Discrepancy between endoscopic forceps biopsy and endoscopic resection in gastric epithelial neoplasia

Background

Endoscopic forceps biopsy (EFB) is a major diagnostic procedure for gastric epithelial neoplasia (GEN). However, discrepancy between the result of EFB and endoscopic resection (ER) is not uncommon. Thus, there is controversy over whether specimens obtained by EFB are optimal for diagnosis of GEN. We investigated the discrepancy between EFB and ER in the diagnosis of GEN.

Methods

A total of 1,850 GEN cases were histologically diagnosed with EFB, including 954 low-grade dysplasias (LGDs), 315 high-grade dysplasias (HGDs), and 581 carcinomas. Following diagnosis with EFB, all patients were treated with ER. We retrospectively reviewed the pathologic findings and patient characteristics and analyzed predictors for the discrepancy between the two procedures (largest diameter, number of biopsy fragments, number of biopsy fragments/largest diameter, location, macroscopic type, color, surface unevenness, and erosion).

Results

The overall discrepancy rate between EFB and ER was 31.7 % (587/1,850). Among the discordant group, 440 (23.9 %) cases showed a higher grade of disease after ER; 229 of the 954 LGDs (24.0 %) were diagnosed as HGD or carcinoma, 166 of the 315 HGDs (52.7 %) as carcinoma, and 45 of the 581 differentiated carcinomas (7.7 %) as undifferentiated carcinoma. In the LGD group with EFB, the largest diameter (≥1.8 cm; P < 0.001), surface unevenness (P = 0.014), and depressed macroscopic type (P < 0.001) were factors associated with discrepancy. In the carcinoma group with EFB, flat macroscopic type (P = 0.043) was the only significant factor. In the HGD group with EFB, there were no significant factors for discrepancy.

Conclusions

EFB can be insufficient for diagnosing GENs, and ER can be considered not only as treatment but also as a diagnostic modality in GEN. It is especially pertinent to all cases of HGD regardless of their endoscopic features and to cases of LGDs with the largest lesion diameter ≥1.8 cm, surface unevenness, or a depressed macroscopic type.     

肠镜活检诊断的结直肠高级别上皮内瘤变治疗对策

目的探讨肠镜活检诊断为结直肠高级别上皮内瘤变（HGIN）病例的处理原则。方法对第二军医大学附属长海医院2002年1月至2009年12月间收治的203例肠镜活检诊断为HGIN病例的临床诊治资料进行回顾性分析。直接接受根治术156例,全瘤切除活检47例,分别将术后诊断与肠镜活检诊断进行对比．并对两组问的临床病理学差异进行统计学分析。结果肿瘤位于结肠（P=0．02）、肿瘤无蒂（P=0．00）以及体积大（P=0．00）是导致选择直接行根治术的影响因素。术后共有163例（80．3％）诊断为浸润性癌,而仅有40例（19．7％）证实为HGIN。156例根治性切除患者中,有140例手术标本确诊为浸润性癌,16例仍为HGIN。47例行全瘤切除活检的患者中,24例术后确诊为HGIN,23例被诊断为浸润性癌,其中15例后续行根治术。结论基于肠镜活检诊断的HGIN应积极行全瘤切除活检明确诊断：在不具备全瘤切除的条件下,对于不涉及保留肛门的高度疑癌病例也可直接行根治术以防延误治疗。     

Cost savings for elective laparoscopic resection compared with open resection for colorectal cancer in a region of high uptake

Background

Previous cost analyses of laparoscopic resection for colorectal cancer (CRC) reported slightly higher or similar costs to those of open resection. These analyses were based on randomised controlled trials when the laparoscopic approach was newly adopted. This study compared costs for laparoscopic versus open resection in a region of high uptake where adoption is mature.

Methods

Hospital cost data were obtained for elective resections for CRC that occurred between June 2009 and June 2011 in public hospitals in Queensland, Australia. The primary outcome was total cost and secondary outcomes were length-of-stay, operating time, and ICU admission. Multivariate least-squares regression was used to adjust for potential confounders: age, sex, comorbidities, procedure, and hospital volume.

