Toshiyuki Yoshio

Clinicopathological features of Siewert type II adenocarcinoma: comparison of gastric cardia adenocarcinoma and Barrett’s esophageal adenocarcinoma following endoscopic submucosal dissection

ObjectivesSiewert type II esophagogastric junction adenocarcinoma encompasses both gastric cardia adenocarcinoma (GCA) and Barrett’s esophageal adenocarcinoma (BEA) due to short-segment Barrett’s esophagus. We compared these two types of Siewert type II esophagogastric junction adenocarcinoma in terms of background factors and clinical outcomes of endoscopic submucosal dissection (ESD).MethodsWe enrolled 139 patients (142 lesions) who underwent ESD from 2006 to 2014 at our institution. Background factors evaluated were age, sex, body mass index, hypertension, hyperlipidemia, hyperuricemia, diabetes mellitus, smoking, drinking, double cancer, and endoscopic findings. Clinical outcomes evaluated were procedure time, en bloc resection rate, curative resection rate, and adverse events.ResultsThere were 87 GCA lesions (61.2%) and 55 BEA lesions. Features of BEA [55 lesions (38.8%)] included a younger age, small diameter, and a protruding type, along with a high frequency of esophageal hiatal hernia and less mucosal atrophy. There were no significant differences in lifestyle-related background factors between the GCA and BEA groups. Curative resection rate was greater for GCA (81%) than for BEA (66%) (Pxa0=xa00.01). There were no serious adverse events in either group. Among the factors for noncurative resection, lymphovascular invasion and depth of invasion were greater for BEA (33.3 vs. 7 and 20.7 vs. 8.2%, respectively (Pxa0<xa00.01). Of the noncured patients, 70% underwent additional surgery and none had postoperative lymph node metastasis.ConclusionsSiewert type II adenocarcinoma encompasses two types of cancers with different etiologies: GCA and BEA. Although there are no significant differences in lifestyle-related background factors between GCA and BEA, BEA is a risk factor for noncurative resection via ESD.

Effect of direct oral anticoagulants on the risk of delayed bleeding after gastric endoscopic submucosal dissection

Anticoagulants are used to prevent thromboembolic events. Direct oral anticoagulants (DOAC) are our new choice; however, their effect on bleeding risk for endoscopic treatment has not been reported. We aimed to assess the clinical effect of DOAC compared to warfarin for gastric endoscopic submucosal dissection (ESD).

Correlation of the location of superficial Barrett’s esophageal adenocarcinoma (s-BEA) with the direction of gastroesophageal reflux

Background: Superficial Barrett’s esophageal adenocarcinoma (s-BEA) in Barrett’s esophagus frequently occurs in the right wall of the esophagus. Our aim was to examine the correlation between the location of s-BEA and the direction of acid and non-acid reflux in patients with Barrett’s esophagus. Patients and methods: We performed 24-h pH monitoring in 33 s-BEA patients using a pH catheter with eight sensors. One sensor was located at the 6 o’clock position in the lower esophagus and sensors 1u200a–u200a8 were arranged counterclockwise at the same level. The catheter was positioned at the same level as the s-BEA. We measured the maximal total duration of acid (MTD-A) and non-acid (MTD-NA) reflux. When the direction of MTD-A and MTD-NA coincided with the location of the s-BEA, the case was defined as coincidental and we calculated the rate of coincidence, and the probability of the rate of coincidence was estimated with 95u200a% confidence intervals (95u200a%CI). Results: Among the 33 cases of s-BEA examined, the rate of coincidence of both MTD-A and MTD-NA was 24/33 (72.7u200a%) (95u200a%CI 0.54u200a–u200a0.87). The rate of coincidence of either MTD-A or MTD-NA was 30/33 (90.9u200a%) (95u200a%CI 0.76u200a–u200a0.98). Conclusions: Our study revealed that the location of s-BEA mostly corresponds to the direction of MTD-A or MTD-NA. Accurate observation of the distribution of acid or non-acid reflux by pH monitoring would aid early detection of s-BEA by endoscopy.

