Moon Won Lee

New magnifying endoscopic classification for superficial esophageal squamous cell carcinoma

AIM To assess the accuracy of a new magnifying endoscopy (ME) classification for predicting depth of invasion of superficial esophageal squamous cell carcinoma (SESCC). METHODS This study included a total of 70 lesions in 69 patients with SESCC who underwent ME with narrow-band imaging (ME-NBI) before resection from August 2010 to July 2016. Accuracy of ME-NBI for predicting depth of invasion of SESCC was analyzed by using a new ME classification proposed by the Japan Esophageal Society (JES), and interobserver agreement was assessed. RESULTS Overall accuracy of ME-NBI for estimating depth of invasion of SESCC was 78.6%. Sensitivity and specificity of type B1 for tumors limited to the epithelial layer (m1) or invading into the lamina propria (m2) were 71.4% and 100%, respectively. Sensitivity and specificity of type B2 for tumors invading into the muscularis mucosa (m3) or superficial submucosa (≤ 200 μm, sm1) were 94.4% and 73.1%, respectively, while those of type B3 for tumors invading into the deep submucosa (> 200 μm, sm2) were 75.0% and 97.8%, respectively. Interobserver agreement was excellent (κ = 0.86, 95%CI: 0.76-0.95). CONCLUSION The recently developed JES ME classification is useful for predicting depth of invasion of SESCC, with reliable interobserver agreement.

Maximum standardized uptake value on positron emission tomography/computed tomography predicts clinical outcome in patients with relapsed or refractory diffuse large B-cell lymphoma

Background Few clinical studies have clarified the prognostic factors that affect clinical outcomes for patients with relapsed or refractory diffuse large B-cell lymphoma (DLBCL) after immunochemotherapy. Methods A total of 158 patients with relapsed or refractory DLBCL were enrolled. All patients underwent positron emission tomography/computed tomography (PET/CT) before and after salvage therapy. All enrolled patients previously received the ifosfamide, carboplatin, and etoposide regimen. Clinical outcomes were compared according to several factors (age ≥ 65 years, low age-adjusted International Prognostic Index [aa-IPI], maximum standardized uptake value [SUVmax] <6.0 on PET/CT, time to relapse ≥12 months, complete response after salvage therapy). A low aa-IPI, SUVmax <6.0, and time to relapse ≥ 12 months were independent prognostic factors for survival. Results In univariate analysis and multivariate analysis, SUVmax below 6.0 (P<0.001 for progression-free survival (PFS), P<0.001 for overall survival (OS)) and low aa-IPI (P<0.001 for PFS, P<0.001 for OS) were independent prognostic factors associated with favorable outcome. Conclusion The aa-IPI and initial SUVmax were powerful prognostic factors in patients with relapsed or refractory DLBCL.

Magnifying endoscopy with narrow-band imaging for gastric heterotopic pancreas

Background and study aims  Heterotopic pancreas is a common subepithelial lesion in the stomach. However, its histological diagnosis is difficult when tissue samples are obtained with a conventional biopsy forceps. This study aimed to describe the magnifying endoscopy with narrow-band imaging (ME-NBI) features of gastric heterotopic pancreas. Patients and methods  We retrospectively analyzed a database of all patients who underwent endoscopic ultrasonography (EUS) at Pusan National University Hospital from January 2010 to December 2010. Thirty-six patients with endosonographically diagnosed heterotopic pancreas who underwent ME-NBI and endoscopic ultrasonography (EUS) simultaneously were studied. The ME-NBI features of their lesions were analyzed. Results  Thirty lesions were located in the antrum and six in the body. Six lesions (17 %) showed umbilication or central dimpling on the surface, and nine (25 %) had a macroscopic opening on the surface. On ME-NBI, a microscopic opening was identified in 22 (81 %) of 27 lesions wherein a macroscopic opening was not observed during conventional endoscopy. Macroscopic or microscopic opening was observed in 31 lesions (86 %). The frequency of macroscopic or microscopic opening was higher in lesions with anechoic duct-like structures than in lesions without such structures on EUS (91 % [29/32] vs 50 % [2/4], P  = 0.027). Focal loss of microsurface structure and presence of a thickened submucosal vessel were observed in 6 (17 %) and 5 lesions (14 %), respectively. Conclusions The characteristic ME-NBI feature of heterotopic pancreas is presence of a microscopic opening on its surface. This ME-NBI feature is potentially useful for differentiating heterotopic pancreas from other gastric subepithelial tumors.

