Features of early gastric cancer and gastric adenoma by enhanced-magnification endoscopy

Background Changes to the mucosal surface of early gastric carcinomas and gastric adenomas as viewed by enhanced-magnification endoscopy with acetic acid have not been investigated thoroughly. Using this technology, we investigated the appearance of the gastric surface patterns of neoplastic and surrounding nonneoplastic mucosa. Methods Forty-seven consecutive patients with early gastric carcinomas or gastric adenomas underwent enhanced-magnification endoscopy following 1.5% acetic acid instillation. All biopsy specimens were taken from the area at which the enhanced-magnified endoscopic image was obtained. Results Surface patterns of gastric tumors and the surrounding mucosa were classified into five types: type I, small round pits of uniform size and shape; type II, slit-like pits; type III, gyrus and villous patterns; type IV, irregular arrangements and sizes of pattern types I, II and III; type V, destructive patterns of types I, II and III. The predominant pattern of the surrounding mucosa was type III, and most type III mucosa had characteristics of intestinal metaplasia. Although all elevated adenomas showed type II or type III surface patterns, both depressed adenomas showed type IV. Elevated carcinomas showed type III (42.9%) or type IV (57.1%) surface patterns, while depressed carcinomas showed type IV (70%) or type V (30%). Although differentiated tubular adenocarcinomas showed type III (10.3%), type IV (86.2%), or type V (3.5%) surface patterns, all of the signet-ring cell carcinomas and poorly differentiated tubular adenocarcinomas showed type V. Conclusions Enhanced-magnification endoscopy may be useful for identifying gastric tumors and determining the extent of horizontal spread, especially in tumors of the depressed type.     

胃黏膜低级别上皮内瘤变及早期胃癌活检病理与术后病理差异的危险因素分析

【摘要】 目的 探讨胃黏膜低级别上皮内瘤变及早期胃癌活检病理与术后病理差异的危险因素。方法 回顾性分析行内镜黏膜下剥离术或手术切除,且术后病理诊断为低级别上皮内瘤变或早期胃癌（包括高级别上皮内瘤变）的235例患者资料,按活检病理与术后病理是否有显著差异分组,采用单因素和多因素分析探索病理结果发生显著差异的危险因素。结果 235例患者中33例（14.0%）发生病理显著差异。单因素分析结果提示,隆起型病变、病变表面不发红、病变不伴糜烂或溃疡、组织学类型为弥散型及活检块数与病理差异相关（P＜0.05）。多因素分析结果提示活检块数少（OR=0.574,95%CI：0.363~0.908,P=0.018）是发生活检病理与术后病理差异的独立危险因素。结论 胃黏膜低级别上皮内瘤变及早期胃癌活检病理与术后病理不符的情况临床上较多见,多块活检能提高活检的准确性,降低病理不符情况的发生。     

Increased expression of matrix metalloproteinase-7 in invasive early gastric cancer

Background Matrix metalloproteinase-7 (MMP-7), a proteolytic enzyme, is suspected to play an important role in the progression of various cancers. To clarify the clinical importance of MMP-7, we retrospectively analyzed MMP-7 expression in gastric epithelial tumors.Methods We tested 201 lesions (from 172 patients) of surgically or endoscopically resected gastric epithelial tumors (gastric cancer, 158 lesions; gastric adenoma, 32 lesions; hyperplastic polyp, 11 lesions). MMP-7 expression was immunohistochemically examined. Sections with immunostaining signals in more than 30% of tumor cells were judged to show positive expression.Results MMP-7 was expressed in 33.3% (67/201) of all lesions. MMP-7-positive tumors were significantly more frequent in diffuse-type adenocarcinomas (62.2%; 28/45) compared with intestinal-type lesions (31.9%; 36/113; P < 0.001). Cancers invading the submucosa or deeper (60.5%; 46/76) were showed positivity significantly more frequently than mucosal cancers (22.0%; 18/82; P < 0.001). MMP-7-positive lesions increased with the progression of gastric epithelial tumors, including adenomas, mucosal cancers, and cancers invading the submucosal layer or deeper (P < 0.001). MMP-7 expression occurred significantly more often in lymphatic invasion-positive cancers (65.1%; 41/63) than in lymphatic invasion-negative cancers (24.2%; 23/95; P < 0.001).Conclusions The MMP-7-positive rate increased with the progression of gastric epithelial tumors, such as adenoma, mucosal cancer, and cancer invading the submucosal layer or deeper. MMP-7 was significantly associated with aggressive pathological phenotypes of cancer. The detection of the MMP-7 protein may be useful in pretherapeutic diagnosis.     

