Diagnosis of esophagogastric tumors

There is increasing concern regarding the need to establish guidelines for upper gastrointestinal endoscopy. This applies to the reliability of the diagnosis of early cancer, tolerance, and the need to reduce the use of conscious sedation in order to contain costs--one reason why nasogastroscopy with a thin fiberscope is being applied with increasing success. Recent advances that have been made in the early diagnosis of esophageal and gastric tumors now require high-resolution video gastroscopes and the routine use of chromoscopy. For a long time, the helpful contribution made by the zoom video endoscope to the identification of the pit pattern in neoplastic lesions was limited to the colon. However, the most recent zoom endoscopes, with improved mechanical characteristics and a standard diameter, have now opened up relevant applications in the analysis of early esophageal or gastric malignancies. The best example of this is the identification of the pit pattern in intestinal metaplasia in Barrett's esophagus, although the classification of the pit pattern in upper gastrointestinal neoplasia is still being investigated. Spectroscopic analysis of the response of neoplastic tissue to an applied photon beam has been hampered by the complex origins of the efferent photons. Recent technology, available only through a physical laboratory allows simultaneous analysis of fluorescence, reflectance, and light scattering. In this situation, the method has obtained sensitivity and specificity rates of nearly 100% in classifying low-grade dysplasia, high-grade dysplasia, and cancer in Barrett's esophagus. With regard to depth exploration in the wall of the digestive tract, endosonographic examination using a high-frequency probe (20-30 MHz) may be challenged in the future by the technique of optical coherence tomography, a method that does not require acoustic transmission through water and provides a much higher resolution, of up to 10 microm. Optical coherence tomography could be used in the staging of intramucosal esophageal cancer and for detecting intestinal metaplasia in the esophagus. In conclusion, the increasing progress being made in the accuracy of endoscopic diagnosis emphasizes the need for cost-benefit analyses of screening and surveillance protocols.     

Diagnosis of esophagogastric tumors

Esophagogastric tumors occur in three sectors: the esophagus, the EG junction and the non-cardia stomach. Neoplasia develops in the squamous stratified epithelium of the esophagus and in the columnar epithelium of the Barrett's esophagus or in the stomach. At the junction, tumors arise either in a very short Barrett's esophagus or in the gastric epithelium of the cardia. The prognosis of tumors detected at the advanced stage is poor. Secondary prevention requires detection at the early stage. Most superficial neoplastic lesions in the esophagus and in the stomach have a non-protruding appearance, which is similar for premalignant and malignant lesions. Improved accuracy in endoscopic diagnosis and prediction of histology prior to biopsy and treatment decision is based upon magnification with a optical zoom and electronic processing of the captured image with structure enhancement, enhancement of the color of hemoglobin and narrow band imaging. This applies particularly to the exploration of the Barrett's esophagus for identification of the areas with intestinal metaplasia and of flat neoplastic areas. In spite of the predictive value of endoscopy for histology, biopsy samples are still required for pathology and eventually studies with biological markers. Spectroscopic techniques provide a new perspective, up to the level of molecular endoscopy, but they are unlikely to be cost/effective. The classification in the sub-types 0 of neoplastic lesions has some relevance to prediction of depth of invasion. In the esophagus, EUS staging with high frequency miniprobes is a useful complement.     

Diagnosis of esophagogastric tumors

The incidence of esophageal tumors, and of adenocarcinoma in particular, has risen markedly in recent years in the developed countries. The use of a variety of histopathological and biological markers is now offering promising prospects for the future. Vertical tumor invasion, intratumoral microvessel density, antimucin monoclonal antibodies, flow cytometry, telomerase activity, and overexpression of cyclin D1 have been correlated with the staging and prognosis of esophageal carcinomas. By combining these markers with Lugol staining, a practical new method of staging esophageal tumors may become available in the coming years. As is well known, Barrett's mucosa is a preneoplastic condition. Discussions in the literature concerning short forms of Barrett's esophagus and their relationship to inflammation of the gastric cardia appear to describe two different scenarios--a gastroesophageal reflux condition for short forms of Barrett's esophagus, and an inflammatory phenomenon (perhaps unrelated to Helicobacter pylori infection) for inflammation of the gastric cardia. Cost-benefit studies of follow-up procedures in Barrett's esophagus have yet to be conducted, and considerable efforts--mainly using biological markers--are being made to identify those patients who are at greatest risk. Although the frequency of gastric tumors has declined in recent years, many as yet unclear aspects of these tumors have been studied. Technological progress has not led to substantial changes in the diagnostic procedures used, although autofluorescence methods and three-dimensional reconstruction have been analyzed. Laparoscopy, preferably combined with the use of ultrasound probes, may be a valuable tool for staging. The suggestion that endoscopy should be avoided in young patients (the "treat but do not scope" approach) has been seriously questioned, as it may lead to early cancer being overlooked. There is thought to be an intermediate stage of gastric cancer (between the early and advanced stages) in which the muscularis propria, but not the serosa, is invaded. Endoscopic ultrasonography is becoming increasingly established as a basic tool for the staging of gastric cancer. Gastric MALT lymphoma can be cured by H. pylori eradication therapy in many cases, but there is still uncertainty regarding the limitations of this approach.     

