Long-term outcome after endoscopic mucosal resection in patients with esophageal squamous cell carcinoma invading the muscularis mucosae or deeper

BACKGROUND: Endoscopic mucosal resection is recommended for squamous cell carcinoma of the esophagus confined to the lamina propria. However, endoscopic mucosal resection is often performed in patients with tumors that invade the muscularis mucosa or upper submucosa to minimize surgical invasiveness, despite the increased risk of lymph node metastasis. This study prospectively evaluated long-term outcome in such patients. METHODS: Twenty-six consecutive patients with squamous cell esophageal carcinoma invading the muscularis mucosa or submucosa who underwent endoscopic mucosal resection from June 1992 through March 2000 (extended endoscopic mucosal resection group) were studied. As control group, 44 consecutive patients with esophageal carcinoma invading the muscularis mucosae or upper third of the submucosa and no preoperative evidence of lymph node metastasis who underwent esophagectomy during the same period (surgical resection group) were studied. RESULTS: Overall survival rates at 5 years in the extended endoscopic mucosal resection group and surgical resection group were, respectively, 77.4% and 84.5%. There was no significant difference between survival distributions. Cause-specific survival rates at 5 years in extended endoscopic mucosal resection and surgical resection groups were, respectively, 95.0% and 93.5%. Survival curves for the groups were similar. CONCLUSION: Although patients were not randomized to extended endoscopic mucosal resection or surgical resection in this study, the results suggest that endoscopic mucosal resection may be safe and effective for management of squamous cell esophageal carcinoma invading the muscularis mucosae or upper submucosa.     

Predictive factors for local recurrence and incomplete resection of early gastric cancer treated by endoscopic resection: A Western experience

BACKGROUND:

Early gastric cancer (EGC) is defined as adenocarcinoma limited to the mucosa or submucosa regardless of lymph node involvement. Local EGC recurrence rates have been described in up to 6% of cases.

OBJECTIVES:

To evaluate predictive factors for incomplete resection and local recurrence of EGC treated by endoscopic mucosal resection (EMR) that was followed up for at least one year.

METHODS:

From June 1994 to December 2005, 46 patients with EGC underwent EMR. Possible predictive factors for incomplete endoscopic resection and local recurrence were identified by medical chart analysis. Demographic, endoscopic and histopathological data were retrospectively evaluated. EMR was considered complete or incomplete. Patients from the complete resection group were divided into subgroups (with and without local EGC recurrence).

RESULTS:

Complete resection was possible in 36 cases (76.6%). Predictive factors for incomplete resection were tumour location (P=0.035), histological type (P=0.021), lesion size (P=0.022) and number of resected fragments (P=0.013). On multivariate analysis, undifferentiated histological type (OR 0.8; 95% CI 0.036 to 0.897) and number of resected fragments (OR 7.34; 95% CI 1.266 to 42.629) were independent predictive factors for incomplete resection. In the complete resection group, a larger lesion size was associated with a higher the number of resected fragments (P=0.018). Local recurrence occurred in nine cases (25%). Use of the cap technique was the only predictive factor for local recurrence in five of seven cases (71.4%) (P=0.006).

CONCLUSIONS:

A larger lesion size was associated with a higher number of resected fragments. Undifferentiated adenocarcinoma and piecemeal resection were predictive factors for incomplete resection. Technique type was a predictive factor for local EGC recurrence.     

Endoscopic ultrasound assessment of lesions of the ampulla of Vater is of particular value in low-grade dysplasia

Background

The accurate diagnosis of dysplasia or carcinoma within ampullary lesions can be difficult, but, when possible, identifies patients who require endoscopic or surgical resection, respectively. The role of endoscopic ultrasound (EUS) in diagnosing these lesions and the degree of dysplasia is unclear.

Methods

Patients with lesions of the ampulla were identified over 5 years. Patients who did not undergo EUS were compared with those who did.