Diagnosis of Helicobacter pylori‐related chronic gastritis,gastric adenoma and early gastric cancer by magnifying endoscopy

Evaluating the prevalence and severity of gastritis by endoscopy is useful for estimating the risk of gastric cancer (GC). Moreover, understanding the endoscopic appearances of gastritis is important for diagnosing GC due to the fact that superficial mucosal lesions mimicing gastritis (gastritis‐like lesions) are quite difficult to be detected even with optimum preparation and the best technique, and in such cases tissue biopsy is often not very accurate for the diagnosis of gastric epithelial neoplasia. Magnifying endoscopy is a highly accurate technique for the detection of early gastric cancer (EGC). Recent reports have described that various novel endoscopic markers which, visualized by magnifying endoscopy with image‐enhanced system (ME‐IEE), can predict specific histopathological findings. Using ME‐IEE with vessels and surface classification system (VSCS) may represent an excellent diagnostic performance with high confidence and good reproducibility to the endoscopists if performed under consistent conditions, including observation under maximal magnification. The aim of this review was to discuss how to identify high‐risk groups for GC by endoscopy, and how to detect effectively signs of suspicious lesions by conventional white light imaging (C‐WLI) or chromoendoscopy (CE). Furthermore, to characterize suspicious lesions using ME‐IEE using the criteria and classification of EGC based upon VSCS.     

Diagnosis of boundary in early gastric cancer

Endoscopic submucosal dissection (ESD) is an advanced therapeutic endoscopic technique,which allowsresection of larger superficial tumors in the esophagus,stomach,and colon.Precise diagnosis of the boundary between tumor and the non-tumorous surrounding portion is especially important before starting ESD,because too much resection can potentially take more time and can induce a higher complication rate,while too little resection can result in a non-curative resection.The boundary diagnosis is often difficult for early gastric cancer,mainly because of the underlying condition of chronic gastritis.Due to recent developments in endoscopy,including magnified endoscopy and narrow band endoscopy,the boundary diagnosis is becoming easy and more accurate.We have also applied magnified endoscopy combined with narrow band imaging to fresh specimens immediately after resection using thetiling method and XY stage.     

Diagnosis of gastric cancer by using autofluorescence spectroscopy

AIMS: To evaluate the clinical use of laser‐induced fluorescence (LIF) spectra for diagnosing gastric cancer during gastroscopy. METHODS: A helium?cadmium laser system (excitation wavelength = 442 nm) was used to detect autofluorescence in 38 patients with endoscopically and histologically diagnosed gastric cancer and chronic gastritis. RESULTS: The LIF spectra produced by the helium? cadmium laser from gastric cancer tissue had one major peak (510 nm) and three minor peaks (590, 670, 710 nm). The intensity and shape of the LIF spectra in gastric cancer and normal gastric tissue were significantly different. Using the integral fluorescence intensities (FI) at 662?677 and 701?716 nm and the FI ratio of 510 nm/710 nm as the diagnostic parameters, it was possible to diagnose gastric cancer with a sensitivity of 83%, a specificity of 91%, a positive predictive value of 88% and a negative predictive value of 88%. The diagnostic accuracy was 88%. CONCLUSIONS: Using autofluorescence spectro­scopy to detect gastric cancer allows real‐time detection of gastric cancerous lesions and it serves as a guide for taking biopsy specimens. The technique may become a useful tool in the diagnosis of early gastric cancer.     

早期胃癌的内镜识别与诊断

不同类型的胃癌,其形态表现各不相同。尤其是早期胃癌病灶黏膜的形态改变可自细微异常至显著病变,即使是有经验的专业人员也常常误判。浅表隆起较小的0-Ⅱa病灶通常局限于黏膜内。图1A示胃窦大弯匍匐状微隆病灶,表面均匀发红,手术病理证实为高分化腺癌,浸润黏膜肌。0-Ⅱa+Ⅱc型是较多见的一种早期胃癌形态,周     

