Yosuke Izumi

Endosonography during endoscopic mucosal resection to enhance its safety : A new technique

AbstractBackground: We have performed endoscopic mucosal resection of the esophagus (172 cases), stomach (102 cases), and colon (28 cases) using a transparent plastic cap. Because the lesion-bearing mucosa is suctioned up inside the cap under endoscopic suction, the mucosa should be dissected sufficiently from the proper muscle layer to prevent perforation. Methods: To avert the risk of perforation, we introduced endosonographic assessment of submucosal dissection (47 cases). In all cases, just keeping the ultrasonic probe on the surface of the mucosa allowed us to evaluate whether the mucosal lesion was lifted up sufficiently from the proper muscle layer after local saline injection. Results: It was possible to confirm that the muscle layer was kept outside the strangulating snare by the same procedure (32 of 37 cases, 86.5%). Conclusions: We experienced five muscular resections in cases without the ultrasonic probe and no muscular resection with the ultrasonic probe. Thus we recommend endosonographic assessment during endoscopic mucosal resection to enhance its safety.

Superficial basaloid squamous carcinoma of the esophagus. A clinicopathological and immunohistochemical study of 12 cases.

Basaloid squamous carcinoma (BSC) is a rare variant of squamous cell carcinoma (SCC). In this study, clinicopathological and immunohistochemical characteristics of 12 superficial esophageal BSCs were examined and compared with those of typical superficial SCCs. Eight cases were classified into an elevated type, and the other four into a depressed type. High-grade intraepithelial neoplasia was not observed around the invasive lesions in five cases, and only BSC components were apparent. High-grade intraepithelial neoplasia was demonstrated in seven cases, five of which had both BSC and SCC components in the invasive lesion. A cribriform growth pattern, comedo-type necrosis, and hyaline deposits were conspicuous histological findings. CK14 was positively stained in 90% of the series, but the proportion of positive cells was small in most cases. Type IV collagen was increased or well preserved in the basement membrane in 70% of cases, but heparan sulfate was decreased in the majority. In comparison with SCCs, lymphatic permeation was observed less frequently. However, regarding the frequencies of venous permeation, nodal metastasis, p53 protein expression, and Ki-67 labeling index, no significant differences were noted. Thus, esophageal BSCs demonstrate the pathological features characteristic of an early stage, but pathological parameters related to biological behavior do not significantly vary from those typical of SCCs.

Superficial esophageal carcinoma: An in vitro study of high‐resolution MR imaging at 1.5T

The purpose of this study was to determine the diagnostic accuracy of high‐resolution MR imaging at 1.5T for evaluating the mural invasion of superficial esophageal carcinoma. Forty‐one esophageal specimens taken from patients suspected of having superficial carcinoma were studied using a 1.5T MR system with a surface coil. Spin‐echo MR images were obtained with a field of view of 50mm, matrix of 256 × 256, and section thickness of 2mm (voxel size = 0.08mm3). MR findings were compared with histopathologic findings. T2‐weighted images clearly depicted the normal esophageal wall as consisting of 8 layers. In 39 (95%) of 41 carcinomas, the depth of mural invasion determined by MR imaging correlated well with that determined with histopathologic examination. The MR‐based stage was higher in 2 (5%) cases than the histopathologic stage. High‐resolution MR imaging at 1.5T shows a high diagnostic accuracy for evaluating the mural invasion of superficial esophageal carcinoma, thus potentially enabling preoperative histopathologic staging. J. Magn. Reson. Imaging 2001;13:225–231.

Esophageal carcinoma: Evaluation with high‐resolution three‐dimensional constructive interference in steady state MR imaging in vitro

To determine the usefulness of high‐resolution three‐dimensional (3D) constructive interference in steady state (CISS) MRI for evaluating mural invasion and morphologic features in esophageal carcinomas.

Development and clinical application of semi-loop-shaped retractor for gasless laparoscopic surgery

Background: Gasless laparoscopy has the advantage of avoiding the risk inherent in pneumoperitoneum, but has not gained widespread popularity because of limited exposure of the operative field. Improved retraction devices are therefore needed. Methods: A loop-shaped metallic retractor was designed for planar lifting of the anterior abdominal wall. Four types of retractor (5/6-, 3/4-, and 1/2-circle with rod at 90°, and 1/2-circle with rod at 97°) were studied in 15 pigs. The device was then used for 47 patients. Results: The 1/2-circle was the most smoothly inserted retractor and was significantly safer than the 5/6-circle (p < 0.05, Fisher’s exact probability test). The 1/2-circle with rod at 97° was utilized for clinical cases. This retractor can be readied within 1 min and was used successfully for all operations. Conclusions: This new retractor for gasless laparoscopic surgery provides good exposure and has the potential to enhance the performance of advanced laparoscopic surgery.

