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Dong J, Grant C, Vuong B, Nishioka N, Gao AH, Beatty M, Baldwin G, Bailargeon A, Bablouzian A, Grahmann P, Bhat N, Ryan E, Barrios A, Giddings S, Ford T, Beaulieu-Ouellet E, Hosseiny SH, Lerman I, Trasischker W, Reddy R, Singh K, Gora M, Hyun D, Queneherve L, Wallace M, Wolfsen H, Sharma P, Wang KK, Leggett CL, Poneros J, Abrams JA, Lightdale C, Leeds S, Rosenberg M, Tearney G. Feasibility and Safety of Tethered Capsule Endomicroscopy in Patients With Barrett's Esophagus in a Multi-Center Study. Clin Gastroenterol Hepatol 2022; 20:756-765.e3. [PMID: 33549871 PMCID: PMC8715859 DOI: 10.1016/j.cgh.2021.02.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 02/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Tethered capsule endomicroscopy (TCE) involves swallowing a small tethered pill that implements optical coherence tomography (OCT) imaging, procuring high resolution images of the whole esophagus. Here, we demonstrate and evaluate the feasibility and safety of TCE and a portable OCT imaging system in patients with Barrett's esophagus (BE) in a multi-center (5-site) clinical study. METHODS Untreated patients with BE as per endoscopic biopsy diagnosis were eligible to participate in the study. TCE procedures were performed in unsedated patients by either doctors or nurses. After the capsule was swallowed, the device continuously obtained 10-μm-resolution cross-sectional images as it traversed the esophagus. Following imaging, the device was withdrawn through mouth, and disinfected for subsequent reuse. BE lengths were compared to endoscopy findings when available. OCT-TCE images were compared to volumetric laser endomicroscopy (VLE) images from a patient who had undergone VLE on the same day as TCE. RESULTS 147 patients with BE were enrolled across all sites. 116 swallowed the capsule (79%), 95/114 (83.3%) men and 21/33 (63.6%) women (P = .01). High-quality OCT images were obtained in 104/111 swallowers (93.7%) who completed the procedure. The average imaging duration was 5.55 ± 1.92 minutes. The mean length of esophagus imaged per patient was 21.69 ± 5.90 cm. A blinded comparison of maximum extent of BE measured by OCT-TCE and EGD showed a strong correlation (r = 0.77-0.79). OCT-TCE images were of similar quality to those obtained by OCT-VLE. CONCLUSIONS The capabilities of TCE to be used across multiple sites, be administered to unsedated patients by either physicians or nurses who are not expert in OCT-TCE, and to rapidly and safely evaluate the microscopic structure of the esophagus make it an emerging tool for screening and surveillance of BE patients. Clinical trial registry website and trial number: NCT02994693 and NCT03459339.
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Affiliation(s)
- Jing Dong
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA,Harvard Medical School, MA
| | - Catriona Grant
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Barry Vuong
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA,Harvard Medical School, MA
| | - Norman Nishioka
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA,Harvard Medical School, MA
| | - Anna Huizi Gao
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Matthew Beatty
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Grace Baldwin
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Aaron Bailargeon
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Ara Bablouzian
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Patricia Grahmann
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Nitasha Bhat
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Emily Ryan
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Amilcar Barrios
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Sarah Giddings
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Timothy Ford
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA,Harvard Medical School, MA
| | | | | | - Irene Lerman
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Wolfgang Trasischker
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA,Harvard Medical School, MA
| | - Rohith Reddy
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA,Harvard Medical School, MA
| | - Kanwarpal Singh
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA,Harvard Medical School, MA
| | - Michalina Gora
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA,Harvard Medical School, MA,ICube Laboratory, CNRS, Strasbourg University, France
| | - Daryl Hyun
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA
| | - Lucille Queneherve
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA,Harvard Medical School, MA
| | - Michael Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, FL
| | - Herbert Wolfsen
- Division of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, FL
| | - Prateek Sharma
- Department of Gastroenterology, Kansas City Veterans Administration and University of Kansas School of Medicine, MO
| | - Kenneth K. Wang
- Division of Gastroenterology and Hepatology,, Mayo Clinic Rochester, MN
| | - Cadman L. Leggett
- Division of Gastroenterology and Hepatology,, Mayo Clinic Rochester, MN
| | | | | | | | | | - Mireille Rosenberg
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA,Harvard Medical School, MA
| | - Guillermo Tearney
- Wellman Center for Photomedicine, Massachusetts General Hospital, MA,Harvard Medical School, MA,Department of Pathology, Massachusetts General Hospital, MA,Harvard-MIT Division of Health Science and Technology (HST)
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Gupta N, Brill JV, Canto M, DeMarco D, Fennerty BM, Laine L, Lieberman D, Lightdale C, Montgomery E, Odze R, Rex D, Sharma P, Tokar JL, Kochman ML. AGA White Paper: Training and Implementation of Endoscopic Image Enhancement Technologies. Clin Gastroenterol Hepatol 2017; 15:820-826. [PMID: 28528939 DOI: 10.1016/j.cgh.2017.01.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 01/23/2017] [Accepted: 01/23/2017] [Indexed: 02/06/2023]
Abstract
Endoscopic image-enhancement technologies provide opportunities to visualize normal and abnormal tissues within the gastrointestinal (GI) tract in a manner that complements conventional white light endoscopic imaging. The additional information that is obtained enables the endoscopist to better identify, delineate, and characterize lesions and can facilitate targeted biopsies or, in some cases, eliminate the need to send samples for histologic analysis. Some of these technologies have been available for more than a decade, but despite this fact, there is limited use of these technologies by endoscopists. Lack of formalized training in their use and a scarcity of guidelines on implementation of these technologies into clinical practice are contributing factors. In November 2014, the American Gastroenterological Association's Center for GI Innovation and Technology conducted a 2-day workshop to discuss endoscopic image-enhancement technologies. This article represents the third of 3 separate documents generated from the workshop and discusses the published literature pertaining to training and outlines a proposed framework for the implementation of endoscopic image-enhancement technologies in clinical practice. There was general agreement among participants in the workshop on several key considerations. Training and competency assessment for endoscopic image-enhancement technologies should incorporate competency-based education paradigms. To facilitate successful training, multiple different educational models that can cater to variations in learning styles need to be developed, including classroom-style and self-directed programs, in-person and web-based options, image and video atlases, and endoscopic simulator programs. To ensure safe and appropriate use of these technologies over time, refresher courses, skill maintenance programs, and options for competency reassessment should be established. Participants also generally agreed that although early adopters of novel endoscopic image-enhancement modalities can successfully implement these technologies by pursuing training and ensuring self-competency, widespread implementation is likely to require support from GI societies and buy-in from other key stakeholders including payors/purchasers and patients. Continued work by manufacturers and the GI societies in providing training programs and patient education, working with payors and purchasers, and creating environments and policies that motivate endoscopists to adopt new practices is essential in creating widespread implementation.