Results

The crude mean cost for laparoscopic resection was €20,036 compared with that for open resection of €22,780 (difference = €2,744). Patients who underwent laparoscopic resection (744/1,397; 53 %) were slightly younger and had fewer comorbidities (decreasing costs) but more had rectal surgery (increasing costs). The adjusted mean cost for laparoscopic resection was €20,396 compared with €22,442 for open resection (difference = €2,054). Compared with open resection, when adjusted for potential confounders, laparoscopic resection resulted in similar operating time (216 vs. 214 min), shorter length-of-stay (difference = ?1.1 days, 95 % CI ?1.9, ?0.3), and shorter admission to ICU (difference = ?7.3 h, 95 % CI ?11.9, ?2.7).

Conclusions

This non-randomised study in a region of high uptake found a similar operating time and lower cost for laparoscopic resection for CRC compared with those of open resection due to a shorter length-of-stay and shorter time in ICU. Laparoscopic resection for CRC saves money when the procedure is widely adopted and surgeons are experienced in the technique.     

Carotid artery atheroma: comparison of preoperative B-mode ultrasound appearance with carotid endarterectomy specimen pathology

This paper describes a prospective study comparing the preoperative Duplex ultrasound appearance of carotid bifurcation atheroma with the pathological characteristics found in the endarterectomy specimens of the same vessels. Initial studies of carotid atheroma using Duplex scanning classified plaques into heterogeneous and homogeneous and found a strong correlation between heterogeneous lesions and the presence of intraplaque haemorrhage or ulceration in the endarterectomy specimen. The B-mode classification of plaque appearance described in this paper is an expansion of the above classification. The study group comprised 220 patients who underwent 244 procedures. The indication for carotid endarterectomy was symptomatic disease in the great majority of cases. We found a high incidence of unstable plaque pathology in the operative specimens, and a predominance of the more echolucent ultrasound plaque appearances (types 1 and 2). There is a statistically significant relationship (p less than 0.001) between ultrasound appearance types 1 and 2 and the presence of either intraplaque haemorrhage or ulceration in the endarterectomy specimen.     

MRI-guided stereotactic biopsy in the diagnosis of glioma: comparison of biopsy and surgical resection specimen

BACKGROUND: Although there has been a dramatic increase in the accessibility and utilization of high-resolution MRI techniques for the evaluation of brain tumors, there is currently only a single report comparing stereotactic brain biopsy specimen to subsequent resection specimen exclusively in the management of gliomas. METHODS: The diagnoses in 43 cases of astrocytic brain tumors were derived using MRI-guided stereotactic biopsy followed by open resection of the lesion. The histologic diagnoses yielded by biopsy were compared with subsequent histologic diagnosis after open tumor resection. All biopsies and histologic diagnoses were made by the same surgeon and pathologist, respectively. RESULTS: In 23 patients undergoing resection <60 days after biopsy, the biopsy diagnosis was consistent with resection diagnosis in 18 cases (79%) and led to the correct treatment in 22 cases (96%). Recurrent glioblastoma multiforme (GBM) was undergraded as anaplastic astrocytoma in 4 patients. GBM was misdiagnosed as radiation necrosis in 1 patient. MR-nonenhancing lesions [10/10 (100%)] yielded histology that correlated with subsequent craniotomy, while only 8/13 (61%) MR-enhancing lesions yielded histology that was consistent with that at craniotomy (p < 0.05). In 20 patients undergoing resection because of radiologic tumor progression (mean 7 months after biopsy), 6/6 (100%) biopsy diagnoses of a specific glioma grade correlated with resection diagnosis, while only 6/14 (43%) biopsy diagnoses of radiation effect correlated with resection diagnosis (p < 0.01). CONCLUSION: MRI-guided stereotactic brain biopsy specimen accurately represents the grade of the larger glioma mass sufficiently to guide subsequent therapy. Enhancement on MR may be a negative prognostic indicator of biopsy accuracy.     

