2020年日本食管癌内镜黏膜下剥离术和内镜黏膜切除术指南的解读：食管鳞癌部分

2020年日本胃肠内镜学会制定并发布了食管癌内镜黏膜下剥离术/内镜黏膜切除术指南。该指南基于已发表的大量临床研究证据,针对18个临床问题提出建议,问题涉及食管癌的术前诊断、内镜切除适应证、内镜切除方案、可治愈性评估以及术后监测5个方面,旨在解决实际工作中的问题并提高临床实践质量,主要内容包括食管鳞癌和食管腺癌2个部分,本文主要就食管鳞癌部分的指南内容进行解读。     

Endoscopic management of gastric dysplasia: Cutting edge technology needs a new paradigm

There has been tremendous progress in endoscopic techniques for the management of premalignant or malignant gastric lesions. Gastric cancer remains the second most common cause of cancer related mortality worldwide. This means that there is a need for early detection and diagnosis of premalignant lesions or early cancer in clinical practice. Despite substantial development of endoscopic resection techniques, the management of gastric premalignant lesions is controversial because of the lack of consensus and accurate risk stratification. Future study of various aspects would clarify these issues but in the meantime we should reconsider the current algorithm approach for the management of gastric low grade dysplasia.     

Magnifying endoscopy simple diagnostic algorithm for early gastric cancer (MESDA‐G)

Gastric cancer is the third leading cause of cancer death worldwide. Early detection and accurate diagnosis of mucosal cancer is desirable in order to achieve decreased mortality; cause‐specific survival of patients with early gastric cancer is reported to exceed 95%. Endoscopy is the functional modality to detect early cancer; however, the procedure is not definitive when using conventional white‐light imaging. In contrast, magnifying narrow‐band imaging (M‐NBI), a novel endoscopic technology, is a powerful tool for characterizing gastric mucosal lesions because it can visualize the microvascular architecture and microsurface structure. To date, many reports on the diagnosis of early gastric cancer by M‐NBI, including multicenter prospective randomized studies conducted in Japan, have been published in peer‐reviewed international journals. Based on these published data, we devised a proposal for a diagnostic strategy for gastric mucosal cancer using M‐NBI to simplify the process of diagnosis and improve accuracy. Herein, we recommend a diagnostic algorithm for early gastric cancer using magnifying endoscopy.     

A Case of Gastric Lipoma Removed by Endoscopic Polypectomy

Abstract: A rare case of gastric lipoma removed by endoscopic polypectomy is presented herein. A 64-year-old female was found to have a polypoid lesion in the stomach on periodic X-ray examination. Endoscopy revealed a submucosal tumor located on the posterior wall of the antrum. Endoscopic ultrasonography demonstrated a homogeneous, hyperechoic mass continuous with the submucosal layer, suggesting a lipoma. Because the likelihood of the tumor ultimately causing obstruction or prolapse into the duodenum was high, endoscopic polypectomy was performed. There were no complications. The histological examination revealed a mass of mature adipose tissue underneath the normal mucosa, which was consistent with the diagnosis made prior to polypectomy. The preferred treatment for gastric lipomas to date has been surgical excision, because the diagnosis is difficult to make prior to treatment. In the literature, only 17 cases undergoing endoscopic treatment for gastric lipomas have been reported. Endoscopic ultrasonography and computed tomography apparently facilitate preoperative diagnosis of lipomas.     

胃体萎缩的内镜诊断

胃体萎缩是较为少见的胃黏膜萎缩,多见于自身免疫性胃炎。胃体萎缩伴肠化生是胃癌的癌前病变。内镜是诊断胃体萎缩的重要手段。本文就胃体萎缩的内镜诊断进展作一综述。     

Vigilancia tras resección de pólipos de colon y de cáncer colorrectal. Actualización 2018