Results

A total of 27 of 58 (47%) patients were investigated with EUS. Pretreatment diagnoses were correct in 93% of the EUS group vs. 78% of the no-EUS group. Rates of diagnostic accuracy in low-grade dysplasia (LGD), high-grade dysplasia (HGD) and adenocarcinoma (ADC) were 72%, 20% and 96%, respectively, in the no-EUS group, and 93%, 50% and 100%, respectively, in the EUS group. Every diagnosis of LGD in the EUS group was correct, whereas these diagnoses accounted for the majority of errors (eight of 13) in the no-EUS group. High-grade dysplasia was frequently misdiagnosed. More patients were treated by endoscopic resection in the EUS group (12 of 27 vs. five of 31; P= 0.025).

Conclusions

Endoscopic ultrasound increases the accuracy of preoperative diagnosis of ampullary lesions and is particularly useful in patients with LGD because it permits safe endoscopic management. Patients with HGD must be reviewed carefully and considered for pancreatoduodenectomy.     

Long-Term Outcome after Endoscopic Submucosal Dissection in Patients with Superficial Esophageal Squamous Cell Carcinoma: A Single-Center Study

Background/Aims

Superficial esophageal squamous cell carcinoma (SESCC) is being increasingly detected during screening endoscopy. Endoscopic submucosal dissection (ESD) allows for en bloc and histologically complete resection of lesions. This study assessed the technical feasibility and long-term outcomes of ESD for SESCCs.

Methods

Between January 2005 and August 2012, 27 patients with 28 SESCCs underwent ESD at Pusan National University Hospital. The en bloc and pathologically complete resection rates, complication (perforation and bleeding) rate, incidence of esophageal stricture after ESD, and overall and disease-specific survival rates were evaluated.

Results

The en bloc and pathologically complete resection rates were 93% and 83%, respectively. No significant bleeding occurred, and perforation with mediastinal emphysema was observed in two patients (7%). Post-ESD stricture occurred in two patients (7%) who had mucosal defects involving more than three-fourths of the esophageal circumference. During a mean follow-up of 23 months, local tumor recurrence was seen in two of four lesions with pathologically incomplete resection; one was treated by re-ESD, and the other was treated by surgical esophagectomy. The 5-year overall and disease-specific survival rates were 84% and 100%, respectively.

Conclusions

ESD seems to be a feasible, effective curative treatment for SESCCs. All patients should be closely followed after ESD.     

Diagnostic value of endoscopic and endoscopic ultrasound characteristics of duodenal submucosal tumour-like heterotopic gastric mucosa

OBJECTIVE:

Recent studies have reported that duodenal heterotopic gastric mucosa (HGM) has been observed in 8.9% of patients who undergo esophagogastroduodenoscopy. However, there are few reports concerning the endoscopic and endoscopic ultrasound characteristics of submucosal tumour-like HGM in the duodenum.

METHODS:

Endoscopic, endoscopic ultrasound (EUS) and histological findings were analyzed in six patients with submucosal tumour-like HGM, which were confirmed by pathological examination of biopsy or endoscopic polypectomy specimens.

RESULTS:

Endoscopically, the lesions appeared as a solitary, sessile submucosal tumour-like mass with a depression at the top. In four of six patients, small granular structures were found in the depressed area of the mass. On EUS, all masses demonstrated a heterogeneous pattern, among which four patients presented anechoic areas while two patients showed no anechoic areas. All lesions were localized within the mucosa and submucosa on EUS. Histologically, they consisted of gastric glands and some dilated glands, and were covered with normal duodenal epithelium. In four of six lesions, the tumours were composed of gastric-type foveolar epithelium showing papillary growth, fundic glands and pyloric glands, while the others consisted of gastric-type foveolar epithelium and pyloric glands.

CONCLUSION:

A heterogeneous pattern on EUS and small granular structures on esophagogastroduodenoscopy represent valuable diagnostic features of submucosal tumour-like HGM.     

Endoscopic and Oncologic Outcomes of Endoscopic Resection for Superficial Esophageal Neoplasm

Background/Aims

Endoscopic resection (ER) of superficial esophageal neoplasm (SEN) is a technically difficult procedure. We investigated the clinical outcomes of ER for SEN to determine its feasibility and effectiveness.

