Satoru Nonaka

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.

Complications of Gastric Endoscopic Submucosal Dissection

Endoscopic resection is now a widely accepted treatment for early gastric cancer, having a negligible risk of lymph‐node metastasis. Endoscopic submucosal dissection (ESD) is a relatively new endoscopic resection method developed in the mid‐1990s that facilitates en‐bloc resection even in patients with large or ulcerative lesions difficult to resect using conventional endoscopic mucosal resection (EMR). However, compared to EMR, ESD requires a longer procedure time and a higher level of technical expertise, in addition to having a slightly greater risk of complications. Endoscopists must be aware of not only the risk factors for, and incidence of, complications, but also how to effectively treat such complications. Perforation and bleeding are the major complications associated with gastric ESD. The perforation and delayed bleeding rates have been reported to range from 1.2% to 5.2% and 0% to 15.6%, respectively, and can usually be managed with appropriate endoscopic treatment. Immediate bleeding during gastric ESD is quite common and controlling such bleeding, which is primarily achieved by carrying out electrocautery, plays a critical role in the successful completion of ESD.

Short- and long-term outcomes of endoscopic submucosal dissection for undifferentiated early gastric cancer.

BACKGROUND AND STUDY AIMS Intramucosal undifferentiated early gastric cancer (EGC) up to 2 cm in size without ulceration has been treated by endoscopic submucosal dissection (ESD) because the incidence of lymph node metastasis is negligible. The aim of this retrospective study was to clarify the short-term and long-term outcomes of ESD carried out to treat undifferentiated EGC. PATIENTS AND METHODS Between January 1999 and September 2011, 113 patients with poorly differentiated adenocarcinoma or signet ring cell carcinoma on preoperative biopsy underwent ESD. In 16 patients differentiated EGC had been diagnosed after the ESD and these patients were excluded from the study. Short-term outcomes were evaluated in the remaining 97 patients with undifferentiated EGC, and long-term outcomes analyzed in the 79 patients with undifferentiated EGC who had undergone ESD between 1999 and 2008. RESULTS En bloc and R0 resection were achieved in 99.0 % and 90.7 % of patients, respectively. Median procedure time was 45 minutes. Postoperative bleeding, perforation during the procedure, and delayed perforation were noted in 4.1 %, 3.1 %, and 1.0 % respectively. Curative resection was achieved in 63.9 %. Additional surgery was performed in 21 of 35 patients in whom resection was noncurative: one (4.8 %) had local residual tumor and two (9.5 %) had lymph node metastases. Of the 46 /79 patients in the long-term outcome group who had curative resection, none had local recurrence or lymph node or distant metastasis during a median follow-up of 76.4 months. The 5-year overall mortality rate after curative resection was 7.0 %, and no patient died of gastric cancer. CONCLUSIONS ESD for undifferentiated EGC can achieve curative resection with an excellent 5-year mortality rate.

LEARNING CURVE FOR ENDOSCOPIC SUBMUCOSAL DISSECTION OF EARLY GASTRIC CANCER BASED ON TRAINEE EXPERIENCE

Background and Aim:  There have been few previous reports on endoscopic submucosal dissection (ESD) learning curve for early gastric cancer (EGC) so we retrospectively assessed this subject based on experience of our trainees.

