Simplified criteria for diagnosing superficial esophageal squamous neoplasms using Narrow Band Imaging magnifying endoscopy

Pre-Surgical Endoscopic Biopsies Are Representative of Esophageal and Esophago-Gastric Junction Adenocarcinoma Histologic Classes and Survival Risk

Background and Objectives: The Esophageal Adenocarcinoma Study Group Europe (EACSGE) recently proposed a granular histologic classification of esophageal-esophago-gastric junctional adenocarcinomas (EA-EGJAs) based on the study of naïve surgically resected specimens that, when combined with the pTNM stage, is an efficient indicator of prognosis, molecular events, and response to treatment. In this study, we compared histologic classes of endoscopic biopsies taken before surgical resection with those of the surgical specimen, to evaluate the potential of the EACSGE classification at the initial diagnostic workup. Methods: A total of 106 EA-EGJA cases with available endoscopic biopsies and matched surgical resection specimens were retrieved from five Italian institutions. Histologic classification was performed on all specimens to identify well-differentiated glandular adenocarcinoma (WD-GAC), poorly differentiated glandular adenocarcinoma (PD-GAC), mucinous muconodular carcinoma (MMC), infiltrative mucinous carcinoma (IMC), diffuse desmoplastic carcinoma, diffuse anaplastic carcinoma (DAC), and mixed subtypes. Related risk subgroups (low-risk versus high-risk) were also assessed. The correlations of histologic classes and risk subgroups between diagnostic biopsies and surgical resection specimens were explored with Spearman's correlation test. Sensitivity, specificity, accuracy, positive predictive value, negative predictive value, true positives, true negatives, false positives, and false negatives were also calculated. Results: A strong positive correlation between biopsies and surgical specimens occurred for both histologic classes (coefficient: 0.75, p < 0.001) and risk subgroups (coefficient: 0.65, p < 0.001). The highest sensitivities and specificities were observed for MMC, IMC, and DAC (100% and 99% for all), followed by WD-GAC (sensitivity 91%, specificity 79%) and PD-GAC (sensitivity 722%, specificity 86%). The low-risk and high-risk groups presented a sensitivity and specificity of 89% and 76% (low-risk) and 76% and 89% (high-risk). Conclusions: The EACSGE histologic classification of EA-EGJAs and associated prognostic subgroups can be reliably assessed on pre-operative diagnostic biopsies. Further studies on larger and more representative cohorts of EA-EGJAs will allow us to validate our findings and confirm if the EA-EGJA biopsy histomorphology and clinical TNM staging will be as efficient as the surgical specimen histomorphology and pTNM in predicting patient prognoses and tailoring personalized therapeutic approaches.

Diagnostic Performance of a Novel Ultra-Thin Endoscopy under Narrow-Band Imaging for Superficial Squamous Cell Carcinoma of the Pharynx and Esophagus

This study aimed to evaluate the diagnostic utility of the ultra-thin endoscope (UTE) for superficial squamous cell carcinoma (SSCC) compared to magnifying endoscopy (ME) under narrow-band imaging. Participants underwent endoscopic examination, and images of pharyngeal and esophageal SCCs, as along with suspicious SSCC lesions, were collected using UTE and ME on the same day. Three image catalogs (UTE, ME-1, and ME-2) were created and reviewed by three expert endoscopists. ME-1 and ME-2 contained the same endoscopic images. The primary endpoint was the intra-observer agreement for diagnosing SCC. Eighty-six lesions (SCC = thirty-nine, non-SCC = forty-seven) in 43 participants were identified. The kappa values for the intra-observer agreement between UTE and ME-1 vs. the control (ME-1 vs. ME-2) were 0.74 vs. 0.84, 0.63 vs. 0.76, and 0.79 vs. 0.88, respectively. The accuracies for diagnosing SCC by UTE and ME-1 were 87.2% vs. 86.0%, 78.0% vs. 73,2%, and 75.6 vs. 82.6%, respectively, with no significant differences (p > 0.05). The rates of lesions that were diagnosed with confidence by UTE and ME-1 were 30.2% vs. 27.9%, 55.8% vs. 62.8%, and 58.1% vs. 55.8%, respectively. UTE demonstrates substantial diagnostic performance for SSCC in the pharynx and esophagus.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