Methods

Subjects who underwent ER for SEN at Asan Medical Center between December 1996 and December 2010 were eligible. The clinical features of patients and tumors, histopathological characteristics, adverse events, ER results and survival were investigated.

Results

A total of 129 patients underwent ER for 147 SENs. En bloc resection (EnR) was performed in 118 lesions (80.3%). Complete resection (CR) was accomplished in 128 lesions (86.5%), and curative resection (CuR) was performed in 118 lesions (79.7%). The EnR, CR, and CuR rates were significantly greater in the endoscopic submucosal dissection group when compared to those in the endoscopic resection group. Adverse events occurred in 22 patients (17.1%), including bleeding (n=2, 1.6%), perforation (n=12, 9.3%), and stricture (n=8, 6.2%). Local tumor recurrence occurred in 2.0% of patients during a median follow-up of 34.8 months. The 5-year overall and disease-specific survival rates were 94.0% and 97.5%, respectively.

Conclusions

ER is a feasible and effective method for the treatment of SEN as indicated by favorable clinical outcomes.     

Endoscopic Papillectomy for Benign Ampullary Neoplasms: How Can Treatment Outcome Be Predicted?

Background/Aims

Endoscopic papillectomy is increasingly performed with curative intent for benign papillary tumors. This study was performed to identify factors that predict the presence of malignancy and affect endoscopic success.

Methods

We retrospectively analyzed the medical records of patients who received an endoscopic papillectomy for papillary adenoma from 2006 to 2009.

Results

A total of 43 patients received endoscopic papillectomy. The pathologic results after papillectomy revealed adenocarcinoma in five patients (12%), and the risk of malignancy was high in cases of large lesions, preprocedural pathology of high-grade dysplasia or high serum alkaline phosphatase. Endoscopic success was observed in 37 patients (86%) at the end of follow-up (mean duration, 10.4±9.6 months). The factor significantly affecting success was a complete resection at the initial papillectomy (p=0.007). Two patients experienced recurrence 10 and 32 months after the complete resection, but both achieved endoscopic success with repeated endoscopic treatment. Six patients with endoscopic failure received surgical resection.

Conclusions

Endoscopic papillectomy is a safe and effective method for the curative resection of benign papillary tumors, especially when complete resection is achieved at the initial papillectomy. Follow-up with surveillance should be performed for at least 3 years because of the possible recurrence of tumors during these periods.     

Endoscopic Resection for Synchronous Esophageal Squamous Cell Carcinoma and Gastric Adenocarcinoma in Early Stage Is a Possible Alternative to Surgery

Background/Aims

We investigated the clinical outcomes according to the method of treatment in synchronous esophageal and gastric cancer.

Methods

Synchronous esophageal squamous cell carcinoma and gastric adenocarcinoma were diagnosed in 79 patients between 1996 and 2010. We divided the patients into four groups according to treatment; Group 1 received surgical resection for both cancers or surgery for gastric cancer with chemoradiotherapy for esophageal cancer (n=27); Group 2 was treated by endoscopic resection with or without additional treatment (n=14); Group 3 received chemoradiotherapy only (n=18); and Group 4 received supportive care only (n=20).

Results

The median survival times in groups 1 and 2 were 86 and 60 months, respectively. The recurrence rate and mortality were 23% and 48%, respectively, in group 1 and 21% and 4%, respectively, in group 2. The median survival time was 12 months in group 3 and 9 months in group 4. Multivariate analysis showed that age (p<0.001) and treatment group (p=0.019) were significantly associated with death. Compared with group 1, treatment in the intensive care unit (p=0.003), loss of body weight (p=0.042), and decrease in hemoglobin (p=0.033) were worse in group 1.

Conclusions

Endoscopic resection for synchronous esophageal and gastric cancer could be considered as a possible alternative to surgery for early-stage cancer.     

Growth Patterns of Signet Ring Cell Carcinoma of the Stomach for Endoscopic Resection

Background/Aims

It is difficult to precisely detect the lateral margin during endoscopic submucosal dissection (ESD) for signet ring cell carcinoma (SRC) because SRC often expands to lateral direction through the lamina propria. Thus, the aim of this study was to classify the intramucosal spreading patterns of SRC and to analyze the patients’ clinicopathological findings according to the spreading patterns.

