Endoscopic ultrasonography with three miniature probes of different frequency is an accurate diagnostic tool for endoscopic submucosal dissection

BACKGROUND/AIMS: Endoscopic ultrasound (EUS) examinations are necessary to determine the vertical cancer invasion depth. In this study, we prospectively performed EUS with three miniature probes of different frequency (12, 20, and 30 MHz) in patients with early gastric cancer scheduled for endoscopic submucosal dissection (ESD) based on endoscopic findings. METHODOLOGY: The study included 142 early gastric cancer lesions in 132 patients in our hospital. We then evaluated the diagnostic accuracy of the use of three miniature probes of different frequency in the determination of vertical margins. Finally, we evaluated the value of EUS as an additional examination tool used along with conventional endoscopic findings for determination of indication for ESD. RESULTS: The accuracies of the early gastric cancer invasion depths of the m+sm1 group were 81.0%, 86.0% and 92.3% as measured by the 12-, 20- and 30-MHz probes, respectively. Even though ulceration was associated with the lesions, the 30-MHz probe was the most accurate as compared to the 12- or 20-MHz probes in the m+sml cancer group. CONCLUSIONS: EUS examinations with probes of varying frequency are useful for determining appropriate treatment strategies for early gastric cancer.     

Experience with photodynamic therapy (endoscopic laser therapy) for the treatment of early gastric cancer

BACKGROUND/AIMS: Photodynamic therapy has been developed as an endoscopic laser therapy for gastrointestinal malignant tumors. The targets for curative upper gastrointestinal endoscopic therapy are carcinomas that are considered statistically unlikely to be accompanied with metastases to the lymph nodes. Endoscopic mucosal resection is the therapy of first choice for such carcinomas. In the application of photodynamic therapy, we narrow down its practical indications to patients who are not indicated for curative endoscopic treatment by preoperative examination or those with histologic findings of endoscopic mucosal resection specimens who reject surgical treatment or are at high risk in surgical treatment. METHODOLOGY: The effect of photodynamic therapy using Porfimer sodium and an Excimer dye laser was evaluated endoscopically in 8 lesions of 7 patients with early gastric cancer. RESULTS: Complete responses were obtained in all patients. As side effects, mild photosensitivity was seen in 6 patients and lasted for several months. CONCLUSIONS: Photodynamic therapy was safety employed, with success in 7 patients with early gastric cancer. We conclude that photodynamic therapy can be a useful palliative method with high tumor selectivity in the treatment of early gastric cancer.     

蓝光成像放大内镜下误诊为早期胃癌的胃血吸虫病一例

胃血吸虫病是血吸虫虫卵侵犯消化道黏膜并在胃壁沉积引起的急慢性特异性炎性病变。该病少见,且临床及内镜表现缺乏特异性,故有时较难诊断。随着胃镜检查的普及与诊断技术的提高,该病的病例报道逐渐增多,但胃血吸虫病与胃癌的关系尚不清楚。本文报道1例蓝光成像放大内镜下误诊为早期胃癌的胃血吸虫病,结合文献复习,以期提高临床医师对该病的认识。     

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.     

Endoscopic ultrasound using ultrasound probes for the diagnosis of early esophageal and gastric cancers

