SOLITARY PEDUNCULATED GASTRIC GLAND HETEROTOPIA TREATED BY ENDOSCOPIC POLYPECTOMY: REPORT OF A CASE

The patient, a 68‐year‐old woman with a long‐standing history of schizophrenia, was admitted to our hospital complaining of vomiting which had lasted approximately 3 weeks. Endoscopic examination of the stomach revealed a solitary pedunculated submucosal tumor, of approximately 2 cm in diameter, on the anterior wall of the upper body, close to the greater curvature. The lesion was endoscopically excised using a polypectomy snare without any complication. Microscopic examination was compatible with the diagnosis of gastric gland heterotopia showing submucosal proliferation of pseudopyloric glands, fundic glands and foveolar epithelium with fibromuscular stromal framework. The proliferating foveolar epithelium and fibromuscular stroma were in continuity with the overlaying gastric mucosa and muscularis mucosae, respectively. The lesion was entirely covered by normal gastric epithelium. No atypical cells were revealed in the lesion. The clinical significance of gastric gland heterotopia is unclear because of its controversial histogenesis and carcinogenetic potential. We herein report a rare case of solitary pedunculated gastric gland heterotopia with some review of scientific reports.     

BorrmannⅣ型胃癌超声内镜诊断价值的研究

目的:评价超声内镜(EUS)对 BorrmannⅣ型胃癌的诊断效果。材料与方法:138例胃癌病例术前均经内镜和病理活检检查。其中36例胃镜疑为 BorrmannⅣ型胃癌的病例术前同时做了 EUS 检查,结果与术后外科病理诊断进行对照。结果:胃镜检出的138例胃癌中,Borrmann Ⅰ型、Ⅱ型和Ⅲ型胃癌内镜活检多能明确诊断,第1次活检确诊率达88.5%以上。再次内镜活检取材,97.4%以上的病例能确诊。36例内镜可疑为 BorrmannⅥ型胃癌首次活检14例(38.9%)为粘膜炎症反应,未见癌瘤细胞。虽经再次活检,仍有12例(33.3%)未能获得明确诊断.该型胃癌在 EUS 下声像图常有特征性的变化,表现为大部分或全胃壁弥漫性全层增厚,粘膜下层尤明显,回声减弱。增厚的胃壁并无明显结构紊乱,其层次尚可辨认。根据这一特征,36例内镜疑诊为该型的胃癌病变均行 EUS 检查,均作出了正确的诊断,确诊率达100%。结论:EUS 能显示 BorrmannⅣ型胃癌特征性的变化,用于该型胃癌的诊断,优于内镜及活检检查。     

ENDOSCOPIC ULTRASOUND STAGING OF GASTRIC MALIGNANCY

Endoscopic ultrasound (EUS) has been well established as a good tool for the staging of gastric malignancy. So far, it is accepted as the most accurate image study for local staging of gastric malignancy. Staging of gastric carcinoma is important for decision‐making in management and prediction of prognosis. With the power of high‐resolution imaging on gastric layering, the overall accuracy rate of T staging by EUS ranges 70–98%. For T2 tumors, however, EUS assessment is less reliable. N staging by EUS for gastric carcinoma is unsatisfactory and its accuracy rate has been reported 55–87%. However, the application of EUS should depend on whether examination will alter the choice of therapeutic methods and whether patients benefit from EUS evaluation. Among the indications, EUS staging is very important for the patients referred for local endoscopic treatment, such as endoscopic mucosal resection, endoscopic submucosal dissection or tumor ablation by argon plasma coagulation (APC) tumor ablation. EUS can provide the depth of invasion of the gastric wall, and also the longitudinal spread of lymphoma in the gastric wall. The overall accuracy rate of depth staging is 80–96%. For the metastatic lymph nodes, accuracy rate of N staging is 72–90%. EUS is also applied to restaging of gastric lymphoma after chemotherapy. Mucosa‐associated lymphoid tissue (MALT) lymphoma is a subset of B‐cell lymphoma with good prognosis and high prevalence of Helicobacter pylori infection. EUS staging of depth invasion of MALT lymphoma can predict the outcome of antimicrobial treatment. Taiwan's experience shows that lesions limited to mucosal and submucosal layers respond better after treatment than lesions with deeper infiltration, no matter if the MALT lymphoma is low‐grade or high‐grade.     