Diagnosis of esophagogastric tumors

It has been suggested that certain histological criteria may serve to indicate a good prognosis in patients with esophageal carcinoma. These include absence of subepithelial extension of the carcinoma cells, stage no higher than m2, and no neoplastic involvement near the resection margin. As endoscopic mucosal resection is becoming an accepted treatment option in this type of tumor, prognostic parameters of this type are of particular interest. By contrast, when metastases are detected in the celiac lymph nodes, it implies that the tumor is unresectable and that palliative treatment is required. Endoscopic ultrasound (EUS)-guided fine-needle aspiration has been found to be the most cost-effective option in this setting. Although autofluorescence endoscopy is being tested as a new technique for endoscopic diagnosis, its value is at present unclear. However, such developments may lead to improved diagnosis in the future, particularly in relation to the initial stages of carcinoma. For the moment, EUS is still the most widely accepted method for early diagnosis and staging. Esophageal squamous-cell carcinoma appears to be commonly associated with head and neck cancer, but the cost-effectiveness of surveillance is a matter of controversy. With regard to Barrett's esophagus and adenocarcinoma, p53 staining in areas of low-grade dysplasia appears to be helpful for predicting progression to high-grade dysplasia. The prevalence of short-segment Barrett's esophagus increases with age, but the length of the segment does not increase with time; the length probably depends on individual conditions, not merely on elapsed time. Helicobacter pylori infection appears to be associated with intestinal metaplasia at the esophagogastric junction. However, the most recent data appear to suggest that this scenario (usually termed "carditis") may be different from intestinal metaplasia in the lower esophagus, related to acid reflux. A follow-up program might be able to detect Barrett's esophagus adenocarcinoma at earlier stages, but only a minority of Barrett's esophagus patients are likely to be detected before neoplasia has developed. Gastric cancer appears to develop in individuals with H. pylori infection, but not in uninfected persons. In addition, those with severe gastric atrophy, corpus-predominant gastritis, and intestinal metaplasia may be at greater risk for gastric cancer. This again raises the question of H. pylori eradication in asymptomatic individuals with infection, and surveillance of patients with severe intestinal metaplasia. The most recent data appear to support the notion that healing of MALT lymphoma depends not only on H. pylori eradication and on the stage of the tumor, but also on individual factors (possibly immunology-related).     

Treatment of esophagogastric tumors

Palliative endoscopic treatment of esophagogastric cancer is now possible using expandable metal stents. The properties, advantages, and drawbacks of these stents have been extensively analyzed, and there is no doubt that they are now easy and safe to introduce, without serious morbidity. However, the frequency of persistent thoracic pain and delayed complications, as well as the high rate of repeat interventions required, justify limited use of the procedure. The major indication for the procedure is dysphagia due to cancer in the esophagus or at the cardia. Enteral stents have been used in the treatment of malignant duodenal or jejunal stenoses, but the results are poor. A promising new area is the treatment of benign stenoses using expandable and biodegradable stents. It may be possible to use this technique for surgical anastomoses after tumor resection. Careful endoscopic analysis of the mucosal surface is necessary to establish the strict indications for endoscopic mucosal resection for mucosal malignancy. Biopsy evidence of the relation between lesion diameter, a depressed surface pattern and the depth of invasion into the submucosa, as well as the extent of regional or distant lymphatic invasion, provides the best guidelines for safe curative mucosectomy in gastric cancer. Endoscopic therapy is always safe in lesions less than 1cm in diameter; for other lesions, resection is safe when the depth of submucosal invasions is less than 300 microm. In other situations, surgery is preferable in patients who are otherwise in good health. In Japan, the results of the National Survey of Gastric Cancer, with cases detected by screening, confirmed the benefits of adherence to these guidelines; most patients were treated surgically, and only 7% with endoscopic therapy.     

Treatment of esophagogastric tumors

Esophageal and gastric tumors are often considered as a single group: they share similar symptoms - upper GI endoscopy with a flexible video-endoscope is the gold standard procedure of detection - similar techniques of endotherapy for cure or palliation are offered for both types of tumors. When the endoscopic procedure is performed for a superficial cancer or its precursors, with a curative intent, endoscopic mucosal resection (EMR) is generally preferred to mucosal ablation with a thermal (Nd:YAG) or non-thermal (photodynamic therapy) procedure. In addition to esophageal squamous cell cancer and gastric cancer, new indications of EMR arise in the Barrett esophagus. Guidelines for safe indications concern diameter, polypoid or non polypoid morphology with the subtypes elevated, flat and depressed, and depth of invasion. A superficial invasion in the sub-mucosa is a relative contra-indication in the esophagus, but not in the stomach. The technique of EMR is now codified with an injection into the submucosa for lifting the lesion and either suction with a cap, grasping with a forceps if a 2 channel instrument is used, or tissue incision with a needle knife. En bloc, gives better results than piecemeal resection. The most frequent complication is bleeding. When legitimate indications are respected, the results of EMR are equivalent to those of surgical resection and have reached the consensus level. The major indication in palliation is the relief of dysphagia from malignant esophageal obstruction. Increased indications are proposed for malignant pyloric obstruction. Multiple models of metal expandable and coated stents with appropriate balance between rigidity and flexibility (nitinol alloy) and enough expansive radial force are now offered. After stenting the survival period is short and there is a toll of complications.     