Endoscopic ultrasound(EUS) devices were first designed and manufactured more than 30 years ago,and since then investigators have reported EUS is effective for determining both the staging and the depth of invasion of esophageal and gastric cancers.We review the present status,the methods,and the findings of EUS when used to diagnose and stage early esophageal and gastric cancer.EUS using high-frequency ultrasound probes is more accurate than conventional EUS for the evaluation of the depth of invasion of superficial esophageal carcinoma.The rates of accurate evaluation of the depth of invasion by EUS using high-frequency ultrasound probes were 70%-88% for intramucosal cancer,and 83%-94% for submucosal invasive cancer.But the sensitivity of EUS using high-frequency ultrasound probes for the diagnosis of submucosal invasive cancer was relatively low,making it difficult to confirm minute submucosal invasion.The accuracy of EUS using highfrequency ultrasound probes for early gastric tumor classification can be up to 80% compared with 63% for conventional EUS,although the accuracy of EUS using high-frequency ultrasound probes relatively decreases for those patients with depressed-type lesions,undifferentiated cancer,concomitant ulceration,expanded indications,type 0-Ⅰ lesions,and lesions located in the upper-third of the stomach.A 92% overall accuracy rate was achieved when both the endoscopic appearance and the findings from EUS using high-frequency ultrasound probes were considered together for tumor classification.Although EUS using high-frequency ultrasound probes has limitations,it has a high depth of invasion accuracy and is a useful procedure to distinguish lesions in the esophagus and stomach that are indicated for endoscopic resection.     

内镜Nd：YAG激光治疗食管和贲门早期浅表癌远期疗效评价

应用内镜Ｎｄ：ＹＡＧ激光治疗３３例食管和贲门早期浅表癌。经１～６次（平均２．６次）激光照射，３２例（９７％）癌细胞消失。其中２２例已随访２４～５５个月，１６例（７２．７％）无癌复发；另外６例（２７．３％）於治愈后第３６～４０个月又发现早期癌灶，可能是早期癌复发或再发的早期癌。认为内镜Ｎｄ：ＹＡＧ激光治疗食管和贲门早期浅表癌的远期疗效还相当满意。本文对内镜Ｎｄ：ＹＡＧ激光治疗的适应证、影响疗效的因素和减少治疗后癌复发的措施进行了分析。     

Management of esophageal superficial tumors: non take away approaches

Development of screening programs in patients with high risk of developing esophageal cancer, as well as recent advances in diagnostic endoscopic techniques, have allowed clinicians to improve early detection of esophageal malignant tumors. Surgical resection, although currently considered as the standard of care for patients with early stage esophageal cancer, is sometimes contra-indicated. In this subset of patients, endoscopic resection techniques including endoscopic mucosal resections (EMR), thermal or non-thermal laser, or cryoablation are amongst the well-recognized modalities safely and efficiently used by gastroenterologists. However, in some patients, these options are contra-indicated or incomplete, necessitating medical treatments such as chemotherapy and/or radiation therapy. A systematic search of all the English literature regarding non-take away approaches has therefore been performed, based on a MEDLINE search (Pubmed) carried out between January 1990 and March 2011. Future radiation therapy developments will also be pointed out.     

Endoscopic Treatment of Early Gastric Cancer

Abstract: Successful radical endoscopic treatment of early gastric cancer has recently progressed using chiefly the high frequency electric current method and the laser method. The forms of treatment can be classified into mucosal resection and non mucosal resection. The high frequency electric current method is a typical method for mucosal resection and makes it possible to confirm by pathology the complete curability of the excised and collected lesion, but it has limits in terms of the size of the lesion. Of the high frequency electric current method, there are two chief methods used which are endoscopic polypectomy and strip biopsy or ERHSE. Laser endoscopy is a typical method for non mucosal resection, however it cannot remove the lesion and therefore needs a follow-up study including biopsy after the treatment, it can treat however much larger lesions than the mucosal resection method. Laser endoscopy includes the three main methods of vaporization, photodynamic therapy and laserthermia. Indications for radical treatment of early gastric cancer by endoscopy should be limited to lesions without lymph node metastasis. Radical endoscopic treatment for early gastric cancer has recently become the treatment of choice for lesions, even in patients without surgical risk, because of the decreased quality of life which may follow after surgery. The ratio of radical endoscopic treatment to surgery for early gastric cancer has been increasing yearly. Recent advances in the area are reviewed, here.     

