Modes of spread in early ampullary cancer in terms of establishing proper indications for endoscopic papillectomy

Background: Endoscopic papillectomy for adenomas of the ampulla of Vater has been reported and is gaining acceptance as an alternative to surgery in the treatment of early ampullary cancer. However, whether endoscopic treatment is justified as a treatment of choice for early ampullary cancer remains controversial. The aim of the present study was to elucidate the possibility of endoscopic papillectomy as a treatment of early ampullary cancer from the review of pathology of cases treated by surgical resection. Patients and methods: Twenty‐three cases of early ampullary cancer (m—tumor limited to the mucosa of the ampulla 14; od—tumor that invades Oddi's sphincter, 9) treated by surgical resection from January 1984 to March 2003 were investigated as to the following: (i) macroscopic type, maximum size, and histological type of tumor; (ii) main location and extension of tumor; (iii) prevalence of extension into the lower bile duct or pancreatic duct, and relationship between ductal infiltration and macroscopic type, maximum size, main location, or depth of invasion of tumor; (iv) lymphatic permeation, vascular invasion, and lymph node metastasis; and (v) prognosis. Results: All cases were classified macroscopically as exposed‐tumor type or non‐exposed‐tumor type without ulceration. Extension into the lower bile duct or the pancreatic duct was observed in 43% of the cases. There was no correlation between ductal infiltration and macroscopic type, maximum tumor size, main tumor location, or tumor depth. No lymphatic permeation, vascular invasion, or lymph node metastasis were proven in cases with ampullary cancer confined to the mucosa. In the nine cases with involvement of Oddi's sphincter, lymphatic permeation and lymph node metastasis were observed in two cases and one case, respectively. Conclusion: Endoscopic treatment for early ampullary cancer confined to the mucosa without spread to the bile duct or pancreatic duct is justified as a treatment of choice if detailed histological examination of the resected specimen indicated no invasion beyond its margin.     

Focal early stage cancer in ampullary adenoma: surgery or endoscopic papillectomy?

BACKGROUND: Recently, the evidence has been accumulating that endoscopic resection may be curative in treating ampullary adenoma that contains high-grade intraepithelial neoplasia/in situ tumor (HGIN/Tis). However, there are only anecdotal reports of endoscopic management of "focal" T1 ampullary cancer (T1 cancer), and radical surgery is still considered the only accepted treatment modality. OBJECTIVE: To assess the possibility of endoscopic papillectomy as an alternative to radical surgery for the treatment of ampullary adenoma with HGIN/Tis or focal T1 cancer. DESIGN: Retrospective evaluation of case series of our hospital from 1996 to 2006. SETTING: Tertiary-care university teaching hospital. PATIENTS: Twenty-three patients who had HGIN/Tis or focal T1 cancer in ampullary adenoma resected by endoscopic papillectomy and 60 patients who initially underwent radical surgery for HGIN/Tis or T1 cancer of the ampulla of Vater. "Focal" was defined as a lesion involving only mucosa, with a size less than a fourth the diameter of main adenoma. INTERVENTIONS: Review of medical records and analysis of surgically or endoscopically resected specimens of ampullary tumors. MAIN OUTCOME MEASUREMENTS: Locoregional extension and follow-up data. RESULTS: Patients with HGIN/Tis of the ampulla of Vater had no lymphovascular invasion or lymph-node metastasis, and there were no occurrences of cancer or deaths during a mean (standard error [+/-SE]) 27.1 +/- 5.9 months after endoscopic papillectomy. T1 cancer was shown to have lymphovascular invasion and/or lymph-node metastasis in 10.7% and duct mucosal involvement in another 17.9%. Among them, patients with focal T1 cancer showed no lymphovascular invasion or lymph-node metastasis and no ductal involvement, and none of the patients who underwent endoscopic papillectomy alone had cancer recurrence or disease-related death for mean (+/-SE) 32.2 +/- 6.7 months. LIMITATIONS: Single-center, retrospective study, small number of patients, and medium-term follow-up period. CONCLUSIONS: Endoscopic papillectomy may be a curative treatment for ampullary adenoma with HGIN/Tis and should also be considered as an alternative to surgery in focal T1 cancer in ampullary adenoma.     