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Affiliation(s)
- Neil Gupta
- Loyola University Health System, Maywood, Illinois.
| | | | | | | | | | - Loren Laine
- Yale University of Medicine, New Haven, Connecticut
| | | | - Charles Lightdale
- New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | | | - Robert Odze
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Douglas Rex
- Indiana University Medical Center, Indianapolis, Indiana
| | - Prateek Sharma
- University of Kansas School of Medicine, Kansas City, Kansas
| | | | - Michael L Kochman
- University of Pennsylvania Health System, Philadelphia, Pennsylvania
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Tsai FC, Ghorbani S, Greenwald BD, Jang S, Dumot JA, McKinley MJ, Shaheen NJ, Habr F, Wolfsen HC, Abrams JA, Lightdale C, Nishioka NS, Johnston MH, Zfass A, Coyle W. Safety and efficacy of endoscopic spray cryotherapy for esophageal cancer. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.4_suppl.83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
83 Background: Although surgery is traditionally the standard of care for esophageal cancer, esophagectomy carries significant morbidity and mortality. Alternative endoscopic therapies are needed for patients who are not candidates for conventional treatment. The objective of this study was to assess the safety, efficacy, and tolerability of spray cryotherapy of esophageal cancer. Methods: This study includes patients enrolled retrospectively and prospectively in an open-label registry and patients in a retrospective cohort from twelve academic and community practices. Endoscopic spray cryotherapy was performed until local tumor eradication was confirmed by biopsy or until treatment was halted due to progression of disease, patient withdrawal or co-morbidities. Results: One-hundred and eight patients (median age 75.5, 79.6% male, 93.5% adenocarcinoma, mean length 5.2 cm) underwent 442 treatments (mean 4.2 per patient). Tumor stages included 40 with T1a, 27 with T1b, 10 with unspecified T1, 15 with T2, and 16 with no T stage reported. One-hundred and six patients completed treatment with complete response of intraluminal disease in 54.7%, including complete response in 74.4% for T1a, 50% for T1b, 65.3% for all T1, 6.7% for T2, and 50% for those with no T stage reported. Mean follow-up was 17.3 months. There were no deaths or perforations related to spray cryotherapy. Strictures developed in 11 of 108 patients (10.2%) but were present before spray cryotherapy in 3 of 11. Conclusions: This study suggests that endoscopic spray cryotherapy is safe, well tolerated and effective for early esophageal cancer in patients who are not candidates for conventional therapy.
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Affiliation(s)
| | | | - Bruce D Greenwald
- University of Maryland School of Medicine, Greenebaum Cancer Center, Baltimore, MD
| | | | | | - Matthew J McKinley
- North Shore-LIJ Health System, ProHEALTHcare Associates, Syosset, Lake Success, NY
| | | | - Fadlallah Habr
- Alpert Medical School of Brown University, Providence, RI
| | | | | | | | | | | | - Alvin Zfass
- Virginia Commonwealth University, Richmond, VA
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Sharma P, Brill J, Canto M, DeMarco D, Fennerty B, Gupta N, Laine L, Lieberman D, Lightdale C, Montgomery E, Odze R, Tokar J, Kochman M. White Paper AGA: Advanced Imaging in Barrett's Esophagus. Clin Gastroenterol Hepatol 2015; 13:2209-18. [PMID: 26462567 DOI: 10.1016/j.cgh.2015.09.017] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 09/16/2015] [Accepted: 09/21/2015] [Indexed: 02/07/2023]
Abstract
Enhanced imaging technologies such as narrow band imaging, flexible spectral imaging color enhancement, i-Scan, confocal laser endomicroscopy, and optical coherence tomography are readily available for use by endoscopists in routine clinical practice. In November 2014, the American Gastroenterological Association's Center for GI Innovation and Technology conducted a 2-day workshop to discuss endoscopic image enhancement technologies, focusing on their role in 2 specific clinical conditions (colon polyps and Barrett's esophagus) and on issues relating to training and implementation of these technologies (white papers). Although the majority of the studies that use enhanced imaging technologies have been positive, these techniques ideally need to be validated in larger cohorts and in community centers. As it stands today, detailed endoscopic examination with high-definition white-light endoscopy and random 4-quadrant biopsy remains the standard of care. However, the workshop panelists agreed that in the hands of endoscopists who have met the preservation and incorporation of valuable endoscopic innovation thresholds (diagnostic accuracy) with enhanced imaging techniques (specific technologies), use of the technique in Barrett's esophagus patients is appropriate.
