Mitsuru Kaise

Early Detection of Superficial Squamous Cell Carcinoma in the Head and Neck Region and Esophagus by Narrow Band Imaging: A Multicenter Randomized Controlled Trial

PURPOSE Most of the esophageal squamous cell carcinomas (ESCCs) and cancers of the head and neck (H&N) region are diagnosed at later stages. To achieve better survival, early detection is necessary. We compared the real-time diagnostic yield of superficial cancer in these regions between conventional white light imaging (WLI) and narrow band imaging (NBI) in high-risk patients. PATIENTS AND METHODS In a multicenter, prospective, randomized controlled trial, 320 patients with ESCC were randomly assigned to primary WLI followed by NBI (n = 162) or primary NBI followed by WLI (n = 158) in a back-to-back fashion. The primary aim was to compare the real-time detection rates of superficial cancer in the H&N region and the esophagus between WLI and NBI. The secondary aim was to evaluate the diagnostic accuracy of these techniques. RESULTS NBI detected superficial cancer more frequently than did WLI in both the H&N region and the esophagus (100% v 8%, P < .001; 97% v 55%, P < .001, respectively). The sensitivity of NBI for diagnosis of superficial cancer was 100% and 97.2% in the H&N region and the esophagus, respectively. The accuracy of NBI for diagnosis of superficial cancer was 86.7% and 88.9% in these regions, respectively. The sensitivity and accuracy were significantly higher using NBI than WLI in both regions (P < .001 and P = .02 for the H&N region; P < .001 for both measures for the esophagus, respectively). CONCLUSION NBI could be the standard examination for the early detection of superficial cancer in the H&N region and the esophagus.

Combined use of a magnifying endoscope with a narrow band imaging system and a multibending endoscope for en bloc EMR of early stage gastric cancer.

BACKGROUND En bloc EMR is performed in Japan as a curative treatment for early stage gastric cancer. However, current methods of EMR are technically difficult and require proficiency in determining the extent of the cancer. This study assessed the feasibility of a new method to obviate these problems and to facilitate en bloc EMR. METHODS The new method uses two types of endoscopes: a magnifying endoscope with a narrow band imaging system to enhance the definition of mucosal and microcirculatory structure, and an endoscope with multibending tip deflection to maintain orientation during EMR. Forty-two consecutive cases of mucosal gastric cancer treated by EMR were reviewed retrospectively. In 12 of these patients, 12 lesions that fulfilled guideline criteria for EMR were treated by the modified, en bloc EMR method of circumferential incision and snare resection by using the two endoscopes. RESULTS The rate of complete en bloc resection with the new method of EMR was 91.7%, (11/12). There was no major complication. CONCLUSIONS The new en bloc resection method for EMR with two endoscopes described here is feasible and may be a safe and a reliable technique for curative treatment of mucosal gastric cancer.

Magnifying endoscopy combined with narrow-band imaging for differential diagnosis of superficial depressed gastric lesions

BACKGROUND AND AIM Magnifying endoscopy combined with narrow-band imaging (ME-NBI) has been used for differential diagnosis of various focal lesions. The aim of our study was to evaluate ME-NBI criteria for cancer diagnosis in superficial depressed gastric lesions in comparison to conventional white light endoscopy (WLE). PATIENTS AND METHODS ME-NBI and WLE images of 100 superficial gastric depressions (55 depressed cancers, 45 benign depressions) were independently evaluated by 11 endoscopists blinded to the diagnosis in each case. The presence or absence of predefined ME-NBI findings relating to microvasculature and fine mucosal structure (FMS) was recorded. A general diagnosis of benign or malignant also had to be given on the basis of a general assessment of features of color and shape as shown in the ME-NBI and WLE images, respectively, without regard to any prespecified criteria. RESULTS Multivariate and ROC analysis demonstrated that the triad of FMS disappearance, microvascular dilation, and heterogeneity appeared to be the best combination for diagnosis of gastric cancer. ME-NBI diagnosis with the triad attained a good specificity (85 %, theoretically calculated if all of the triad were positive), which was significantly ( P < 0.001) superior to WLE general diagnosis (65 %), and comparable with ME-NBI general diagnosis (80 %). The sensitivities of the three diagnoses (ME-NBI with the triad 69 %, WLE general diagnosis 71 %, ME-NBI general diagnosis 72 %) were comparably moderate. The kappa values (interobserver concordance) for ME-NBI diagnosis with the triad (0.47) and ME-NBI general diagnosis (0.48) were superior to the kappa value for WLE diagnosis (0.34). CONCLUSION The triad of FMS disappearance, microvascular dilation, and heterogeneity has good specificity for the diagnosis of superficial depressed gastric carcinoma, but the sensitivity needs to be improved.

