Tai Omori

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.

Endoscopic diagnosis of early squamous neoplasia of the esophagus with iodine staining: High-grade intra-epithelial neoplasia turns pink within a few minutes

Background and Aim:  The ability to detect early squamous neoplasia of the esophagus can be enhanced considerably by iodine staining during endoscopic examination; however, there has been no study on distinguishing high‐grade intra‐epithelial squamous neoplasia from low‐grade dysplasia by endoscopic examination. We assumed that high‐grade intra‐epithelial neoplasia could be identified as iodine‐unstained areas more distinct and reddish than low‐grade dysplasia after the brown color of iodine solution has faded, because there is almost no remaining glycogen‐containing epithelium in high‐grade intra‐epithelial neoplasia.

Risk of Squamous Cell Carcinoma of the Upper Aerodigestive Tract in Cancer-Free Alcoholic Japanese Men: An Endoscopic Follow-up Study

Asian case-control studies have shown a strong relationship between the development of squamous cell carcinoma (SCC) of the esophagus and alcohol consumption combined with inactive aldehyde dehydrogenase-2 (ALDH2*1/*2), less-active alcohol dehydrogenase-1B (ADH1B*1/*1), high mean corpuscular volume (MCV), and self-reported facial flushing in response to alcohol. However, little is known about whether these risk factors prospectively influence cancer development in cancer-free alcoholics. Between 1993 and 2005, 808 Japanese alcoholic men diagnosed as cancer-free by an initial endoscopic screening examination received follow-up examinations ranging from 1 to 148 months (median, 31 months) later, and SCC of the upper aerodigestive tract was diagnosed in 53 of them (esophagus in 33 and oropharyngolarynx in 30). Cox proportional hazards analysis showed that the age-adjusted relative hazard for SCC was 11.55 [95% confidence interval (95% CI), 5.73-23.3] in ALDH2*1/*2 heterozygotes compared with ALDH2*1/*1 homozygotes, 2.02 (95% CI, 1.02-4.02) in ADH1B*1/*1 homozygotes compared with ADH1B*1/*2 heterozygotes or *2/*2 homozygotes, 2.64 (95% CI, 1.49-4.67) in patients with flushing compared with those who had never experienced flushing, 2.91 (95% CI, 1.63-5.20) in those with an MCV ≥ 106 compared with those with an MCV < 106, 2.52 (95% CI, 1.22-5.22) in those who smoked ≥30 cigarettes per day compared with those who smoked 0 to 19 cigarettes per day, 7.26 (95% CI, 3.99-13.23) in those with esophageal dysplasia compared with those without distinct iodine-unstained lesions ≥5 mm, and 0.28 (95% CI, 0.09-0.85) in those with body mass index ≥ 23.2 (highest quartile) compared with those with body mass index < 19.0 (lowest quartile). These predictors are useful for selecting appropriately patients for careful follow-up examinations. (Cancer Epidemiol Biomarkers Prev 2006;15(11):2209–15)

Helicobacter pylori, chronic atrophic gastritis, inactive aldehyde dehydrogenase-2, macrocytosis and multiple upper aerodigestive tract cancers and the risk for gastric cancer in alcoholic Japanese men

Background:  Gastric carcinoma occurs at a high rate in alcoholic Japanese men. Inactive heterozygous aldehyde dehydrogenase‐2 (ALDH2*1/2*2) and macrocytosis (mean corpuscular volume [MCV] ≥ 106 fl) enhance the risk for esophageal carcinoma, which frequently occurs with gastric carcinoma in this population. Whether alcoholism affects Helicobacter pylori‐induced chronic atrophic gastritis (CAG) is unknown.

Borderline cases between benignancy and malignancy of the duodenum diagnosed successfully by endoscopic submucosal dissection

