Ryuta Takenaka

Risk factors associated with local recurrence of early gastric cancers after endoscopic submucosal dissection

BACKGROUND Although endoscopic submucosal dissection (ESD) is expected to reduce the local recurrence of gastric cancers, we still experience cases of recurrence after an ESD. OBJECTIVE To characterize clinical and pathologic features of cases with local recurrence of early gastric cancer after an ESD. DESIGN A prospective cohort study. SETTING AND PATIENTS A total of 306 patients with gastric cancers removed by ESD at Okayama University Hospital and Tsuyama Central Hospital between March 2001 and December 2005 were enrolled. INTERVENTION ESD. MAIN OUTCOME MEASUREMENT Local recurrence. RESULTS The incidence of a complete en bloc resection was 80.4% when pathologically evaluated. Within a median follow-up period of 26 months (12-64 months), a local recurrence was found in 7 cases, all of which had been declared incomplete resections. One patient underwent a second ESD, and the remaining 6 underwent a surgical resection. All removed lesions were mucosal cancers. No lymph-node metastases were found in patients with a surgical resection. There was a significant correlation between the incidence of an incomplete resection and that of a local recurrence (P < .0001). Among the clinical characteristics, tumor size (>30 mm vs <20 mm; odds ratio [OR] 16 mm [95% CI, 2.0-130 mm]) and tumor location (upper vs middle or lower; OR 7.6 [95% CI, 1.3-45]) were identified as factors that were significantly associated with the incidence of a local recurrence. LIMITATION Short follow-up duration. CONCLUSIONS The incidence of a local recurrence was strongly associated with that of an incomplete resection. The frequency of a local recurrence also showed significant correlations with the tumor size and location within the stomach.

Helicobacter pylori eradication reduced the incidence of gastric cancer, especially of the intestinal type

Although Helicobacter pylori infection is closely associated with gastric cancer development, follow‐up studies after H. pylori eradication are still scarce.

Narrow-Band Imaging Provides Reliable Screening for Esophageal Malignancy in Patients With Head and Neck Cancers

OBJECTIVES:The narrow-band imaging (NBI) system is a novel technology that enhances the visualization of microvasculature and mucosal patterns. The aim of this study was to assess the reliability of the NBI system for esophageal cancer screening in patients with head and neck cancers.METHODS:A total of 142 patients with head and neck squamous cell carcinoma (SCC) were examined by NBI endoscopy, followed by Lugol chromoendoscopy between April 2006 and June 2008 at the Okayama University Hospital, Okayama, Japan. Detection of SCC and high-grade intraepithelial neoplasia (HGIN) was conducted.RESULTS:The median age of the patients was 64 years (range: 29–86 years), and approximately three-fourths of all the patients were male. In total, 21 superficial lesions in 16 patients were detected by NBI endoscopy. Of these, 4 lesions were diagnosed histologically as SCC and 11 lesions as HGIN. An additional 22 Lugol-voiding lesions ≥5 mm were detected in 19 patients by Lugol chromoendoscopy. Although 1 of these lesions was diagnosed as HGIN, 21 lesions were diagnosed as low-grade intraepithelial neoplasia or lesions without atypical findings. The sensitivity of NBI endoscopy for detecting esophageal SCC and HGIN was 90.9% (95% confidence interval (CI), 58.7–99.8), specificity was 95.4% (95% CI, 90.3–98.3), and accuracy was 95.1% (95% CI, 90.1–98.0).CONCLUSIONS:NBI seems to be useful and reliable for screening for esophageal SCC in patients with head and neck cancers.

Lugol-Voiding Lesions Are an Important Risk Factor for a Second Primary Squamous Cell Carcinoma in Patients With Esosphageal Cancer or Head and Neck Cancer

OBJECTIVES:Lugol-voiding lesions (LVLs), detected by chromoendoscopy using iodine dye in patients with esophageal squamous cell carcinoma (EC) or head and neck squamous cell carcinoma (HNC), are associated with a second primary carcinoma in the other organ. We undertook a cross-sectional and retrospective cohort study to assess the risk for second primary carcinomas according to the severity of LVLs, on the basis of their number and size.METHODS:A total of 1,060 patients with only EC, only HNC, or both EC and HNC (EC+HNC) underwent esophageal endoscopic examination between January 1994 and January 2010. The patients were classified according to the number of LVLs in an endoscopic visual field and the size of the largest LVLs. Factors associated with the second primary EC or HNC were analyzed.RESULTS:Univariate analysis showed that a larger number and size of LVLs increased the risk for synchronous and early metachronous second primary cancer (P value for trend <0.0001). Multivariate analysis showed that a number of LVLs ≥20 (EC+HNC vs. only HNC, odds ratio (OR)=15.7; EC+HNC vs. only EC, 3.5) and a size ≥10 mm (EC+HNC vs. only HNC, OR=3.1; EC+HNC vs. only EC, 3.2) were independent risk factors for synchronous and early metachronous second primary cancer. A larger number of LVLs was a risk factor for metachronous EC and HNC, and a size ≥10 mm was a risk factor for late metachronous EC.CONCLUSIONS:The severity of LVLs in patients with HNC or EC closely correlated with a second primary carcinoma in the other organ. Patients with LVLs must be followed closely for development of a second primary carcinoma.

