Michael Vieth

Long-term Efficacy and Safety of Endoscopic Resection for Patients With Mucosal Adenocarcinoma of the Esophagus

BACKGROUND & AIMSnBarretts esophagus-associated high-grade dysplasia is commonly treated by endoscopy. However, most guidelines offer no recommendations for endoscopic treatment of mucosal adenocarcinoma of the esophagus (mAC). We investigated the efficacy and safety of endoscopic resection in a large series of patients with mAC.nnnMETHODSnWe collected data from 1000 consecutive patients (mean age, 69.1 ± 10.7 years; 861 men) with mAC (481 with short-segment and 519 with long-segment Barretts esophagus) who presented at a tertiary care center from October 1996 to September 2010. Patients with low-grade and high-grade dysplasia and submucosal or more advanced cancer were excluded. All patients underwent endoscopic resection of mACs. Patients found to have submucosal cancer at their first endoscopy examination were excluded from the analysis.nnnRESULTSnAfter a mean follow-up period of 56.6 ± 33.4 months, 963 patients (96.3%) had achieved a complete response; surgery was necessary in 12 patients (3.7%) after endoscopic therapy failed. Metachronous lesions or recurrence of cancer developed during the follow-up period in 140 patients (14.5%) but endoscopic re-treatment was successful in 115, resulting in a long-term complete remission rate of 93.8%; 111 died of concomitant disease and 2 of Barretts esophagus-associated cancer. The calculated 10-year survival rate of patients who underwent endoscopic resection of mACs was 75%. Major complications developed in 15 patients (1.5%) but could be managed conservatively.nnnCONCLUSIONSnEndoscopic therapy is highly effective and safe for patients with mAC, with excellent long-term results. In an almost 5-year follow-up of 1000 patients treated with endoscopic resection, there was no mortality and less than 2% had major complications. Endoscopic therapy should become the standard of care for patients with mAC.

Endoscopic Resection of Superficial Esophageal Squamous-Cell Carcinomas: Western Experience

OBJECTIVES:Endoscopic resection of esophageal squamous-cell neoplasia with curative intent appears to be an alternative treatment to radical surgery when the malignant neoplasia is intraepithelial or limited to the mucosal layer, since the risk for lymph-node metastases is very low. In contrast to Japan, there has so far been only limited experience in Europe and the United States with endoscopic resection in such cases. In the present observational study, we report on the largest prospective series so far in Western countries of patients with early squamous-cell cancer or carcinoma in situ, who were treated using endoscopic resection therapy.METHODS:Between December 1997 and November 2001, 115 patients with a suspicion of early squamous cancer were referred for local endoscopic therapy. A total of 39 patients (mean age 61.4 ± 10.2 yr) with early esophageal carcinoma (n = 29) and carcinoma in situ (Cis) (n = 10) fulfilled the criteria for local endoscopic therapy and were treated using endoscopic resection. Ten patients had Cis (group A), 19 had mucosal cancer (group B), and 10 had submucosal cancer (group C). All patients in group C were inoperable or had refused surgery.RESULTS:A total of 94 resections were performed. Nine of the 10 patients in group A (90%), 19 of the 19 in group B (100%), and 8 of the 10 in group C (80%) achieved a complete response during a mean follow-up period of 29.7 ± 14.3 months. Tumor-related deaths occurred in three patients (one in group B, who was inoperable; two in group C, who refused surgery). No major complications such as perforation or bleeding requiring blood transfusion occurred. Minor complications were seen in six patients (15%)—three with minor bleeding after endoscopic resection and three with esophageal stenoses, who were successfully treated using injection therapy or dilatation. Calculated 5-yr survival was 90% in group A, 89% in group B, and 0% in group C.CONCLUSIONS:Endoscopic resection appears to be an effective and safe method of curative treatment in patients with Cis and mucosal squamous-cell carcinomas of the esophagus. The preferred method in patients with submucosal cancer should be esophagectomy or chemoradiotherapy, whenever possible.

Endocytoscopy allows accurate in vivo differentiation of mucosal inflammatory cells in IBD: A pilot study.