Clinicopathological study of lymph-node metastasis in 1,389 patients with early gastric cancer: assessment of indications for endoscopic resection

BACKGROUND: The endoscopic resection of early gastric cancers (EGC) is a standard technique in Japan and is increasingly used throughout the world. Further experience in the treatment of EGC and a clearer delineation of the factors related to lymph‐node metastasis would permit a more accurate assessment of endoscopic resection. METHODS: The study group comprised 1389 patients with EGC who underwent gastrectomy with lymph‐node dissection. We evaluated the relations of lymph‐node metastasis to clinicopathological factors. RESULTS: Of the 718 patients with intramucosal carcinomas, 14 (1.9%) had lymph‐node metastasis. All cases of lymph‐node metastasis were associated with ulceration. No lymph‐node metastasis was found in patients with intramucosal carcinomas without ulceration, irrespective of tumor size and histological type. Lymph‐node metastasis was present in 14 (4.7%) of the 296 patients who had cancer with a submucosal invasion depth of less than 500 μm (sm1). Significantly increased rates of lymph‐node metastasis were associated with undifferentiated types, ulcerated lesions and lymphatic invasion. No lymph‐node metastasis was found in patients with differentiated sm1 carcinomas 30 mm or less in diameter without ulceration. Lymph‐node metastasis occurred in 29% of the patients who had cancer with a submucosal invasion depth of 500 μm or more (sm2). CONCLUSION: This large series of patients with EGC provides further evidence supporting the expansion of indications for endoscopic treatment, as well as warns against potential risks.     

Ampullary neuroendocrine tumor diagnosed by endoscopic papillectomy in previously confirmed ampullary adenoma

Ampullary adenoma is a common indication for endoscopic papillectomy. Ampullary neuroendocrine tumor(NET) is a rare disease for which complete surgical resection is the treatment of choice. However, because of the morbidity and mortality associated with surgical resection, endoscopic papillectomy is increasingly used in selected cases of low grade, with no metastasis and no invasion of the pancreatic or bile duct. Also, confirmed and complete endoscopic resection of ampullary NET accompanied by adenoma has not been reported to date. We report herein a rare case of an ampullary NET accompanied with adenoma, which was successfully and completely resected via endoscopic papillectomy. Prior to papillectomy, this case was diagnosed as an ampullary adenoma.     

New indication for endoscopic treatment of colorectal carcinoma with submucosal invasion

BACKGROUND AND AIMS: Although an increasing number of early colorectal cancers (CRC) have been curatively treated by endoscopy, there have been no definitive criteria to decide the effectiveness of such therapy. We retrospectively analyzed clinicopathological factors to establish criteria for curative endoscopic treatment of early CRC. METHODS: First, risk factors of lymph node metastasis were analyzed in 171 patients who received surgery with postoperative histology of CRC submucosal invasion. The resultant new criteria were evaluated in another 60 patients who experienced endoscopic resection of CRC and surgery according to the current criteria most often used in Japan. RESULTS: In the first substudy, lymph node metastasis was present in 18 of 171 patients (10.5%). Lymphatic permeation, sprouting and infiltrative growth of cancer cells were identified as histological factors significantly related to lymph node metastasis, and observed in much higher rates when the depth of submucosal invasion was beyond 1,500 micron. The minimum depth with positive lymph nodes was 1,075 micron. In the second group of 60 patients, lymph node metastasis was recorded in none of nine patients who met our new criteria of complete endoscopic treatment: submucosal invasion below 1,500 micron in depth, and no lymphatic permeation, sprouting or infiltrative growth pattern on tumor histology. Lymph node metastasis was positive in three of the other cases who did not meet our new criteria. CONCLUSIONS: The present study showed that endoscopic treatment of early CRC may be considered complete when submucosal invasion beyond 1,500 micron, lymphatic permeation, sprouting, and infiltrating growth are all denied.     

Prognostic factors of tracheobronchial mucoepidermoid carcinoma--15 years experience

Background and objectives:   Mucoepidermoid carcinoma of the tracheobronchial tree is a rare tumour which displays a variable degree of clinical aggressiveness and malignancy. The relationship between the patient's prognosis and the tumour's histological features and clinical behaviour is uncertain. The aim of this study was to identify the clinicopathological features and analyse the outcomes of patients with this type of cancer.
Methods:   A retrospective analysis of the medical records of patients diagnosed with mucoepidermoid carcinoma of the lung between 1991 and 2006 was conducted.
Results:   The study comprised 15 patients. Higher histological grade tumours had a higher proportion of squamoid cells ( P  = 0.019); the tumours of patients with lymph node metastases also had a higher proportion of squamoid cells than did the tumours of patients without lymph node metastases ( P  = 0.015). Patients with early stage tumours (stage IA, IB, IIB) had better outcomes (10-year survival rate = 87.5%), than did patients with late-stage tumours (stage IIIB, IV) (1-year survival rate = 28.6%; 2-year survival rate = 0%, P  = 0.001). Patients with lower-grade tumours (grade 1 and grade 2) had better outcomes (1-year survival rate = 80%; 5-year survival rate = 57.1%) than did patients with higher-grade tumours (grade 3) (1-year survival rate = 20%, P  = 0.035). Tumour staging was a significant independent predictor of survival on Cox proportional hazards analysis.
Conclusions:   The proportion of squamoid cells on tumour histology may be an indicator of the level of tumour malignancy. Tumour, node, metastasis staging is a significant determinant of prognosis in patients with tracheobronchial mucoepidermoid carcinoma.     