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Affiliation(s)
- Prateek Sharma
- University of Kansas School of Medicine, Kansas City, Missouri.
| | - Joel Brill
- Predictive Health, LLC, Paradise Valley, Arizona
| | | | | | | | - Neil Gupta
- Loyola University Health System, Chicago, Illinois
| | - Loren Laine
- Yale School of Medicine, New Haven, Connecticut
| | | | - Charles Lightdale
- New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | | | - Robert Odze
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Jeffrey Tokar
- Temple/Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Michael Kochman
- University of Pennsylvania Health System, Philadelphia, Pennsylvania
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Lieberman D, Brill J, Canto M, DeMarco D, Fennerty B, Gupta N, Laine L, Lightdale C, Montgomery E, Odze R, Rex D, Sharma P, Kochman M, Tokar J. Management of Diminutive Colon Polyps Based on Endoluminal Imaging. Clin Gastroenterol Hepatol 2015; 13:1860-6; quiz e168-9. [PMID: 26192139 DOI: 10.1016/j.cgh.2015.07.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 07/12/2015] [Accepted: 07/14/2015] [Indexed: 02/07/2023]
Abstract
Diminutive colon polyps, defined as 5 mm or less, are encountered increasingly at colonoscopy. The risk of serious pathology in such polyps is low. There is a risk and cost of resecting all such polyps and sending tissue for pathologic evaluation. Enhancement of endoluminal imaging may enable discrimination of neoplastic vs non-neoplastic polyps. If this discrimination can be performed accurately with high confidence, it may be possible to either resect and discard diminutive adenomas, or inspect and do-not-resect diminutive hyperplastic polyps. In 2011, an expert group recommended thresholds of 90% negative predictive value for adenomas, and 90% accuracy in predicting appropriate surveillance intervals. Since 2011, criteria for polyp discrimination have been published and validated by experts and nonexperts. In vivo studies have been performed to compare endoscopic impression and pathologic diagnosis. An expert panel was convened in late 2014 to review the literature to determine if the proposed thresholds for discrimination can be attained and to recommend the next steps for introducing changes in clinical practice. We conclude that threshold levels can be achieved with several endoscopic image enhancements. The next steps to implementation of practice change include acquiring data on training and competence, determining best practices for auditing performance, understanding patient education needs, and the potential cost benefit of such changes.
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Affiliation(s)
- David Lieberman
- Department of Medicine, Division of Gastroenterology, Oregon Health and Science University, Portland, OR.
| | - Joel Brill
- Predictive Health, LLC, Paradise Valley, AZ
| | - Marcia Canto
- Department of Medicine, Division of Gastroenterology, Johns Hopkins University, Baltimore, MD
| | - Daniel DeMarco
- Department of Medicine, Division of Gastroenterology, Baylor University Medical Center, Dallas, TX
| | - Brian Fennerty
- Department of Medicine, Division of Gastroenterology, Oregon Health and Science University, Portland, OR
| | - Neil Gupta
- Department of Medicine, Division of Gastroenterology, Loyola University Health System, Chicago, IL
| | - Loren Laine
- Department of Medicine, Division of Gastroenterology, Yale University of Medicine, New Haven, CT
| | - Charles Lightdale
- Department of Medicine, Division of Gastroenterology, New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY
| | - Elizabeth Montgomery
- Department of Medicine, Division of Gastroenterology, Johns Hopkins Medical Laboratories, Baltimore, MD
| | - Robert Odze
- Department of Medicine, Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA
| | - Douglas Rex
- Department of Medicine, Division of Gastroenterology, Indiana University Medical Center, Indianapolis, IN
| | - Prateek Sharma
- Department of Medicine, Division of Gastroenterology, University of Kansas School of Medicine, Kansas City, KS
| | - Michael Kochman
- Department of Medicine, Division of Gastroenterology, University of Pennsylvania Health System, Philadelphia, PA
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Quante M, Bhagat G, Abrams J, Marache F, Good P, Lee MD, Lee Y, Friedman R, Asfaha S, Dubeykovskaya Z, Mahmood U, Figueiredo JL, Kitajewski J, Shawber C, Lightdale C, Rustgi AK, Wang TC. Bile acid and inflammation activate gastric cardia stem cells in a mouse model of Barrett-like metaplasia. Cancer Cell 2012; 21:36-51. [PMID: 22264787 PMCID: PMC3266546 DOI: 10.1016/j.ccr.2011.12.004] [Citation(s) in RCA: 340] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Revised: 06/02/2011] [Accepted: 12/01/2011] [Indexed: 02/06/2023]
Abstract
Esophageal adenocarcinoma (EAC) arises from Barrett esophagus (BE), intestinal-like columnar metaplasia linked to reflux esophagitis. In a transgenic mouse model of BE, esophageal overexpression of interleukin-1β phenocopies human pathology with evolution of esophagitis, Barrett-like metaplasia and EAC. Histopathology and gene signatures closely resembled human BE, with upregulation of TFF2, Bmp4, Cdx2, Notch1, and IL-6. The development of BE and EAC was accelerated by exposure to bile acids and/or nitrosamines, and inhibited by IL-6 deficiency. Lgr5(+) gastric cardia stem cells present in BE were able to lineage trace the early BE lesion. Our data suggest that BE and EAC arise from gastric progenitors due to a tumor-promoting IL-1β-IL-6 signaling cascade and Dll1-dependent Notch signaling.