Current status of endoscopic resection strategy for large, early colorectal neoplasia in Japan

Background

Conventional endoscopic resection (CER) for early colorectal neoplasia (CRN) is widely accepted as a minimally invasive treatment. Endoscopic submucosal dissection (ESD) was developed in Japan to resect larger lesions, but ESD was not covered by the Japanese national health insurance until April 2012. In addition, treatment strategies vary considerably among medical facilities. To evaluate the current situation in Japan regarding endoscopic treatment of CRNs measuring ≥20 mm, we conducted a prospective multicenter study at 18 medium-volume and high-volume specialized facilities in cooperation with the Japan Society for Cancer of the Colon and Rectum (JSCCR).

Methods

The JSCCR conducted a multicenter, observational study of all patients treated by CER and ESD of CRNs measuring ≥20 mm.

Results

From October 2007 to December 2010, CERs and ESDs were performed on 1,845 CRNs (CERs 1,029; ESDs 816). Lesions diagnosed as protruded, flat, and depressed totaled 541, 1224, and 48, respectively. En bloc resection rates and mean procedure times for CER/ESD were 56.9 %/94.5 % (P < 0.01) and 18 ± 23 min/96 ± 69 min, respectively. The average ESD procedure time was 129 ± 83 min in the ≥40-mm group. As lesion size increased, the CER en bloc resection rate decreased significantly (trend P < 0.01), but the ESD en bloc resection rate remained over 93 %. Perforation and delayed bleeding rates of CER/ESD were 0.8 %/1.6 % (P < 0.05) and 2 %/2.2 % (P = 0.3), respectively.

Conclusions

The en bloc resection rate for ESD was significantly higher than for CER, although complication rates were fairly low. Despite a longer procedure time, safety of colorectal ESD has improved in various facilities in Japan. However, ESD for lesions measuring ≥40 mm must be performed by experienced endoscopists due to the longer procedure time.     

Incisional hernia rate after laparoscopic colorectal resection is reduced with standardisation of specimen extraction

IntroductionIncisional hernia is a common complication of laparoscopic colorectal surgery. Extraction site may influence the rate of incisional hernias. Major risk factors for the development of incisional hernias include age, diabetes, obesity and smoking status. In this study, we investigated the effect of specimen extraction site on incisional hernia rate.MethodsTwo cohorts of patients who underwent laparoscopic colorectal resections in a single centre in 2005 (n=85) and 2009 (n=139) were studied retrospectively. In 2005 all specimens were extracted through transverse muscle cutting incisions. In 2009 all specimens were extracted through midline incisions. Demographic variables, rate of incisional hernias and risk factors for hernia development were compared between the year groups. All patients had been followed up clinically for two years.ResultsA total of 224 patients (mean age: 67.5 years, standard deviation: 16.35 years) were included in this study. Of these, 85 patients were in the 2005 transverse group and 139 were in the 2009 midline group. The total incisional hernia rate for the series was 8.0% at the two-year follow-up visit. For the 2005 group, the incisional hernia rate was 15.3% (n=13) and for the 2009 group, it was 3.6% (n=5) (p<0.01). The body mass index was higher in patients who developed incisional hernias than in those who did not (p=0.02).ConclusionsThe 2005 group had a significantly higher incisional hernia rate than the 2009 group. This is due to the differences in the incision technique and extraction site between the two groups.     

