Management of Early-stage Esophageal Neoplasia (MESEN) Consensus

Background

Treatment of esophageal adenocarcinoma often involves surgical resection. Newer technologies in interventional endoscopy have led to a substantial paradigm shift in the management of early-stage neoplasia in Barrett’s esophagus comprising high-grade dysplasia (HGD), intramucosal carcinoma, and, in some cases, submucosal carcinoma. However, there has been no consensus regarding the indications for esophageal preservation in these cases. In this work, consensus guidelines were established for the management of early-stage esophageal neoplasia considering clinically relevant aspects (age, comorbidities, and social environment) in each scenario.

Methods

Seventeen experts were invited to participate based on their background and clinical expertise at high-volume centers. A questionnaire was created that included four clinical scenarios covering a wide range of situations within HGD and/or early esophageal neoplasia, particularly where controversies are likely to exist. Each of the clinical scenarios was open to discussion subdivided by patient age (20, 50, and 80 s). For each clinical scenario an expert was chosen to defend that position. Each defense triggered a subsequent discussion during a consensus meeting. Conclusions of that discussion together with an accompanying literature analysis allowed experts to confirm or change their original choices and served as the basis for the recommendations stated in this article.

Results

There was 100 % consensus supporting esophageal preservation in patients with HGD, independent of patient age or Barrett’s length. In patients with T1a adenocarcinoma, consensus for preservation was not reached (65 %) for young and middle-aged individuals but was supported for elderly patients (100 %). For T1b adenocarcinoma, consensus was reached for surgical resection (90 %), leaving organ preservation for patients with very low risk of nodal invasion or poor surgical candidates.

Conclusion

Advances in endoscopic imaging and therapy allow for organ preservation in most settings of early-stage neoplasia of the esophagus, provided that the patient understands the implications of this decision.     

Principles and practice to facilitate complete photodocumentation of the upper gastrointestinal tract: World Endoscopy Organization position statement

Although esophagogastroduodenoscopy (EGD) is the most commonly used procedure in the gastrointestinal (GI) tract, the method of esophageal, gastric and duodenal mucosa photodocumentation varies considerably worldwide. One probable explanation is that for generations, EGD has primarily been taught by GI faculty and instructors based on their perceptions and experience, which has resulted in EGD being a non-standardized procedure. Currently, the procedure is facing a challenging scenario as endoscopy societies are implementing procedure-associated quality indicators aiming for best practice among practitioners and evidence-based care for patients. Contrary to colonoscopy where cecum landmarks photodocumentation is considered proof of completeness, there are currently no reliable performance measures to gauge the completeness of an upper endoscopy nor guidance for complete photodocumentation. This World Endoscopy Organization (WEO) position statement aims to provide practical guidance to practitioners to carry out complete EGD photodocumentation. Hence, an international group of experts from the WEO Upper GI Cancer Committee formulated the following document using the body of evidence established through literature reviews, expert opinions, and other scientific sources. The group acknowledged that although the procedure should be feasible in any facility, what is needed to achieve a global shift on the concept of completeness is a common written statement of agreement on its potential impact and added value. This best practice statement offers endoscopists principles and practical guidance in order to carry out complete photodocumentation from the hypopharynx to the second duodenal portion.     

Waterborne outbreak of Norwalk-like virus gastroenteritis at a tourist resort,Italy

In July 2000, an outbreak of gastroenteritis occurred at a tourist resort in the Gulf of Taranto in southern Italy. Illness in 344 people, 69 of whom were staff members, met the case definition. Norwalk-like virus (NLV) was found in 22 of 28 stool specimens tested. The source of illness was likely contaminated drinking water, as environmental inspection identified a breakdown in the resort water system and tap water samples were contaminated with fecal bacteria. Attack rates were increased (51.4%) in staff members involved in water sports. Relative risks were significant only for exposure to beach showers and consuming drinks with ice. Although Italy has no surveillance system for nonbacterial gastroenteritis, no outbreak caused by NLV has been described previously in the country.     

Gap junctions in the inner ear: comparison of distribution patterns in different vertebrates and assessement of connexin composition in mammals

The distribution and size of gap junctions (GJ) in the sensory epithelia of the inner ear have been examined in a reptile (gecko), birds (chicken and owl), and mammals (mouse, guinea pig, gerbil, and bat), and the connexin composition of GJs in the mammalian inner ear has been assessed. Freeze fracture revealed a common pattern of GJ distribution in auditory and vestibular sensory epithelia in the different vertebrate classes. In all these tissues, GJs are numerous, often occupying more than 25% of the plasma membrane area of supporting cells and sometimes composed of more than 100,000 channels. Screening for 12 members of the connexin family in the mammalian inner ear by RT-PCR, Western blotting, and immunohistochemistry revealed four connexin isotypes, cx26, cx30, cx31, and cx43, in the cochlea and three, cx26, cx30, and cx43, in the vestibular organs. With antibodies characterised for their specificity, cx26 and cx30 colocalised in supporting cells of the organ of Corti, in the basal cell region of the stria vascularis, and in type 1 fibrocytes of the spiral ligament. No other connexin was detected in these regions. Cx31 was localised among type 2 fibrocytes below the spiral prominence, a region where cx30 was not expressed and cx26 expression appeared to be low. Cx43 was detected only in the region of "tension fibrocytes" lining the inner aspect of the otic capsule. This suggests separate functional compartments in the cochlea. In addition to cx26 and cx30, cx43 was detected in supporting cells of the vestibular sensory epithelia. Where cx26 and cx30 were colocalised, double immunogold labelling of thin sections showed both cx26 and cx30 evenly distributed in individual GJ plaques, a pattern consistent with the presence of heteromeric connexons. Coimmunoprecipitation of cochlear membrane proteins solubilised with a procedure that preserves the oligomeric structure of connexons confirmed the presence of heteromeric cx26/cx30 connexons. Heteromeric cx26/cx30 connexons may be unique to the inner ear, which could be one factor underlying the non-syndromic character of the deafness caused by mutations in cx26.     

Connexins and gap junctions in the inner ear

Mutations in the genes for three different isotypes of the gap junction channel protein connexin are associated with deafness. This indicates an important role for gap junctions in auditory function and provides an opportunity to explore structure-function relationships in the connexin molecule. We have been examining the distribution of gap junctions and the pattern of connexin expression in the mature inner ear and during development, and the effect of specific mutations on the processing and functionality of the expressed connexin proteins in an in vitro system.     

Sonographic findings in septo-optic dysplasia in the fetus and newborn infant

A 28-year-old primigravida woman was referred for ultrasound studies at 27 weeks' gestation. Sonographic examination found enlarged cerebral ventricles, communicating lateral ventricles, bilateral cleft lip and palate. A 2500 gm male infant was delivered at 36 weeks' gestation, after which the diagnosis of septo-optic dysplasia was made.     

Extracranial internal carotid artery occlusion associated with ipsilateral cerebral glioblastoma

A case of left extracranial internal carotid artery occlusion, associated with ipsilateral parietal glioblastoma, is reported. The clinical and radiological aspects are discussed. The Authors stress the usefulness of a complete investigation in patients with symptoms of cerebrovascular insufficiency.