Submucosal tunneling endoscopic resection for tumors of the esophagogastric junction

Background: For submucosal tumors (SMTs) originating from the muscularis propria (MP) layer of the esophagogastric junction (EGJ), submucosal tunneling endoscopic resection (STER) is now widely used, and it shows promise in overcoming the limitations of endoscopic submucosal dissection. Aims: This study aimed to evaluate the efficacy and safety of the STER technique for treating SMTs of the EGJ originating from the MP layer. Material and methods: From October 2011 to February 2014, 20 patients were enrolled for STER surgery. Results: The patients were categorized into three groups according to the tumor location. The esophagocardiac group had a lower complication rate (0/7) compared with the cardiac group (3/6) and the gastrocardiac group (3/7). The mean operation time in the esophagocardiac (83?±?24?min) and cardiac (83?±?55?min) groups was significantly shorter than that of the gastrocardiac group (145?±?44?min) (P?Conclusions: The STER technique appears to be a feasible and safe minimally invasive approach for SMTs originating from the MP layer of the EGJ, with satisfying en bloc resection, a short operation time, and low rates of severe complications.     

Efficacy and safety of endoscopic submucosal dissection for tumors of the esophagogastric junction

BACKGROUND AND STUDY AIMS: The esophagogastric junction (EGJ) has been considered a difficult location for endoscopic treatment of tumors, due to its narrow lumen and sharp angle. Endoscopic submucosal dissection (ESD) is a method of endoscopic resection, capable of removing large tumors in an en bloc fashion. The aim of this study was to evaluate the efficacy and safety of ESD for EGJ tumors. PATIENTS AND METHODS: For 30 lesions of EGJ tumors treated by ESD, the size of the lesions and resected specimens, the en bloc resection rate, complications, and local recurrence were assessed. RESULTS: The average maximum diameters of the lesions and resected specimens were 22.4 mm and 40.6 mm respectively. The complete en bloc resection (R0) rate was 97% (29/30). Histological evaluation of the resected specimens revealed five cases of angiolymphatic invasion and five cases of submucosal invasion deeper than 500 microm. Perforation occurred in one case but was safely managed by rotatable clips and administration of antibiotics for 3 days. Local recurrence was not observed in any patient during follow-up (mean 14.6 months, range 6-31 months). CONCLUSIONS: ESD can be safely performed for EGJ tumors, with a high en bloc resection rate. For lesions with no apparent submucosal invasion findings, ESD is a curative and diagnostic treatment option that may be considered before open surgery.     

肾上腺肿瘤的CT诊断

目的 讨论CT对肾上腺肿瘤的诊断价值。方法 回顾性分析50例经手术病理证实的各类肾上腺肿瘤,观察其CT征象,结合病理,提出诊断和鉴别诊断。结果 醛固酮腺瘤肿块小,细胞内富含脂质而密度低;皮质醇腺瘤肿块稍大,中等密度,嗜铬细胞瘤肿块较大,囊变及周围强化明显为其特征;肾上腺髓脂瘤为一种少见无功能性能上腺良性肿瘤,肿块大,内含低密度脂肪成分为其特征;肾上腺转移瘤表现多样,肿块大小不等,密度不均匀,主要依据原发肿瘤。神经节瘤及肾上腺皮质腺瘤CT表现光明显特异性,定性诊断较难,病理有一定特点。结论 CT对肾上腺肿瘤检出率高,在定性诊断有一定参考价值。本组诊断符合率为78％。     

小脑常见肿瘤的CT诊断和鉴别诊断

目的 探讨小脑常见肿瘤的CT特征性表现。方法搜集我院2002年1月-2004年7月经临床、病理和CT、MRI综合诊断的250例小脑常见肿瘤。全部病例均做增强扫描检查，大部分病例做叠加增强扫描检查。结果76例在术前经行CT平扫及增强扫描得到明确诊断，有特征性表现147例。结论根据患者的年龄、部位及CT表现有助于小脑常见肿瘤的诊断和鉴别诊断。     

Diagnosis of primary tumors of the trachea

The paper presents 10-year results of endoscopic examinations which have been performed of late in the Endoscopy Department of the All-Union Cancer Research Center. Altogether 36 patients with primary tracheal tumors (PTTs) were evaluated. The study of PTTs endoscopic pattern suggested the conclusion on feasibility of visual differential diagnosis of various tumors and assessment of the tumor spread along the bronchial tree.