Endoscopic gastric mucosal atrophy distinguishes the characteristics of superficial esophagogastric junction adenocarcinoma

Western studies have suggested two distinct etiologies of esophagogastric junction (EGJ) cancer: Helicobacter pylori‐associated atrophic gastritis and non‐atrophic gastric mucosa resembling esophageal adenocarcinoma. The present study investigated whether endoscopic gastric mucosal atrophy can distinguish between these two types of EGJ adenocarcinoma.

Efficacy of double-scope endoscopic submucosal dissection and long-term outcomes of endoscopic resection for superficial pharyngeal cancer.

Owing to increased awareness and use of narrow‐band imaging, there are more opportunities to treat superficial pharyngeal cancer (SPC). The present study aimed to describe the short‐ and long‐term outcomes of endoscopic resection (ER) for SPC.

Endoscopic tissue shielding for esophageal perforation caused by endoscopic resection

In Japan, endoscopic resection (ER), including endoscopic mucosal resection and endoscopic submucosal dissection, is widely performed for superficial esophageal neoplasms and accepted as a minimally invasive treatment. Perforation is a major complication of ER, with an incidence rate of 1–5%. While conservative treatment has become a more common choice, surgical treatment of perforations is sometimes required, especially for large perforations. Of 1408 cases of esophageal ER that have been performed, 17 cases of perforation occurred at the Cancer Institute Hospital between 2005 and 2016. Most cases were treated with endoscopic clipping and managed conservatively; however, 2 cases were not eligible for endoscopic closure. We report two cases of large perforations of 15 and 20xa0mm, respectively. Both cases were treated conservatively with endoscopic tissue shielding, in which the perforations were covered with a large polyglycolic acid (PGA) sheet that was affixed with fibrin glue. Neither of the cases required open surgery. In both cases, feeding started three weeks after the procedure (19 and 21xa0days), and both were discharged within a month (29 and 30xa0days). In conclusion, tissue shielding with PGA sheets in large perforations after esophageal ER is a good choice to safely proceed with conservative treatment. On the other hand, endoscopic clipping is effective and reasonable for small perforations.

Synchronous triple primary cancers of the pharynx and esophagus

A 72-year-old male with nausea and heartburn was found to have early pharyngeal squamous cell carcinoma, superficial and advanced esophageal squamous cell carcinoma and early esophageal adenocarcinoma by esophagogastroduodenoscopy. Computerized tomography demonstrated left cardiac lymph node swellings. We prioritized the treatment for esophageal squamous cell carcinoma, as this was the most advanced cancer among the triple primaries. The patient underwent neoadjuvant chemotherapy for esophageal squamous cell carcinoma followed by esophagectomy. Four months after esophagectomy, endoscopic submucosal dissection for pharyngeal squamous cell carcinoma was performed. This is a first report of pharyngeal squamous cell carcinoma, esophageal squamous cell carcinoma and esophageal adenocarcinoma occurring as triple primary cancers in a single patient. Smoking-induced tumor formation through DNA methylation is a common risk factor for patients with triple primary malignancies, being an example of epigenetic field cancerization induced by exposure to carcinogenic factors.

Chemotherapy is effective for stage I gastric cancer in patients with synchronous esophageal cancer

BackgroundDiagnostic endoscopy occasionally shows synchronous early gastric cancer (EGC) and esophageal cancer (EC) in the same patient. The treatment plan for these comorbid cancers is unclear because, as EGC is commonly treated surgically, information on post-chemotherapy outcomes for EGC are lacking, although chemotherapy and chemoradiotherapy are important in treating EC. Here, we evaluated whether unresected EGC could be safely observed while synchronous EC is treated with chemotherapy in patients with both cancers.MethodsWe enrolled 30 patients with both EGC and EC who were treated with 5-FU plus cisplatin (FP) from January 2006 to September 2013, and who were evaluated with endoscopy before chemotherapy, and approximately every 3xa0months afterwards.ResultsThe response rate to FP for EGC was 46.8xa0%. Notably, five cases (16.7xa0%) had clinically complete responses with no progressive disease. Progression-free survival was 100xa0% at 6xa0months and 96.2xa0% at 1xa0year. In univariate analysis, FP was significantly more effective for mixed-type and undifferentiated adenocarcinoma than for differentiated adenocarcinoma.ConclusionsFP was effective for EGC. EGC was stable without progression for more than 6xa0months while patients underwent FP treatment for EC. We consider observing EGC with no treatment during chemotherapy for EC to be appropriate disease management.