Background:Precise activity assessment of inflammatory bowel disease (IBD) is essential to determine extent and severity of disease for optimized therapy. Despite ongoing developments in endoscopy, final diagnosis still relies on the interpretation of histopathological features. Recently, endocytoscopy (EC) was introduced as a new endoscopic imaging modality, enabling in vivo microscopic imaging within the mucosal layer of the gut at a magnification up to 1400-fold. The aim of our study was to determine the reliability of EC for the discrimination of mucosal inflammatory cells and intestinal inflammatory disease activity in patients with IBD. Methods:In all, 40 patients with IBD (Crohns disease n = 19; ulcerative colitis n = 21) who underwent colonoscopy were prospectively included in this study. Methylene blue or toluidine blue was topically applied to enable EC. Data were digitally saved and analyzed blinded to clinical and endoscopic data. Results:EC enabled visualization of different histopathological features. Based on these specifications, it was possible to reliably distinguish single inflammatory cells by EC with the following respective sensitivities and specificities: neutrophilic (60% and 95%), basophilic (74.43% and 94.44%), eosinophilic granulocytes (75% and 90.48%), and lymphocytes (88.89% and 93.33%). Interobserver agreement between two investigators was substantial (kappa 0.61–0.78), while intraobserver agreement was substantial to almost perfect (kappa 0.76–0.88). Concordance between EC and histopathology for grading intestinal disease activity was 100%. Conclusions:EC enabled the detection and discrimination of single mucosal inflammatory cells and inflammatory disease activity. Therefore, this technique has the potential to improve both in vivo diagnosis and clinical management of IBD patients.

Distinction of High-Grade Intraepithelial Neoplasia and Tubular Gastric Adenocarcinoma

In 2000, the World Health Organization (WHO) recommended to no longer use the term “dysplasia” but rather “intraepithelial neoplasia” throughout the gastrointestinal tract. This change has been suggested because the term dysplasia has been overstressed in the past (Table 1) because of the weak descriptive nature of its definitions. Also, the term dysplasia was used in part for early carcinomas [4]. The WHO classification [5] describes high-grade intraepithelial neoplasia in the stomach as a lesion with “glandular crowding and prominent cellular atypia. Tubules can be irregular in shape, with frequent branching and folding: there is no stromal invasion.” Mucin secretion is believed to be absent or minimized. Additionally, increased proliferative activity is present throughout the epithelium. According to the WHO classification, invasive adenocarcinoma is diagnosed whenever the tumor invades into the lamina propria or the submucosal layer. Also mentioned is that in bioptic diagnosis isolated tumor cells and glandlike and/or papillary projections are believed to help differentiate it from intraepithelial neoplasia.

Extracranial metastasizing solitary fibrous tumors (SFT) of meninges: histopathological features of a case with long-term follow-up.

Extrapleural solitary fibrous tumors are uncommon mesenchymal neoplasms frequently observed in middle‐aged adults and are classified, according to the WHO classification of soft tissue tumors, as part of the hemangiopericytoma tumor group. However, these two entities remain separated in the WHO classification of tumors of the central nervous system. In fact, meningeal solitary fibrous tumors are believed to be benign lesion and only in a minority of cases local relapses have been described, although detailed survival clinical studies on solitary fibrous tumors of meninges are rare. In contrast to hemangiopericytoma, which frequently shows distant extracranial metastases, such an event is exceptional in patients with meningeal solitary fibrous tumors and has been clinically reported in a handful of cases only and their histopathological features have not been investigated in detail. In this report, we describe the detailed clinico‐pathological features of a meningeal solitary fibrous tumor presenting during a 17‐year follow‐up period, multiple intra‐, extracranial relapses and lung metastases.

The esophageal mucosa and submucosa: immunohistology in GERD and Barrett's esophagus

This paper presents commentaries on the microscopic morphology of esophageal squamous epithelium; the frequency of duplication of the muscularis mucosae (MM) in Barretts esophagus (BE); the significance of multilayered epithelium; whether cells in the lamina propria reflect those in the epithelium; how stem cells are identified in the squamous esophagus; dilated intercellular spaces; the metastasizing potential of early carcinoma‐dependent, molecular or immunohistochemical tests that improve diagnosis; the role of immunohistochemistry IHC in grading of neoplasia in Barretts esophagus and defining the risk of progression to adenocarcinoma; the roles of CDX1 and CDX2 in squamous and cardiac mucosa; and the role of desmosomal cadherins and lectins in squamous and cardiac mucosa.

The esophageal mucosa and submucosa

This paper presents commentaries on the microscopic morphology of esophageal squamous epithelium; the frequency of duplication of the muscularis mucosae (MM) in Barretts esophagus (BE); the significance of multilayered epithelium; whether cells in the lamina propria reflect those in the epithelium; how stem cells are identified in the squamous esophagus; dilated intercellular spaces; the metastasizing potential of early carcinoma‐dependent, molecular or immunohistochemical tests that improve diagnosis; the role of immunohistochemistry IHC in grading of neoplasia in Barretts esophagus and defining the risk of progression to adenocarcinoma; the roles of CDX1 and CDX2 in squamous and cardiac mucosa; and the role of desmosomal cadherins and lectins in squamous and cardiac mucosa.