Clinicopathological evaluation of duodenal well-differentiated endocrine tumors

AIM:To assess the clinicopathological characteristics of duodenal well-differentiated endocrine tumors.METHODS:We examined clinicopathological characteristics in 11 consecutive patients with duodenal well-differentiated endocrine tumors treated by endoscopic therapy or surgery in our hospital from 1992 through 2007.Patients with well-differentiated endocrine tu-mors of the papilla of Vater or with gastrinoma were excluded.RESULTS:Three patients received endoscopic treatment,and 8 underwent surgery.In patients who received endoscopic treatment,the tumor diameter was less than 1.0 cm,with no histopathological evidence of lymphovascular invasion or invasion of the muscularis.There were no complications such as late bleedingor perforation after treatment.Among 8 patients with tumors less than 1.0 cm in diameter,3 underwent partial resection,and 2 underwent radical surgery.Three patients had lymphovascular invasion,1 had invasion of the muscularis,and 1 had proximal lymph node metastasis.Among 3 patients with tumors 1.0 cm or more in diameter,1 underwent partial resection,and 2 under-went radical surgery.One patient had lymphovascular invasion,with no lymph node metastasis.After treatment,all patients are alive and have remained free of metastasis and recurrence.CONCLUSION:Duodenal well-differentiated endocrine tumors less than 1.0 cm in diameter have a risk of lym-phovascular invasion,invasion of the muscularis,and lymph node metastasis,irrespective of procedural prob-lems.     

A case of early carcinoma of the papilla of Vater confined to the mucosa and continuative epithelium of glands in Oddi's sphincter (m-God) treated by endoscopic papillectomy

We herein report a case of early stage ampullary cancer, treated by endoscopic papillectomy, in which tumor extension was confined to the mucosa and adjacent epithelium of the glands in Oddi's sphincter. A 77-year-old man underwent screening esophagogastroduodenoscopy, which revealed a mass in the papilla of Vater, which was well-differentiated adenocarcinoma as proven by biopsy. The tumor was diagnosed as T1 and endoscopic papillectomy was performed. Histological examination showed adenocarcinoma limited to the mucosa of the common channel and continuative epithelium of the neighboring glands in Oddi's sphincter. No signs of recurrence have been observed during a follow-up of 23 months.     

Predictive factors for lymph node metastasis of differentiated submucosally invasive gastric cancer

BACKGROUND: For early gastric cancer, submucosal invasion may be unrecognized until histopathologic examination of the specimen obtained by EMR. Gastrectomy with lymphadenectomy is the standard treatment for such submucosal cancers. However, approximately 80% of submucosal cancers do not have lymph node metastasis. Unnecessary surgery could be avoided if a subgroup of patients with submucosal cancer with negligible risk of lymph node metastasis can be defined. This study was conducted to define such a subgroup. METHODS: Data from 104 patients surgically treated for differentiated submucosal cancers were retrospectively collected. A multivariate analysis of clinicopathologic factors was performed to identify predictive factors for lymph node metastasis. RESULTS: Three independent risk factors, namely, female gender (p=0.0174), deep invasion (> or =500 microm) into the submucosal layer (p=0.001), and presence of lymphatic involvement (p < 0.0001) were associated with lymph node metastasis. Lymph node metastasis was not observed in any patient who had limited submucosal invasion and absence of lymphatic involvement. The rate of lymph node metastasis was calculated to be 80% in patients who had both deep submucosal invasion and lymphatic involvement. CONCLUSIONS: If endoscopic resection specimens exhibit no deep penetration (<500 microm) into the submucosal layer and lymphatic involvement is absent, EMR may be sufficient treatment for submucosal well-differentiated early gastric cancers. A long-term follow-up study of patients with such lesions treated by EMR alone is required.     

