach or large intestine. The clinicopathological characteristics of duodenal epithelial tumors remain a matter of debate. We therefore studied resected specimens to investigate the clinicopathological characteristics of duodenal epithelial tumors. Materials and methods Among duodenal epithelial tumors resected endoscopically or surgically in our hospital, we studied the clinicopathological characteristics of 110 adenomas or intramucosal carcinomas. The grade of atypia of all tumors was classified into 3 groups according to the World Health Organization (WHO) 2010 classification. The tumors were immunohistochemically evaluated to determine the frequency of differentiation toward fundic glands. Results As for patient characteristics, there were 76 men (75.2%) and 25 women (24.8%), with a median age of 65 years (range, 34 to 84). The tumors most commonly arose in the first to second part of the duodenum. Many lesions were flat, and the median tumor diameter was 8.0 mm. The lesions were classified into 2 types according to mucin phenotype: intestinal-type tumors (98 lesions, 89.1%) and gastric-type tumors (12 lesions, 10.9%). Intestinal-type tumors were subdivided into 2 groups: tubular-type tumors (91 lesions, 82.7%) and tubulovillous-type tumors (7 lesions, 6.4%). Gastric-type tumors were classified into 2 types: foveolar type (3 lesions, 2.7%) and pyloric gland-type (PG) tumors (9 lesions, 8.2%). The grade of atypia was significantly higher in gastric-type tumors (p<0.01). PG tumors were gastric-type tumors characterized by pyloric glands and findings suggesting differentiation toward fundic glands. Conclusions About 10% of the duodenal tumors had a gastric-type mucin phenotype. Gastric-type tumors showed high-grade atypia. In particular, PG tumors showed similarities to PG tumors of the stomach, such as differentiation toward fundic glands.
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Affiliation(s)
- Takehiro Mitsuishi
- Department of Pathology, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
- * E-mail:
| | - Shigeharu Hamatani
- Department of Pathology, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Shinichi Hirooka
- Department of Pathology, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Nei Fukasawa
- Department of Pathology, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Daisuke Aizawa
- Department of Pathology, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Yuko Hara
- Department of Endoscopy, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Akira Dobashi
- Department of Endoscopy, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Kenichi Goda
- Department of Endoscopy, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Takahiro Fukuda
- Division of Neuropathology, Department of Pathology, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Masayuki Saruta
- Division of Gastroenterology and Hepatology, Department of Internal medicine, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Mitsuyoshi Urashima
- Division of Molecular Epidemiology, Research Center for Medical Sciences, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Masahiro Ikegami
- Department of Pathology, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
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Tomizawa M, Shinozaki F, Motoyoshi Y, Sugiyama T, Yamamoto S, Ishige N. Duodenal Adenocarcinoma Diagnosed from a Biopsy Specimen of a Depressed Lesion Obtained by Magnifying Endoscopy. Case Rep Gastroenterol 2016; 10:161-7. [PMID: 27403120 PMCID: PMC4929374 DOI: 10.1159/000444441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 02/02/2016] [Indexed: 12/13/2022] Open
Abstract
Biopsies are necessary for the management of duodenal tumors. However, the most suitable targets for biopsy are not known. An 82-year-old woman who regularly visited our hospital for rheumatoid arthritis underwent abdominal ultrasonography. This screening revealed a dilated pancreatic duct. Magnetic resonance cholangiopancreatography was performed, and dilatation of the pancreatic duct was confirmed. The patient underwent duodenoscopy to investigate the possibility of obstruction of the papilla of Vater. The examination revealed an elevated lesion around the papilla of Vater. Endoscopic ultrasonography and a 20-MHz mini-probe were used to investigate the depth of the invasion. The common bile and pancreatic ducts were intact. The mucosal and submucosal borders were indistinct; however, the border between the submucosa and muscularis propria was clear, suggesting that the muscularis propria was intact. Magnifying endoscopy was used to examine the surface of the elevated lesion, which revealed a depressed lesion. A biopsy specimen of the depressed lesion was taken, and the tumor was diagnosed as an adenocarcinoma. Another biopsy specimen from a non-depressed lesion was diagnosed as an adenoma. The patient was diagnosed with duodenal adenocarcinoma, and was recommended surgery. She declined surgery and was followed up for 34 months. Because it is possible for depressed lesions of duodenal tumors to be adenocarcinomas, biopsy specimens should be obtained from depressed lesions of duodenal tumors.
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Affiliation(s)
- Minoru Tomizawa
- Department of Gastroenterology, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Japan
| | - Fuminobu Shinozaki
- Department of Radiology, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Japan
| | - Yasufumi Motoyoshi
- Department of Neurology, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Japan
| | - Takao Sugiyama
- Department of Rheumatology, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Japan
| | - Shigenori Yamamoto
- Department of Pediatrics, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Japan
| | - Naoki Ishige
- Department of Neurosurgery, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Japan
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