Jorge Lage

A multicenter prospective study of the real-time use of narrow-band imaging in the diagnosis of premalignant gastric conditions and lesions

BACKGROUND AND AIM Some studies suggest that narrow-band imaging (NBI) can be more accurate at diagnosing gastric intestinal metaplasia and dysplasia than white-light endoscopy (WLE) alone. We aimed to assess the real-time diagnostic validity of high resolution endoscopy with and without NBI in the diagnosis of gastric premalignant conditions and to derive a classification for endoscopic grading of gastric intestinal metaplasia (EGGIM). METHODS A multicenter prospective study (five centers: Portugal, Italy, Romania, UK, USA) was performed involving the systematic use of high resolution gastroscopes with image registry with and without NBI in a centralized informatics platform (available online). All users used the same NBI classification. Histologic result was considered the diagnostic gold standard. RESULTS A total of 238 patients and 1123 endoscopic biopsies were included. NBI globally increased diagnostic accuracy by 11 percentage points (NBI 94 % vs. WLE 83 %; P < 0.001) with no difference in the identification of Helicobacter pylori gastritis (73 % vs. 74 %). NBI increased sensitivity for the diagnosis of intestinal metaplasia significantly (87 % vs. 53 %; P < 0.001) and for the diagnosis of dysplasia (92 % vs. 74 %). The added benefit of NBI in terms of diagnostic accuracy was greater in OLGIM III/IV than in OLGIM I/II (25 percentage points vs. 15 percentage points, respectively; P < 0.001). The area under the curve (AUC) of the receiver operating characteristic (ROC) curve for EGGIM in the identification of extensive metaplasia was 0.98. CONCLUSIONS In a real-time scenario, NBI demonstrates a high concordance with gastric histology, superior to WLE. Diagnostic accuracy higher than 90 % suggests that routine use of NBI allows targeted instead of random biopsy samples. EGGIM also permits immediate grading of intestinal metaplasia without biopsies and merits further investigation.

Surveillance of patients with gastric precancerous conditions

Intestinal-type gastric adenocarcinoma arises from a multistep process starting with Helicobacter pylori infection followed by gastric atrophy, gastric intestinal metaplasia and dysplasia. Indeed, patients with gastric precancerous conditions or lesions (GPC) are at increased risk to develop gastric cancer even in regions with low incidence. Thus, the identification and surveillance of a high risk subgroup could lead to the diagnosis of cancer at early stage and improve survival. However, both endoscopic and histological accuracy and interobserver agreement in the diagnosis of GPC are still far from optimal. Also, there are conceptual differences between the West and the East in the diagnosis and surveillance of patients. In the former, multiple gastric biopsies are still recommended but Eastern gastroenterologists select patients to surveillance according to the results of endoscopy or serology. In this literature review we describe the cascade of GPC and we highlight the differences between eastern and western clinical practice.

Light-NBI to identify high-risk phenotypes for gastric adenocarcinoma: do we still need biopsies?

Abstract Objective Early diagnosis of gastric cancer may be achieved through surveillance of patients with extensive gastric intestinal metaplasia (eGIM). However, diagnosis of eGIM generally implies histology. We aimed at determining the accuracy of high-resolution endoscopy with light-narrow band imaging (NBI) to assess the presence of eGIM on a per-patient basis. Material and methods Prospective cohort of 60 patients divided into two groups: derivation cohort (n = 25) to evaluate the reliability and validity, and a real-time validation group (n = 35). In the derivation group, six endoscopists with two levels of expertise were asked to estimate the grade of GIM based in endoscopic images (white light endoscopy, light-NBI and amplification/near focus). In the real-time validation set, experienced endoscopists were asked to similarly record their real-time optical diagnosis. Histology was then considered as the gold standard. Results In the derivation group diagnosis accuracy was 60% with WLE (non-expert 59% vs. 61% experts), increasing to 73% after NBI magnification (non-expert 63% vs. 83% expert, p < 0.05). Moreover, proportion of agreement with histology was 83%, with a correct diagnosis of eGIM in 87% for experienced observers. In the real-time group experts obtained 89% global diagnostic accuracy correctly identifying 91% of the eGIM. The sensitivity, specificity, LR + and LR- of real-time endoscopic diagnosis of eGIM was 0.92 (CI95%:0.67–0.99), 0.96 (0.79–0.99), 21.1 (3.08–144) and 0.09 (0.013–0.57). Conclusion For the first time the reliability of high-resolution endoscopy with light-NBI for extension of GIM is described. Our results suggest that more than 90% of individuals at risk could be identified without the need for biopsies, simplifying the current recommendations.