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Affiliation(s)
- Michael Quante
- Division of Digestive and Liver Diseases, Irving Cancer Research Center, Department of Medicine, Columbia University Medical Center, New York, NY
- II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675 München
- Corresponding authors: Timothy C. Wang, M.D., Division of Digestive and Liver Diseases, Columbia University Medical Center, 1130 St. Nicholas Avenue, Room 925, 9th Floor; New York, NY 10032, Phone: (212) 851-4581; Fax: (212) 851-4590; . Michael Quante, M.D., II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675 München, Phone: +49 89 4140 6795; Fax: +49 89 4140 6796;
| | - Govind Bhagat
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY
| | - Julian Abrams
- Division of Digestive and Liver Diseases, Irving Cancer Research Center, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Frederic Marache
- Division of Digestive and Liver Diseases, Irving Cancer Research Center, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Pamela Good
- Division of Digestive and Liver Diseases, Irving Cancer Research Center, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Michele D. Lee
- Division of Digestive and Liver Diseases, Irving Cancer Research Center, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Yoomi Lee
- Division of Digestive and Liver Diseases, Irving Cancer Research Center, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Richard Friedman
- Department of Biomedical Informatics, Columbia University Medical Center, New York, NY
| | - Samuel Asfaha
- Division of Digestive and Liver Diseases, Irving Cancer Research Center, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Zinaida Dubeykovskaya
- Division of Digestive and Liver Diseases, Irving Cancer Research Center, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Umar Mahmood
- Nuclear Medicine & Molecular Imaging, Harvard Medical School and Massachusetts General Hospital, Boston, MA
| | - Jose-Luiz Figueiredo
- Center for Systems Biology, Harvard Medical School and Massachusetts General Hospital, Boston, MA
| | - Jan Kitajewski
- Pathology, Obstetrics and Gynecology, and Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY 10032, USA
| | - Carrie Shawber
- Pathology, Obstetrics and Gynecology, and Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY 10032, USA
| | - Charles Lightdale
- Division of Digestive and Liver Diseases, Irving Cancer Research Center, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Anil K. Rustgi
- Division of Gastroenterology, Department of Medicine and Genetics, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Timothy C. Wang
- Division of Digestive and Liver Diseases, Irving Cancer Research Center, Department of Medicine, Columbia University Medical Center, New York, NY
- Corresponding authors: Timothy C. Wang, M.D., Division of Digestive and Liver Diseases, Columbia University Medical Center, 1130 St. Nicholas Avenue, Room 925, 9th Floor; New York, NY 10032, Phone: (212) 851-4581; Fax: (212) 851-4590; . Michael Quante, M.D., II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675 München, Phone: +49 89 4140 6795; Fax: +49 89 4140 6796;
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Chang KJ, Erickson RA, Chak A, Lightdale C, Chen YK, Binmoeller KF, Albers GC, Chen WP, McLaren CE, Sivak MV, Lee JG, Isenberg GA, Wong RCK. EUS compared with endoscopy plus transabdominal US in the initial diagnostic evaluation of patients with upper abdominal pain. Gastrointest Endosc 2010; 72:967-74. [PMID: 20650452 PMCID: PMC3775486 DOI: 10.1016/j.gie.2010.04.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2009] [Accepted: 04/07/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Primary upper endoscopy (EGD) and transabdominal US (TUS) are often performed in patients with upper abdominal pain. OBJECTIVE Primary: Determine whether the combination of EGD and EUS was equivalent to EGD plus TUS in the diagnostic evaluation of upper abdominal pain. Secondary: Compare EUS versus TUS in detecting abdominal lesions, and compare EGD by using an oblique-viewing echoendoscope versus the standard, forward-viewing endoscope in detecting mucosal lesions. DESIGN Prospective, paired design. SETTING Six academic endoscopy centers. PATIENTS This study involved patients with upper abdominal pain referred for endoscopy. INTERVENTION All patients had EGD, EUS, and TUS. The EGD was done using both an oblique-viewing echoendoscope and the standard, forward-viewing endoscope (randomized order) by two separate endoscopists in a blinded fashion, followed by EUS. TUS was performed within 4 weeks of EGD/EUS, also in a blinded fashion. FOLLOW-UP telephone interviews and chart reviews. MAIN OUTCOME MEASUREMENTS Diagnose possible etiology of upper abdominal pain and detect clinically significant lesions. RESULTS A diagnosis of the etiology of upper abdominal pain was made in 66 of 172 patients (38%). The diagnostic rate was 42 of 66 patients (64%) for EGD plus EUS versus 41 of 66 patients (62%) for EGD plus TUS, which was statistically equivalent (McNemar test; P = .27). One hundred ninety-eight lesions were diagnosed with either EUS or TUS. EUS was superior to TUS for visualizing the pancreas (P < .0001) and for diagnosing chronic pancreatitis (P = .03). Two biliary stones were detected only by EUS. Two hundred fifty-one mucosal lesions were similarly diagnosed with EGD with either the standard, forward-viewing endoscope or the oblique-viewing echoendoscope (kappa = 0.48 [95% CI, .43-.54]). EGD with the standard, forward-viewing endoscope was preferred for biopsies. LIMITATIONS No cost analysis. CONCLUSION The combination of EGD with EUS is equivalent to EGD plus TUS for diagnosing a potential etiology of upper abdominal pain. EUS is superior to TUS for detecting chronic pancreatitis. EGD combined with EUS should be considered in the first-line diagnostic evaluation of patients with upper abdominal pain.
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Wallace MB, Sharma P, Lightdale C, Wolfsen H, Coron E, Buchner A, Bajbouj M, Bansal A, Rastogi A, Abrams J, Crook JE, Meining A. Preliminary accuracy and interobserver agreement for the detection of intraepithelial neoplasia in Barrett's esophagus with probe-based confocal laser endomicroscopy. Gastrointest Endosc 2010; 72:19-24. [PMID: 20381042 PMCID: PMC3144146 DOI: 10.1016/j.gie.2010.01.053] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Accepted: 01/22/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND Confocal laser endomicroscopy (CLE) is a rapidly emerging method for in vivo imaging of the GI tract. OBJECTIVE To determine the preliminary evaluation accuracy and interobserver agreement of probe-based CLE (pCLE) in Barrett's esophagus (BE). DESIGN Prospective, double-blind review of pCLE images of 40 sites of BE tissue by using matching biopsies as the reference standard. A training set of 20 images with known histology was first reviewed to standardize image interpretation, followed by blinded review of 20 unknown images. SETTING Eleven experts in BE imaging from 4 different endoscopy centers from the United States and Europe evaluated the images. PATIENTS This study involved nonconsecutive patients undergoing BE surveillance or evaluation of high-grade intraepithelial neoplasia or early adenocarcinoma. INTERVENTION Intravenous fluorescein pCLE imaging of each site within the BE segment, followed by matching biopsy. MAIN OUTCOME MEASUREMENTS Sensitivity, specificity, and agreement for the pCLE diagnosis of high-grade intraepithelial neoplasia or carcinoma. RESULTS In the validation set (n = 20), 11 cases had high-grade intraepithelial neoplasia or invasive carcinoma. The sensitivity for the diagnosis of neoplasia for the 11 endoscopists was 88% (range 6 of 11 to 11 of 11), and the specificity was 96% (range 7 of 9 to 9 of 9). There was substantial agreement on the pCLE diagnosis (86%, kappa 0.72; 95% confidence interval, 0.58-0.86). Endomicroscopists with prior pCLE experience had an overall sensitivity of 91% (all 10 of 11), specificity of 100% (all 9 of 9), and almost perfect agreement (92%, kappa 0.83; 95% confidence interval, 0.64-1.0). LIMITATIONS Small sample size and use of offline video sequences. CONCLUSION Results suggest that pCLE for the diagnosis of neoplasia in BE has very high accuracy and reliability.