Magnifying Endoscopy for Esophageal Ectopic Sebaceous Glands

Ectopic sebaceous glands are found very rarely in the esophagus; heretofore, several cases have been reported. The sebaceous gland is originally a source of an endodermal origin; however, there have been controversies regarding whether the origin of the esophageal ectopic sebaceous gland is ectodermal or endodermal. Ectopic sebaceous glands of the esophagus usually do not cause symptoms; thus, they are often found incidentally on endoscopy for routine health screening. Endoscopic findings are characterized by single or multiple yellow patches or nodular lesions of various sizes, sometimes with small central openings. We report two cases of esophageal ectopic sebaceous glands found incidentally during endoscopy with magnifying endoscopic findings. The lesions were in the mid-esophagus and lower esophagus, respectively, and both endoscopic findings were similar as multiple yellowish patches or plaques. Magnifying endoscopy revealed the openings of the excretory ducts surrounded by circular microvessels in both cases.

Is a Cytopathologist Always Needed during Endoscopic Ultrasonography-Guided Tissue Acquisition?

Gastrointestinal (GI) subepithelial tumors (SETs) detected during routine endoscopy demonstrate a prevalence of 0.36%, which is found to increase with age. Based on a recent Korean multicenter study that included 87,578 subjects undergoing routine screening endoscopy, the incidence of SETs in the upper GI tract was noted to be 3.1% (unpublished data). GI SETs include malignant tumors (such as GI stromal tumors, neuroendocrine tumors, or lymphomas), as well as benign tumors (such as leiomyomas, lipomas, heterotopic pancreas, or cysts). Although surgical resection is the primary diagnostic and therapeutic modality used for management of SETs, particularly for symptomatic or large tumors, it might not be needed for all cases with SETs. Although endoscopic ultrasonography (EUS) is the best diagnostic modality for evaluation of SETs, it cannot be a substitute for a histopathological diagnosis. Because a histopathological diagnosis plays an important role in determining the most appropriate treatment strategy, EUS-guided tissue acquisition such as fine-needle aspiration (FNA) is attempted in many clinical settings. EUS-FNA is a well-known and useful diagnostic modality for the management of solid pancreatic lesions. Rapid on-site evaluation (ROSE) performed by an attending cytopathologist can improve the adequacy rate of FNA specimens, resulting in a higher diagnostic yield of EUS and can reduce the number of needle passes required/performed. ROSE can also be performed by endoscopists instead of cytopathologists. A retrospective study compared the diagnostic accuracy of EUS-FNA with ROSE performed by endoscopists and cytopathologists and found no statistically significant differences between the two groups (endoscopists and cytopathologists) with respect to the mean number of passes required (4.0±1.6 vs. 3.4±1.5, p=0.06) and specimen adequacy (97.4% vs. 97.1%, p=0.51). Another recent study showed that endoscopists who participated in pathologist-guided training programs could improve the adequacy of specimens (from 75% to 98%) and diagnostic accuracy (from 61% to 82%). However, a recent, multicenter, prospective, randomized controlled trial using EUS-FNA for pancreatic lesions, showed that the diagnostic yield and proportion of inadequate specimens did not differ between EUS-FNA performed with and without ROSE. A meta-analysis comprising seven studies involving 1,299 patients, compared EUS-FNA performed with and without ROSE and showed that ROSE did not significantly affect the cytological adequacy or diagnostic yield. This is because, due to rapidly advancing technology, EUS-FNA has become a widely used diagnostic procedure, and endoscopists are now better equipped to target lesions and obtain samples even from very small pancreatic lesions along with maintaining proper positioning of the needle under direct visualization Received: June 26, 2017 Accepted: July 10, 2017 Correspondence: Gwang Ha Kim Department of Internal Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan 49241, Korea Tel: +82-51-240-7869, Fax: +82-51-244-8180, E-mail: doc0224@pusan.ac.kr

Bile Duct Patency Maintained after Intraductal Radiofrequency Ablation in a Case of Hepatocellular Cholangiocarcinoma with Bile Duct Invasion

Combined hepatocellular-cholangiocarcinoma (HCC-CC) with bile duct invasion (BDI) is rare. In unresectable cases, biliary stent placement and photodynamic therapy (PDT) are used for resolving obstructive jaundice. However, stent occlusion remains problematic, and PDT is expensive and time-consuming. Intraductal radiofrequency ablation (RFA) is an emerging procedure for palliation in these patients. It has potential benefits including less expense, lower rates of severe complication, longer maintenance of ductal patency, and easier technique compared with PDT or stenting alone. We report a 67-year-old man who underwent repeated intraductal RFA for HCC-CC and HCC with BDI, for whom bile duct patency was maintained without additional biliary procedures.