早期胃癌的内镜下特征分析

目的探讨早期胃癌的内镜下特征。方法对2010年1月至2014年7月北京军区总医院消化科胃镜检查发现并经病理确诊的119例早期胃癌患者（130处病灶）和695例进展期胃癌患者（695处病灶）的临床资料进行回顾性总结,对比分析早期胃癌的内镜下特征。结果早期胃癌癌灶多位于胃窦部（34．6％,45／130）,镜下形态分类以0-Ⅱc型最多见（55．4％,72／130）,白光内镜下97处（74．6％）病灶可见色调发红、121处（93．1％）具有清晰的边界、46处（35．4％）边缘部有明显“毛刺征”、116处（89．2％）具有明显不规则的表面形态或颜色、35处（26．9％）表面可见并发的溃疡、57处（43．8％）可见自发性出血、108处（83．1％）周边背景黏膜有肠化／萎缩改变、23处（17．7％）表面可见白色不透明物质,病理分型以分化型为主（90．8％,118／130）;进展期胃癌癌灶多位于胃底／贲门部（39．1％,272／695）,病理分型以未分化型为主（81．3％,565／695）。两者在病变分布和病理分型构成方面差异均有统计学意义（P〈0．05）。结论清晰的边界和表面不规则是早期胃癌的重要内镜下特征,胃镜检查时重视上述特点的观察将有助于早期胃癌的发现和诊断。     

Chromoendoscopy of gastric adenoma using an acetic acid indigocarmine mixture

AIM:To investigate the usefulness of chromoendoscopy,using an acetic acid indigocarmine mixture(AIM),for gastric adenoma diagnosed by forceps biopsy.METHODS:A total of 54 lesions in 45 patients diagnosed as gastric adenoma by forceps biopsy were prospectively enrolled in this study and treated by endoscopic submucosal dissection(ESD)between January 2011 and January 2012.AIM-chromoendoscopy(AIMCE)was performed followed by ESD.AIM solution was sprinkled and images were recorded every 30 s for 3min.Clinical characteristics such as tumor size(<2cm,≥2 cm),surface color in white light endoscopy(WLE)(whitish,normochromic or reddish),macroscopic appearance(flat or elevated,depressed),and reddish change in AIM-CE were selected as valuables.RESULTS:En bloc resection was achieved in all 54 cases,with curative resection of fifty two lesions(96.3%).Twenty three lesions(42.6%)were diagnosed as welldifferentiated adenocarcinoma and the remaining 31lesions(57.4%)were gastric adenoma.All adenocarcinoma lesions were well-differentiated tubular adenocarcinomas and were restricted within the mucosal layer.The sensitivity of reddish color change in AIM-CE is significantly higher than that in WLE(vs tumor size≥2 cm,P=0.016,vs normochromic or reddish surface color,P=0.046,vs depressed macroscopic type,P=0.0030).On the other hand,no significant differences were found in the specificity and accuracy.In univariate analysis,normochromic or reddish surface color in WLE(OR=3.7,95%CI:1.2-12,P=0.022)and reddish change in AIM-CE(OR=14,95%CI:3.8-70,P<0.001)were significantly related to diagnosis of early gastric cancer(EGC).In multivariate analysis,only reddish change in AIM-CE(OR=11,95%CI:2.3-66,P=0.0022)was a significant factor associated with diagnosis of EGC.CONCLUSION:AIM-CE may have potential for screening EGC in patients initially diagnosed as gastric adenoma by forceps biopsy.     

Diagnosis of early gastric cancer using narrow band imaging and acetic acid

AIM: To determine whether the endoscopic findings of depressed-type early gastric cancers(EGCs) could precisely predict the histological type.METHODS: Ninety depressed-type EGCs in 72 patients were macroscopically and histologically identified. We evaluated the microvascular(MV) and mucosal surface(MS) patterns of depressed-type EGCs using magnifying endoscopy(ME) with narrow-band imaging(NBI)(NBI-ME) and ME enhanced by 1.5% acetic acid, respectively. First, depressed-type EGCs were classified according to MV pattern by NBI-ME. Subsequently, EGCs unclassified by MV pattern were classified according to MS pattern by enhanced ME(EME) images obtained from the same angle.RESULTS: We classified the depressed-type EGCs into the following 2 MV patterns using NBI-ME: a fine-network pattern that indicated differentiated adenocarcinoma(25/25, 100%) and a corkscrew pattern that likely indicated undifferentiated adenocarcinoma(18/23, 78.3%). However, 42 of the 90(46.7%) lesions could not be classified into MV patterns by NBI-ME. These unclassified lesions were then evaluated for MS patterns using EME, which classified 33(81.0%) lesions as MS patterns, diagnosed as differentiated adenocarcinoma. As a result, 76 of the 90(84.4%) lesions were matched with histological diagnoses using a combination of NBI-ME and EME.CONCLUSION: A combination of NBI-ME and EME was useful in predicting the histological type of depressedtype EGC.     