Proposed indications for limited resection of early ampulla of Vater carcinoma: clinico-histopathological criteria to confirm cure

Background

Limited resection is reserved for patients with high operative risk or benign adenomas. We aimed to define indications for limited resection of early ampulla of Vater carcinoma with curative intent through detailed preoperative examinations and histopathological evaluations.

Methods

We performed a retrospective cohort study of all consecutive Japanese patients who underwent resection for ampulla of Vater neoplasms at our hospital from 1986 to 2010.

Results

A total of 75 patients were identified. Moderately/poorly differentiated histology, lympho-vascular/perineural invasion, and duodenal/pancreatic invasion were significant risk factors for lymph node metastases. Macroscopically, non-exposed protruded- or ulcerative-type disease did not correlate directly with lymph node metastases; however, these tumor types were associated with other invasive features. In a subset of early carcinomas fulfilling the conditions of exposed protruded adenoma or papillary/well-differentiated adenocarcinoma determined by endoscopic biopsy, negative duodenal invasion determined by endoscopic ultrasonography, no tumor infiltration into the pancreatic duct determined by intraductal ultrasound, and diameter of the pancreatic duct ≤3?mm determined by endoscopic retrograde cholangiopancreatography (N?=?11), the incidence of lymph node metastasis and tumor infiltration into the pancreatic duct was 0%.

Conclusion

Strictly selected patients with early ampulla of Vater carcinomas may benefit from limited resection if the resected specimen is evaluated to confirm all histopathological criteria.     

Risk Factors for Occult Lymph Node Metastasis of Colorectal Cancer Invading the Submucosa and Indications for Endoscopic Mucosal Resection

Purpose Although risk factors for histologically overt lymph node metastasis in patients with early-stage colorectal cancer have been clarified, the risk factors for occult lymph node metastasis are not clear. This study was designed to clarify risk factors for lymph node metastasis, including occult metastasis, in patients with colorectal cancer invading the submucosa and to determine the criteria for endoscopic resection of early colorectal cancer. Methods The risk factors for lymph node metastasis, including occult metastasis, were analyzed in 86 cases of surgically resected colorectal cancer invading the submucosa. The lymph nodes were assessed by immunohistochemistry with cytokeratin antibody CAM5.2. Results The frequencies of overt and occult metastasis to the lymph nodes were 13 percent (11/86) and 13 percent (10/75), respectively. Multivariate analysis showed vascular invasion (P = 0.001) and tumor budding (P = 0.003) to be independent risk factors for lymph node metastasis, including occult metastasis. For tumors with submucosal invasion ≤1,000 μm, no lymph node metastasis was found. The frequencies of lymph node metastasis for tumors with submucosal invasion of 1,000 to 2,000 μm and >2,000 μm were 21 and 37 percent, respectively. In considering combinations of risk factors, there was no lymph node metastasis in tumors having neither vascular invasion nor tumor budding and submucosal invasion of ≤3,000 μm. Conclusions Vascular invasion, tumor budding, and the degree of submucosal invasion were significant risk factors for lymph node metastasis, including occult metastasis. These three factors can be used in combination to identify patients requiring additional surgery after endoscopic resection. Supported in part by a Grant-in-Aid for Scientific Research (no. 15390401) from the Japanese Ministry of Education, Science, and Culture. Presented at the Congress of Japan Surgery Society, Tokyo, Japan, March 29 to 31, 2006. Reprints are not available.     

MUC-1 expression as a predictor of the curative endoscopic treatment of submucosally invasive colorectal carcinoma

PURPOSE: This study was undertaken to clarify the clinical significance of MUC-1 expression in the endoscopic treatment of colorectal carcinoma with submucosal invasion. METHODS: One hundred eighty-four colorectal carcinomas with submucosal invasion were examined. The depth of submucosal invasion was classified as scanty or massive. The histologic subclassfication at the deepest invasive portion was defined as well-differentiated, moderately well-differentiated, moderately to poorly differentiated, poorly differentiated, or mucinous adenocarcinoma. MUC-1 expression was examined immunohistochemically at the deepest invasive portion. In addition, the Ki67 labeling index was also examined immunohistochemically. RESULTS: Lymph node metastases were detected in 28 (15.2 percent) of 184 lesions. Lesions with both scanty submucosal invasion and well-differentiated or moderately well-differentiated adenocarcinomas had no lymph node metastases. MUC-1 expression was detected in 88 (47.8 percent) of 184 lesions and correlated significantly with the presence of lymph node metastases. The Ki67 labeling index also correlated significantly with lymph node metastases. Furthermore, lesions with both MUC-1-negative and low Ki67 labeling index showed no lymph node metastases, even in lesions with massive submucosal invasion. Multivariate analysis indicated that MUC-1 expression was one of the most important risk factors for lymph node metastases and histologic grade among the clinicopathologic factors usually examined. CONCLUSION: MUC-1 expression is one of the accurate predictors of the presence of lymph node metastases among the clinicopathologic factors commonly used. Combined analysis of MUC-1 expression and Ki67 labeling index may be a useful indicator of lymph node metastases and may broaden the indications for the curative endoscopic treatment of carcinoma with massive submucosal invasion.     