Novel chromoendoscopic method using an acetic acid-indigocarmine mixture for diagnostic accuracy in delineating the margin of early gastric cancers

Background and Aim:  Recent endoscopic imaging techniques for recognition of unclear lesions in the stomach (e.g. narrow band imaging, magnifying endoscopy) require special equipment and therefore are not commonly used. The aim of the present study was to estimate the accuracy of a new chromoendoscopic method using an acetic acid–indigo carmine mixture (AIM) in diagnosing early gastric cancers (EGC).

Mucosa‐associated lymphoid tissue lymphoma of the rectum that regressed spontaneously

We report a case of mucosa‐associated lymphoid tissue (MALT) lymphoma of the rectum that regressed spontaneously. A 76‐year‐old man visited our hospital because of positive faecal occult blood testing. Colonoscopic examination revealed a slightly yellowish protruded lesion with a grooved depression in the lower rectum and two flat elevations in the upper rectum. Microscopic and immunohistological studies led to a diagnosis of MALT lymphoma. As the patient exhibited severe renal dysfunction and angina pectoris, the lesions were left untreated. Three months later, the protruded lesion became flat and the other lesions became unclear. He was followed up closely with endoscopy, but no relapse of these lesions was detected 19 months after the diagnosis.

Endoscopic submucosal dissection for cancers of the remnant stomach after distal gastrectomy

BACKGROUND Endoscopic submucosal dissection (ESD) of early gastric cancer is less invasive than surgical resection, and if technically feasible, it may result in less long-term morbidity than does incisional surgery. However, ESD is technically difficult in patients who have had a previous distal gastrectomy. OBJECTIVE Our purpose was to retrospectively assess the results of ESD of early gastric cancer in the remnant stomach. DESIGN Case series. SETTING AND PATIENTS A total of 31 lesions in 30 patients with early remnant gastric cancer were treated with ESD at Okayama University Hospital, Tsuyama Central Hospital, Hiroshima City Hospital, Kagawa Prefectural Central Hospital, and Mitoyo General Hospital from March 2001 to January 2007. INTERVENTION ESD. MAIN OUTCOME MEASUREMENTS En bloc resection rate, complete resection rate, operation time, and complications. RESULTS En bloc resection and complete resection were achieved in 30 (97%) and in 23 (74%) lesions, respectively. The median operation time required for ESD in the remnant stomach was 113 minutes (range 45-450 minutes). Perforation occurred in 4 (13%). The incidence of delayed bleeding requiring blood transfusion was 0%. LIMITATION Short duration of follow-up. CONCLUSIONS ESD is feasible in the remnant stomach but has a relatively high complication rate and should only be performed by experienced endoscopists.

RISK MANAGEMENT TO PREVENT PERFORATION DURING ENDOSCOPIC SUBMUCOSAL DISSECTION

En bloc resection is beneficial for accurate histological assessment of resected specimens of endoscopic mucosal resection. Conventional endoscopic mucosal resection is simple and convenient but with this procedure the size of specimen obtained from one‐piece resection is very limited. Endoscopic submucosal dissection (ESD) using IT knife, Hook knife, Flex knife and so on has already been reported and it is useful to some expert endoscopists, but sometimes difficult for general endoscopists to use safely. The drawback of ESD is that it is difficult and is consequently associated with a higher rate of perforation, which may reach up to 2–6% . In addition, ESD requires advanced endoscopic techniques. Further improvement of devices and techniques is expected to be developed to prevent perforation for ESD procedure.

Proton pump inhibitor dose-related healing rate of artificial ulcers after endoscopic submucosal dissection: A prospective randomized controlled trial

Background/Aims: Two studies have reported on the superiority of a proton pump inhibitor (PPI) compared with a histamine-2-receptor antagonist for the treatment of artificial ulcers after endoscopic submucosal dissection (ESD), but the optimal dose of PPI remains to be defined. The aim of this study was to evaluate the possibility of reducing the dose of PPI. The authors thus compared 30 mg (standard-dose) and 15 mg (half-dose) lansoprazole in terms of ulcer healing, prevention of bleeding and quality of life. Methods: 91 patients with gastric mucosal neoplasm were enrolled. All patients who underwent ESD were administered lansoprazole 30 mg daily during the first week, after which they were randomly assigned to either the standard-dose or half-dose group. Results: One patient in each group developed hematemesis. The stage of ulcers, ulcer reduction ratios and scores on the Gastrointestinal Symptom Rating Scale did not differ at 28 and 56 days. The costs of PPI for the half-dose group and standard-dose group were 7,326.5 and 11,698.4 JPY, respectively, i.e. a difference of 471.9 JPY. Conclusions: A reduced dose of PPI after 1 week of ESD was equivalent in treatment performance to the standard dose and cheaper.

Esophageal xanthoma: report of two cases and a review of the literature.

Abstract  So far, three cases of esophageal xanthoma have been reported. We describe here endoscopic, microscopic and immunohistochemical findings of two new cases of this rare condition, and a review of five cases of esophageal xanthoma, including our cases. Esophageal xanthomas endoscopically show yellow granular spots or a slightly elevated lesion, and are similar to an ectopic sebaceous gland. Microscopically, an aggregate of foamy histiocytes (lipid islands) is seen immediately beneath the squamous epithelium, particularly between the rete ridges. Immunohistochemically, xanthoma cells are positive for CD68, which indicate a histiocytic origin. The etiology of esophageal xanthoma remains unclear. We emphasize that esophageal xanthomas may have been erroneously diagnosed as an ectopic sebaceous gland on endoscopic examination.