There is limited scientific evidence available to stratify the risk of developing metachronous colorectal cancer after resection of colonic polyps and to determine surveillance intervals and is mostly based on observational studies. However, while awaiting further evidence, the criteria of endoscopic follow-up needs to be unified in our setting. Therefore, the Spanish Association of Gastroenterology, the Spanish Society of Family and Community Medicine, the Spanish Society of Digestive Endoscopy, and the Colorectal Cancer Screening Group of the Spanish Society of Epidemiology, have written this consensus document, which is included in chapter 10 of the “Clinical Practice Guideline for Diagnosis and Prevention of Colorectal Cancer. 2018 Update”.Important developments will also be presented as regards the previous edition published in 2009. First of all, situations that require and do not require endoscopic surveillance are established, and the need of endoscopic surveillance of individuals who do not present a special risk of metachronous colon cancer is eliminated. Secondly, endoscopic surveillance recommendations are established in individuals with serrated polyps. Finally, unlike the previous edition, endoscopic surveillance recommendations are given in patients operated on for colorectal cancer. At the same time, it represents an advance on the European guideline for quality assurance in colorectal cancer screening, since it eliminates the division between intermediate risk group and high risk group, which means the elimination of a considerable proportion of colonoscopies of early surveillance. Finally, clear recommendations are given on the absence of need for follow-up in the low risk group, for which the European guidelines maintained some ambiguity.     

Lymphoepithelioma-like gastric carcinoma: A case report and review of the literature

Lymphoepithelioma-like gastric carcinoma is a rare type of gastric cancer characterized by a carcinoma with intense stromal lymphocytic infiltration. Although lymphocytic infiltration is closely associated with EpsteinBarr virus(EBV) infection, concomitant occurrence with differentiated adenocarcinoma is relatively rare. The clinical manifestations of lymphoepithelioma-like gastric carcinoma(including EBV-positive and-negative forms) are similar to those of gastric cancer, and the diagnosis is based on pathologic, histologic, and immunohistochemical findings. This report describes the case of a 55-year-old female patient who presented with a 10-year history of recurrent and worsening abdominal pain and melena that had been occurring for 2 mo. An ulcerative lesion was detected in the stomach by endoscopic examination, which raised suspicion of early gastric cancer. A subsequent preoperative endoscopic biopsy showed adenocarcinoma, but the postoperative pathologic, histologic, and immunohistochemical analyses of the resected specimen revealed a final diagnosis of lymphoepithelioma-like gastric carcinoma.     

Usefulness of artificial intelligence in gastric neoplasms

Recently, studies in many medical fields have reported that image analysis based on artificial intelligence (AI) can be used to analyze structures or features that are difficult to identify with human eyes. To diagnose early gastric cancer, related efforts such as narrow-band imaging technology are on-going. However, diagnosis is often difficult. Therefore, a diagnostic method based on AI for endoscopic imaging was developed and its effectiveness was confirmed in many studies. The gastric cancer diagnostic program based on AI showed relatively high diagnostic accuracy and could differentially diagnose non-neoplastic lesions including benign gastric ulcers and dysplasia. An AI system has also been developed that helps to predict the invasion depth of gastric cancer through endoscopic images and observe the stomach during endoscopy without blind spots. Therefore, if AI is used in the field of endoscopy, it is expected to aid in the diagnosis of gastric neoplasms and determine the application of endoscopic therapy by predicting the invasion depth.     

Endoscopic resection of benign very low-risk gastric gastrointestinal stromal tumors. Is it enough?

Great ongoing debate still exists over the definition, diagnosis and treatment of gastrointestinal stromal tumour especially for small gastric submucosal tumours. Simple endoscopic biopsy is not sufficient to determine their biological behaviour and their complete excision is necessary. We report the case of a 65-year-old woman, who was kept under observation after previously operated breast cancer, with a casual computed tomography-diagnosed submucosal gastric lesion. Endoscopy and endoscopic ultrasound confirmed a submucosal mass of 2-3 cm in diameter. An endoscopic resection was performed and the mass was integral at pathologic examination. It confirmed the stromal origin with a mitotic index of 1 (5/50 high power field). No more treatment was carried out because it was classified as a very low risk gastrointestinal stromal tumour according to Fletcher's classification. After 34 months follow-up, the patient is disease free and we believe that endoscopic treatment is sufficient and recommended for mainly intragastric growing gastrointestinal stromal tumour with a diameter of less than 3 cm.     