Diagnostic outcomes of esophageal cancer by artificial intelligence using convolutional neural networks.

BACKGROUND AND AIMSnThe prognosis of esophageal cancer is relatively poor. Patients are usually diagnosed at an advanced stage when it is often too late for effective treatment. Recently, artificial intelligence (AI) using deep learning has made remarkable progress in medicine. However, there are no reports on its application for diagnosing esophageal cancer. Here, we demonstrate the diagnostic ability of AI to detect esophageal cancer including squamous cell carcinoma and adenocarcinoma.nnnMETHODSnWe retrospectively collected 8428 training images of esophageal cancer from 384 patients at the Cancer Institute Hospital, Japan. Using these, we developed deep learning through convolutional neural networks (CNNs). We also prepared 1118 test images for 47 patients with 49 esophageal cancers and 50 patients without esophageal cancer to evaluate the diagnostic accuracy.nnnRESULTSnThe CNN took 27 seconds to analyze 1118 test images and correctly detected esophageal cancer cases with a sensitivity of 98%. CNN could detect all 7 small cancer lesions less than 10xa0mm in size. Although the positive predictive value for each image was 40%, misdiagnosing shadows and normal structures led to a negative predictive value of 95%. The CNN could distinguish superficial esophageal cancer from advanced cancer with an accuracy of 98%.nnnCONCLUSIONSnThe constructed CNN system for detecting esophageal cancer can analyze stored endoscopic images in a short time with high sensitivity. However, more training would lead to higher diagnostic accuracy. This system can facilitate early detection in practice, leading to a better prognosis in the near future.

Endoscopic criteria to evaluate tumor response of rectal cancer to neoadjuvant chemoradiotherapy using magnifying chromoendoscopy

BACKGROUND AND AIMSnPrecise endoscopic assessment of complete response to neoadjuvant chemoradiotherapy before surgery is important for optimizing surgical and non-surgical treatment. We prospectively evaluated the accuracy of the newly proposed endoscopic criteria to identify complete response, using magnifying chromoendoscopy.nnnMETHODSnNew endoscopic criteria were created to define endoscopic complete response, near complete response and incomplete response, using magnifying chromoendoscopy. The criteria contained notable endoscopic findings, including shape of the scar, state of the ulcer, finding of white moss, presence of residual protruded nodules, regenerated pits of the scar, presence of neoplastic pit patterns, and extension of rectal wall. Seventy-nine patients with rectal cancer who received neoadjuvant chemoradiotherapy were prospectively evaluated 1-3 days before resection. Diagnostic accuracy to identify pathological complete response and interobserver agreement among a supervising colonoscopist and two trainees were investigated.nnnRESULTSnPathological complete response was obtained in 17 patients (21.5%). The diagnostic accuracy of endoscopic complete response was 85%, with a sensitivity of 47%, specificity of 97%, positive predictive value of 80% and negative predictive value of 77%. The kappa-value for interobserver agreement across 3 doctors was 0.57 (standard error, 0.74; 95% confidence interval, 0.39-0.76).nnnCONCLUSIONnThe newly proposed endoscopic criteria using magnifying chromoendoscopy achieved excellent diagnostic accuracy to determine good responders to neoadjuvant chemoradiotherapy in rectal cancer, with fair interobserver agreement. The criteria could be clinically useful to select patients for non-surgical management.