Case of early ampullary cancer treated by endoscopic papillectomy

We herein report a case of ampullary cancer in a 65‐year‐old man who underwent endoscopic papillectomy. Duodenoscopy revealed an exposed‐type tumor mass at the ampulla of Vater. Histology of the biopsy specimen demonstrated well‐differentiated adenocarcinoma. Endoscopic ultrasonography and intraductal ultrasonography showed a hypoechoic mass limited to the ampulla of Vater (clinical stage, T1). Endoscopic papillectomy was performed after informed consent was obtained. Histological examination of the resected specimen revealed adenocarcinoma limited to the ampulla of Vater (final stage, pT1). Both accurate preoperative T staging and proper histological evaluation of the resected specimen appear to justify endoscopic treatment of early ampullary cancer.     

Predictive factors of lymph node metastasis in patients with undifferentiated early gastric cancers

BACKGROUND: For intramucosal differentiated early gastric cancer that has little risk of lymph node metastasis, local treatment such as endoscopic mucosal resection has been generally accepted as an adequate treatment. We studied clinicopathological characteristics of undifferentiated early gastric cancer at our institution to identify the predictive factors for lymph node metastasis and qualify lesions that should be referred for gastrectomy and not endoscopic mucosal resection. METHODS: We retrospectively analyzed the clinicopathological features (patient age and gender, tumor size, location, macroscopic type and histological type, presence of ulceration, depth of tumor invasion, and lymphatic-vascular involvement) in 332 patients with undifferentiated early gastric cancer who underwent gastrectomy with regional lymph node dissection. RESULTS: Lymph node metastasis was observed in 45 patients (14%). Univariate analysis revealed that depth of tumor invasion (submucosa), tumor size (>30 mm), and lymphatic-vascular involvement (positive) were associated with lymph node metastasis. Only lymphatic-vascular involvement (positive) was found to have a significant association (odds ratio, 7.4; 95% confidence interval, 2.9-19.0) by multivariate analysis. CONCLUSIONS: Lymphatic-vascular involvement was the only independent predictive risk factor for lymph node metastasis. This pathologic factor was not useful for identifying patients at high risk of lymph node metastasis who should be offered gastrectomy rather than endoscopic mucosal resection.     

Pathological characteristics of early to advanced gallbladder carcinoma and extrahepatic cholangiocarcinoma

Biliary tract cancer (cancer of gallbladder and extrahepatic bile duct) is the most common malignancy of the biliary tract, and is considered to be a high‐grade malignancy. In this study, we reviewed 293 gallbladder cancers and 102 bile duct cancers for clarifying growth and invasion of the extrahepatic bile duct cancer. Only 10.5% (9/86) of the early gallbladder cancers showed lymphatic invasion, but neither venous invasion nor lymph node metastasis was noted in the early cancers. 70.6% (207/293) of the gallbladder cases were pT2‐3 cancers, and frequently showed lymphatic/venous/perineural invasion and/or lymph node metastasis. 12.7% (13/102) of the extrahepatic bile duct cancers were pTis or pT1 cancers, which were categorized as early cancers. Only 15.4% (2/13) of the early cancer showed vascular/perineural invasion and/or lymph node metastasis. The majority (87.3%) of the extrahepatic bile duct cases was pT2‐3 cancers, and frequently showed vascular/perineural invasion and/or lymph node metastasis. We also examined intramural invasion patterns; i.e. intramural invasion patterns were defined as infiltrative growth (IG) type, and destructive growth (DG) type. The overall survival rate of the gallbladder cancer patients with the DG type was significantly lower than that of the patients with the IG type, associated with frequent lymphatic/venous invasion and/or lymph node metastasis. Therefore, pathological characteristics are important for clinical manifestation of the gallbladder/extrahepatic bile duct cancers.     

