Misao Yoshida

Evaluation of endoscopic ultrasonography for the diagnosis of submucosal tumors of the esophagus

SummaryEndoscopic ultrasonography was carried out on 55 patients whose X-ray films or endoscopic examinations indicated the presence of a submucosal tumor. Endoscopic ultrasonography revealed 8 cases of extraluminal compression and 48 cases of submucosal tumors. Histological studies were performed on 29 cases with submucosal tumors. In 28 of the 29 cases (97%) the location of the tumor in the esophageal wall was correctly estimated ultrasonographically, and appropriate treatment was selected. Tumors ranging from 3 to 50 mm in diameter could be measured accurately. This method may be helpful in follow-up studies. Endoscopic ultrasonographic findings, such as characteristics of the tumor border and internal echoes, were studied to predict the histological diagnosis of the tumor. Leiomyoma, cyst, granular cell tumor, lipoma, and intraluminal metastasis of esophageal cancer were all found to have specific ultrasonographic findings indicating the histological nature of the tumor.

Superficial basaloid squamous carcinoma of the esophagus. A clinicopathological and immunohistochemical study of 12 cases.

Basaloid squamous carcinoma (BSC) is a rare variant of squamous cell carcinoma (SCC). In this study, clinicopathological and immunohistochemical characteristics of 12 superficial esophageal BSCs were examined and compared with those of typical superficial SCCs. Eight cases were classified into an elevated type, and the other four into a depressed type. High-grade intraepithelial neoplasia was not observed around the invasive lesions in five cases, and only BSC components were apparent. High-grade intraepithelial neoplasia was demonstrated in seven cases, five of which had both BSC and SCC components in the invasive lesion. A cribriform growth pattern, comedo-type necrosis, and hyaline deposits were conspicuous histological findings. CK14 was positively stained in 90% of the series, but the proportion of positive cells was small in most cases. Type IV collagen was increased or well preserved in the basement membrane in 70% of cases, but heparan sulfate was decreased in the majority. In comparison with SCCs, lymphatic permeation was observed less frequently. However, regarding the frequencies of venous permeation, nodal metastasis, p53 protein expression, and Ki-67 labeling index, no significant differences were noted. Thus, esophageal BSCs demonstrate the pathological features characteristic of an early stage, but pathological parameters related to biological behavior do not significantly vary from those typical of SCCs.

Vertical and horizontal growth features of superficial esophageal squamous cell carcinomas: histopathological evaluation of endoscopically resected specimens.

Abstract. Endoscopic mucosal resection (EMR) has been performed for intramucosal carcinomas with excellent results. To evaluate invasion depth of superficial esophageal squamous cell carcinomas (SESCCs) accurately, it is important to elucidate vertical and horizontal growth features. Using 179 specimens of SESCC taken by EMR, various factors associated with vertical and horizontal growth were examined pathologically to determine which were correlated with invasion depth, classified for this purpose into four levels, m1, m2, m3, and sm. Maximum tumor diameter, including high-grade intraepithelial neoplasia, differed between m1 and m2 cases and for invasive lesions between m2 and m3. Maximum tumor thickness varied between m1 and m2, m2 and m3, and m3 and sm. Multivariate analysis showed tumor thickness and diameter of invasion to be correlated with submucosal invasion. Tumor thickness and depth of the depressed lesions were correlated in depressed/flat type cases. In elevated type cases the thickness of the tumor did not differentiate between m3 and sm. Shape of the elevated lesion also influenced the invasion depth. Frequency of infiltrating type tumors, composed of irregular and small invading nests, was higher with sm than m3. To differentiate m3 and sm tumor the classification of gross type, thickness, depth of depressed lesions, shape of elevated lesions, and invasion patterns should all be evaluated.

Linitis plastica-type adenocarcinoma of the esophagus: a case report

Abstract“Linitis plastica” refers to a histological characterization of diffusely infiltrating, poorly differentiated adenocarcinoma. Linitis plastica-type esophageal adenocarcinoma is extremely rare: this is thought to be only the sixth case report of linitis plastica involving the esophagus. A 60-year-old man was referred to our hospital after repeated endoscopic examinations over the course of a few months. Because he complained of dysphagia, upper endoscopy was performed, revealing stenosis with a few mucosal changes of the lower esophagus. Gastroesophageal reflux disease was initially diagnosed, but biopsy revealed adenocarcinoma. At the time of operation, peritoneal metastasis was noted. Macroscopically, the lesion was diffusely infiltrating, almost completely covered with normal squamous epithelium that showed positive staining with iodine. Pathological examination showed poorly differentiated adenocarcinoma. Despite the poor prognosis, the patient survived a comparatively long 18 months following esophagectomy with oral chemotherapy using S-1.

A Study on the Mode of Recurrence in Cases with Esophagectomy and Extensive Lymph Node Dissections

In cases with thoracic esophageal cancer, postoperative recurrence at the posterior mediastinum and the neck are frequently observed as well as metastasis in distant organs. Extensive lymph node dissection procedures have been developed and applied in cases of thoracic esophageal cancer for these 8 years in Japan, with the expectation that a decrease in the rate of recurrence in the neck and the mediastinum would occur. In this paper, the rate and mode of recurrence among patients with thoracic esophageal cancer who underwent esophagectomy with extensive lymph node dissection at our hospital were studied. It was expected that the results would yield improved indications and postoperative care of this type of patient.

