Endoscopic Diagnosis and Therapy for Early Colorectal Cancer

The overall prevalence of colorectal neoplasm is increasing in Japan due to the westernization of diet. According to the official health and welfare statistics, there were 32,630 deaths from colorectal cancer in 1996. This is a more than six-fold increase from the 5037 deaths in 1960. The increase in cases of colorectal cancer has become very notable. For early detection of colorectal cancer there is a mass-survey by immunological fecal occult reaction. A patient with the positive result is performed a scrutiny of the large bowel (barium enema or colonoscopy). We have found many colorectal polypoid lesions by the scrutiny.     

黏膜染色提高早期大肠癌的诊断率及内镜下治疗的临床研究

目的 提高早期大肠癌的诊断水平,探索早期大肠癌的内镜下治疗方法.方法 对结肠镜检查发现的小病变用0.4％靛胭脂行黏膜染色,观察腺管开口及分型,对早期大肠癌直接切除或行内镜下黏膜切除术.结果 发现大肠癌23例,其中早期大肠癌14例,行内镜下治疗10例.结论 黏膜染色及对腺管开口分型,能明显提高早期大肠癌的诊断水平,早期大肠癌的内镜下治疗安全有效.     

Follow-up Study of Early Colorectal Cancer After Endoscopic Resection

Abstract: This study was conducted to determine the significance of long-term follow-up observation of early colorectal cancer following endoscopic resection. The subjects included 100 patients who had undergone early colorectal cancer resection by endoscopic polypectomy with prior injection of the base (73 patients with mucosal carcinoma (m cancer), 24 Patients with submucosal carcinoma (sm cancer), and 3 patients with multiple early colorectal cancers. Posttherapeutic observation was carried out by endoscopy. The results were, briefly, as follows: 1) No cases of local recurrence or metastasis were observed during the follow-up observation period for up to a period of 14 years. 2) 3 cases (3%) of metachronous carcinoma were detected, 2 of these patients had early carcinoma and 1 had advanced carcinoma. The mean period which elapsed before the detection of metachronous cancers was 35.0 ± 15.3 months. 3) The incidence of adenoma during the follow-up period was 40%, the frequency of newly detected adenoma was relatively high among the patients with coexisting adenoma at the time of treatment for early carcinoma and among the elderly patients aged 60 years or over, 4) No cancer was detected after establishing a clean colon, and the incidence of adenoma in such cases was relatively low, i. e., 14.5%. The mean period of time which elapsed until the detection of the adenoma was 24.4 ± 18.0 months. The results of this study indicated that endoscopic examination is necessary and useful for surveillance of local recurrence or metachronous carcinoma as well as the detection of adenoma.     

Endoscopic Treatment of Colorectal Polyps and Early Cancer

To analyze the efficacy and outcome of colonoscopic resection for colorectal neoplastic lesions, we retrospectively reviewed 338 colorectal lesions from 232 patients regarding the clinical profiles, colonoscopic findings, histological findings, complications, and outcome. Morphologically, these lesions were classified into three categories: pedunculated (n = 140), sessile (n = 176); and flat (n = 22). Histological findings of lesions included adenoma (n = 248), carcinoma in situ (n = 17), submucosal carcinoma (n = 2), hyperplastic polyp (n = 57), and inflammatory polyp (n = 14). Neoplastic lesions are generally larger than nonneoplastic lesions (² test, P < 0.05). The incidence of carcinoma was 5.6% of 338 resected lesions. The rate of cancer or high-grade dysplasia in flat polyps was greater than in pedunculated and sessile polyps (13.6 vs 4.54 vs 5.71%; P < 0.05). There were no perforations or deaths after colonoscopic treatment, and only mild bleeding occured in two patients. To date, 19 patients with early colorectal cancer were treated successfully by endoscopy with no recurrence or metastasis. To reduce the incidence and mortality of colorectal cancer, colonoscopic resection is a simple and safe procedure for removing neoplastic lesions. Detailed histological examinations are essential to decide the indications of surgery.     

Endoscopic Therapy in Patients with Inoperahle Early Gastric Cancer

The efficacy and safety of endoscopic therapy was investigated prospectively in 42 patients with 44 early gastric cancers who were not candidates for surgery. Thirty-five of the 44 lesions (80%) were treated by endoscopic therapy alone. Adequate tumor resection was possible in lesions less than 2 cm in diameter, in those of the protruding, flat, and erosive types, and in those located in the antrum. None of the 35 patients who were judged completely cured by the initial therapy developed recurrence or lymph node metastases in the follow-up period (range, 3-114 months; mean, 37 months). Therefore, endoscopic therapy appears effective in the treatment of patients with early gastric cancer when the risks of surgery are too high.     