Predictive factors for lymph node metastasis in t1 stage colorectal Carcinomas

Purpose Selective endoscopie resection may cure early colorectal cancer (Tl), but the management is controversial. There is concern about the small risk of lymph node metastasis, which will not be treated by endoscopie resection alone. The authors sought predictive markers of lymph node metastasis to assist patient management. METHODS: The authors retrospectively analyzed consecutive cases of Tl stage colorectal cancer resected using endoscopie resection or bowel surgery over the period 1979 to 2000. The risk of lymph node metastasis was analyzed using logistic regression model for the markers selected by univariate analysis: the type of initial treatment, depth of submucosal invasion, lymphatic channel invasion, differentiation of histology, and invasive front histology. RESULTS: Two hundred seventy-eight patients were available for study. Twenty-one had lymph node metastasis. Depth of submucosal invasion (2 2,000 yum) and lymphatic channel invasion significantly predicted risk of lymph node metastasis in multivariate analysis. When these two factors were adopted for the prediction of lymph node metastasis, sensitivity, specificity, positive predictive value, and negative predictive value were 100, 55.6, 15.6, and 100 percent, respectively. CONCLUSIONS: Depth of submucosal invasion and lymphatic channel invasion were accurate predictive factors for lymph node metastasis. These two factors could be used in selecting appropriate cases for surgery after endoscopie resection. Poster presentation at meeting of the American Society of Colon and Rectal Surgeons, San Diego, California, June 2 to 7, 2001.     

A proposal of an appropriate surgical approach for cancer of the ampulla of Vater: retrospective analysis of 73 resected cases

BACKGROUND/AIMS: Because early ampullary cancer has a good prognosis, less invasive surgery should be considered. But recent reports point out limitations of ampullectomy. METHODOLOGY: Between April 1975 and March 2005, seventy-three patients with ampullary cancer were treated. The survival rates of different clinicopathologic features were analyzed retrospectively. RESULTS: Macroscopically, N(-) (negative lymph node metastasis), Panc(-) (no invasion of the pancreatic parenchyma) patients had a significantly longer 5-year survival rate than N(+) (positive lymph node metastasis), Panc(+) (invasion of the pancreatic parenchyma) patients (61.1% vs. 23.1%, 62.2% vs. 21.9%). Histologically, n(-), panc(-), and du(-) (no invasion of the duodenum) patients also had a significantly longer 5-year survival rate than n(+), panc(+), and du(+) (invasion of the duodenum) patients (63.3% vs. 21.1%, 64.3% vs. 29.8%, 83.3% vs. 36.8%, respectively). Patients with Panc(+), Du(+), mixed type and tumors other than the exposed type had significantly more lymph node metastases. CONCLUSIONS: We propose PpPD and regional lymph node dissection as the reasonable operative method. If the tumor is preoperatively diagnosed as Panc(-), Du(-) and N(-), less invasive surgery may be indicated.     

Lymphatic invasion in small differentiated-type mucosal gastric cancer

Endoscopic resection for early gastric cancer is indicated for patients who are at negligible risk of lymph node metastasis. A 71-year-old female underwent endoscopic resection for a 15-mm differentiated-type mucosal gastric tumor, as recommended in the Japanese treatment guidelines. A histological examination revealed lymphatic invasion. Therefore, we performed laparoscopy-assisted distal gastrectomy and D1+ lymph node dissection. A histological examination detected no.3 lymph node metastasis, but no residual cancer cells were observed at the site of the endoscopic resection. This case is rare as lymphatic invasion and lymph node metastasis are highly unusual in small differentiated-type mucosal gastric cancer. Having experienced this case, we consider that en-bloc endoscopic resection of such lesions is extremely important, as it allows precise histological examinations to be performed, which can determine the necessity of additional treatment.     

INDICATIONS FOR ENDOSCOPIC MUCOSAL RESECTION FOR EARLY COLORECTAL CANCER: SHOULD THEY BE STRICT OR SHOULD THEY BE EXPANDED?

Endoscopic technologies have been developed greatly. As for early gastric cancer, the indications for endoscopic mucosal resection for early colorectal cancer have been widened recently. Technological advances can support wider and deeper resections using endoscopy but the remaining problem for the endoscopic management of cancer is lymph node metastasis. I discuss here the indication for endoscopic mucosal resection for early colorectal cancer to bring into focus the risk factors for metastasis to lymph nodes.     

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.