A case of lymph node metastasis after endoscopic mucosal resection of esophageal cancer invading the muscularis mucosa

A 70-year-old man was diagnosed with a thoracic esophageal squamous cell carcinoma invading the muscularis mucosa without lymph node or distant metastases in June 2003. Endoscopic mucosal resection was conducted. Histological examination showed squamous cell carcinoma invading the deep mucosal layer without lymphatic permeation. In April 2006, a chest CT scan revealed a metastasis to the right recurrent laryngeal nerve chain (106recR) lymph node, and chemoradiotherapy and chemotherapies were performed but were not very effective. He died of esophagobronchial fistula in October 2007. We reexamined this case in detail, and a deeper cut of the block revealed positive lymph vessel invasion and droplet infiltrations. We were initially unable to identify lymphatic permeation but specific findings were determined, such as high degrees of cellular atypia, downward extension of irregular epithelial processes, and irregular margins of cancer alveoli. Extreme caution is required for treating patients with these morphological changes.

Strategy for Treatment of Superficial Esophageal Cancer

The number of patients with superficial esophageal cancer has increased during the last 25 years in Japan, and the clinical result has been excellent. At the same time, the pathological characteristics of mucosal cancer are different from those of submucosal cancer and therefore there is a difference in the treatment. We studied the clinical results of patients with superficial esophageal cancer treated at our hospital, and the strategy for treating superficial esophageal cancer is discussed.

Clinical Estimation of Mucosal Cancer of the Esophagus by Endoscopic Staining

Recent advances in esophageal cancer clinics in Japan include the early detection and treatment of esophageal mucosal cancer. Endoscopic staining techniques have made possible the early detection of mucosal cancers and their eradication using endoscopic mucosal resection techniques (EMR) with minimal invasion, thus preserving the esophagus. The iodine staining technique is the most sensitive in detection of mucosal cancer, for it can differentiate abnormal mucosa as a yellowish white “unstained area” against a dark brown normal mucosa. The number, size and distribution of mucosal cancers can also be identified with ease. EMR can be employed as a radical treatment for mucosal cancers confined to the lamina propria mucosae, which seldom have lymph node metastasis. Ten-year-survival curves of our patients with mucosal cancer of the esophagus treated by esophagectomy and that by EMR showed no significant difference. Clinical estimation of the depth of a cancer invasion into the esophageal wall was essential for the precise indication of EMR. Endoscopy aided by toluidin blue-iodine double staining was most useful for this estimation, and its accuracy rate was 96%. In the case of type IIc lesions (slightly depressed type), which is most frequent among mucosal cancers of the esophagus, the area unstained by toluidine blue can be observed when the lesion is confined to the epithelium layer. Blue stained dots, or reticulum, in a unstained area strongly suggests cancer infiltration into the lamina propria mucosae.

5. Early Detection of Esophageal Carcinoma and Result of Its Treatment

There are many cases which developed recurrence after esophagectomy for superficial esophageal carcinoma. In order to identify clinical features of ideal target of early detection of esophageal carcinoma 160 cases of superficial cancer were analyzed.1. Depth of tumor invasion and incidence of recurrence: Lymph node metastases among mucosal carcinomas were 12% and five-year-survival rate of 13 cases was 100%. There found no recurrence among them. Lymph node metastases among submucosal carcinomas were 38% and 58% of those with lymph node metastases developed recurrence. Five-year-survival rate of submucosal carcinoma cases was 56%.2. Gross findings of intraepithelial or mucosal carcinoma: Revised endoscopic classification of superficial esophageal carcinoma was composed of 1) O-I (superficial and protruded type), 2) O-II (superficial and flat type), 3) O-III (superficial and excavated type) and 4) O-V (superficial and unclassified type) . O-II type could be classified into a) II. (slightly elevated), b) II, (flat) and c) II, (slightly depressed) types. Ninety-six percent of intraepithelial or mucosal carcinomas were classified into O-II type (II, , 4, II, 16, II, 9) . Eighty-eight percent of submucosal carcinomas were classified into O-I, O-III and O-V.3. Screening of O-II type lesions: Endoscopy was most successful in detection of O-II type lesions and it was facilitated by endoscopic staining methods.Conclusion: Intraepithelial or mucosal carcinomas were estimated as ideal target for early detection of esophageal carcinoma considering their excellent prognosis. They could be identified as O-II type lesions at endoscopy. It was difficult to detect O-II lesions even by endoscopy, but endoscopic staining facilitated their detection.

LONG-TERM SURVIVAL RATE OF ESOPHAGEAL CANCER

食 道癌 の治療 成績 にお い て,手 術 死 亡率 の改善 は み られ るものの,そ の遠隔 成績 につ い ては,い まだ し と い うところで あ る.図1は,消 化器 病 セ ン ターでの最 近 の長期遠 隔成 績 を,17年 前 の千葉 大 学第2外 科で の 成績1)と比較 した もので あ る.か つて の5年 生存 率(以 下5生 率)が,現 在の10年 生存率(以 下10生 率)に な っ て はい る ものの,満 足す べ き改善 は み られて い ない. 今 回,消 化 器病 セ ン ターで1965年 か ら1978年 まで に 切 除 したCe癌 を除 く食道 癌耐 術例763例 と,1973年 ま で のCe癌 を除 く食 道癌耐 術例459例 とか ら,5生 率, 10生 率 を各 因 子 別 に検 討 して み た.な お,5生 率 は 23%,10生 率 は15%で あ る. 1.性 との関係