Management of Patients with Hereditary Colorectal Cancer Syndromes

Colorectal cancer (CRC) is one of the most important causes of death in the world. Hereditary CRC is found in 5–10% of CRC patients. In this review, we will focus on the major forms of hereditary CRC and their management according to the most recent literature available.

Two-step two-stent technique to manage a large gastrocolonic fistula

Gastrocolonic malignant fistulas can occur, although rarely, complicating gastric or colonic neoplasms. En bloc resection of the fistulous tract and involved segments is the first-line treatment whenever possible, with endoscopic treatment an alternative. Endoscopic closure has been described using covered stents [1, 2], over-the-scope clips [3], and atrial septal defect occlusion devices [4]. However, in the colon, covered stents are associated with a high migration risk [5]. We therefore developed a new technique to allow fistula closure, overcoming the risks of stent migration by initially placing an uncovered stent, which is followed by the deployment of a covered stent inside the first stent a few days later and fixation of the two stents to each other using through-the-scope clips. Our patient, a 58-year-old woman, had a metastatic and locally advanced intestinal-type gastric cancer with colonic invasion. After receiving 12 cycles of palliative chemotherapy, she was admitted with fecaloid emesis and a computed tomography (CT) scan showed a large fistulous tract (approximately 5 cm in length with a large orifice) between the stomach and the transverse colon. Although the patient had a good performance status, surgical resection was not considered feasible and endoscopic palliation was proposed. Esophagogastroduodenoscopy (EGD) showed a large ulcerated neoplasm in the greater curvature of the gastric antrum, with a large orifice communicating with an ulcerated fistulous tract. Colonoscopy revealed a stenosis in the transverse colon and contrast instillation allowed characterization of the stricture and of the fistulous tract. An uncovered metal stent (WallFlex; 22–27mm×90mm; Boston Scientific, Marlborough, Massachusetts, USA) was then placed in the strictured transverse colon where the colonic fistulous orifice was located. After 3 days (to allow time for embedment of the uncovered stent in the colonic wall), a similar E-Videos

Graft-Versus-Host Disease Presenting as Anorectal Ulcer.

49-year-old man presented with a 2-week history Aof anorectal pain denying fever, altered intestinal habits, rectal bleeding, or trauma. His past medical history was relevant for allogeneic hematopoietic stem cell transplantation for myelodysplastic syndrome 2 years before and his current medications included tacrolimus, acyclovir, and voriconazole. We performed a rectosigmoidoscopy that showed a posterior acute anal fissure (Figure A) and then the patient was managed medically for the anal fissure. However, the anorectal pain worsened over time and became constant and intense, leading to a second endoscopic examination 2 months after the first. At this time we found a large, deep, necrotic ulcer extending from the anal canal to the distal rectum (Figure B). The remaining observed mucosa had a normal appearance. Biopsy specimens were taken from the borders and the base of the ulcer and the histopathologic examination (Figure C) showed granulation tissue, fibrosis, mononuclear inflammatory infiltrates, and the presence of crypt atrophy and apoptotic bodies in the lamina propria. These findings were consistent with anorectal graft-versus-host disease (GVHD). The patient started corticosteroids and mycophenolate mofetil with gradual clinical improvement. The rectosigmoidoscopy performed 1 month later showed the ulcer in the process of epithelialization (Figure D). GVHD is common in patients who have undergone allogeneic hematopoietic stem cell transplantation. The disease frequently affects the digestive tract, usually presenting with diarrhea, abdominal pain, rectal bleeding, nausea, and/or vomiting. The endoscopic features of gastrointestinal GVHD can range between normal mucosa to edema, erythema, friability, erosions, and ulcerations.