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Affiliation(s)
- Michael B Wallace
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida 32224, USA
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Topazian M, Enders F, Kimmey M, Brand R, Chak A, Clain J, Cunningham J, Eloubeidi M, Gerdes H, Gress F, Jagannath S, Kantsevoy S, LeBlanc JK, Levy M, Lightdale C, Romagnuolo J, Saltzman JR, Savides T, Wiersema M, Woodward T, Petersen G, Canto M. Interobserver agreement for EUS findings in familial pancreatic-cancer kindreds. Gastrointest Endosc 2007; 66:62-7. [PMID: 17382940 DOI: 10.1016/j.gie.2006.09.018] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2006] [Accepted: 09/12/2006] [Indexed: 02/08/2023]
Abstract
BACKGROUND EUS is a promising modality for pancreatic-cancer screening in high-risk persons, including familial pancreatic-cancer (FPC) kindreds. OBJECTIVE To assess interobserver agreement for interpretation of EUS in persons at high risk for pancreatic cancer. DESIGN Seventeen expert endosonographers blinded to patients' clinical history rated a "training set" of pancreatic EUS video clips for the presence of a normal examination, masses, cysts, and features of chronic pancreatitis. Clips included high-risk persons and controls (normal and various pancreatic diseases). The endosonographers then participated in a workshop on EUS findings in high-risk persons and drafted a consensus statement. Three months later, they blindly rated a "test set" composed of the same video clips. MAIN OUTCOME MEASUREMENTS Interobserver agreement at baseline (training set) and after a consensus process (test set). RESULTS For the training set, interobserver agreement was good (kappa>or=0.4) for the presence of cysts and was fair to poor for all other rated EUS features and diagnosis of normal. There was no overall improvement in the test set. In both the training and test sets, agreement was worse for clips from FPC kindreds (kappa>or=0.4 for cysts and <0.4 for all other features) than for controls (kappa>or=0.4 for normal, cysts, masses, echogenic strands, and lobularity). LIMITATIONS Video clips were not of identical image quality and duration as a clinical EUS examination. CONCLUSIONS There was fair to poor interobserver agreement for the interpretation of pancreatic EUS video clips from members of FPC kindreds. Agreement was not improved by a consensus process.
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Affiliation(s)
- Mark Topazian
- Mayo Clinic, Rochester, Minnesota 55905, and University of Washington, Seattle, Washington, USA
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10
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Sharma P, Marcon N, Wani S, Bansal A, Mathur S, Sampliner R, Lightdale C. Non-biopsy detection of intestinal metaplasia and dysplasia in Barrett's esophagus: a prospective multicenter study. Endoscopy 2006; 38:1206-12. [PMID: 17163320 DOI: 10.1055/s-2006-944974] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND STUDY AIMS There have been no multicenter studies investigating the use of magnification chromoendoscopy (MCE) for the detection of intestinal metaplasia and dysplasia/cancer in Barrett's esophagus. Our aims were to assess the ability of MCE to predict the histological diagnosis (non-biopsy detection), to compare the yield of MCE-targeted versus random biopsies for dysplasia, and to compare procedure times. PATIENTS AND METHODS In this prospective multicenter study, patients with known or suspected Barrett's esophagus underwent MCE with indigo carmine dye staining. Three mucosal patterns (ridge/villous, circular, and irregular/distorted) were standardized, based on past experience. Mucosal patterns were noted and target biopsies were obtained only if irregular/distorted patterns were identified. Otherwise, random four-quadrant biopsies were obtained. RESULTS A total of 56 patients (mean age 64 years, mean length of Barrett's esophagus 2.7cm) were prospectively evaluated: 38 patients (67.8 %) had ridge/villous patterns, four patients (7.1 %) had circular patterns, four patients (7.1 %) had irregular/distorted patterns, and ten patients (17.8 %) had a combination of patterns. Histologically, intestinal metaplasia was not shown in eight patients (14.2 %), nondysplastic Barrett's esophagus was diagnosed in 30 patients (53.5 %), low-grade dysplasia was detected in 12 patients (21.4 %), and high-grade dysplasia was detected in six patients (10.7 %). An irregular/distorted pattern either throughout the entire segment of Barrett's esophagus or in combination with a ridge/villous or circular pattern had a sensitivity or 83 %, a specificity of 88 %, a positive predictive value of 45 %, and a negative predictive value of 98 % for high-grade dysplasia. The yield of high-grade dysplasia was similar for the two techniques but the time taken to perform MCE was less than the time taken to perform random biopsies. CONCLUSION An irregular/distorted pattern is specific for high-grade dysplasia and so it may not be necessary to perform biopsies in patients with ridge/villous or circular mucosal patterns.
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Affiliation(s)
- P Sharma
- University of Kansas School of Medicine and Veterans Affairs Medical Center, Kansas City, MO, USA.