内镜黏膜下剥离术在早期胃癌治疗中的应用进展

随着色素放大内镜、窄带成像技术、共聚焦内镜等的出现和应用,以及人们对恶性肿瘤认识的提高,越来越多的胃癌在早期阶段即被发现,其手术后5年生存率可达90%.自内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)出现以来,在消化系早期肿瘤中的治疗优势越来越明显.因其治疗效果确切、创伤小、安全性高、患者依从性好、治疗成本低、可完整切除癌灶等而备受各界关注.本文就ESD在早期胃癌(early gastric cancer,EGC)中的临床应用作一综述.     

Chronological changes of characteristics of early gastric cancer and therapy: Experience in the Cancer Institute Hospital of Tokyo, 1950–1994

Gastric cancer, the leading cause of death from cancer in Japan, has long been studied. We received our first patient with early gastric cancer in 1950 and have since treated 2382 patients with this cancer up to 1990. The percentage of early gastric cancers diagnosed has been on the increase following the improvement in diagnostic skills and the establishment of mass screening. At present, more than half of the gastric cancers presenting are in the early stages. Chronological changes in diagnoses of early gastric cancer are characterized by the increased findings of (a) small tumors less than 4 cm in diameter (b) depressed-type carcinoma (c) lesions of the upper part of the stomach, and (d) undifferentiated-type adenocarcinoma. The standard method of treatment for early gastric cancer was standard radical operation in the 1970s. In the 1980s endoscopic mucosal resection and limited operation were adopted and their use has been increasing annually. The prognosis for early gastric cancer is quite favorable (the 5-year survival rate is more than 90%), and it is regarded as a disease with good prognosis. To obtain still better therapeutic results, it is essential to increase the proportion of early gastric cancers where endoscopic mucosal resection or limited operation is indicated, and improve the techniques of those procedures.     

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.     

32例食管和贲门早期浅表癌内镜激光治疗远期疗效

对内镜Ｎｄ：ＹＡＧ激光治疗细胞消失的３２例食管和贲门早期浅表癌病人进行了３３～７８个月（平均５５．２５个月）的前瞻性随访。应用ＰｒｏｄｕｃｔＬｉｍｉｔＥｓｔｉｍａｔｅ方法计算其存活率，并与１１７例早期食管癌和贲门癌的自然病程对比分析。内镜激光治疗五年存活率为９７％，未经治疗的早期食管贲门癌的五年存活率为６７％（Ｐ＜０．０１），表明内镜激光是一种有效的治疗方法。在对影响疗效的因素中，发现抗癌基因Ｐ５３是一个非常有价值的独立预后因素。     

Endoscopic submucosal dissection of early gastric cancer

The purpose of this review was to examine a remarkable technical advance regarding the indications for and the technique of endoscopic resection of early gastric cancer. Endoscopic mucosal resection (EMR) of early gastric cancer with no risk of lymph node metastasis has been a standard technique in Japan, probably owing to the high incidence of gastric cancer in Japan and the fact that more than half of Japanese gastric cancer cases are diagnosed at an early stage. Very recently, several EMR techniques have become increasingly accepted and regularly used in Western countries. Although these minimally invasive techniques are safe, convenient, and efficacious, they are unsuitable for large lesions in particular. Difficulty in correctly assessing the depth of tumor invasion and an increase in local recurrence when standard EMR procedures are used have been reported in cases of large lesions, because such lesions are often resected piecemeal owing to the technical limitations of standard EMR. A new development in therapeutic endoscopy, called endoscopic submucosal dissection (ESD), allows the direct dissection of the submucosa, and large lesions can be resected en bloc. ESD is not limited by resection size and is expected to replace surgical resection. However, it is still associated with a higher incidence of complications than standard EMR procedures and requires a high level of endoscopic skill. The endoscopic indications, techniques, and management of complications of ESD for early gastric cancer for properly carrying out established therapeutic endoscopy are described.     