Cardiac tamponade due to metastasis from early gastric cancer

We report a case of cardiac tamponade caused by metastasis from early gastric cancer. A 44-year-old woman was detected to have an abnormality of the stomach on barium meal during an annual medical checkup. Gastroendoscopy disclosed superficial depressed gastric lesions, and histopathological examination of biopsy specimens revealed the diagnosis of poorly differentiated adenocarcinoma and signet-ring cell carcinoma. Computed tomography (CT) and ultrasonography (US) revealed no evidence of metastasis. We performed distal gastrectomy with regional lymph node dissection. Histopathological examination revealed poorly differentiated adenocarcinoma and signet-ring cell carcinoma confined to the mucosal layer. Lymphatic invasion was detected only in the mucosal region beneath the tumor; however, lymph node metastasis was found in almost half of dissected lymph nodes. Adjuvant chemotherapy was administered on an outpatient basis with 36 courses of mitomycinC infused (8 mg/day) once every 4 weeks. However, 3 years after the surgery, the patient developed cardiac tamponade due to carcinomatous pericarditis. We performed drainage of the malignant effusion and initiated treatment with S-1 and docetaxel. Although the patient showed some clinical improvement, the patient died 15 months after the occurrence of cardiac tamponade.     

Endoscopic submucosal dissection of early gastric cancer

Gastric cancer is the most common cancer worldwide. The proportion of early gastric cancer (EGC) cases at diagnosis has increased because of the use of mass screening endoscopy in older adults. Endoscopic mucosal resection has become the standard treatment for EGC in cases with standard indications because of its low risk of lymph node metastasis. A new endoscopic method, endoscopic submucosal dissection, has recently become available. This method allows en bloc resection without limitation of the size of the lesion. The goal of this article is to review the history and methods of endoscopic treatment with EGC, the conventional and extended indications, the therapeutic outcomes, and the complication rates.     

胃癌神经内分泌分化的免疫组化及超微结构观察

目的观察胃癌神经内分泌（NE）分化的CgA、Syn、NSE免疫组化表达及超微结构形态。方法对168例手术切除石蜡包埋胃癌标本进行CgA、Syn、NSE免疫组化标记,阳性病例分别进行电镜检查。对CgA、Syn、NSE免疫组化在胃癌神经内分泌分化中的诊断价值进行了讨论。结果80例NE标记阳性标本中,电镜下发现NE颗粒39例,检出率为48.8%。Syn^＋组灵敏度最高,为66.7%;最低的是Syn、CgA、NSE均阳性组,为15.4%。在所有的标记中特异度最高为Syn、CgA、NSE均阳性组,其特异度为97.6%。NSE^＋组的特异度最低,为24.4%。约登指数排在最前的为CgA^＋组（0.495）,最后的为NSE^＋组（-0.271）。结论电镜下发现NE颗粒可确定胃癌神经内分泌分化的诊断,免疫组化CgA、Syn阳性可协助诊断。     

Flat gastric polyps: Results of forceps biopsy,endoscopic mucosal resection,and long-term follow-up

Objective. Histological examination of specimens obtained by forceps biopsy sampling of gastric polyps is of limited accuracy, and their management on this basis is therefore controversial. The aim of this prospective study was to assess the value of forceps biopsy sampling in establishing the correct diagnosis revealed by endoscopic mucosal resection (EMR). The complication rate of EMR was also determined. Material and methods. Subjects with gastric polyps of epithelial origin, of at least 0.5?cm in diameter, and not associated with polyposis syndromes, were included in the study. Between 1994 and 2004, 56 gastric polyps in 44 patients (30?F, 14?M, mean age 67 years) met the inclusion criteria. Indigo carmine dye staining and electronic magnification were used in all cases. Following forceps biopsy sampling, 56 EMRs were performed. The histological results of the forceps biopsy and the resected specimens were analyzed. Results. The initial forceps biopsies identified in situ carcinoma in 3 cases, adenoma with no dysplasia in 19, adenoma with low-grade dysplasia in 2, adenoma with moderate-grade dysplasia in 6, adenoma with high-grade dysplasia in 7, and hyperplastic lesions in 19 cases. The histological examination of the resected polyps revealed in situ carcinoma in 5 cases, carcinoid in 1, gastrointestinal stromal tumor in 1, adenoma with no dysplasia in 14, adenoma with low-grade dysplasia in 3, adenoma with moderate-grade dysplasia in 9, adenoma with high-grade dysplasia in 1, hyperplastic lesions in 21, and no diagnosis in 1 case. Complete agreement between the histological results on the forceps biopsy sample and on the ectomized polyp was seen in only 31 (55.3%) polyps. There were important disagreements in 12 cases. In 14 neoplastic and 1 hyperplastic polyps, the degree of dysplasia seen on histological examination of the forceps biopsy specimens differed from that observed for the resected specimens. Post-mucosectomy bleeding was observed in 3 patients, all of whom were successfully treated endoscopically. Conclusions. Forceps biopsy is not sufficiently reliable for the identification of gastric polyps. These lesions should be fully resected by EMR for a final diagnosis and (depending on the lesion size and type) possibly definitive treatment.     