Linitis plastica-type adenocarcinoma of the esophagus: a case report

Abstract“Linitis plastica” refers to a histological characterization of diffusely infiltrating, poorly differentiated adenocarcinoma. Linitis plastica-type esophageal adenocarcinoma is extremely rare: this is thought to be only the sixth case report of linitis plastica involving the esophagus. A 60-year-old man was referred to our hospital after repeated endoscopic examinations over the course of a few months. Because he complained of dysphagia, upper endoscopy was performed, revealing stenosis with a few mucosal changes of the lower esophagus. Gastroesophageal reflux disease was initially diagnosed, but biopsy revealed adenocarcinoma. At the time of operation, peritoneal metastasis was noted. Macroscopically, the lesion was diffusely infiltrating, almost completely covered with normal squamous epithelium that showed positive staining with iodine. Pathological examination showed poorly differentiated adenocarcinoma. Despite the poor prognosis, the patient survived a comparatively long 18 months following esophagectomy with oral chemotherapy using S-1.

A case of lymph node metastasis after endoscopic mucosal resection of esophageal cancer invading the muscularis mucosa

A 70-year-old man was diagnosed with a thoracic esophageal squamous cell carcinoma invading the muscularis mucosa without lymph node or distant metastases in June 2003. Endoscopic mucosal resection was conducted. Histological examination showed squamous cell carcinoma invading the deep mucosal layer without lymphatic permeation. In April 2006, a chest CT scan revealed a metastasis to the right recurrent laryngeal nerve chain (106recR) lymph node, and chemoradiotherapy and chemotherapies were performed but were not very effective. He died of esophagobronchial fistula in October 2007. We reexamined this case in detail, and a deeper cut of the block revealed positive lymph vessel invasion and droplet infiltrations. We were initially unable to identify lymphatic permeation but specific findings were determined, such as high degrees of cellular atypia, downward extension of irregular epithelial processes, and irregular margins of cancer alveoli. Extreme caution is required for treating patients with these morphological changes.

Strategy for Treatment of Superficial Esophageal Cancer

The number of patients with superficial esophageal cancer has increased during the last 25 years in Japan, and the clinical result has been excellent. At the same time, the pathological characteristics of mucosal cancer are different from those of submucosal cancer and therefore there is a difference in the treatment. We studied the clinical results of patients with superficial esophageal cancer treated at our hospital, and the strategy for treating superficial esophageal cancer is discussed.

Ball Measure for Quantitative Analysis of Minute Morphological Changes in Mucosal and Submucosal Cancer

Abstract: We introduce the “ball measure” concept, which is utilized for quantitatively evaluating minute morphological changes in the mucosal surface of superficial cancer. The ball measure device is a completely spherical, white‐colored, plastic ball with a 1‐mm outer diameter. An applicator is also available, which can settle the ball accurately on any mucosal surface target. The ball measure device is attached around the lesion, allowing precise assessment of the height of a marginal elevation or depression. The actual sizes of granules in the ulcer bed can also be described with this method. We believe that the ball measure technique is an indispensable means of objectively assessing morphology, and thereby of providing an accurate diagnosis of the infiltrative depth of an early cancer.

A Case of Leiomysarcoma of the Esophagus.

症例は21歳の男性. 平成4年8月より嚥下困難, 吐血が出現し, 平成5年1月8日呼吸困難のため緊急入院. 内視鏡では食道入口部直下から白苔に覆われた易出血性の隆起性病変を認めたが生検では壊死組織および真菌であった. 胸部CTでは縦隔内に内部の不均一な腫瘤影を認めた. Open biopsyにより, 食道の筋原性腫瘍が疑われたため1月26日, 右開胸開腹食道亜全摘経後縦隔胃管再建術を施行した. Ao, N (-), Mo, Ploであった. 切除標本では, 13.0×7.5×3. 2Cmの有茎性腫瘍で, 組織学的に平滑筋肉腫と診断した. 術後3か月で右頸部, 上縦隔, 右肺, 右胸膜に再発し化学療法と放射線療法を行った. 一部に効果も認められたが急速に増大し術後6か月目に呼吸不全により死亡した. 本例は本邦における食道平滑筋肉腫報告例では最年少であり診断と治療を中心に考察を加えた.