Non-healing perianal ulcer in an immunocompetent patient as the presenting sign of a systemic disease

Dear Editor: Tuberculosis (TB) is still a major health problem worldwide. In Western countries, the incidence of pulmonary TB has decreased, and extrapulmonary tuberculosis has become very rare with the introduction of effective antituberculous chemotherapy. Extra pulmonary TB accounts for less than 15 % of all cases, while the gastrointestinal location constitutes less than 1 % of extrapulmonary forms of the disease. We report the case of a 39-year-old man with an unremarkable past medical history that presented to the emergency department complaining about perianal itching and pain. On physical examination he had an infiltrative ulcer at the right perianal region that was treated with antifungals, antibiotics, and antihistamines without significant relief. Four months later, the patient started complaining about diarrhea and abdominal pain in addition to the perianal symptoms. He also reported anorexia and weight loss (5 Kg in the last 2 months), without other associated symptoms. On physical examination, he was pale, had a painful abdomen without any tenderness on palpation, and maintained the perianal ulcer previously described. Laboratory tests were remarkable for microcytic anemia, hypoalbuminemia, and elevated C-reactive protein and sedimentation rate. Abdominal ultrasound showed a diffuse wall thickening of distal ileum and cecum. The patient was admitted to the hospital, and a biopsy of the perianal ulcer was performed. Histological examination of perianal ulcer showed epithelioid granulomas with caseous necrosis and Langhans’ type multinucleated giant cells. Ziehl–Neelsen (Z-N) staining was positive for acid-fast bacilli. A thoracic computed tomography (CT) scan was performed and revealed multiple micronodules, tree-in-bud opacities, and peribronchial nodules with cavitation predominantly on upper lobes. The abdomino-pelvic CT scan revealed several areas of intestinal wall thickening in the proximal and distal ileum and cecum and multiple enlarged lymph nodes in the mesentery root. A colonoscopy was also performed and showed ulceration of cecum and ulceration and stenosis of ileocecal valve preventing ileal intubation. The histological examination confirmed intestinal involvement by a granulomatous chronic inflammatory process with acid-fast bacilli on Z-N staining polymerase chain reaction (PCR), and culture analysis confirmed the diagnosis of perianal, intestinal, and pulmonary tuberculosis. HIV serologies were negative. Patient was started on antituberculous (anti-TB) treatment with isoniazid, rifampicin, ethambutol, and pyrazinamide, and after 6 weeks of treatment the perianal ulcer was completely healed. Although, the patient had to be admitted to the hospital due to subocclusive symptoms in the context of intestinal tuberculosis that were treated with steroids in addition to anti-TB treatment. Now, the patient is on the eleventh month of treatment (he will complete 1 year), healthy and asymptomatic. Perianal ulcer did not recur, and PCR/cultural analysis of sputum and intestinal samples are already negative. TB is still a major health problem worldwide. Indeed, there are nine million cases of active tuberculosis being reported annually, and one third of the world’s population is supposed * Patrícia Andrade anapatriciarandrade@gmail.com

Squamous cell carcinoma arising from a presacral cyst in a patient with ulcerative colitis under azathioprine and infliximab: first case report.