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

BACKGROUND

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

DETECTION

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

CHARACTERIZATION

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

TUMOUR-STAGING

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

CONCLUSIONS

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

Electronic chromo-endoscopy: technical details and a clinical perspective

Precise endoscopic assessment is necessary to detect neoplastic changes in an early stage. Electronic or virtual chromo-endoscopy (ECE) is an alternative to conventional dye-based chromo-endoscopy which markedly improves capillary pattern and hence can detect micro-vessel morphological changes of early neoplasia to target biopsies and aid in diagnosis. The clinical significance increased after the advent of endoscopic treatment modalities like ESD/EMR which requires precise delineation of extent and depth of lesion. Most of the studies have used narrow-band imaging (NBI) (Olympus Medical Systems Tokyo, Japan), although data from i-SCAN (PENTAX Endoscopy, Tokyo, Japan) and flexible spectral imaging color enhancement (FICE) (Fujinon, Fujifilm Medical Co, Saitama, Japan) are emerging. Electronic chromo-endoscopy is convenient compared to dye-based chromo-endoscopy in the sense that it is available at the push of a button in endoscope and reduces procedure time substantially with comparable efficacy. Scope of this review is to discuss available electronic chromo-endoscopy modalities and their role in the diagnosis, surveillance, and management of early GI neoplasia.

Diagnostic yield of fourth-generation endocytoscopy for esophageal squamous lesions using a modified endocytoscopic classification

OBJECTIVES

Endocytoscopy (EC) is an ultra-high magnification endoscopy designed to provide in vivo histologic assessment. This study aimed to evaluate the diagnostic yield of the newly developed fourth-generation EC for esophageal squamous lesions by using a modified EC classification.

METHODS

A total of 2548 EC images of 57 esophageal targeted areas between June 2015 and October 2017 were retrospectively collected. Two lesions with low-quality images were excluded. Only EC images were independently reviewed by two expert and two non-expert endoscopists. The lesions were classified according to a three-tier modified EC classification. We used a multilevel logistic regression to analyze the data.

RESULTS

The sensitivity and specificity of diagnosing non-squamous cell cancer (SCC) vs SCC were 82.5% and 83.0% by the experts; 90.1% and 75.0% by non-experts. The interobserver agreement among the four raters was good (kappa statistic 0.59). The diagnostic accuracy of experts and non-experts was similar (P = 0.16 for specificity and P = 0.20 for sensitivity). The sensitivity and specificity of EC for non-neoplasia vs neoplasia were 88.7% and 74.6% by experts; 90.3 and 52.1% by non-experts. The interobserver agreement among the four raters was moderate (kappa statistic 0.44). The specificity of experts was higher compared to non-experts, although the difference did not reach statistical significance (P = 0.08 for specificity and P = 0.93 for sensitivity).

CONCLUSIONS

Fourth-generation EC offers acceptable diagnostic accuracy and reliability in both experts and non-experts, especially when diagnosing SCC lesions.

Controversies in EUS: Do we need miniprobes?

This is the fifth in a series of papers entitled "Controversies in EUS." In the current paper, we deal with high-resolution catheter probes, otherwise known as EUS miniprobes (EUS-MPs). The application of miniprobes for early carcinomas in the entire intestinal tract, for subepithelial lesions, and for findings in the bile duct and pancreatic duct as well as endobronchial use is critically discussed. Submucous lesions, especially in the colon, but also early carcinomas in special cases are considered the most important indications. The argument is illustrated by numerous examples.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND AND GOALS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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