Michio Iida

MAGNIFYING ENDOSCOPIC OBSERVATION OF THE UPPER GASTROINTESTINAL TRACT

Recent advances in technology enable us to obtain more detailed information during endoscopic procedures. Diagnosis of the pit pattern or microvascular architecture allow the earlier detection of neoplastic lesions in the gastrointestinal tract. These advances have led to the enhanced selection of appropriate treatments. Cancers that are discovered at an early stage can be treated by mucosal resection, whereas advanced cancers are treated with surgery. Recently, some groups have tried to acquire direct in vivo histological images of gastrointestinal mucosa (virtual histology or optical biopsy). Now optical coherence tomography (OCT), confocal laser endoscopy and endo‐cytoscopy systems enable this conception. However, none of these techniques has been proven, although some investigators have been able to use them to enhance cancer detection, and have reported the usefulness of these techniques. The present review assesses the strengths and weaknesses of these technologies, and describes the magnifying observations of the upper gastrointestinal tract using magnifying endoscopy equipment available on the market as well as newly developed endo‐cytoscopy systems. Published and unpublished data for this review were identified by searches of MEDLINE, Register of Cancer Trials: National Cancer Institute (http://cancertrials.nci.nih.gov/) and references from relevant articles. We also contacted researchers. The authors’ own database of references was also used. The search items were as follows: magnifying endoscopy, endo‐cytoscopy system, confocal endoscopy, optical coherence tomography, contact endoscopy, esophageal cancer, Barrett’s esophagus, Barrett’s esophageal cancer, gastric cancer, colon cancer, chromoendoscopy, methylene blue etc.

ENDOCYTOSCOPIC OBSERVATION OF ESOPHAGEAL SQUAMOUS CELL CARCINOMA

The endocytoscopy system (ECS), adapted for clinical use in 2003, is an ultra‐high‐power magnifying endoscope that allows observations at the cell level. ECS is based on the technology of light‐contact microscopy. The most evident use of ECS is for real‐time, high‐resolution diagnosis of nuclear abnormalities, mainly in patients with esophageal cancer. Up to now, three different types of ECS have been available. This diagnostic tool makes it possible to omit histological examination of biopsy samples in approximately 84% of esophageal squamous cell carcinoma, as evidence for both an increase of cell density and nuclear abnormalities is considered to be convincing proof that a lesion is malignant. Here we describe the features of ECS and the background that led to its development, and review the published literature pertaining to the observation of esophageal neoplasms using ECS.

Treatment strategy for blunt hepatic trauma: analysis of 183 consecutive cases.

BACKGROUND/AIMS Non-operative management of hemodynamically stable trauma has proven successful; however laparotomy for hemodynamically unstable patients is still insufficient. We evaluated the results of treating blunt hepatic injury and appraised the appropriate surgical procedures. METHODOLOGY We analyzed the demographics, vital status, and severity of hepatic and concomitant organ injuries of 183 consecutive patients with blunt hepatic injuries between January 2001 and December 2008, retrospectively. RESULTS Twenty five of 183 patients died before the treatment was selected. The initial management was operative for 24 and non-operative for 134, 15 of whom later required laparotomy. Of the 134 treated non-operatively, 2 died after arterial embolization for pelvic fractures. Twelve patients died postoperatively: 6 of the hepatic injury and 6 of concomitant organ injuries. Considering Liver Injury Scale of operated patients, there was no liver-related death with grades I-III; however, liver-related mortality of grades IV and V was 37.5%. The incidence of liver-related deaths after anatomical resection was 0% of patients with grade IV, but 50% of patients with grade V, despite anatomical resection being the only effective procedure for grade V. CONCLUSIONS The results of anatomical resection for grade IV is satisfactory, but additional strategies are still required for grade V.

A tiny esophageal cancer diagnosed accurately by magnifying endoscopy and endocytoscopy: report of a case

An 82-year-old woman presented for a periodic endoscopic examination after radiotherapy and endoscopic mucosal resection (EMR) of a cancer in the esophagus. Conventional endoscopy demonstrated a tiny, flat, reddish lesion about 1 mm in diameter proximal to the scar of the previous esophageal EMR. Observation after iodine staining showed an apparent unstained area in the lesion. Magnifying observation using a Q240Z (Olympus, Tokyo, Japan) revealed a clearly demarcated aggregation of dilated intrapapillary capillary loops in this part of the lesion. Endocytoscopic observation (XEC120U prototype; Olympus) showed increased cellular density and irregularity of the epithelial nuclei. Endoscopic mucosal resection of the lesion was performed. Pathological studies of the resected specimen revealed a squamous cell carcinoma, maximal diameter 920 μm, confined to the epithelium. We believe that the Endocytoscope has the potential to reduce biopsy histology in cases of esophageal squamous cell carcinoma.

High resectability of colorectal liver metastases with aggressive chemotherapy in the era of molecular target-based agents.