DIAGNOSIS OF GASTRIC MUCINOUS CARCINOMA BY ENDOSCOPIC ULTRASONOGRAPHY

Background: Biopsy diagnosis of gastric mucinous carcinoma (GMC) is sometimes dif?cult. Endoscopic ultrasonography (EUS) can visualize the change in the gastric wall in detail. We reviewed the EUS images and histological ?ndings of cases of GMC and evaluated the correlation between them to identify the characteristic ?ndings of GMC on EUS. Methods: Thirty‐one GMC patients who had undergone both preoperative EUS and surgery were studied. The EUS images of these patients and the histological ?ndings were compared with those for other histological types of gastric cancer (OGC). Results: The tumor echo showed high echoic in GMC cases more frequently than that in OGC. The frequency of visualization of the layer structure above the tumor was higher compared with OGC. Histology veri?ed the presence of ?ne septa composed of thin ?brotic tissue and ?oating cancer cells in the mucus lake. The mucus lake was often located in the submucosa and the tumor was covered with cancerous mucosa of other histological types with preserved lamina muscularis mucosae. Conclusions: The EUS ?ndings of GMC are characteristic and re?ect its histological changes well, and would complement the preoperative diagnosis of this tumor.     

食管和贲门早癌内镜激光治疗的五年存活率和预后因素

为探索食管和贲门早癌激光治疗的五年生存率和影响其预后的因素，对内镜ＮｄＹＡＧ激光治疗后癌细胞消失的３２例食管和贲门早期浅表癌病人进行了３３～７８个月（平均５５．３个月）的前瞻性随访。应用Ｐｒｏｄｕｃｔｌｉｍｉｔｅｓｔｉｍａｔｅ方法计算其存活率；并与１１７例食管和贲门早期浅表癌的自然病程进行了对比分析。内镜激光治疗五年存活率为９７％，未经治疗的早期食管贲门癌五年存活率为６７％，（Ｐ＜０．０１），表明内镜ＮｄＹＡＧ激光是一种有效的治疗方法。在对影响疗效因素的分析中，发现癌基因ｐ５３是一个有价值的独立预后因素。     

FEASIBILITY OF ENDOSCOPIC SUBMUCOSAL DISSECTION FOR ELDERLY PATIENTS WITH EARLY GASTRIC CANCERS AND ADENOMAS

Background: Endoscopic submucosal dissection (ESD) has the advantage of permitting en bloc and histologically complete resection for early gastric cancer. Elderly patients often have surgical operative risks due to disease, and the feasibility of this treatment for such patients will improve the quality of life. The aim of the present study is to evaluate the efficacy and safety of ESD in elderly patients. Methods: We reviewed patients who underwent ESD for gastric lesions at Maebashi Red Cross Hospital. Among 251 gastric lesions treated by ESD from 2002 to 2006, 110 lesions were discovered in 93 elderly patients who were 75 years of age or older. The one‐piece resection with tumor‐free margin rate and the complications were assessed in comparison with younger patients under 75 years old. Results: The average age of the elderly patients was 79.8 years (range 75–92 years). The one‐piece resection with tumor‐free margin rate was 96.4% (106/110). Immediate bleeding occurred in one lesion (0.9%) and delayed bleeding requiring emergency endoscopy occurred in five lesions (4.5%). Perforation during ESD occurred in two patients (1.8%), and was immediately closed with endoclips and managed by conservative medical treatment. One case (0.9%) complicated with delayed perforation was managed by conservative medical treatment. The one‐piece resection with tumor‐free margin rate and the complication rate in elderly patients were not significantly different from those of younger patients. Conclusion: The present study shows the technical feasibility of ESD for gastric neoplasms in elderly patients.     

A CASE OF DIFFUSE‐TYPE EARLY GASTRIC CANCER WITH NODULAR GASTRITIS

A 39‐year‐old woman was referred to Osaka Police Hospital and admitted for surgical treatment of gastric cancer. Barium upper gastrointestinal study and endoscopic examination showed a 3.0 × 3.0 cm depressed lesion in the greater curvature of the middle corpus. An unusual miliary pattern resembling ‘goose flesh’ was observed endoscopically in the antrum. Biopsy specimens from the tumor showed poorly differentiated adenocarcinoma, and specimens from the antrum showed many lymphoid follicles with a germinal center. Rapid urease test and histological tests (Giemsa stain) for Helicobacter pylori were both positive. Early gastric cancer with nodular gastritis (NG) was diagnosed and a partial gastrectomy was performed. Histological examination of the resected specimen showed a stage I tumor consisting mainly of signet‐ring cell carcinoma restricted to the mucosa. Postoperatively H. pylori eradication therapy was performed and proved to be successful. One year after eradication therapy, endoscopy with biopsy showed no recurrence of gastric cancer and the remarkable regression of antral NG.     