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11
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Rothstein R, Filipi C, Caca K, Pruitt R, Mergener K, Torquati A, Haber G, Chen Y, Chang K, Wong D, Deviere J, Pleskow D, Lightdale C, Ades A, Kozarek R, Richards W, Lembo A. Endoscopic full-thickness plication for the treatment of gastroesophageal reflux disease: A randomized, sham-controlled trial. Gastroenterology 2006; 131:704-12. [PMID: 16952539 DOI: 10.1053/j.gastro.2006.07.004] [Citation(s) in RCA: 121] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2006] [Accepted: 06/08/2006] [Indexed: 01/11/2023]
Abstract
BACKGROUND & AIMS The aim of this study was to determine the effectiveness of endoscopic full-thickness plication for the treatment of gastroesophageal reflux disease (GERD) in comparison with a sham procedure. METHODS Patients with symptomatic GERD requiring maintenance proton pump inhibitor (PPI) therapy were entered into a randomized, single-blind, prospective, multicenter trial. Seventy-eight patients were randomly assigned to undergo endoscopic full-thickness restructuring of the gastric cardia with transmural suture. Eighty-one patients underwent a sham procedure. Group assignments were revealed following the 3-month evaluation. The primary end point was > or =50% improvement in GERD health-related quality of life (HRQL) score. Secondary end points included medication use and esophageal acid exposure. RESULTS By intention-to-treat analysis, at 3 months, the proportion of patients achieving > or =50% improvement in GERD-HRQL score was significantly greater in the active group (56%) compared with the sham group (18.5%; P < .001). Complete cessation of PPI therapy was higher among patients in the active group than in the sham group by intention-to-treat analysis (50% vs 24%; P = .002). The percent reduction in median percent time pH < 4 was significantly improved within the active group versus baseline (7 vs 10, 18%, P < .001) but not in the sham group (10 vs 9, -3%, P = .686). Between-group analysis revealed the active therapy to be superior to the sham in improving median percent time pH < 4 (P = .010). There were no perforations or deaths. CONCLUSIONS Endoscopic full-thickness plication more effectively reduces GERD symptoms, PPI use, and esophageal acid exposure than a sham procedure.
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Affiliation(s)
- Richard Rothstein
- Section of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA.
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12
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Inoue H, Rey JF, Lightdale C. Lugol chromoendoscopy for esophageal squamous cell cancer. Endoscopy 2001; 33:75-9. [PMID: 11204992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- H Inoue
- First Dept. of Surgery, Tokyo Medical and Dental University, Japan.
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13
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Kozarek RA, Raltz S, Marcon N, Kortan P, Haber G, Lightdale C, Stevens P, Lehman G, Rex D, Benjamin S, Fleischer D, Bashir R, Fry S, Waxman I, Benson J, Polio J. Use of the 25 mm flanged esophageal Z stent for malignant dysphagia: a prospective multicenter trial. Gastrointest Endosc 1997; 46:156-60. [PMID: 9283867 DOI: 10.1016/s0016-5107(97)70065-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND An initial multicenter study using a 21 mm flanged esophageal Z stent demonstrated excellent palliation but an 11% immediate complication rate at placement and a 27% migration rate at 1 month. This North American multicenter trial prospectively studied a 25 mm flanged Z stent to define its palliative ability and whether the increased diameter affected placement or migration problems. METHODS Fifty patients who had esophageal Z stents at seven university or regional referral hospitals were prospectively studied. Indications for prosthesis placement, previous therapy, patient demographics, incidence of concomitant tracheoesophageal fistula, and degree of dysphagia were defined, as were procedural and subsequent stent-related problems, survival times, the ability to occlude a tracheoesophageal fistula, and subsequent degree of dysphagia. RESULTS Twenty-four patients had infiltrating malignancy (16 exophytic and 10 extrinsic), 9 of whom had concomitant tracheoesophageal fistulas. Ten patients (20%) had misplaced stents requiring retrieval and replacement, 12 patients (24%) had subsequent stent-related problems including exsanguination (2), aspiration (3), tumor overgrowth (3), and postplacement migration (4) (8%). There was statistically significant improvement in prestent versus poststent dysphagia and two thirds of patients had complete occlusion of their tracheoesophageal fistula. CONCLUSIONS Redesign of the esophageal Z stent has decreased the migration rate without increasing placement or subsequent erosion problems. Its efficacy appears comparable to the currently marketed Z stent for the palliation of malignant dysphagia and occlusion of tracheoesophageal fistula.
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Affiliation(s)
- R A Kozarek
- Virginia Mason Medical Center, Seattle, Washington 98101, USA
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14
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Arber N, Lightdale C, Rotterdam H, Han KH, Sgambato A, Yap E, Ahsan H, Finegold J, Stevens PD, Green PH, Hibshoosh H, Neugut AI, Holt PR, Weinstein IB. Increased expression of the cyclin D1 gene in Barrett's esophagus. Cancer Epidemiol Biomarkers Prev 1996; 5:457-9. [PMID: 8781742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Previous studies have found a 3-10-fold amplification and overexpression of the cyclin D1 gene in about 32% of human esophageal squamous cell carcinoma. The purpose of this study was to evaluate the prevalence of increased expression of the cyclin D1 protein in Barrett's esophagus. Using 69 formalin-fixed and paraffin-embedded human esophageal specimens, which had been removed endoscopically or obtained at surgery during 1993 and 1994, all immunohistochemical analyses were performed using an avidin-biotin complex immunoperoxidase technique. Increased nuclear expression of the cyclin D1 protein was noted in 32 of 69 samples (46%; 44% of the samples from males and 50% of the samples from females). Positive nuclear staining for the cyclin D1 protein in Barrett's disease with intestinal metaplasia was found in 38% of the male cases and 25% of the female cases, whereas in gastric metaplasia it was positive in 33% of men and 48% of women. Nuclear accumulation of the cyclin D1 protein was also found in both dysplastic and nondysplastic lesions, and it was not associated with sex, age, or cigarette or alcohol consumption. Samples from patients taking proton pump inhibitors tended to be less frequently positive (32%) for cyclin D1 nuclear staining when compared to patients taking H2 antagonists (45%) or antacids (55%). These studies suggest that increased expression of cyclin D1 is an early event in the tumorigenic process of esophageal adenocarcinomas and that the increased expression of this gene might predispose the epithelium to malignant transformation.