早期大肠癌内镜治疗的临床评价

背景：早期大肠癌可以采用内镜下切除治疗，但其疗效和预后仍是人们普遍关心的问题。目的：评价内镜治疗早期大肠癌的疗效和预后。方法：对1986年1月～2005年10月经内镜确诊的早期大肠癌患者，按治疗方法的不同分为内镜治疗组和外科手术治疗组，对两组的临床资料、治疗方法和随访结果进行回顾性分析。结果：99例早期大肠癌（104个癌灶）中，无症状人群普查发现34例，临床就诊发现65例。内镜治疗69例（共72个癌灶），外科手术治疗30例（包括内镜治疗后追加手术者，共32个癌灶）。内镜治疗组癌灶完全切除率为97．5％，无严重并发症发生。外科手术治疗组有1例病理证实癌组织浸润达黏膜下深层，肝脏有多个微结节转移灶。内镜治疗组经3个月～19年的随访，除19例失访、6例死于心脏病等疾病外，无一例肿瘤复发。比较两组黏膜和黏膜下层早期大肠癌的临床资料、随访结果和5年生存率，内镜治疗组的疗效与手术治疗组相似（P〉0．05）。结论：早期大肠癌，特别是黏膜层早期大肠癌内镜治疗的疗效和随访结果与手术治疗相似，且损伤小、安全、简便。黏膜下深层癌易发生转移，内镜下切除应注意判断肿瘤黏膜浸润深度，非提起征是内镜切除的关键指征。无症状自然人群普查是发现早期大肠癌的重要途径。     

A Prospective Diet-Wide Association Study for Risk of Colorectal Cancer in EPIC

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Endoscopic Mucosal Resection (EMR) of Early Gastric Cancer

Abstract: We conducted this study to clarify the effectiveness of aspiration endoscopic mucosal resection (EMR) using a cap-fitted scope for early gastric cancer in the C and M regions of the stomach. EMR was performed in 111 early gastric cancer patients with 123 lesions in the C and M regions. The patients were divided into three groups. The EMR-1CS group consisted of patients who had undergone EMR with a one-channeled scope, the EMR-2CS group those who had received EMR in which a two-channeled scope was utilized. The EMRC group consisted of patients who had undergone aspiration EMR with a cap-fitted scope. The rate of complete resection improved to a statistically significant degree in the EMRC group in comparison with that in the EMR-1CS group. In type lie, a statistically significant improvement was achieved in the EMRC group in comparison with the EMR-2CS group. In the M region or in lesions 10 mm or less in diameter, the rate of complete resection improved in the EMRC group as compared with that in the EMR-2CS group. Our results suggest that EMRC is useful for lesions of early gastric cancer in the C and M regions.     

Usefulness of Simple Endoscopic Aspiration Cytology of Pancreatic Juice for Diagnosis of Early Pancreatic Neoplasm (A Prospective Study)

For detection of early cancer of the pancreas,endoscopic aspiration cytology of pancreatic juicewithout endoscopic retrograde pancreatography wasperformed in 64 consecutive outpatients who had symptoms or findings that suggested pancreatic disease.Patients with positive or suspicious cytologic resultsor abnormal US findings were admitted and underwentdetailed examinations. Positive and suspicious cytologic results were obtained in 2 and 10 patients,respectively. Of those with positive and suspiciouscytologic results, two, and one patient, respectively,were ultimately found to have pancreatic neoplasms. Of these three resected specimens, one was insitu carcinoma and two presented marked atypia. Allpatients were alive with no evidence of recurrence. Nofurther cases of pancreatic neoplasm were found. Complications from the procedure did notdevelop in any patient. This technique is useful in thediagnosis of early neoplasms of the pancreas, because itis simple and safe to perform for outpatients.     

Endoscopic Diagnosis of Invasion Depth for Early Colorectal Carcinomas: A Prospective Comparative Study of Narrow-Band Imaging,Acetic Acid,and Crystal Violet

Several studies have validated the effectiveness of narrow-band imaging (NBI) in estimating invasion depth of early colorectal cancers. However, comparative diagnostic accuracy between NBI and chromoendoscopy remains unclear. Other than crystal violet, use of acetic acid as a new staining method to diagnose deep submucosal invasive (SM-d) carcinomas has not been extensively evaluated. We aimed to assess the diagnostic accuracy and interobserver agreement of NBI, acetic acid enhancement, and crystal violet staining in predicting invasion depth of early colorectal cancers.A total of 112 early colorectal cancers were prospectively observed by NBI, acetic acid, and crystal violet staining in sequence by 1 expert colonoscopist. All endoscopic images of each technique were stored and reassessed. Finally, 294 images of 98 lesions were selected for evaluation by 3 less experienced endoscopists.The accuracy of NBI, acetic acid, and crystal violet for real-time diagnosis was 85.7%, 86.6%, and 92.9%, respectively. For image evaluation by novices, NBI achieved the highest accuracy of 80.6%, compared with that of 72.4% by acetic acid, and 75.8% by crystal violet. The kappa values of NBI, acetic acid, and crystal violet among the 3 trainees were 0.74 (95% CI 0.65–0.83), 0.68 (95% CI 0.59–0.77), and 0.70 (95% CI 0.61–0.79), respectively.For diagnosis of SM-d carcinoma, NBI was slightly inferior to crystal violet staining, when performed by the expert endoscopist. However, NBI yielded higher accuracy than crystal violet staining, in terms of less experienced endoscopists. Acetic acid enhancement with pit pattern analysis was capable of predicting SM-d carcinoma, comparable to the traditional crystal violet staining.     