Predictors of prostate cancer on extended biopsy in patients with high-grade prostatic intraepithelial neoplasia: a multivariate analysis model

OBJECTIVE: To define the importance of extended biopsy in patients with high-grade prostatic intraepithelial neoplasia (HGPIN) and to define predictors of cancer in extended biopsy in patients with HGPIN, using multivariate analysis. PATIENTS AND METHODS: In all, 83 patients with previous sextant biopsy of HGPIN had an extended 11-core biopsy taken. Patients with a negative biopsy for cancer were followed by serum prostate-specific antigen (PSA) and digital rectal examination (DRE) every 6 months. The extended biopsy was repeated in 21 patients. The criteria for second biopsy were an increase in PSA and/or abnormal changes on DRE. Overall, 49 patients had a transurethral resection of the prostate (TURP). The cancer-detection rate on extended biopsy was correlated with risk factors using the chi-square test and multivariate analysis. RESULTS: Extended biopsy detected prostate cancer in 30 of the 83 men (36%), with positive cores in only 20 sextant biopsy sites (67%), in only seven in additional sites (23%), and both in three (10%). Of the 21 patients who had repeat extended biopsy, four (19%) had cancers. There were two carcinomas in the 49 TURP specimens (4%). The PSA level, DRE and transrectal ultrasonography findings were not predictive of cancer in extended biopsies (chi-square test). Patient age, PSA density and the number of cores with HGPIN (all P < 0.001) had a significant effect on the cancer-detection rate, and multivariate analysis showed that all three were independent predictors of cancer. A logistic regression model was designed to predict the probability of cancer in extended biopsy, with an overall accuracy of 78%. CONCLUSION: Extended biopsy improved the cancer detection rate by 23% in patients with HGPIN. Patient age, PSA density and the number of cores with HGPIN were the only independent predictors of cancer.     

A novel approach of robotic-assisted anterior resection with transanal or transvaginal retrieval of the specimen for colorectal cancer

Background  

The surgical robot (da Vinci S) is superior to conventional laparoscopy; it provides clearer, three-dimensional images and an extended range of motion for the instruments. We used this robot for laparoscopic surgery to perform a totally intracorporeal resection of the rectum and colorectal anastomosis, with transanal or transvaginal retrieval of specimens.     

Risk factors for under-diagnosis of gastric intraepithelial neoplasia and early gastric carcinoma in endoscopic forceps biopsy in comparison with endoscopic submucosal dissection in Chinese patients

Differences in pathologic diagnosis between endoscopic forceps biopsy (EFB) and endoscopic submucosal dissection (ESD) for gastric intraepithelial neoplasia (GIN) and early gastric carcinoma (EGC) in Chinese patients remain unknown. The aim of the study was to investigate risk factors for under-diagnosed pathology in initial EFB, compared to final ESD. We reviewed endoscopic and histopathologic findings for tumor location, size, macroscopic pattern, nodularity, erythema, erosion, GIN (low and high grade), and EGC diagnosed with the WHO criteria. Differences in those features between EFB and ESD were compared and risk factors for under-diagnosis by EFB were analyzed. Although concordant in most (74.9 %) cases between EFBs and ESDs, pathological diagnoses in 57 (25.1 %) cases were upgraded in ESDs. Compared to the concordant group, the lesion size ≥2 cm, and depressed and excavated patterns were significantly more frequent in the upgraded group. Further multivariate regression analysis demonstrated the depressed pattern and lesion size ≥2 cm as independent risk factors for upgraded pathology with the odds ratio of 5.778 (95 % confidence interval 2.893–11.542) and 2.535 (95 % confidence interval 1.257–5.111), respectively. Lesion size ≥2.0 cm and the depressed pattern at initial EFB were independent risk factors for pathologic upgrade to advanced diseases in ESD. Therefore, these endoscopic characteristics should be considered together with the initial EFB diagnosis to guide the optimal clinical management of patients with GIN and EGC.     