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Affiliation(s)
- N Arber
- Columbia-Presbyterian Cancer Center, Columbia University, New York, New York 10032, USA
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15
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Kelsen D, Karpeh M, Schwartz G, Gerdes H, Lightdale C, Botet J, Lauers G, Klimstra D, Huang Y, Saltz L, Quan V, Brennan M. Neoadjuvant therapy of high-risk gastric cancer: a phase II trial of preoperative FAMTX and postoperative intraperitoneal fluorouracil-cisplatin plus intravenous fluorouracil. J Clin Oncol 1996; 14:1818-28. [PMID: 8656250 DOI: 10.1200/jco.1996.14.6.1818] [Citation(s) in RCA: 95] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
PURPOSE AND METHODS We identified patients with gastric cancer at high risk for recurrence before therapy using endoscopic ultrasonography (EUS). Neoadjuvant therapy using the fluorouracil, doxorubicin, and metrotrexate (FAMTX) regimen was given for three courses before planned laparotomy with the intention to perform curative resection. Postoperatively, intraperitoneal (IP) cisplatin and fluorouracil (FU) and intravenous (i.v.) FU were administered to patients undergoing resection. RESULTS Fifty-six assessable patients were treated. Preoperative FAMTX therapy was tolerable, with the major toxicity being neutropenic fever. One treatment-related death was seen. Eighty-nine percent of patients underwent surgical exploration and 61% had potentially curative resections. There were two postoperative deaths. Comparison of pathologic tumor (pT) stage with EUS-predicted tumor stage showed apparent downstaging in 51% of patients. Postoperative IP chemotherapy was delivered to 75% of eligible patients. Toxicity was acceptable. There was no increase in operative morbidity or mortality compared with concurrent nonstudy patients undergoing a similar operative procedure and not receiving preoperative therapy. With a median follow-up time of 29 months, the median survival duration was 15.3 months. For patients who underwent potentially curative resections, the median survival duration was 31 months. Peritoneal failure was seen in 16% of patients. CONCLUSION Chemotherapy with the FAMTX regimen is tolerable in patients with locally advanced gastric cancer, without an increase in operative morbidity or mortality. IP therapy can be successfully delivered to most resected patients. The intraabdominal failure pattern appears to be decreased compared with expected. This approach is an appropriate investigational arm to pursue in future studies.
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Affiliation(s)
- D Kelsen
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY USA
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16
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Botet JF, Lightdale C. Endoscopic ultrasonography of the gastrointestinal tract. Gastroenterol Clin North Am 1995; 24:385-412. [PMID: 7642249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Endoscopic ultrasonography (EUS) combines the advantages of conventional endoscopy with the capabilities of ultrasonography. EUS allows clinicians to see through the wall of the gastrointestinal tract. The close proximity allows the use of relatively high frequencies with the resulting increase in tissue contrast and resolution. Despite some limitations, this new modality does open new horizons in the diagnosis and characterization of upper gastrointestinal diseases.
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Affiliation(s)
- J F Botet
- Cornell University Medical College, New York, New York, USA
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17
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Botet JF, Lightdale C. Endoscopic ultrasonography of the upper gastrointestinal tract. Radiol Clin North Am 1992; 30:1067-83. [PMID: 1518929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Endoscopic ultrasonography combines the advantages of conventional endoscopy with the capabilities of ultrasonography. This permits the examiner to see through the wall of the gastrointestinal tract. The close proximity permits the use of relatively high frequencies, with the resulting increase in tissue contrast and resolution. There are limitations to its use, however, with the main one being a field of view limited to a 7-cm radius. Discussed in this article is its use for the gastrointestinal wall, the esophagus, the stomach, the duodenum, and the pancreas.
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Affiliation(s)
- J F Botet
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, New York
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18
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Kelsen D, Atiq OT, Saltz L, Niedzwiecki D, Ginn D, Chapman D, Heelan R, Lightdale C, Vinciguerra V, Brennan M. FAMTX versus etoposide, doxorubicin, and cisplatin: a random assignment trial in gastric cancer. J Clin Oncol 1992; 10:541-8. [PMID: 1548519 DOI: 10.1200/jco.1992.10.4.541] [Citation(s) in RCA: 230] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE The chemotherapy regimens of high-dose methotrexate, high-dose fluorouracil (FU), Adriamycin (doxorubicin; Adria Laboratories, Columbus, OH), and leucovorin (FAMTX) and etoposide, Adriamycin, and cisplatin (EAP) have both been reported in nonrandom assignment trials to have high overall response rates and substantial complete response rates in patients with gastric cancer, as well as major toxicities of myelosuppression. Here we report a prospective, stratified, random-assignment comparison of the two combinations in previously untreated patients with advanced gastric cancer. PATIENTS AND METHODS Sixty patients were entered onto the trial, 30 receiving EAP and 30 FAMTX. All patients had measurable or assessable tumor masses. Patient entry was stopped at the point when significant toxicity differences were seen at interim analysis. RESULTS Response rates were similar between the two arms (FAMTX, 33% [95% confidence interval (CI), 16% to 50%]; EAP, 20% [95% Cl, 6% to 34%]). Three FAMTX and no EAP patients had complete remissions. The median survival for the two arms were similar (EAP, 6.1 months; FAMTX, 7.3 months). At 1 year, 7% of EAP and 17% of FAMTX patients were alive. EAP caused significantly more myelosuppression (leukopenia, P = .002; anemia, P = .03; thrombocytopenia, P = .0001) than did FAMTX. EAP also resulted in significantly longer hospitalizations per study month (8 v 5 days). Four EAP patients died of lethal toxicity, whereas no FAMTX patients died of treatment-related causes (P = .04). CONCLUSIONS FAMTX is at least as active as EAP and is significantly less toxic. Although both regimens remain investigational, the toxicities of FAMTX are more manageable. Further studies involving FAMTX in both the adjuvant and advanced disease setting are underway.