Endoscopic resection for early gastric cancer: Towards a global understanding

Gastric cancer is widespread globally, and disease diagnosis is accompanied by high mortality and morbidity rates. However, prognoses and survivability have improved following implementation of surveillance and screening programs, which have led to earlier diagnoses. Indeed, early diagnosis itself supports increased surgical curability, which is the main treatment goal and guides therapeutic choice. The most recent Japanese guidelines for endoscopic submucosal dissection and endoscopic mucosal resection for early gastric cancer consider the degree of endoscopic curability in relation to the characteristics of the gastric lesions. In clinical practice, the management approach for both prevention and treatment should be similar to that of colon lesions; however, unlike the established practices for colorectal cancer, the diagnostic and therapeutic pathways are not shared nor widespread for gastric cancer. Ultimately, this negatively impacts the opportunity to perform an endoscopic resection with curative intent.     

Clinical outcomes of endoscopic submucosal dissection (ESD) for treating early gastric cancer: Comparison with endoscopic mucosal resection after circumferential precutting (EMR-P)

BackgroundTo achieve en bloc resection for large lesions, endoscopic mucosal resection after circumferential precutting and endoscopic submucosal dissection techniques have been developed.AimTo compare endoscopic submucosal dissection with endoscopic mucosal resection after circumferential precutting in terms of the clinical efficacy and safety.Patients and methods346 consecutive patients underwent their first endoscopic mucosal resection after circumferential precutting (103 patients) or endoscopic submucosal dissection (243 patients) for early gastric cancer and their clinical outcomes were compared.ResultsFor early gastric cancer ≥20 mm endoscopic submucosal dissection group demonstrated significantly higher en bloc resection and en bloc plus R0 resection rate compared with endoscopic mucosal resection after circumferential precutting group. For early gastric cancer with size of 10–19 mm, endoscopic submucosal dissection group also showed significantly higher en bloc resection rate. For early gastric cancer <20 mm, however, en bloc plus R0 resection rate for endoscopic mucosal resection after circumferential precutting group was comparable to that for endoscopic submucosal dissection group. In case of R0 resection of intramucosal differentiated cancer, neither group showed local recurrence during the median 29 and 17 months of follow-up. Two groups did not show significant difference in the bleeding or perforation rates.ConclusionFor early gastric cancer <20 mm endoscopic mucosal resection after circumferential precutting may be considered as an alternative choice to endoscopic submucosal dissection. However, for early gastric cancer ≥20 mm endoscopic submucosal dissection should be considered as the first choice for treating early gastric cancer.     

EARLY GASTRIC CANCER: PROPOSAL FOR A NEW DIAGNOSTIC SYSTEM BASED ON MICROVASCULAR ARCHITECTURE AS VISUALIZED BY MAGNIFIED ENDOSCOPY

We have developed a magnified endoscopic technique for observing the microvascular architecture within the gastric mucosa in units as small as capillary and we have reported the characteristic findings of the microvascular architecture in both normal gastric mucosa and early gastric cancer. The findings in the normal stomach were different depending on the section of the stomach. The body mucosa demonatrated a regular honeycomb‐like subepithelial capillary network pattern with a collecting venule, while the antral mucosa demonstrated a regular coil‐shaped subepithelial capillary network pattern. The magnified endoscopic findings of early gastric carcinoma were different depending on the types of histological differentiation. The characteristic findings of differentiated carcinoma were (1) the presence of a demarcation line; (2) the disappearance of the regular subepithelial capillary network pattern; and (3) the presence of an irregular microvascular pattern. The findings of undifferentiated carcinoma showed only a reduction in or else the complete disappearance of the regular subepithelial capillary network pattern. In clinical practice, the magnified endoscopic findings of differentiated carcinoma are useful both for determining the margin of early gastric cancer and for making a differential diagnosis between gastritis and gastric cancer in the case of flat reddened lesions. The microvascular architecture as visualized by magnified endoscopy could be a new diagnostic system for the endoscopic diagnosis of early gastric cancer.     