双胃镜粘膜切除法切除早期胃癌及其癌前病变

自１９９１年３月至１９９２年１２月，我院应用双胃镜对６例粘膜层早期胃癌及其癌前病变进行了内镜下粘膜切除术，其中Ⅱｃ型早期胃癌１例，Ⅱａ型早期胃癌２例，扁平隆起型重度异型增生２例，山田１型腺瘤１例，所有病变直径均小于２ｃｍ。一次操作病变完全切除３例，经第二次操作又完全切除２例，残留切除１例，后又补充外科手术切除。经追踪３～２１个月，尚未见复发征象。文中对本法适应症、完全切除的标准等也进行了讨论     

COMPARISON OF ENDOSCOPIC DETECTION RATE OF EARLY GASTRIC CANCER AND GASTRIC ADENOMA USING TRANSNASAL EGD WITH THAT OF TRANSORAL EGD

Background: To investigate the influence of the reduced image quality of transnasal esophagogastroduodenoscopy (EGD) with the ultrathin endoscope (transnasal EGD) on endoscopic diagnoses, we compared the detection rate (DR) of early gastric cancer and gastric adenoma by transnasal EGD with that of transoral EGD using a standard endoscope. Methods: Transnasal EGD was carried out in 2791 examinations for the purposes of screening or other reasons. Controls were examined by transoral EGD and numbered 3591 examinations. The transnasal endoscope used was an EG530N. Lesions graded C‐3 or higher by Kimura‐Takemoto's classification were regarded as endoscopic atrophy. Results: (i) DR in all subjects and those with atrophy were not different between transnasal and transoral EGD. (ii) Multivariate analysis of DR in subjects with atrophy was carried out using five variables: gender, age, purposes of endoscopy, endoscopic insertion route and the four endoscopists. DR was significantly higher in males or subjects ≥60 years. No difference was noted between the endoscopic insertion routes (transnasal vs transoral). (iii) The subjects analyzed in (ii) were divided into the transnasal and transoral groups, and multivariate analysis of DR was carried out using four variables. DR was not different among the endoscopists in the transoral group. However, in the transnasal group, DR increased as the years of endoscopic experience was prolonged. Conclusions: Multivariate analysis detected no significant difference in DR between transnasal and transoral EGD. However, a significant difference in DR by transnasal EGD among the endoscopists is detected. Transnasal EGD should be carefully carried out by experienced endoscopists.     

MAGNIFICATION ENDOSCOPIC VIEW OF AN EARLY GASTRIC CANCER USING ACETIC ACID AND NARROW‐BAND IMAGING SYSTEM

A 62‐year‐old woman was referred to Mie University Hospital, Tsu, Japan, for examination of upper gastrointestinal tract. The conventional endoscopy showed a slightly depressed lesion on the greater curvature at the gastric body. The surface of surrounding non‐neoplastic mucosa using magnification endoscopy with acetic acid was gyrus‐villous pattern whereas the surface of the lesion was rough. Furthermore, magnification endoscopy using acetic acid and narrow‐band imaging system visualized clearer fine surface pattern of carcinoma. The lesion had a rough mucosa with irregularly arranged small pits. The lesion was resected completely by endoscopic mucosal resection with insulated‐tip electrosurgical knife. Narrow‐band imaging system with acetic acid may be able to visualize not only the capillary pattern but also the fine surface pattern of gastric carcinoma.     

ENDOSCOPIC FINDINGS OF ENTEROPATHY‐TYPE T‐CELL LYMPHOMA BY DOUBLE‐BALLOON ENTEROSCOPY AND CAPSULE ENDOSCOPY

Enteropathy‐type T‐cell lymphoma (ETL) is a rare primary intestinal disorder, particularly in Japan, and there have been few reports on the endoscopic findings of the disease. Here we report detailed endoscopic findings of ETL based on double‐balloon enteroscopy and capsule endoscopy. Double‐balloon enteroscopy and capsule endoscopy may be useful tools for diagnosing and monitoring the effects of therapy in patients with ETL.     