Magnifying endoscopy with narrow-band imaging achieves superior accuracy in the differential diagnosis of superficial gastric lesions identified with white-light endoscopy: a prospective study

BACKGROUND Conventional, white-light imaging endoscopy (WLE) results in a significant number of misdiagnoses in early gastric cancer. Magnifying endoscopy combined with narrow-band imaging (ME-NBI) is more accurate in the diagnosis of gastric cancer when the diagnostic triad of the disappearance of fine mucosal structure, microvascular dilation, and heterogeneity is used. OBJECTIVE The aim of the present study was to evaluate the superiority of ME-NBI in the differential diagnosis of superficial gastric lesions identified with conventional WLE. DESIGN Prospective, comparative study. SETTING Single academic center. PATIENTS This study involved patients who underwent WLE and ME-NBI for surveying synchronous or metachronous cancers because they had a high risk of gastric cancer. INTERVENTION Patients with superficial gastric lesions that were diagnosed by WLE as cancer or non-cancer with a slight suspicion of cancer were prospectively enrolled in the study. ME-NBI was used to further characterize lesions picked up with WLE. MAIN OUTCOME MEASUREMENTS Sensitivity and specificity for the diagnosis of gastric cancer, with pathology as the criterion standard. RESULTS A total of 201 lesions (mean diameter [+/- SD] 7.0 +/- 4.0 mm) from 111 patients (98 men, 13 women; mean age 66.3 years) were evaluated. Fourteen of the 201 lesions were pathologically proven as gastric cancer; the others were noncancerous lesions. The sensitivity and specificity for ME-NBI diagnosis with the use of the triad (92.9% and 94.7%, respectively) were significantly better than for WLE (42.9% and 61.0%, respectively; P < .0001). LIMITATIONS Single center and a highly selected population at high risk for gastric cancer. CONCLUSION ME-NBI achieved superior accuracy in the differential diagnosis of superficial gastric lesions identified with WLE. Thus, ME-NBI may increase the diagnostic value of endoscopy in a population at high risk of gastric cancer.

CpG Island Hypermethylation of Tumor-Suppressor Genes in H. pylori-Infected Non-Neoplastic Gastric Mucosa Is Linked with Gastric Cancer Risk

Background and aim:  Gastric carcinogenesis involves CpG island hypermethylation (CIHM) of tumor‐suppressor genes. Although the CIHM of these genes occurs in non‐neoplastic gastric cells, it is unclear whether this epigenetic alteration is linked with aging and/or gastric cancer risk. We investigated this linkage in noncancerous gastric mucosa infected with H. pylori.

New approach to diagnosing ampullary tumors by magnifying endoscopy combined with a narrow-band imaging system

BackgroundA newly developed narrow-band imaging (NBI) system, which uses modified optical filters, can yield clear images of microvessels and surface structure in gastric and colonic diseases. In the present study, we investigated the ability of magnifying endoscopy with NBI (MENBI) to diagnose and differentiate between benign and malignant ampullary tumors.MethodsFourteen patients, whose ampullas were noted to be significantly enlarged or protruding with conventional endoscopy, were enrolled in the study. Specimens, which were obtained by forceps biopsy, endoscopic papillectomy, and/or surgery, were retrieved for histopathological examination. The correlation between MENBI images and histopathological findings was investigated. MENBI findings were classified as I, oval-shaped villi; II, pinecone/leaf-shaped villi; or III, irregular/nonstructured. In addition, tortuous, dilated, and network-like vessels noted on the ampullary lesions with MENBI were defined as abnormal vessels.ResultsIn 6 of 14 patients, the ampullary changes were proven to be inflammatory in forceps biopsy specimens, without any evidence of malignancy after more than 1 year of follow-up. In five patients, ampullary lesions were treated by endoscopic papillectomy, and in three, by pancreatoduodenectomy. All adenomas and adenocarcinomas had type II and/or type III surface structures, and patients whose ampulla had a type I surface structure had only inflammatory or hyperplastic changes. In addition, abnormal vessels were seen only in adenocarcinomas and never in adenomas.ConclusionsMENBI has the ability and potential to predict histological characteristics of ampullary lesions.

A Prospective Comparison of EUS-Guided FNA Using 25-Gauge and 22-Gauge Needles

Background and Aims. There are limited data on the differences in diagnostic yield between 25-gauge and 22-gauge EUS-FNA needles. This prospective study compared the difference in diagnostic yield between a 22-gauge and a 25-gauge needle when performing EUS-FNA. Methods. Forty-three patients with intraluminal or extraluminal mass lesions and/or lymphadenopathy were enrolled prospectively. EUS-FNA was performed for each mass lesion using both 25- and 22-gauge needles. The differences in accuracy rate, scoring of needle visibility, ease of puncture and quantity of obtained specimen were evaluated. Results. The overall accuracy of 22- and 25-gauge needle was similar at 81% and 76% respectively (N.S). Likewise the visibility scores of both needles were also similar. Overall the quantity of specimen obtained higher with the 22-gauge needle (score: 1.64 vs. P < .001). However the 25-gauge needle was significantly superior to the 22-gauge needle in terms of ease of puncture (score: 1.9 vs. 1.29, P < .001) and in the quantity of specimen in the context of pancreatic mass EUS-FNA (score: 1.8 vs. 1.58, P < .05). Conclusion. The 22-gauge and 25-gauge needles have similar overall diagnostic yield. The 25-gauge needle appeared superior in the subset of patients with hard lesions and pancreatic masses.