Dear Editor: Extra-intestinal malignancies occurring in Inflammatory Bowel Disease (IBD) patients under immunosuppressive treatment have become a major concern for both patients and physicians. We report the case of a 60-year-old woman with long lasting extensive ulcerative colitis (UC) complained about lower back pain for about 3 months. She was being treated with messalazine 3 g/day, azathioprine 2.2 mg/kg/day for about 10 years, and infliximab 5 mg/kg every 6 weeks for about 4 years. Besides UC, she was otherwise healthy and had no other associated symptoms. Physical examination and laboratorial workup were unremarkable, with a Mayo score of zero. Because lower back pain was progressively getting worse and associated with paresthesias of the right lower limb, a computed tomography (CT) was performed. CT scan revealed in the presacral space, posterior to the right side of rectum, a large, complex, cystic lesion, measuring about 60 × 36× 25 mm. There was an irregular parietal thickening and contrast enhancement in the rightposterior side of the lesion. That lesion involved the right sacral roots and infiltrated the right side of distal sacrum and coccyx. The rectum, colon, and the other structures of the pelvis were not involved. There were no lesions on ileocolonoscopy. A percutaneous biopsy guided by ultrasonography of the solid parietal component was performed, and the histological examination revealed a squamous cell carcinoma (SCC). Positron emission tomography (PET) scan also showed a hypermetabolic neoplasia on the right presacral space without evidence of hypermetabolic metastasis. The patient was proposed for neoadjuvant radiotherapy and chemotherapy with cisplatin and after that, she was submitted to surgery (tumorectomy plus partial sacrectomy) and intraoperative radiotherapy. The histogical specimen revealed abundant fibrotic tissue and necrosis without viable cells, which was compatible with a complete response to preoperative treatment. Three months after surgery, the patient is asymptomatic without evidence of cancer recurrence. In 1975, Uhlig and Johnson proposed a classification system for retrorectal/presacral cysts that was later modified by Lovelady and Dockerty. According to this classification, presacral cysts can be divided into five categories: congenital, inflammatory, neurogenic, osseous, and miscellaneous. Presacral or retrorectal congenital cysts can be tailgut cysts, epidermoid cysts, dermoid cysts, teratomas, and rectal intussusceptions. Epidermoid cysts account for about 1:16 presacral cysts. It develops from a remnant of ectodermal tissue misplaced during embryogenesis. The vast majority of epidermoid cysts are histologically benign, but isolated cases of premalignant and malignant conditions have been identified in their walls. Indeed, SCC arising from an epidermoid cyst has been described in different locations including the brain, liver, or skin. Until now, only one case of SCC arising from a presacral epidermoid cyst was previous described. Prolonged treatment with immunosuppressive agents has been shown to determine an increased risk of a broad range of cancers not only in solid organ transplant recipients but also in IBD patients. These agents may promote the development and recurrence of cancer by a variety of established mechanisms * Patrícia Andrade anapatriciarandrade@gmail.com

A truly visible vessel in an endoscopic submucosal dissection scare: thinking outside recommendations.

A 75-year-old woman with a superficial lesion type IIaþc (intramucosal adenocarcinoma) 12 15 mm in diameter in the incisura angularis (A) was admitted for endoscopic submucosal dissection (ESD). During the procedure, mild bleeding was observed, which was controlled by vessel coagulation by use of the dissection IT knife (Olympus, Tokyo, Japan). Later, in the posterior area, a big vessel, approximately 3 mm in diameter, was seen (B). The decision was made not to coagulate that vessel immediately, to dissect around the vessel, and to complete en bloc resection. Upon completion of the ESD, a fine layer of submucosa was apparent over the vessel without bleeding (C). Even though the team was aware of the suggestion to coagulate the visible vessels in the artificial ulcer, the decision was not to coagulate that particular

Incidental Diagnosis of Mantle Lymphoma Made by Sigmoidoscopy

A 82-year-old man has been followed in our oncology hospital after prostatic cancer and prostatectomy. He was medicated with gonadotropin releasing hormone superagonist goserelin and olmesartan for arterial hypertension. Due to the recent installation of orthopnea, a chest X-ray was carried out, revealing a mass in the right hilar region which was subsequently characterized as right hilar and mediastinal lymphadenopathy by chest CT. Bronchoscopy with bronchial biopsies, citology and microbiological studies revealed no signs of malignancy or infection. Taking into consideration the patient’s medical history and the occasional back pain he referred, PET scan was thought to be the appropriate following exam. In addition to confirming hypermetabolism in the already known lymphadenopathies, PET-CT scan also showed a hypermetabolic focus at the rectosigmoid junction (Fig. 1). Sigmoidoscopy was performed and revealed two subepithelial lesions at 10 and 18 cm from the anal verge (Fig. 2). Biopsy specimens were obtained by using a ‘‘biopsy-onbiopsy’’ technique. Histological examination showed the presence of a lymphoid neoplasia of small sized cells with irregular nuclei, fine chromatin, small inconspicuous