Abstract Objective. Due to advances in endoscopic equipment, primary duodenal tumors are found more frequently than in the past. We performed endoscopic submucosal dissection (ESD) to diagnose and treat four non-ampullary duodenal tumors. Material and methods. During endoscopic treatment, marks were placed around the circumference of the tumor and sufficient amounts of physiological saline with epinephrine were injected into the submucosal layer to elevate the lesion. An incision was made around the lesion using a long-type needle knife and the isolated lesion was resected completely “en bloc”. In this procedure, a cylindrical transparent hood was attached to the endoscopy apparatus to allow for satisfactory visualization of the procedure. Results. The mean age of the patients was 69 years. The patients consisted of two males and two females. Gross examination showed three flat, elevated lesions and one polypoid lesion. Tumor size ranged from 10 to 31 mm in maximum diameter. Histological examination revealed two cases of well-differentiated adenocarcinomas and two cases of tubular adenomas with severe atypia. Procedure-related complications consisting of perforation occurred in two cases and were resolved under close postoperative observation including antibiotics, use of a nasogastric tube and nil per oral feeding status. The mean follow-up period was 18 months and none of the patients experienced tumor recurrence after the treatment. Conclusions. Since tissue obtained from endoscopic biopsies can sometimes prove difficult for definitive histological diagnosis, ESD may play an important role in the management of cases appearing to border on malignancy. In addition, ESD allows for minimally invasive treatment without sacrificing the possibility of cure for duodenal carcinoma.

The Impact of Postoperative Complications on Survivals After Esophagectomy for Esophageal Cancer.

AbstractThe aim of this study was to assess the impact of postoperative complications after esophagectomy on long-term outcome.The treatment of esophageal cancer has recently been improved; however, esophagectomy with thoracotomy and laparotomy carries considerable postoperative morbidity and mortality. The real impact of postoperative complications on overall survival is still under evaluation.A retrospective analysis was performed on patients with esophageal cancer who underwent esophagectomy with thoracotomy and laparotomy, with R0 or R1 resection between January 1997 and December 2012. Of 402 patients, we analyzed the following parameters 284 patients who could be followed up for over 5 years: stage of disease, neoadjuvant therapies, surgical approaches, surgical complications, postoperative medical complications, and overall and relapse-free survivals using medical records.Of the 284 patients, 64 (22.5%) had pneumonia, 55 (19.4%) had anastomotic leakage, and 45 (15.8%) had recurrent laryngeal nerve paralysis (RLNP). Pneumonia had a significant negative impact on overall survival (P = 0.035); however, anastomotic leakage and RLNP did not affect overall survival. Multivariate analysis revealed that the presence of pneumonia was predictive of poorer overall survival; the multivariate hazard ratio was 1.456 (95% confidence interval 1.020–2.079, P = 0.039).Pneumonia has a negative impact on overall survival after esophagectomy. Strategies to prevent pneumonia after esophagectomy should improve outcomes in this operation.

Primary invasive micropapillary carcinoma of the stomach

Reported herein is the case of a 74‐year‐old man with an unusual gastric carcinoma that developed at the lesser curvature of the stomach. The tumor consisted of small clusters of carcinoma cells surrounded by clear spaces, with histopathology similar to invasive micropapillary carcinoma (IMPC) of the breast. The carcinoma cells, which had downregulation of E‐cadherin expression, invaded the subserous tissue and metastasized to the perigastric lymph nodes. IMPC, an unusual subtype of invasive breast carcinoma, is known to have frequent lymph node metastases, resulting in a poor clinical outcome. Although IMPC has been reported in breast, urinary bladder, ureter, lung, salivary gland and colon, to the best of the authors’ knowledge this is the first report of IMPC arising in the stomach. Presented here are the clinicopathological features of primary IMPC of the stomach.

Health Risk Appraisal Models for Mass Screening of Esophageal Cancer in Japanese Men

Background: Because early squamous cell carcinoma (SCC) of the esophagus is detectable by endoscopic esophageal iodine staining with high accuracy and is easily treated by endoscopic mucosectomy, it is important to develop efficient methods for screening candidates for the endoscopic examination. Inactive aldehyde dehydrogenase-2 (ALDH2) is a very strong risk factor for esophageal SCC in alcohol drinkers and thus may be suitable as a screening tool. Purpose: To assess the performance of health risk appraisal (HRA) models in screening for esophageal SCC in the Japanese male population. Methods: Two types of HRA models were developed based on our previous case-control study, which included assessment of ALDH2 activity and selected risk factors (HRA-G and HRA-F: activities of ALDH2 assessed by genotype and questionnaire for alcohol flushing, respectively). Each individuals risk of esophageal SCC was calculated quantitatively as a risk score. The sensitivity and specificity of the HRA models at various cutoff values of risk score was estimated by a leave-one-out cross-validation. The positive predictive value was estimated assuming the prevalence of esophageal SCC in the whole population to be 0.17% or 0.39% according to literatures. Results: When individuals ranked in the top 10% of the HRA-F risk score was screened, the sensitivity was 57.9% and positive predictive value was 0.93% or 2.12% according to the above assumptions, respectively. The sensitivity was slightly better by the HRA-G model than by the HRA-F model. Conclusion: The HRA models may provide an important approach to early intervention strategies to control esophageal SCC in Japanese men. (Cancer Epidemiol Biomarkers Prev 2008;17(10):2846–54)