Methods

The intramucosal spreading patterns of SRC were classified as expansive or infiltrative types. A total of 100 surgical and 42 ESD specimens were reviewed.

Results

In the surgical specimens, the proportions of expansive and infiltrative types were 44% and 56%, respectively. The infiltrative type was more commonly associated with old age, atrophy, and intestinal metaplasia in surrounding mucosa and the absence of Helicobacter pylori compared with the expansive type. In ESD specimens, the proportions of expansive and infiltrative types were each 50%. When lateral margin-positive lesions were compared with -negative lesions, larger size, residual lesion, and the lack of a neutrophil infiltration were more significantly associated with lateral margin-positive lesions. All cases with residual tumors in lateral margin-positive lesions were classified as the infiltrative type.

Conclusions

SRC surrounded with atrophy and/or intestinal metaplasia often spreads subepithelially in the margin. This finding may suggest that a larger safety margin is necessary in this type during ESD.     

Reconstruction techniques for hypopharyngeal and cervical esophageal carcinoma

Objective

To investigate the incidence of perioperative complications in patients with hypopharyngeal and cervical esophageal carcinoma who underwent three types of esophageal defect reconstruction procedures.

Methods

Clinical data from 105 patients with hypopharyngeal and cervical esophageal carcinoma who were treated at SUN YAT-SEN Memorial Hospital from January 2003 to February 2013 were retrospectively analyzed. Among these patients, 45 underwent a pectoral major muscle skin flap reconstruction following carcinoma resection (group A); 32 patients were treated with stomach replacement of the esophagus (group B), and 28 patients were treated with tube stomach replacement of the esophagus (group C). The incidences of perioperative complications were compared among these three groups.

Results

The incidences of anastomotic leakage, neck swelling, and incision infection were significantly lower in group C than in group A (P<0.05). The incidences of anastomotic leakage, reflux esophagitis, and thoracic stomach syndrome were significantly lower in group C than in group B (P<0.05).

Conclusions

Tube stomach replacement of the esophagus in the setting of hypopharyngeal and cervical esophageal carcinoma reduced the incidence of complications; therefore, it is a reasonable procedure for the management of esophageal defects.     

Indications of Endoscopic Polypectomy for Rectal Carcinoid Tumors and Clinical Usefulness of Endoscopic Ultrasonography

PURPOSE This study was designed to define the indications of endoscopic polypectomy for rectal carcinoid tumors and evaluate the diagnostic value of endoscopic ultrasonography.METHODS A total of 66 rectal carcinoid tumors treated at our hospital were analyzed histopathologically to clarify risk factors for metastasis. The depth of invasion was determined for 52 lesions examined by endoscopic ultrasonography, and the value of endoscopic ultrasonography for deciding whether a lesion is indicated for endoscopic polypectomy was assessed.RESULTS None of the 57 lesions measuring 10 mm in diameter invaded the muscularis propria or had metastasis. Of nine lesions with a diameter of 11 mm, five invaded the muscularis propria and four had metastasis. A central depression was found in three of the lesions with metastasis. The depth of invasion of 49 lesions examined by endoscopic ultrasonography was limited to the submucosa; 3 lesions invaded the muscularis propria. The depth of invasion of all lesions was correctly diagnosed by endoscopic ultrasonography. Ninety-six percent of the lesions that had submucosal invasion with narrowing of the upper two-thirds of the third layer (submucosa) as evaluated by endoscopic ultrasonography could be completely resected by endoscopic polypectomy.CONCLUSIONS Rectal carcinoid tumors that satisfy the following three conditions are indicated for local resection, including endoscopic polypectomy: a maximum diameter of 10 mm, no invasion of the muscularis propria, and no depression or ulceration in the lesion. Endoscopic ultrasonography also is useful for estimating the depth of invasion of rectal carcinoid tumors and for determining whether endoscopic polypectomy is indicated.Published online: 28 January 2005.Reprints are not available.     