PREDICTIVE VALUE OF ENDOSCOPY AND ENDOSCOPIC ULTRASONOGRAPHY FOR REGRESSION OF GASTRIC DIFFUSE LARGE B‐CELL LYMPHOMAS AFTER HELICOBACTER PYLORI ERADICATION

Background: Some gastric diffuse large B‐cell lymphomas have been reported to regress completely after the successful eradication of Helicobacter pylori. The aim of this study was to investigate the clinical characteristics of gastric diffuse large B‐cell lymphomas without any detectable mucosa‐associated lymphoid tissue (MALT) lymphoma that went into complete remission after successful H. pylori eradication. Patients and Methods: We examined the effect of H. pylori eradication in 15 H. pylori‐positive gastric diffuse large B‐cell lymphoma patients without any evidence of an associated MALT lymphoma (clinical stage I by the Lugano classification) by endoscopic examination including biopsies, endoscopic ultrasonography, computed tomography, and bone marrow aspiration. Results: H. pylori eradication was successful in all the patients and complete remission was achieved in four patients whose clinical stage was I. By endoscopic examination, these gastric lesions appeared to be superficial. The depth by endoscopic ultrasonography was restricted to the mucosa in two patients and to the shallow portion of the submucosa in the other two patients. All four patients remained in complete remission for 7–100 months. Conclusion: In gastric diffuse large B‐cell lymphomas without a concomitant MALT lymphoma but associated with H. pylori infection, only superficial cases and lesions limited to the shallow portion of the submucosa regressed completely after successful H. pylori eradication. The endoscopic appearance and the rating of the depth of invasion by endosonography are both valuable for predicting the efficacy of H. pylori eradication in treating gastric diffuse large B‐cell lymphomas.     

THERAPEUTIC OUTCOMES OF ENDOSCOPIC SUBMUCOSAL DISSECTION OF UNDIFFERENTIATED‐TYPE INTRAMUCOSAL GASTRIC CANCER WITHOUT ULCERATION AND PREOPERATIVELY DIAGNOSED AS 20 MILLIMETRES OR LESS IN DIAMETER

Aim: The aim of the present study was to examine therapeutic outcomes of endoscopic submucosal dissection (ESD) of undifferentiated‐type intramucosal gastric cancer and the problems of diagnosis. Methods: We reviewed 58 patients with preoperatively diagnosed undifferentiated‐type intramucosal early gastric cancer (EGC) without ulceration with a diameter of 20 mm or smaller (expanded‐indication lesion) who underwent ESD at the Cancer Institute Hospital between September 2003 and August 2008. Results: The overall rates of one‐piece resection and complete resection were 98% and 90% respectively, and the median operation time was 70 min. Bleeding was seen in 8.6% and perforation in 3.4%. The curative resection rate was low at 79%. Factors responsible for non‐curative resection were most commonly submucosal invasions. If limited to pathologically diagnosed expanded‐indication lesions, the curative resection rate was 98%. The difference in tumor size between a macroscopic diameter and a histological diameter was within ±5 mm in 96% of expanded‐indication lesions, with none of these cases having a histological diameter that exceeded the macroscopic diameter by more than 5 mm. Conclusion: ESD was technically feasible for expanded‐indication lesions of undifferentiated‐type EGC. We achieved a high rate of curative resection by the markings at sites 5 mm beyond the preoperatively determined lesion area. Factors responsible for non‐curative resection were most commonly submucosal invasions. We should diagnose the depth of such lesions more carefully.     

SYNCHRONOUS MULTICENTRIC SIGNET‐RING CELL CARCINOMA OF THE STOMACH

A case of simultaneous multicentric signet‐ring cell carcinoma (SRC) of stomach is presented. Initially, an early gastric cancer (IIc) was diagnosed and this was cured with distal gastrectomy. Thirty‐eight months after the operation, follow‐up endoscopy revealed a tiny mucosal discoloration lesion, which was diagnosed as a minute SRC focus with biopsy. This was successfully treated with endoscopic mucosal resection (EMR). Nine months later, gastroscopy discovered another small mucosal lesion and it was again diagnosed as a tiny SRC lesion, which was also successfully treated with EMR. After a further 2 months, endoscopy showed three small mucosal lesions (discoloration) similar to previous lesions, two of which proved to be SRC with biopsy. As these lesions distributed widely over the remnant stomach, total gastrectomy of the residual stomach was performed. Pathological examination demonstrated a total of 22 simultaneous multifocal SRC lesions, which were all very small mucosal cancer. These cancers, including previously EMR‐treated ones, seemed to develop in a multicentric manner, as they were diagnosed within 11 months. This case also indicated that even subtle endoscopic findings should vigorously be sought and, if in doubt, be biopsied in order to locate gastric cancer early enough for minimal invasive curative treatment to be feasible.     

