Keita Sasajima

The clinical meaning of a nonstructural pattern in early gastric cancer on magnifying endoscopy

BACKGROUND In the field of colorectal cancer, the presence of a nonstructural pattern in magnifying colonoscopy means that cancer involves the submucosal layer. Since en bloc EMR was developed, differentiation between mucosal and submucosal cancer is a critical issue in the management of gastric cancer. In this study, we evaluated the clinical meaning of a nonstructural pattern in magnifying gastroscopy. METHODS Between April 2002 and July 2003, 59 patients with 50 cancers and 11 adenomas were enrolled in this study. A cancerous lesion was subclassified into a differentiated-type group or a undifferentiated-type group according to histologic type. Before treatment, magnifying endoscopic observation was performed. After EMR or surgical intervention, resected specimens were observed by using stereomicroscopy. In both in vivo magnifying endoscopic and in vitro stereomicroscopic observations, the presence of a nonstructural pattern on the lesion was investigated. Compared with histologic findings, the clinical meaning of the presence of a nonstructural pattern on the gastric neoplastic lesion was evaluated. RESULTS A nonstructural pattern could not be confirmed in any adenomas and in 29 of 31 mucosal differentiated cancers. However, in 9 of 11 submucosal cancers, a nonstructural pattern could be identified. CONCLUSIONS The presence of a nonstructural pattern appeared to be a useful marker to not proceed with EMR of gastric cancer.

Endoscopic submucosal dissection for an early ileal cancer

A previously healthy, asymptomatic 38-year-old woman was referred to our hospital because of abnormal liver biochemical test results (aspartate aminotransferase and alanine aminotransferase at twice the upper limit of normal [ULN], alkaline phosphatase level at 4 times the ULN, and g-glutamyltransferase at 17 times the ULN; bilirubin and lactate dehydrogenase were normal) and right intrahepatic bile duct dilatation on US. A triple-phase CT confirmed the presence of dilated right intrahepatic ducts, but no other abnormality was seen. ERCP revealed a stricture in the right hepatic duct (A). There was no evidence of malignancy with the use of fluoroscopy-guided biliary brushing cytology or on cytology of bile aspirated through a nasobiliary tube. Peroral cholangioscopy (Olympus CHF-B260; Olympus Medical Systems, Tokyo, Japan) with duodenoscopic assistance revealed a whitish cicatricial stricture of the right hepatic duct (B) (with petechial hemorrhage around the stricture resulting from contact with the cholangioscope). Biopsy specimens were taken with cholangioscopy-guided forceps (video 1, available online at www.giejournal.org). Histopathologic examination with hematoxylin and eosin staining showed spindle-shaped cells arranged in intersecting fascicles (C). Immunohistochemical examination demonstrated that the spindle cells were positive for a-smooth muscle antibody (D) and focally positive for desmin, but