SOX9 Is Highly Expressed in Nonampullary Duodenal Adenoma and Adenocarcinoma in Humans

Background/Aims

SOX9 is a marker for stem cells in the intestine, and overexpression of SOX9 is found in gastric and colon cancer; however, the expression of SOX9 in nonampullary duodenal adenoma and adenocarcinoma has not yet been evaluated. This study aimed to investigate SOX9 expression in nonampullary duodenal adenoma and adenocarcinoma by immunohistochemistry.

Methods

We evaluated SOX9 expression in 43 clinical samples (nonampullary duodenal adenoma in 22 lesions and nonampullary duodenal adenocarcinoma in 21 lesions) resected under endoscopic mucosal resection or endoscopic submucosal dissection.

Results

SOX9 was expressed in part of the base of the normal duodenal mucosa surrounding adenomas and adenocarcinomas. In contrast, SOX9-positive cells were found in more than half of the crypts from the bottom part of the crypt in all of the 43 samples. Moreover, in 15 adenoma samples (68.2%) and 19 carcinoma samples (90.5%), SOX9 was expressed in more than three-quarters of the crypts from the bottom part of the crypt.

Conclusions

SOX9 is overexpressed in nonampullary duodenal adenoma and adenocarcinoma in humans.     

Is Endoscopic Mucosal Resection a Sufficient Treatment for Low-Grade Gastric Epithelial Dysplasia?

Background/Aims

The rate of diagnosis of gastric adenoma has increased because esophagogastroduodenoscopy is being performed at an increasingly greater frequency. However, there are no treatment guidelines for low-grade dysplasia (LGD). To determine the appropriate treatment for LGD, we evaluated the risk factors associated with the categorical upgrade from LGD to high grade dysplasia (HGD)/early gastric cancer (EGC) and the risk factors for recurrence after endoscopic treatment.

Methods

We compared the complication rates, recurrence rates, and remnant lesions in 196 and 56 patients treated with endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR), respectively, by histologically confi rming low-grade gastric epithelial dysplasia.

Results

The en bloc resection rate was significantly lower in the EMR group (31.1%) compared with the ESD group (75.0%) (p<0.001). However, no significant difference was observed in the prevalence of remnant lesions or recurrence rate (p=0.911) of gastric adenoma. The progression of LGD to HGD or EGC caused an increase in the incidence of tumor lesions >1 cm with surface redness and depressions.

Conclusions

For the treatment of LGD, EMR resulted in a higher incidence of uncertain resection margins and a lower en bloc resection rate than ESD. However, there was no signifi cant difference in recurrence rate.     

食管早期癌和癌前病变超声内镜诊断及内镜下食管黏膜切除术的临床研究

目的探讨食管早期癌和癌前病变超声内镜诊断价值及内镜下食管黏膜切除术的临床治疗价值。方法 61例食管早期癌和癌前病变行超声内镜检查探测病变浸润深度,位于黏膜层及黏膜肌层的食管早期癌和癌前病变行内镜下食管黏膜切除术（EMR）,位于黏膜下层的食管早期癌行外科手术治疗。EMR术28例,外科手术33例。比较超声内镜和术后病理判断病变浸润深度。结果超声内镜判断食管黏膜内癌的特异性和敏感性为94.1%（48/51）、98.0%（48/49）;黏膜下癌的特异性和敏感性为80.0%（8/10）、72.7%（8/11）;鉴别黏膜内癌及黏膜下癌浸润深度准确率为91.8%（56/61）。28例EMR术后病理：14例食管早期癌和12例食管黏膜中重度异型增生完全切除,完全切除成功率为92.9%（26/28）,观察3～45个月无复发。结论超声内镜能较准确鉴别食管早期癌和癌前病变浸润深度,黏膜切除术治疗食管早期癌和癌前病变是安全有效的内镜治疗方法。     

Incidence of Cholangiocarcinoma with or without Previous Resection of Liver for Hepatolithiasis

Background/Aims

To investigate the incidence of cholangiocarcinoma in patients with hepatolithiasis with or without previous resection of liver.