早期胃癌内镜黏膜下剥离术后超适应证的处理

内镜黏膜下剥离术（ESD）治疗早期胃癌已被广大消化内镜医师接受,国内ESD技术也已逐渐推广。对于早期胃癌诊断、ESD治疗指征、术中操作、术后病理及术后随访处理等也在逐渐规范。随着早期胃癌ESD治疗病例的增多,内镜医师会面对越来越多的ESD术后超适应证病例,如何合理应对是内镜医师必须面对的问题,本文就此做一些探讨。     

Early gastric cancer: diagnosis, treatment techniques and outcomes

The detection of early gastric cancer is performed by endoscopic study with or without the dye-spraying method, which is useful in detecting small lesions or surface lesions. For the diagnosis of early gastric malignancy, magnification endoscopy, narrow-band imaging and optical coherence tomography are used for histological diagnosis and research. On the other hand, endoscopic ultrasonography is used to discuss the depth of carcinoma invasion, but cannot be used to detect the malignant lesions except for the rare cases of scirrhus-type gastric carcinoma, the histological results of which are sometimes difficult to obtain by biopsy study. The role of endoscopic ultrasonography diagnosis is to assist in making a decision of therapeutic strategy. Curative endoscopic treatment of early gastric cancer is common according to the development of various endoscopic techniques and accessories. Curative treatment is feasible using these techniques.     

Neodymium:yttrium-aluminum garnet contact laser ablation of Barrett's high grade dysplasia and early adenocarcinoma

OBJECTIVES: We describe the efficacy and safety of neodymium:yttrium-aluminum garnet (Nd:YAG) contact laser ablation of Barrett's high grade dysplasia (HGD) and/or early adenocarcinoma. METHODS: Consecutive Barrett's patients in whom HGD or adenocarcinoma was detected were eligible. Radial array echoendosonography and high frequency catheter probe ultrasonography were performed. Patients were excluded if ultrasound revealed the presence of Barrett's cancer with regional lymph nodes or celiac trunk metastases or extension of the tumor into superficial submucosa (T1sm1) or greater. Nd:YAG laser used quartz contact probes, with all Barrett's epithelium targeted at each session. Complete ablation was confirmed with Lugol's iodine chromoendoscopy followed by surveillance biopsies of the neosquamous epithelium. Adverse events were ascertained by scheduled telephone contact interviews. RESULTS: A total of 36 patients with HGD/adenocarcinoma were evaluated at our center, 17 of whom met all inclusion criteria. Of the patients, 14 have remained in the study, and all have had successful elimination of HGD and cancer. In addition, 11 patients (78.6%) achieved complete endoscopic and histological ablation of all Barrett's tissue. Two patients (14.3%) achieved 95% destruction of Barrett's with residual metaplastic columnar epithelium containing goblet cells without dysplasia. The remaining patient has obtained 75% ablation of Barrett's, with residual metaplastic columnar epithelium harboring Barrett's with low grade dysplasia. Major complications included two esophageal strictures (11.8%) and one mild upper GI bleed (5.9%). CONCLUSIONS: This preliminary experience with Nd:YAG contact laser for the treatment of Barrett's HGD and early superficial cancers seems promising. The need for additional controlled trials with larger numbers of patients with longer follow-up, as well as consideration of a head-to-head trial with Photofrin photodynamic therapy, is warranted.     

食管和贲门早癌内镜激光治疗的五年存活率和预后因素

为探索食管和贲门早癌激光治疗的五年生存率和影响其预后的因素，对内镜ＮｄＹＡＧ激光治疗后癌细胞消失的３２例食管和贲门早期浅表癌病人进行了３３～７８个月（平均５５．３个月）的前瞻性随访。应用Ｐｒｏｄｕｃｔｌｉｍｉｔｅｓｔｉｍａｔｅ方法计算其存活率；并与１１７例食管和贲门早期浅表癌的自然病程进行了对比分析。内镜激光治疗五年存活率为９７％，未经治疗的早期食管贲门癌五年存活率为６７％，（Ｐ＜０．０１），表明内镜ＮｄＹＡＧ激光是一种有效的治疗方法。在对影响疗效因素的分析中，发现癌基因ｐ５３是一个有价值的独立预后因素。