BACKGROUND/AIMS Advances in chemotherapy have expanded the resectability of colorectal liver (CRC) metastases. We studied treatment results in CRC patients with liver metastases in the era of molecular target-based agents. METHODOLOGY Based on data collected retrospectively, we analyzed the demographics, operative and pathological outcomes, and adjuvant chemotherapy, of 91 consecutive CRC patients with liver metastases treated between January, 2008 and June, 2010. RESULTS Of the 91 patients, 42 (46.2%) underwent liver resection (group 1), 41 underwent only resection of the primary tumor without hepatectomy (group 2), and 8 underwent palliative surgery (group 3). According to multivariate analysis, resection of liver metastases was significantly influenced by the number of metastases and the existence of extrahepatic metastases. Disease-free survival (DFS) differed significantly between patients who received adjuvant therapy and those treated by surgery alone (p<0.001). The regimen (p=0.01) and duration (p<0.0001) of adjuvant chemotherapy also affected DFS. Overall survival after 1 and 3 years was 97.6% and 94.0%, respectively, in group 1, 71.9% and 30.6% in group 2, and 33.3% and 0% in group 3. CONCLUSIONS Although the observation period was short, our findings suggest that high resectability and effective chemotherapy will prolong the survival of patients with colorectal liver metastases.

In Vivo Pathological Diagnosis of Esophageal Lesions Using An Endo-Cytoscopy System

In Vivo Pathological Diagnosis of Esophageal Lesions Using An Endo-Cytoscopy System Youichi Kumagai, Shigeru Yamazaki, Michio Iida Background: Recently, some groups have tried to acquire a direct image of histology in vivo gastrointestinal mucosa (virtual histology). Aim: The aim of this study is to observe the endoscopic characteristics of in vivo cells on the surface layer of various esophageal lesions. Patients and Methods: We examined twenty cases of superficial esophageal@cancer, dysplasia, and Barrett’s esophageal cancer using an newly developed Endo-cytoscopy system with methylene blue staining. Equipment: An Endo-cytoscopy system (Olympus, prototype) consisting of two flexible endoscopes, 380 cm long and 3.2 mm in diameter, was employed. These endoscopes passed through the instrument channel of the GIF-1T240 (Olympus). The low-magnification type (XEC300) provided 450X magnification and a field of view of 300x300fEm of tissue. The second endoscope was a higher-magnification type (XEC120) that provided 1125X magnification and a field of view of 120x120fEm of tissue. Results: By observing the normal esophageal mucosa using an Endocytoscopy@system and methylene blue staining, we were able to observe cells on the surface of the squamous epithelium. These cells were arranged homogeneously with a uniform and low nucleus-cytoplasmic ratio. In esophageal cancer, the density of cells was observed to be much higher than in the normal squamous epithelium. Further, the cell distribution was irregular and the cells were extremely heterogeneous with nuclei that differed in staining, size and shape. The nucleus-cytoplasm ratio was also very irregular. In mild dysplasia, surface cells were observed as normal squamous cells. Histological examination of this lesion showed that the atypical cells were limited to the half of the squamous cell layer close to the basement membrane. The superficial layer was covered by normal squamous cells. In the case of Barrett’s esophageal cancer, we were able to observe the cells and nuclei of the Barrett’s esophageal mucosa. These cells formed a crypt and the cell density was low. In the cancer lesion, the crypt formation was destroyed, and the cell density was high compared with the non-cancerous Barrett’s mucosa. The cells had large and darkly stained nuclei compared with part of the Barrett’s metaplasia. Conclusions: Observation using the Endo-cytoscopy system allowed us to examine in detail histological alterations in esophageal lesions.

Favorable response after gemcitabine-radiotherapy for invasive pancreatic intraductal papillary mucinous neoplasm: a case report.

The efficacy of chemoradiotherapy for invasive pancreatic ductal carcinoma derived from an intraductal papillary mucinous neoplasm (IPMN) has not been established. The subject of the present report was a 53-year-old man admitted for the treatment of IPMN. The tumor, located in the pancreatic body, was of the mixed type of IPMN, and it involved the branch duct, where it was 38 mm in diameter, and the main duct, where it was 6 mm in diameter. Distal pancreatectomy was performed and the postoperative course was uneventful; however, histopathologic diagnosis revealed invasive ductal carcinoma with a positive surgical margin in the pancreatic duct. Although total pancreatectomy was recommended, chemoradiotherapy (50.4-Gy irradiation and gemcitabine) was preferred by the patient. At 9-month follow up, computed tomography and magnetic resonance imaging showed a cystic mass at the surgical margin of the pancreas. Endoscopic ultrasonography showed a 44-mm cystic lesion with nodules in the remnant pancreas, on the basis of which he underwent total pancreatectomy. Pathologic examination of the resected specimen revealed absence of the epithelium at the surgical margin of the main pancreatic duct, and malignant cells were not detected.