SUPERFICIAL ESOPHAGEAL SQUAMOUS CELL CARCINOMA WITH BULKY GASTRIC HIATUS LYMPH NODE METASTASIS: A CASE REPORT

In patients with superficial esophageal cancer, especially in those with tumor invasion above the muscularis mucosae, lymph node metastasis is very rare. We report a case of superficial esophageal cancer who presented with lymph node metastasis. In another hospital a 49‐year‐old man was found to have a bulky tumor adjacent to the cardiac area of the stomach and a total gastrectomy was carried out. Postoperatively, the tumor was identified as a lymph node containing metastatic squamous cell carcinoma. The main lesion could not be identified on fluorodeoxyglucose positron emission tomography. On esophagogastric endoscopy, using the iodine spray technique, we found an unstained lesion about 32 cm from the incisor teeth. The tumor was removed using endoscopic mucosal resection. The entire resected specimen was examined histopathologically; the depth of the tumor was above the muscularis mucosae. Thirty‐four months after endoscopic mucosal resection, there is no sign of tumor recurrence or metastasis.     

食管和贲门早癌内镜激光治疗的五年存活率和预后因素

为探索食管和贲门早癌激光治疗的五年生存率和影响其预后的因素，对内镜Ｎｄ：ＹＡＧ激光治疗后癌细胞消失的３２例食管和贲门早期浅表癌病人进行了３３－７８个月（平均５５．３个月）的前瞻性随访。应用Ｐｒｏｄｕｃｔ ｌｉｍｉｔ ｅｓｔｉｍａｔｅ方法计算其存活率；并与１１７例食管和贲门早期浅表癌的自然病程进行了对比分析。内镜激光治疗五年存活率为９７％，未经治疗的早期食管贲门癌五年存活率为６７％，（Ｐ＜０．０１），表明内镜Ｎｄ：ＹＡＧ激光是一种有效的治疗方法。在对影响疗效因素的分析中，发现癌基因ｐ５３是一个有价值的独立预后因素。     

SHORT‐TERM OUTCOMES OF ENDOSCOPIC SUBMUCOSAL DISSECTION (ESD) FOR EARLY GASTRIC NEOPLASM: MULTICENTER SURVEY BY OSAKA UNIVERSITY ESD STUDY GROUP

Background: Endoscopic submucosal dissection (ESD) was developed for en bloc removal of large and flat gastrointestinal tract neoplasms. In Japan, ESD is performed under conscious sedation. The risks for sedation‐related complications of ESD, such as postoperative pneumonia, have not been evaluated. The aim of this study was to evaluate the incidence of postoperative pneumonia after ESD in a multicenter survey. Patients and Methods: A total of 1188 patients with upper gastric neoplasms treated with ESD in nine hospitals were enrolled from May 2003 to September 2008. The en bloc resection rates and complications (bleeding, perforation, and postoperative pneumonia) were assessed. The correlations between the clinical variables and complications were investigated using logistic regression models. Results: The en bloc resection rate was 95.3%. Bleeding, perforation, and pneumonia occurred in 37 (3.1%), 49 (4.1%), and 19 (1.6%) patients, respectively. Univariate analysis indicated that procedure time, but not specimen size, or patient age, or sex, was significantly related to bleeding and perforation. The incidence of pneumonia was higher in patients with ulceration, older patients (≥75 years), and those with a long procedure duration (≥5 h). Conclusion: The incidence of pneumonia, but not perforation and bleeding, after ESD, is high in older patients (≥75 years). Special care should be taken with older patients undergoing ESD to minimize the risk of postoperative pneumonia.     

ENDOSCOPIC DIAGNOSIS AND TREATMENT OF AMPULLARY NEOPLASM (WITH VIDEO)

Background and aim: For ampullary cancer, pancreaticoduodenectomy is considered to be the standard treatment. Endoscopic papillectomy (EP) has been utilized in cases of ampullary adenoma since the early 1980s. We aimed to provide a review concerning EP. Methods: We conducted a review of studies regarding EP for ampullary neoplasms. Results: Since neither lymphatic permeation, vascular invasion, nor lymph node metastasis is observed in patients with ampullary cancer limited to the mucosa, EP of such tumors without ductal infiltration into the pancreatic/bile duct can be justified as radical treatment. For its application in patients with ampullary neoplasms, accurate pretreatment staging is indispensable. EUS, which can be carried out on an outpatient basis with a low risk of complications, is useful for differential diagnosis as well as detection of periampullary tumors. Although intraductal US of the bile duct tends to result in overestimation of tumor staging in cases of ampullary neoplasm, it can provide useful information for making therapeutic decisions, especially in cases appropriate for EP. While the technical success rate of EP is high, the complication rate and recurrence rate are not as low as a satisfactory level. Pancreatic duct stenting after EP is expected to contribute to prevention of post‐EP pancreatitis. There is no consensus regarding the mode of resection current nor the need for addition of biliary/pancreatic sphincterotomy and biliary stenting. Conclusions: EP has been reported to be useful in selected patients with ampullary neoplasms. Data on further long‐term follow up after EP are awaited.