Miniprobe Endoscopic Ultrasonography Has Limitations in Determining the T Stage in Early Colorectal Cancer

Background/Aims

Mini-probe endoscopic ultrasonography (mEUS) is a useful diagnostic tool for accurate assessment of tumor invasion. The aim of this study was to estimate the accuracy of mEUS in patients with early colorectal cancer (ECC).

Methods

Ninety lesions of ECC underwent mEUS for pre-treatment staging. We divided the lesions into either the mucosal group or the submucosal group according to the mEUS findings. The histological results of the specimens were compared with the mEUS findings.

Results

The overall accuracy for assessing the depth of tumor invasion (T stage) was 84.4% (76/90). The accuracy of mEUS was significantly lower for submucosal lesions compared to mucosal lesions (p=0.003) and it was lower for large tumors (≥2 cm) (p=0.034). The odds ratios of large tumors and submucosal tumors affecting the accuracy of T staging were 3.46 (95% confidence interval [CI], 1.05 to 11.39) and 6.25 (95% CI, 1.85 to 25.14), respectively. When submucosal tumors were combined with large size, the odds ratio was 14.67 (95% CI, 1.46 to 146.96).

Conclusions

The overall accuracy of T stage determination with mEUS was considerably high in patients with ECC; however, the accuracy decreased when tumor size was >2 cm or the tumor had invaded the submucosal layer.     

Transanal Endoscopic Microsurgical Resection of pT1 Rectal Tumors

Purpose Transanal endoscopic microsurgery has emerged as an improved method of transanal excision of neoplasms because its enhanced visibility, superior optics, and longer reach permit a more complete excision and precise closure. This study will show that transanal endoscopic microsurgical treatment of pT1 rectal cancers is safe and achieves low local recurrence and high survival rates. Methods Retrospective review performed of all pT1 rectal cancers treated by a single surgeon (TS) using transanal endoscopic microsurgery between 1991 and 2003. Patient age, gender, tumor distance from the anal verge, lesion size, operative time, blood loss, complications, recurrence, and survival rates were prospectively recorded. Results Fifty-three patients (average age, 65.6 (range, 31–89) years) were studied. Forty-nine percent were male. Average tumor distance from the anal verge was 7 (range, 0–13) cm; average size was 2.4 (range, 1–10) cm. Radiation and/or chemotherapy were not administered. Sixteen patients had pT1 lesions removed piecemeal during colonoscopy; there was no residual tumor after transanal endoscopic microsurgical resection of the polyp site. Mean follow-up was 2.84 years. Fifty-one percent had longer than two-year follow-up. For the entire group, there were four recurrences (7.5 percent) occurring at 9 months, 15 months, 16 months, and 11 years. Two were treated with abdominoperineal resection, one with low anterior resection, and one with fulguration alone. There were no recurrences in the 16 patients who had excision of the polypectomy site. If excluded, recurrence was 11 percent (4/37). Patients were examined at three-month intervals for the first two years and every six months thereafter. There have been no cancer-related deaths. Conclusions Transanal endoscopic microsurgical resection of pT1 rectal cancers yields low recurrence rates. Close follow-up permits curative salvage for those that do recur. Transanal excision remains a viable option. Read at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004. Reprints are not available.     

A Prospective Study of Prognostic Value of Type IV Collagenase Activity in Colorectal Cancer Tissue

The purpose of this prospective study was toevaluate the prognostic value of the type IV collagenase(IVase) activity in colorectal cancer tissue ondisease-free and overall survival in 31 colorectalcancer patients. The clinicopathologic factors studiedfor prognostic value were age, tumor location, tumordifferentiation, preoperative serum levels ofcarcinoembryonic antigen, Dukes' stage, and IVaseactivity in colorectal cancer tissue. IVase activitiesin colorectal cancer tissue were significantly higher inthe group of patients with recurrences than in the groupwithout recurrences (P = 0.019). Patients with high IVase activity in colorectal cancer tissuehad a significantly shorter disease-free survival (P =0.0016) and overall survival (P = 0.022) time than thosewith low IVase activity. Univariate and multivariate analysis showed that significant prognosticfactors for disease-free survival were Dukes' stage (P= 0.029, P = 0.046, respectively) and IVase activitystatus (P = 0.0016, P = 0.0026, respectively). Withrespect to overall survival, only IVase activity statusprovided significant predictive value in multivariateanalysis (P = 0.041). This prospective study suggeststhat IVase activity is a valuable prognostic factor in colorectal cancer patients.