Rationale for aggressive colonoscopy in patients with colorectal neoplasia

The role of colonoscopy in patients with colorectal neoplasia is not well established. The results of colonoscopy, from 1982 through 1987, in 42 patients with cancers who underwent preoperative colonoscopy (group 1), 64 patients with benign polyps (group 2), and 51 patients who were examined only postoperatively (group 3) were reviewed. These results indicated that (1) approximately one third of all findings would have been missed if endoscopy had been performed to only 60 cm; (2) there was a high incidence of synchronous lesions (33.3%) in group 1 and 34.4% in group 2); (3) 57% of patients with synchronous cancer and 63.6% of patients with synchronous polyps developed metachronous lesions, compared with 10.7% and 11.9% of patients with a single lesion; (4) there was a higher incidence of metachronous lesions seen in group 3, compared with group 1; and (5) the median interval for noting metachronous lesions in patients who underwent colonoscopy preoperatively was approximately 18 months. These findings endorsed preoperative colonoscopy and aggressive follow-up in patients with colorectal tumors.     

Ductal carcinoma in situ diagnosed by breast needle biopsy: Predictors of invasion in the excision specimen

BackgroundA substantial proportion of women with a pre-operative diagnosis of pure ductal carcinoma in situ (DCIS) has a final diagnosis of invasive breast cancer (IBC) after surgical excision and, consequently, a potential indication for lymph node staging. The aim of our study was to identify novel predictors of invasion in patients with a needle-biopsy diagnosis of DCIS that would help us to select patients that may benefit from a sentinel node biopsy (SNB).Patients and MethodsWe included 153 patients with a needle-biopsy diagnosis of DCIS between 2000 and 2014, which was followed by surgical excision. Several pre-operative clinical, radiological and pathological features were assessed and correlated with the presence of invasion in the excision specimen. Features that were significantly associated with upstaging in the univariable analysis were combined to calculate upstaging risks.ResultsOverall, 22% (34/155) of the patients were upstaged to IBC. The following risk factors were significantly associated with upstaging: palpability, age ≤40 years, mammographic mass lesion, moderate to severe periductal inflammation and periductal loss of decorin expression. The upstaging-risk correlated with the number of risk factors present: e.g. 9% for patients without risk factors, 29% for patients with 1 risk factor, 37% for patients with 2 risk factors and 54% for patients with ≥3 risk factors.ConclusionThe identified risk factors may be helpful to predict the upstaging-risk for patients with a needle-biopsy diagnosis of pure DCIS, which facilitates the performance of a selective SNB for high-risk patients and avoid this procedure in low-risk patients.     

腹腔镜下结直肠癌体内切除标本经直肠拖出手术(NOSES)的无菌和无瘤操作技巧

目的探讨腹腔镜下结直肠癌自然腔道取标本手术(natural orifice specimen extraction surgery, NOSES)标本体内切除经直肠拖出手术的无菌和无瘤操作技巧及近期疗效分析。 方法回顾性分析四川省肿瘤医院2017年6月至2018年11月采用标本体内切除后经直肠拖出方式行腹腔镜结直肠癌NOSES的26例患者临床资料,分析手术时间、术中出血量、术中污染、术后胃肠功能、并发症、住院时间及肿瘤复发转移等情况。 结果26例患者均顺利完成手术,平均手术时间240.4 min(150～330 min),平均术中出血量56.9 ml(20～100 ml),平均术后排气时间21.3 h(8～48 h),平均住院时间10.0 d(7～15 d),术后无并发症发生;随访至2018年11月,无一例发现复发或转移。 结论腹腔镜下结直肠癌NOSES标本体内切除拖出手术安全可行,创伤小、恢复快;只要术中严格遵守无菌和无瘤原则,掌握关键操作技巧,可以有效降低甚至避免腹腔污染和肿瘤医源性扩散风险。     

Prediction of underestimated invasiveness in patients with ductal carcinoma in situ of the breast on percutaneous biopsy as rationale for recommending concurrent sentinel lymph node biopsy