Endoscopic advances in the management of gastric cancer and premalignant gastric conditions

Gastric cancer is the fifth most common cancer and in 2018, it was the third most common cause of cancer-related deaths worldwide. Endoscopic advances continue to be made for the diagnosis and management of both early gastric cancer and premalignant gastric conditions. In this review, we discuss the epidemiology and risk factors of gastric cancer and emphasize the differences in early vs late-stage gastric cancer outcomes. We then discuss endoscopic advances in the diagnosis of early gastric cancer and premalignant gastric lesions. This includes the implementation of different imaging modalities such as narrow-band imaging, chromoendoscopy, confocal laser endomicroscopy, and other experimental techniques. We also discuss the use of endoscopic ultrasound in the diagnosis and staging of early gastric cancer. We then discuss the endoscopic advances made in the treatment of these conditions, including endoscopic mucosal resection, endoscopic submucosal dissection, and hybrid techniques such as laparoscopic endoscopic cooperative surgery. Finally, we comment on the current suggested recommendations for surveillance of both gastric cancer and its premalignant conditions.     

Characteristics and predictors of gastric cancer after Helicobacter pylori eradication

Helicobacter pylori(H. pylori) eradication can reduce gastric cancer. However, gastric cancer still develops after eradication, and cases who received eradication therapy are increasing. In this study, we have reviewed the characteristics and predictors of primary gastric cancer developing after H. pylori eradication. In terms of the characteristics, endoscopic, histologic, and molecular characteristics are reported. Endoscopically, gastric cancer after eradication is often depressedtype and shows a gastritis-like appearance, which sometimes makes the diagnosis difficult. Histologically, most gastric cancer after eradication is intestinal type, and non-neoplastic epithelium, also called epithelium with low-grade atypia, is frequently seen over the tumor, which is presumably the cause of the endoscopic gastritis-like appearance. As for molecular characteristics, some markers, such as Ki67, MUC2, and Wnt5a expression, are lower in cancer from patients in whom H. pylori has been eradicated. In terms of predictors, several Japanese studies have reported that severe endoscopic atrophy at eradication is a risk factor for gastric cancer development. Histologic intestinal metaplasia, especially in the corpus, and long-term use of proton pump inhibitors, are also reported as risk factors for gastric cancer after H. pylori eradication. These studies on the characteristics and predictors of gastric cancer development will become the cornerstone for establishing a novel surveillance program based on the gastric cancer risk stratification specific to H. pylori-eradicated patients.     

Endoscopic therapy of early gastric cancer

Endoscopic therapy of early gastric cancer is applicable for differentiated-type mucosal carcinomas that have an extremely low potency of lymph-node metastasis. Among various kinds of endoscopic therapy, endoscopic mucosal resection is the most recommended procedure, because pathological evaluation of affected tissues is available using this method. Recently, endoscopic submucosal dissection, a novel method of endoscopic mucosal resection, has gained interest as a more reliable therapeutic procedure. In the present chapter several issues will be presented on endoscopic therapy for early gastric cancer, including endoscopic diagnosis of early gastric cancer, currently accepted indications of endoscopic therapy, and the possibility of extending the indication and techniques used for mucosal resection.     

“中国结直肠肿瘤筛查、早诊早治和综合预防共识意见”解读

"中国结直肠肿瘤筛查、早诊早治和综合预防共识意见"规范了我国结直肠肿瘤早诊、早治和癌前疾病防治的医疗行为,是一部符合国情、实用性较强的综合意见,其统一了结直肠癌的病理描述,强调了早期诊断的重要性,提出了符合国情的早诊途径和方法,指出了癌前疾病防治的方法以及随诊准则,推介了内镜下早诊、早治的基本技术。此"共识意见"必将成为指导我国结直肠癌早诊、早治工作,提高我国结直肠肿瘤研究水平的重要文献。     

High grade dysplasia of the gastric mucosa: a marker for gastric carcinoma.

The natural history of gastric epithelial dysplasia and its relation to gastric cancer are ill defined. A consecutive series of 40 patients with an initial diagnosis of gastric epithelial dysplasia based on examination of endoscopic biopsies has been reviewed to determine the clinical outcome and to evaluate a two tier histological grading system as a predictor of the risk of cancer. On review, only 20 of the 40 patients were considered to have true dysplasia: seven patients had low grade dysplasia and 13 had high grade dysplasia. Of the 13 patients with high grade dysplasia, 11 (85%) were found to have gastric cancer within 15 months. Of the 10 patients with high grade dysplasia who underwent gastrectomy, six were found to have early gastric cancer, three had cancer invading into the muscularis propria, and none had lymph node metastases. High grade dysplasia is thus a marker of gastric cancer. Moreover, the cancers associated with high grade dysplasia are usually pathologically favourable and curable. The finding, by an experienced pathologist, of high grade dysplasia in two separate sets of endoscopic biopsies is therefore an indication for radical surgical treatment, provided that the patient's age and general condition permit such an approach.     