Clinical outcome of endoscopic resection for nonampullary duodenal tumors

BACKGROUND AND STUDY AIMS Compared with any other location in the gastrointestinal tract, the duodenum presents the most challenging site for endoscopic resection. The aim of this study was to analyze the clinical outcomes of duodenal endoscopic resection and to assess the feasibility of the technique as a therapeutic procedure. PATIENTS AND METHODS A total of 113 consecutive patients with 121 nonampullary duodenal tumors underwent endoscopic resection by endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR), or polypectomy between January 2000 and September 2013. Long-term outcomes were investigated in patients with more than 1 year follow-up. RESULTS The median tumor size was 12 mm (range 3 - 50 mm). Lesions consisted of 63 adenocarcinomas/high-grade intraepithelial neoplasias (53 %) and 57 adenomas/low-grade intraepithelial neoplasias (48 %). Endoscopic resection included 106 EMRs (87 %), 8 ESDs (7 %), and 7 polypectomies (6 %). En bloc resection was achieved in 77 lesions (64 %), and 43 lesions (35 %) underwent piecemeal resection; one procedure was discontinued due to perforation. There were 14 cases of delayed bleeding after EMR (12 %), 1 perforation (1 %) during ESD, and 1 delayed perforation (1 %) after ESD, which required emergency surgery. Of the 76 patients who were followed for more than 1 year, none of the patients died from a primary duodenal neoplasm, and there were no local recurrences during the 51-month median follow-up period (range 12 - 163 months). CONCLUSIONS Duodenal endoscopic resection was feasible as a therapeutic procedure, but it should only be performed by highly skilled endoscopists because of its technical difficulty. Piecemeal resection by EMR is acceptable for small lesions, based on these excellent long-term outcomes.

Narrow-band imaging endoscopy with magnification is useful for detecting metachronous superficial pharyngeal cancer in patients with esophageal squamous cell carcinoma.

Background and Aims:  Head and neck cancers, especially pharyngeal cancers, as well as esophageal cancers frequently coexist either synchronously or metachronously, but most cases of pharyngeal cancer are detected at an advanced stage resulting in poor prognosis. The aim of this study is to evaluate the effectiveness of using narrow‐band imaging (NBI) endoscopy with magnification for early detection of pharyngeal cancer on patients following their treatment for esophageal squamous cell carcinoma (SCC).

Long-term outcome of endoscopic resection of superficial adenocarcinoma of the esophagogastric junction

BACKGROUND AND STUDY AIM Endoscopic resection has been favored for the management of intramucosal adenocarcinoma of the esophagogastric junction (AEGJ) over standard treatment with surgical resection. Several previous studies have reported only short-term outcomes. The aim of the present study was to report the long-term follow-up and outcomes of endoscopic submucosal dissection (ESD), a representative endoscopic resection method, for the management of superficial AEGJ. PATIENTS AND METHODS A retrospective cohort study included 53 consecutive patients with superficial AEGJ who underwent ESD between 2001 and 2007 at the National Cancer Center Hospital, Tokyo, Japan. Rates of overall survival, recurrence-free survival, and cause-specific survival of patients with AEGJ after endoscopic resection were analyzed. RESULTS The 5-year overall, recurrence-free, and cause-specific survival rates in the 53 patients were 94.2%, 92.3% and 96.1%, respectively. The median follow-up was 6.1 years. En bloc, R0, and curative resection rates were 100 %, 79 %, 68 %, respectively. In 36 patients with curative resection, the cause-specific survival rate was 100 % and no recurrence or metastases were detected. In 17 patients with non-curative resection, recurrence was found in three patients (17 %); two of the three patients died of their disease whilst one patient received chemotherapy. CONCLUSIONS Superficial AEGJ can be well controlled by ESD when curative resection is achieved.

Endoscopic submucosal dissection of recurrent or residual superficial esophageal cancer after chemoradiotherapy

BACKGROUND Treatment of local recurrent or residual superficial esophageal squamous-cell carcinoma (SCC) with conventional EMR often results in a piecemeal resection that requires further intervention. OBJECTIVE The aim of this study was to evaluate the efficacy of endoscopic submucosal dissection (ESD). DESIGN A case series. PATIENTS Between January 2006 and September 2006, 4 local recurrent or residual superficial esophageal SCCs were treated by ESD. INTERVENTIONS ESD procedures were performed by using a bipolar needle knife and an insulation-tipped knife. After injection of glycerol into the submucosal (sm) layer, a circumferential incision was made, and an sm dissection was performed. All lesions were determined to be intramucosal or sm superficial, without lymph-node metastasis by EUS before treatment. MAIN OUTCOME MEASUREMENTS Tumor size, en bloc resection rate, tumor-free lateral margin rates, and complications were recorded. RESULTS All 4 ESD cases were successfully resected en bloc, and the tumor-free lateral margin rate was 75% (3/4) by histopathology examination. The mean tumor size of the resected specimens was 35 mm (range, 15-50 mm). There were no complications. LIMITATIONS The number of ESDs in our series was limited, and there are no long-term follow-up data. CONCLUSIONS ESD for recurrent or residual superficial esophageal tumors after chemoradiotherapy achieves the goal of an en bloc resection, with a low rate of incomplete treatment without any greater risk than the EMR technique.