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Affiliation(s)
- D Kelsen
- Gastrointestinal Oncology Service, Memorial Sloan-Kettering Cancer Center, New York, NY 10021
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Kelsen D, Lovett D, Wong J, Saltz L, Buckley M, Murray P, Heelan R, Lightdale C. Interferon alfa-2a and fluorouracil in the treatment of patients with advanced esophageal cancer. J Clin Oncol 1992; 10:269-74. [PMID: 1732428 DOI: 10.1200/jco.1992.10.2.269] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
PURPOSE The trial was undertaken to determine the response rate to and toxicities from the combination of interferon alfa-2a (IFN) and fluorouracil (FU) in patients with advanced esophageal cancer. MATERIALS AND METHODS In this prospective phase II trial conducted at a large tertiary referral cancer center and university hospital, 40 patients with advanced locoregional, metastatic epidermoid, or adenocarcinoma of the esophagus were given FU 750 mg/m2 by 24-hour continuous intravenous infusion days 1 to 5, followed by weekly outpatient bolus FU 750 mg/m2 and IFN 9 x 10(6) U three times per week from day 1. Dose was attenuated for fatigue, neurotoxicity, gastrointestinal toxicity, and myelosuppression. RESULTS Complete and partial responses were seen in 10 of 37 assessable patients with esophageal cancer (27%; 95% confidence interval, 0.13 to 0.41). Although substantial, toxicity was tolerable and primarily involved fatigue and mild myelosuppression. The median duration of response was 6.4 months (range, 2.8 to 14+ months). CONCLUSION The combination of IFN and FU is an active regimen in the treatment of advanced esophageal cancer with a response rate similar to that reported for cisplatin-containing combinations in similar patient populations. Further studies based on this combination are indicated.
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Affiliation(s)
- D Kelsen
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10021
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20
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Abstract
Intraluminal brachytherapy with a transcatheter Iridium-192 (Ir-192) wire, as a method to deliver a boost to patients with tumors of the extrahepatic bile ducts, has been well described. A major limitation of current imaging techniques is the inability to accurately define the proximal, distal, and most importantly the lateral extent of the tumor. We have found endoluminal ultrasound, which to this date has been used primarily to measure arterial wall layers, can successfully determine tumor volume in the bile ducts. The small diameter of these ultrasound probes allows easy insertion into a biliary duct drainage tube. Given the uncertainties in the determination of tumor size in the bile ducts, ultrasound is an ideal method by which to obtain the measurements. We present a case of recurrent islet cell carcinoma treated with external beam radiation therapy and an Ir-192 intraluminal brachytherapy boost in which the ultrasound probe was used to determine the tumor volume and response to therapy.
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Affiliation(s)
- B Minsky
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021
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Abstract
Endoscopic sonography was used to examine the upper gastrointestinal tract of 550 patients referred for evaluation of abnormal findings seen on conventional endoscopy, upper gastrointestinal series, and CT. This essay illustrates the potential uses and limitations of this technique. Special emphasis has been given to the use of landmarks to facilitate orientation of the transducer in both the esophagus and stomach. Specific examples demonstrate involvement of individual layers of the bowel wall in both benign and malignant processes. It is stressed that this is a combined procedure requiring both an endoscopist and a radiologist. Endoscopic sonography is a valuable new technology with substantial potential in the evaluation of the upper gastrointestinal tract.
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Affiliation(s)
- J F Botet
- Department of Medical Imaging, Memorial Sloan-Kettering Cancer Center, New York, NY 10021
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Friedman E, Lightdale C, Winawer S. Effects of psyllium fiber and short-chain organic acids derived from fiber breakdown on colonic epithelial cells from high-risk patients. Cancer Lett 1988; 43:121-4. [PMID: 2849504 DOI: 10.1016/0304-3835(88)90223-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The effect of a purified fiber, psyllium and the short-chain organic acids derived from fiber breakdown, were assayed on isolated colonic epithelial cells primary-cultured from patients at high-risk of colon cancer, due to adenoma growth or family history of colon cancer. Psyllium fiber provided colonocytes some protection from deoxycholic acid-induced lysis. Propionic acid, a product of fiber breakdown, was a potent colonocyte mitogen, suggesting that fiber could indirectly protect the colon by providing colonocyte nutrients.
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Affiliation(s)
- E Friedman
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10021
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Abstract
Sigmoidoscopy could aid in the control of large bowel cancer by early detection of the 55% of colorectal cancers that develop in the rectosigmoid and by the identification and eradication of significant rectosigmoid adenomas. Rigid sigmoidoscopy has had poor patient acceptance and therefore has not been successful. The present study is a prospective randomized trial to evaluate patient response to flexible as compared with rigid sigmoidoscopy. Patients reported significantly less discomfort (10.1% versus 29.7%), anxiety (9.8% versus 27.6%) and embarrassment (5.2% versus 12.8%) during flexible as compared with rigid sigmoidoscopy. Flexible sigmoidoscopy appears to have better patient acceptance than rigid sigmoidoscopy (P less than 0.01). This could enhance its value as a cancer-control instrument. This article addresses the feasibility of sigmoidoscopy. Its validity also needs to be addressed within the framework of a long-term trial, evaluating mortality for rectosigmoid cancer.
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Affiliation(s)
- S J Winawer
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10021
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Cheng E, Lightdale C, Young C, Yagoda A, Fortner J, Golbey R. Phase II trial of (m-AMSA) 4'-9-(acridinylamino)-methanesulfon-m-aniside in primary liver cancer. Am J Clin Oncol 1983; 6:211-3. [PMID: 6299095 DOI: 10.1097/00000421-198304000-00013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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25
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Lightdale C, Lipkin M, Deschner E. In vivo measurements in familial polyposis: kinetics and location of proliferating cells in colonic adenomas. Cancer Res 1982; 42:4280-3. [PMID: 7105022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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