Methods

From 2002 to 2009, we retrospectively reviewed 117 patients who were diagnosed and treated for hepatolithiasis in Korea University Guro Hospital. Among the 117 patients, 55 patients who were lost during follow-up were excluded, and 62 patients were eligible for analysis. The hepatic resection group (n=25) included patients who underwent left hemihepatectomy (n=2); left lateral segmentectomy (n=10); left lobectomy (n=9); right lobectomy (n=3); or wedge resection (n=1). The nonhepatic resection group (n=37) included transhepatic cholangiographic lithotomy and endoscopic retrograde cholangiopancreatography-treated patients. The mean follow-up period was 47 months.

Results

The incidence of cholangiocarcinoma while patients were followed for hepatolithiasis was 12.9% (8/62) (hepatic resection group, three cases [12%] vs nonhepatic resection group, five cases [13.5%]; p=1.000). The mean follow-up period was 53 months (47±11 months) until the diagnosis of cholangiocarcinoma.

Conclusions

There was no difference in the incidence of cholangiocarcinoma according to previous liver resections. Patients with hepatolithiasis should be carefully followed up for detection of cholangiocarcinoma even after a previous liver resection.     

Low Pepsinogen I Level Predicts Multiple Gastric Epithelial Neoplasias for Endoscopic Resection

Background/Aims

Synchronous/metachronous gastric epithelial neoplasias (GENs) in the remaining lesion can develop at sites other than the site of endoscopic resection. In the present study, we aimed to investigate the predictive value of serum pepsinogen for detecting multiple GENs in patients who underwent endoscopic resection.

Methods

In total, 228 patients with GEN who underwent endoscopic resection and blood collection for pepsinogen I and II determination were evaluated retrospectively.

Results

The mean period of endoscopic follow-up was 748.8±34.7 days. Synchronous GENs developed in 46 of 228 (20.1%) and metachronous GENs in 27 of 228 (10.6%) patients during the follow-up period. Multiple GENs were associated with the presence of pepsinogen I <30 ng/mL (p<0.001). Synchronous GENs were associated with the presence of pepsinogen I <30 ng/mL (p<0.001).

Conclusions

Low pepsinogen I levels predict multiple GENs after endoscopic resection, especially synchronous GENs. Cautious endoscopic examination prior to endoscopic resection to detect multiple GENs should be performed for these patients.     

Efficacy and long-term outcome of endoscopic treatment of sporadic nonampullary duodenal adenoma

Background/Aims

Endoscopic resection has proven to be a safe and effective alternative to surgery for duodenal adenomas. However, few data are available on the adequacy of resection and long-term outcomes. This study evaluated the efficacy and longterm endoscopic findings in a cohort of Korean patients who underwent endoscopic mucosal resection (EMR) of sporadic duodenal adenomas.

Methods

Seventeen patients with nonampullary duodenal adenomas without familial polyposis syndrome and who were treated by EMR between January 2001 and December 2007 were evaluated retrospectively. Their management, follow-up, and outcomes were reviewed.

Results

In total, seventeen lesions were removed from EMR in 17 patients (mean age, 59.3 years; 6 women, 11 men). The mean size of the tumors was 15.1 mm (median, 13 mm, range, 8-27 mm). Of these 17 adenomas, 16 adenomas were tubulous and 1 was tubulovillous. The EMR was performed successfully in all 17 patients in a single session. After a median follow-up period of 29 months (range, 13-72 months), all patients remained in remission. One patient had bleeding at the site of the EMR. There were no perforations after the EMR.

Conclusions

EMR for sporadic duodenal adenomas seemed to be a safe and effective treatment modality.     

Risk Factors for Metachronous Gastric Neoplasms in Patients Who Underwent Endoscopic Resection of a Gastric Neoplasm

Background/Aims

To identify the risk factors for metachronous gastric neoplasms in patients who underwent an endoscopic resection of a gastric neoplasm.

Methods

We prospectively collected clinicopathologic data and measured the methylation levels of HAND1, THBD, APC, and MOS in the gastric mucosa by methylation-specific real-time polymerase chain reaction in patients who underwent endoscopic resection of gastric neoplasms.