Feasibility of endoscopic mucosal resection for superficial pharyngeal cancer: a minimally invasive treatment

BACKGROUND AND STUDY AIMS New diagnostic techniques have recently been developed so detection of superficial pharyngeal cancer is dramatically increasing and endoscopic mucosal resection (EMR) can now be performed on an experimental basis. The aim of this study was to clarify the effectiveness of EMR for superficial pharyngeal cancer. PATIENTS AND METHODS Between 2004 and 2007, 31 patients with 37 pharyngeal lesions underwent EMR at our hospital. EMR using a cap-fitted endoscope (EMR-C) was used on 34 lesions and strip biopsies on the remaining three. We retrospectively assessed the effectiveness of those procedures in treating superficial pharyngeal cancer. RESULTS Median procedure time was 45 minutes (range 20 - 180 minutes) and median hospital stay was 7 days (range 4 - 12 days). Regarding complications, one patient experienced laryngeal edema, one suffered aspiration pneumonia, and two sustained dermatitis around the mouth caused by Lugol staining. Histologically, 18 lesions were confirmed as carcinoma in situ and the other 19 lesions demonstrated microinvasion of the subepithelial tissue with lymphatic invasion in one case. During the median follow-up period of 40 months (range 21 - 62 months), two patients received radiotherapy and two patients underwent an additional EMR because of recurrent tumors. Five other patients developed metachronous superficial pharyngeal cancers, but all those lesions were resected primarily by EMR while two of the studys 31 patients died from esophageal cancer. None of the remaining 20 patients experienced any recurrent or metachronous tumors during their follow-up periods. CONCLUSIONS Our results indicated that EMR was a safe, effective, and minimally invasive treatment for superficial pharyngeal cancer.

Long-term surveillance and treatment outcomes of metachronous gastric cancer occurring after curative endoscopic submucosal dissection.

BACKGROUND AND STUDY AIMS As more early gastric cancer (EGC) patients are being treated with endoscopic submucosal dissection (ESD), it is important to understand the outcomes of patients who develop metachronous gastric cancer (MGC). The aim of this study was to evaluate the long-term surveillance and treatment outcomes of MGC after curative gastric ESD. PATIENTS AND METHODS The study included 1526 consecutive patients who underwent curative ESD resection of EGC. They were generally followed by annual or biannual esophagogastroduodenoscopy. The risk factors and treatment outcomes for MGC were assessed along with the 5-year, 7-year, and 10-year cumulative incidence functions of MGC and disease-specific survival (DSS). RESULTS During a median follow-up period of 82.2 months, 238 patients developed MGC post-ESD resection of EGC. The 5-year, 7-year, and 10-year cumulative incidence functions of MGC were 9.5%, 13.1% and 22.7%, respectively. Male sex and multiple initial EGCs were independent risk factors for MGC in the Cox proportional hazard model. Of the 238 patients with MGC, 215 were treated with endoscopic resection, of which 183 achieved curative resection, although one patient later died of his initial EGC. A further 14 patients were treated surgically, three had metastatic disease and received palliative chemotherapy, and the remaining six were observed without any intervention. A total of seven patients died of MGC, five at least 5 years after their index ESD. The 5-year, 7-year, and 10-year DSSs were 99.2%, 98.6%, and 92.5%, respectively. CONCLUSIONS The incidence of MGC increases with time after curative gastric ESD, therefore surveillance endoscopy should be continued indefinitely.