早期胃癌的诊治进展

胃癌是严重威胁人类健康的恶性肿瘤,早期胃癌的诊断和治疗对改善患者的预后至关重要。消化内镜的发展和内镜治疗技术的进展为早期胃癌的早期诊断和微创治疗提供了可能。本文就早期胃癌的诊治进展进行总结,希望为消化内镜医师的工作提供帮助。     

Diagnostic evaluation of patients with early gastric cancer--a literature review

Despite the reduction in the incidence and mortality of gastric cancer in recent years, it remains one of the most common and lethal malignant neoplasms worldwide. The diagnosis of gastric cancer at an early stage (early gastric cancer) represents the only hope for improving survival of these patients. Upper GI endoscopy (including chromoendoscopy and magnifying endoscopy) remains the corner-stone for diagnosis, although other modalities such as endoscopic ultrasonography, conventional radiographs, computed tomography, magnetic resonance imaging and virtual endoscopy, are helpful. Histology always seals the correct diagnosis, and makes the final staging. The experience of the endoscopist is a critical point related to correct diagnosis. Better awareness by endoscopists of the various appearances of early gastric cancer, is mandatory. In this review, we discuss the epidemiology, biological characteristics and diagnosis of early gastric cancer based on data derived from the currently available literature.     

Comparing mass screening techniques for gastric cancer in Japan

AIM: To discuss the efficacy of endoscopic mass screening for gastric cancer. METHODS: The data used in this study were the results of mass screening programs for gastric cancer in Niigata City from 2002 to 2004. The number of participants was 35089 in 2002, 34557 in 2003 and 36600 in 2004. The finding ratio referred to the final diagnosis of gastric cancer after a double check of endoscopic files and histological findings. The costs of identifying one case of gastric cancer were calculated based on the total expense for each screening program and additional close examinations. RESULTS: From the analysis of individual screening program with endoscopy, individual screening program with X-ray (ISX) and mass screening program with photofluorography (MSP) in reference to the finding ratio of gastric cancer, endoscopic examination was the best for detecting early gastric cancer, the finding ratio was 0.87% in 2004, approximately 2.7 and 4.6 times higher than those of the ISX and MSP groups. In addition, this novel method was the cheapest means regarding the cost of identifying one case of gastric cancer, which was estimated to be 1608000 Japanese yen in 2004. CONCLUSION: Endoscopic mass screening is a promising method and can be effectively applied if a sufficient number of skilled endoscopists become available to staff the system and if city offices support it.     

High-definition endoscopy and magnifying endoscopy combined with narrow band imaging in gastric cancer

Gastric cancer is the third common cancer and is the second leading cause of cancer deaths worldwide. Endoscopy is being increasingly used for gastric cancer screening because of a high detection rate. Despite promising data, the technique depends heavily on the availability of endoscopic instruments and expertise for mass screening. Furthermore, the introduction of various new endoscopic devices and techniques may enhance the value of endoscopy in efficacious cancer screening. High-definition endoscopy and image-enhanced endoscopy, including narrow band imaging, are the key modalities in advanced endoscopic imaging in gastric cancer.     

Comparing mass screening techniques for gastric cancer in Japan

AIM: To discuss the efficacy of endoscopic mass screening for gastric cancer. METHODS: The data used in this study were the results of mass screening programs for gastric cancer in Niigata City from 2002 to 2004. The number of participants was 35089 in 2002, 34557 in 2003 and 36600 in 2004. The finding ratio referred to the final diagnosis of gastric cancer after a double check of endoscopic files and histological findings. The costs of identifying one case of gastric cancer were calculated based on the total expense for each screening program and additional close examinations. RESULTS: From the analysis of individual screening program with endoscopy, individual screening program with X-ray (ISX) and mass screening program with photofluorography (MSP) in reference to the finding ratio of gastric cancer, endoscopic examination was the best for detecting early gastric cancer, the finding ratio was 0.87% in 2004, approximately 2.7 and 4.6 times higher than those of the ISX and MSP groups. In addition, this novel method was the cheapest means regarding the cost of identifying one case of gastric cancer, which was estimated to be 1 608000 Japanese yen in 2004. CONCLUSION: Endoscopic mass screening is a promising method and can be effectively applied if a sufficient number of skilled endoscopists become available to staff the system and if city offices support it.