Results

A total of 257 patients with gastric neoplasms (113 low-grade dysplasias, 25 high-grade dysplasias, and 119 early gastric cancers) were enrolled. Metachronous gastric neoplasm developed in 7.4% of patients during a mean follow-up of 52 months. The 5-year cumulative incidence of metachronous gastric neoplasm was 4.8%. Multivariate analysis showed that moderate/severe corpus intestinal metaplasia and family history of gastric cancer were independent risk factors for metachronous gastric neoplasm development; the hazard ratios were 4.12 (95% confidence interval [CI], 1.23 to 13.87; p=0.022) and 3.52 (95% CI, 1.09 to 11.40; p=0.036), respectively. The methylation level of MOS was significantly elevated in patients with metachronous gastric neoplasms compared age- and sex-matched patients without metachronous gastric neoplasms (p=0.020).

Conclusions

In patients who underwent endoscopic resection of gastric neoplasms, moderate/severe corpus intestinal metaplasia and a family history of gastric cancer were independent risk factors for metachronous gastric neoplasm, and MOS was significantly hypermethylated in patients with metachronous gastric neoplasms.     

Endoscopic Muscularis Excavation for Subepithelial Tumors of the Esophagogastric Junction Originating from the Muscularis Propria Layer

Background

Because of complicating anatomic factors, endoscopic submucosal dissection is seldom performed in subepithelial tumors of the esophagogastric junction originating from the muscularis propria layer.

Aim

This study was designed to evaluate the feasibility of endoscopic muscularis excavation for treating subepithelial tumors of the esophagogastric junction originating from the muscularis propria layer.

Methods

Between December 2008 and December 2011, 68 patients with subepithelial tumors of the esophagogastric junction originating from the muscularis propria layer were treated with endoscopic muscularis excavation. Key steps of the procedure included the following: (1) injecting a mixture solution into the submucosal layer after making several dots around the tumor; (2) making a cross incision of the overlying mucosa, and excavating the tumor from the muscularis propria layer; (3) closing the artificial ulcer with clips after tumor removal.

Results

The mean tumor size was 16.2 mm (range 7–35 mm). Endoscopic muscularis excavation was successfully performed in 65 out of 68 cases (success rate 95.6 %). Pathological diagnosis of these tumors included leiomyoma (39 out of 68) and gastrointestinal stromal tumor (29 out of 68). Perforation occurred in seven patients (10.3 %). No massive bleeding or delayed bleeding occurred. The median follow-up period after the procedure was 23 months (range 6–42 months). No residual or recurrent tumor was detected and no stricture occurred in patients during the follow-up period.

Conclusions

Endoscopic muscularis excavation is a safe, effective and feasible procedure for providing accurate histopathologic evaluation and curative treatment for subepithelial tumors of the esophagogastric junction originating from the muscularis propria layer.     

An Inverse Relationship between the Expression of the Gastric Tumor Suppressor RUNX3 and Infection with Helicobacter pylori in Gastric Epithelial Dysplasia

Background/Aims

This study was performed to determine the association between RUNX3 expression and Helicobacter pylori infection in premalignant gastric lesions.

Methods

We examined 107 patients with gastric epithelial dysplasia who had undergone endoscopic mucosal resection or submucosal dissection. All tissue samples were evaluated by RUNX3 staining and subclassified by immunophenotype. H. pylori infection in dysplastic lesions and the normal surrounding tissue was examined by silver staining, and cagA status was assessed by polymerase chain reaction.

Results

The loss of RUNX3 expression was observed in 62 cases (57.9%), and an association with H. pylori infection was found in 54 cases (50.5%). The infection rate with the cagA-positive H. pylori strain was 63.0%. In RUNX3-negative lesions, the rate of H. pylori infection (p=0.03) and the frequency of category 4 lesions (according to the revised Vienna classification) were high (p=0.02). In addition, the gastric mucin phenotype was predominant. In RUNX3-negative category 4 lesions, the rate of cagA-positive H. pylori infection rate was high but not significantly increased (p=0.08).

Conclusions

Infection with H. pylori is associated with inactivation of RUNX3 in early gastric carcinogenesis. This mechanism was prominent in gastric cancer with a gastric mucin phenotype.