AimTo develop a model to predict invasion and improve the indication of concurrent sentinel lymph node biopsy (SLNB) for patients with ductal carcinoma in situ (DCIS) on minimally invasive biopsy.MethodsWe evaluated the data of 205 patients with DCIS in minimally invasive biopsy specimens. Clinical, radiological and histological variables were assessed in order to identify predictors of invasive carcinoma in final pathology using logistic regression analyses. We developed and retrospectively tested an algorithm to indicate concurrent SLNB.ResultsInvasiveness was underestimated in 18.0% (37 of 205). Univariate analysis revealed the following significant risk factors: lesion palpability, a mass lesion on ultrasound, the presence of a mammographically detectable mass, architectural distortion or density, a BI-RADS score of 5, a lesion diameter ≥50 mm, and ≥50% of histologically affected ducts. With a palpable mass, which remained the only independent predictor of invasion after multivariate adjustment, and the presence of at least three of the remaining five risk factors, the probability of invasion was 56.0%. If the prediction model had been used to indicate SLNB 9.8% (20 of 205) of patients could have been benefited (i.e. spared unnecessary or correctly recommended concurrent SLNB) compared to the factual performed SLNB procedures. Those patients with pure DCIS treated with breast conserving surgery (BCS) benefited most with a relative risk reduction of nearly 50% for unnecessary SLNB.ConclusionThe prediction model could rationally guide an informed discussion about risks and benefits of concurrent SLNB in patients with DCIS on minimally invasive biopsy.     

Strategy for repeat biopsy in patients with high grade prostatic intraepithelial neoplasia

PURPOSE: The finding of high grade prostatic intraepithelial neoplasia in a biopsy specimen without prostate cancer warrants repeat biopsy because of the risk of concurrent cancer. However, to our knowledge the optimal repeat biopsy technique has not yet been defined. We determined the optimal subsequent biopsy strategy for detecting concurrent cancer in patients diagnosed with high grade prostatic intraepithelial neoplasia. MATERIALS AND METHODS: Of 63 men with isolated high grade prostatic intraepithelial neoplasia on initial biopsy 45 underwent repeat biopsy within 1 year. Certain biopsy patterns were used for repeat biopsy, including only the neoplasia site in 8 men, sextant in 12, sextant plus bilateral transition zone in 13 and 11 core multisite directed (sextant, bilateral transition zone, bilateral anterior horn of the peripheral zone and midline peripheral zone) in 12. We compared the location of high grade disease on the initial biopsy with the cancer site on repeat biopsy. RESULTS: Repeat biopsy revealed cancer in 10 of the 45 men (22%), and the sites of high grade prostatic intraepithelial neoplasia and cancer correlated in 6. Cancer was detected at the sextant locations in 9 men. Of the 15 cores positive for cancer 8 were at the original high grade neoplasia site, 6 at a random sextant biopsy site and 1 in the transition zone. High grade disease was discovered bilaterally in 1 man, while prostatic intraepithelial neoplasia and cancer were detected on the same side in the remaining 9. CONCLUSIONS: The optimal repeat biopsy strategy for patients with high grade prostatic intraepithelial neoplasia has not yet been determined but at a minimum it should include targeting the area of known high grade disease and the ipsilateral sextants.     

Effect of systemic corticosteroids on elective left-sided colorectal resection with colorectal anastomosis

Background

The impact of systemic steroid therapy on surgical outcome after elective left-sided colorectal resection with rectal anastomosis is not well known.

Methods

We compared 606 consecutive patients including 53 patients who were on steroids and undergoing surgery between 1995 and 2005.

Results

Postoperative mortality and anastomotic leakage rates were equivalent. The postoperative complications rate, especially infections, was higher in steroid-treated patients than in non-steroid-treated patients: 38% (20 of 53 patients) versus 25% (139 of 553 patients), respectively (P = .046). In the steroid group, univariate analysis revealed 3 significant risk factors for postoperative complications: blood transfusion, preoperative anticoagulation, and chronic respiratory failure. In a multivariate analysis, blood transfusion and chronic respiratory failure remained independent factors for postoperative complications.

Conclusion

Patients on steroids have a higher incidence of postoperative complications after elective left-sided colorectal resection with rectal anastomosis.