Polyglycolic acid sheet application to prevent esophageal stricture after endoscopic submucosal dissection for esophageal squamous cell carcinoma

BACKGROUND AND STUDY AIM Esophageal stricture following endoscopic submucosal dissection (ESD) can be a serious complication in patients with large mucosal defects. This preliminary study examined the efficacy of using a polyglycolic acid (PGA) sheet with fibrin glue for the prevention of esophageal stricture after ESD. PATIENTS AND METHODS A total of 15 patients were enrolled. After resection, PGA sheets were placed over the surgical wound. The size of the mucosal defect was estimated by dividing the circumference of the esophagus into 12 parts of equal size. The occurrence of esophageal stricture at 6 weeks, along with the proportion of patients who had PGA sheet remaining in place 1 week and 2 weeks after ESD, and the occurrence of adverse events were investigated. RESULTS The size of mucosal defects in the 15 patients were 7/12 (n = 4), 8 /12 (n = 5), 9/12 (n = 4), 10/12 (n = 1) and 11/12 (n = 1). Esophageal stricture occurred in 1/13 patients (7.7 %; two patients were not included in the analysis because they had required surgical resection during the follow-up period). The PGA sheet remained at 1 week after ESD in 13/15 patients (86.7 %) and at 2 weeks after ESD in 6/15 patients (40 %). No adverse events were observed. CONCLUSION PGA sheets may have the potential to prevent esophageal stricture.

Trimodal imaging endoscopy may improve diagnostic accuracy of early gastric neoplasia: a feasibility study

BACKGROUND A considerable number of superficial gastric neoplasias are overlooked with conventional white light imaging (WLI) endoscopy. OBJECTIVE The aim was to investigate the diagnostic potential of trimodal imaging endoscopy (TME), which combines WLI, autofluorescence imaging (AFI), and narrow-band imaging (NBI), for superficial gastric neoplasia. DESIGN Feasibility study. SETTING Single academic center. PATIENTS Sixty-two patients with or without gastric neoplasia. INTERVENTION Each patient serially assessed with WLI, AFI, and magnifying endoscopy with NBI (ME-NBI) by an endoscopist blinded for clinical information. ME-NBI over WLI and AFI was designated as TME. Histopathology of biopsy and ESD specimens was evaluated and used as the gold standard. MAIN OUTCOME MEASUREMENTS Sensitivity and specificity of endoscopic diagnosis of pathology-proven neoplasia by per-patient and per-lesion analyses. RESULTS The study included 47 pathology-proven neoplasias and 44 pathology-proven nonneoplasias that were detected as neoplasias with any of the modalities. By a per-lesion analysis, the sensitivity of TME (89.4%) was higher than that of WLI (76.6%) and AFI (68.1%). The specificity of TME (98.0%) was higher than that of WLI (84.3%) and AFI (23.5%). By a per-patient analysis, the sensitivity of TME (90.9%) was higher than that of WLI (75%) and AFI (68.2%). The specificity of TME (100%) was higher than that of WLI (72.2%) and AFI (44.4%). LIMITATIONS Case-enriched population at a single center. CONCLUSIONS Higher diagnostic accuracy of TME over conventional WLI indicates the feasibility of TME for the efficacious diagnosis of early gastric neoplasia.

Endoscopic submucosal dissection for nonampullary large superficial adenocarcinoma/adenoma of the duodenum: feasibility and long-term outcomes.

Background and study aims: The clinical benefit of endoscopic submucosal dissection (ESD) for superficial duodenal neoplasias has not yet been verified. The aims of this study were to validate the feasibility and long-term outcomes of ESD for nonampullary superficial duodenal neoplasias, larger than 20 mm. Patients and methods: 41 patients, with 41 nonampullary large superficial duodenal neoplasias, who underwent ESD between April 2005 to March 2013 were included in the study. The short- and long-term outcomes were retrospectively evaluated, related to tumor size, resection size, histological type, invasion depth, complete resection rate, operation time, perforation rate, delayed bleeding rate, local recurrence rate, distant metastasis, and survival rate. Results: ESD was successfully completed in 38 of 41 patients (92.7 %). The median sizes of tumors and resected specimens were, respectively, 26 mm (range 20 – 70 mm) and 36.5 mm (range 23 – 80 mm). Histopathological findings showed 13 adenocarcinomas (12 mucosal, 1 submucosal) and 28 adenomas (26 high grade dysplasia, 2 low grade dysplasia). The complete resection rate was 89.5 % (34 /38 tumors). The mean operation time was 128.3minutes. Perforation during ESD occurred in 39 % and delayed bleeding occurred in 18.4 %. The median observation period was 48 months (range 3.2 – 94.1 months), and no local recurrence or distant metastasis was seen during this time, representing a disease-free survival rate of 100 %. Conclusions: ESD for nonampullary large superficial duodenal adenocarcinoma/adenoma is feasible with favorable long-term outcomes. However, because of the high complication rate due to its technical difficulty, experience and skill of the operator, along with adequate perioperative management, are essential.