Clinical Utility of a Novel Hybrid Position Combining the Left Lateral Decubitus and Prone Positions During Thoracoscopic Esophagectomy

BackgroundWe developed a hybrid of the prone and left lateral decubitus positions for thoracoscopic esophagectomy (TE) in 2009. This study aimed to evaluate the feasibility of applying this novel TE position.MethodsWe retrospectively analyzed 78 patients who underwent TE at our institution between 2005 and 2010. Altogether, 33 patients underwent TE in the left lateral decubitus position (LD-TE) from 2005 to 2008, and 45 underwent TE in the hybrid position (hybrid-TE) from 2009 to 2010. Radical lymphadenectomy along the bilateral recurrent laryngeal nerves was performed in both groups. The thoracic duct was preserved in the LD-TE group and resected in the hybrid-TE group. In the LD-TE group, all thoracic procedures were performed with the patient in the left lateral decubitus position. In the hybrid-TE group, the upper mediastinal procedure was performed with the patient in the left lateral decubitus position, and procedures at the middle and lower mediastinum were performed with the patient in the prone position under CO2 pneumothorax.ResultsHybrid-TE was associated with increased operating time. The number of harvested mediastinal nodes and the PaO2/FiO2 ratio on postoperative day 1 were both greater in this position. Although vocal cord palsy was observed more frequently in the hybrid-TE group, there was no significant difference in the rate of other complications or in-hospital mortality between the two groups.ConclusionsThe novel hybrid position is believed feasible for use during TE. We believe that this position facilitates a more radical mediastinal lymphadenectomy with minimal intraoperative pulmonary damage.

Clinical significance of plasma fibrinogen level as a predictive marker for postoperative recurrence of esophageal squamous cell carcinoma in patients receiving neoadjuvant treatment.

Among multidisciplinary therapies developed for advanced esophageal cancer, neoadjuvant chemotherapy and chemoradiotherapy have been established as standard treatments. To deliver cautious follow up and intense treatment for high-risk patients, a simple and instructive biomarker for the postoperative recurrence needs to be identified. Fibrinogen, a common component of hemostasis, has been suggested to not only play an important role in cancer metastasis, but also correlate with tumor recurrence. We aim to clarify the validity of plasma fibrinogen as a marker for predicting the postoperative recurrence of esophageal squamous cell carcinoma patients who received neoadjuvant treatment. We reviewed 72 consecutive patients with esophageal squamous cell carcinoma who received neoadjuvant chemotherapy or chemoradiotherapy, followed by esophagectomy at the Keio University Hospital from 2001 to 2010. Of them, we retrospectively examined 68 patients who underwent plasma fibrinogen examination before and after neoadjuvant treatment and underwent transthoracic radical esophagectomy. We investigated patient characteristics, clinicopathological factors, neoadjuvant treatment effects, postoperative course, and plasma fibrinogen levels. We investigated pretreatment and preoperative (postneoadjuvant treatment) plasma fibrinogen levels, as well as changes in fibrinogen levels before and after neoadjuvant treatment. Patients with preoperative hyperfibrinogenemia (>350 mg/dL) and patients with increased plasma fibrinogen levels during neoadjuvant treatment showed significantly shorter postoperative disease-free survival (DFS) (P = 0.002 and P = 0.037, respectively). Moreover, we classified these patients into three classes on the basis of their preoperative fibrinogen levels and changes in fibrinogen levels during neoadjuvant treatment. Patients who had both high preoperative plasma fibrinogen and increased fibrinogen levels showed significantly shorter DFS than others. In contrast, patients who had normal preoperative plasma fibrinogen and decreased fibrinogen levels showed significantly longer DFS. Based on this fibrinogen classification, we could differentiate between significantly favorable and poor prognosis patients group. Overall, this classification (hazard ratio = 1.812, P = 0.013) and the response to neoadjuvant treatment (hazard ratio = 0.350, P = 0.007) were found to be significant determining factors for postoperative DFS. With the validity of preoperative plasma fibrinogen levels and changes in fibrinogen levels during neoadjuvant treatment, the plasma fibrinogen level was found to be a possible biomarker for postoperative recurrence in advanced esophageal cancer patients who received neoadjuvant treatment. Moreover, plasma fibrinogen classification could be a simple and valuable predictive marker for postoperative follow up.