早期胃癌的内镜下治疗

随着内镜技术的不断进步,越来越多的早期胃癌可经内镜下治疗.本文简要地介绍了早期胃癌内镜下治疗的发展史.重点介绍了目前早期胃癌内镜下治疗最先进的方法一黏膜剥离术的特点、适应征、并发症及处理对策.     

前哨淋巴结检测在早期胃癌中的临床应用价值

[目的]探讨前哨淋巴结（SLN）检测技术（sLNB）在早期胃癌中的临床应用价值。[方法]138例早期胃癌术中亚甲蓝定位活检SLN,术后行常规苏木精一伊红染色病理和AE1／AE3免疫组织化学法检查。[结果]38例中35例检出SLN,检出率为92．1％。由SLN状态预测胃周淋巴结转移情况的准确率为91．4％（32／35）,敏感性为85．7％（18／21）,特异性为100．％（18／18）,假阴性率为14．3％（3／21）。AE1／AE3免疫组化法与常规苏木精一伊红染色法检测SLN转移的检出率比较,差异有统计学意义（P〈O．01）。[结论-1SLN能较准确反映早期胃癌的淋巴结转移状况,AE1／AE3免疫组化法较常规苏木精一伊红染色病理检查更为敏感,能提高SLN微转移的检出率,对确定临床分期、诊疗及判断预后有着积极的临床意义。     

Difference in the prevalence of advanced colon adenoma between patients with gastric neoplasm and healthy people: A STROBE-compliant study

We compared the prevalence of adenoma and cancerous colon polyps in patients undergoing endoscopic removal or gastric surgery for gastric adenoma or gastric cancer and in healthy individuals.The medical records of 707 patients with gastric neoplasm and 798 age- and sex-matched healthy subjects were retrospectively analyzed between January 2010 and July 2018. The clinicopathological characteristics, prevalence of colorectal neoplasm diagnosed by colonoscopy, and risk factors for colorectal polyps were also investigated.When comparing the two groups, the prevalence of overall colorectal polyps and its distribution was not different between the two groups (54.0% vs.49.5%, P = .079), whereas, the number of colon polyps (1.20 ± 1.71 vs 0.99 ± 1.54, P = .015) and the maximal size (3.53 ± 6.14 vs 2.08 ± 2.88, P < .001) were significantly larger in the gastric neoplasm group. The prevalence of advanced colon adenoma was significantly higher in the gastric neoplasm group (10.7% vs 3.8%, P < .001). Risk factors such as elevated glucose levels and the presence of gastric neoplasm were related to the prevalence of all colon polyps. The presence of gastric neoplasm is an important risk factor for advanced colon polyps.Patients with gastric neoplasms had a significantly higher prevalence of advanced colon adenoma. Advanced colon adenoma is associated with the chain from benign adenomas through malignant altered adenomas to advanced colon cancer. Thus, patients with gastric neoplasm are regarded as a high-risk group for colorectal cancer and are recommended for screening colonoscopy at the time of diagnosis.     

Alterations in gastric mucin synthesis by Helicobacter pylori

AIM To determine the role of Helicobacter pylori in altering gastric mucin synthesis and define how thprocess relates to H. pylori-related diseases.METHODS Analyses of human gastric tissues using immunohistochemistry and in situ hybridizatiodocument the role of H. pylori in altering the composition and distribution of gastric mucins.RESULTS These data indicate a decrease in the product of the MUC5 (MUC5AC) gene and aberraexpression of MUC6 in the surface epithelium of H. pylori-infected patients. A normal pattern was restorby H. pylori eradication. Inhibition of mucin synthesis including MUC5AC and MUCl mucins by H. pvlohas been established in vitro using biochemical and Western blot analyses. This effect is not due to inhibitiof glycosylation, but results from inhibition of synthesis of mucin core structures. In vitro experiments usiinhibitors of mucin synthesis indicate that cell surface mucins decrease adhesion of H. pylori to gastepithelial cells.CONCLUSION Inhibition of mucin synthesis by H. pylori in vivo can disrupt the protective mucous layand facilitate bacterial adhesion, which may lead to increased inflammation in thc gastric epithelium.