Evaluating Laryngopharyngeal Tumor Extension Using Narrow Band Imaging Versus Conventional White Light Imaging.

OBJECTIVE/HYPOTHESIS: Comparing detection and extension of malignant tumors by flexible laryngoscopy in the outpatient setting with laryngoscopy under general anesthesia using both White Light Imaging (WLI) and Narrow Band Imaging (NBI). STUDY DESIGN: Prospective study. METHODS: Two hundred and thirty-three patients with laryngeal and pharyngeal lesions underwent flexible and rigid laryngoscopy, with both WLI and NBI. Extension of malignant lesions (n = 132) was compared between both techniques in detail. RESULTS: Sensitivity of NBI during flexible endoscopy (92%), was comparable with that of WLI during rigid endoscopy (91%). The correlation of tumor extension between flexible and rigid laryngoscopy was high (rs  = 0.852-0.893). The observed tumor extension was significantly larger when using NBI in both settings. The use of NBI during flexible laryngoscopy leads to upstaging (12%) and downstaging (2%) of the T classification. CONCLUSIONS: NBI during flexible laryngoscopy could be an alternative to WLI rigid endoscopy. NBI improves visualization of tumor extension and accuracy of T staging. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E2222-E2231, 2021.

Diagnostic performance in gastric cancer is higher using endocytoscopy with narrow-band imaging than using magnifying endoscopy with narrow-band imaging.

BACKGROUND: For diagnosing gastric cancer, differences in the diagnostic performance between endocytoscopy with narrow-band imaging and magnifying endoscopy with narrow-band imaging have not been reported. We aimed to clarify these differences by analyzing diagnoses made by endoscopists in Japan. METHODS: This single-center retrospective cohort study used 106 cancerous and 106 non-cancerous images obtained via both modalities (total, 424 images) for diagnosis. Sixty-one endoscopists with varying experience levels from 45 institutions were included. Diagnostic accuracy, sensitivity, specificity, and positive and negative predictive values were evaluated to determine the diagnostic performance of each modality and compared using the Mann-Whitney U test. RESULTS: Among all endoscopists, diagnostic accuracy, sensitivity, positive predictive value, and negative predictive value were higher with endocytoscopy with narrow-band imaging than with magnifying endoscopy with narrow-band imaging (percentage [95% confidence interval]: 78.8% [76.4-83.0%] versus 72.2% [69.3-73.6%], p < 0.0001; 82.1% [78.3-85.9%] versus 64.2% [60.4-69.8%], p < 0.0001; 88.7% [82.6-90.7%] versus 78.5% [75.4-85.1%], p = 0.0023; 79.0% [75.3-80.5%] versus 68.5% [66.4-71.6%], p < 0.0001, respectively). In the magnifying endoscopy with narrow-band imaging-trained group, these values were also higher with endocytoscopy with narrow-band imaging than with magnifying endoscopy with narrow-band imaging (p < 0.0001, p = 0.0001, p = 0.0143, and p < 0.0001, respectively). Diagnostic accuracy, sensitivity, and negative predictive value were higher with endocytoscopy with narrow-band imaging than with magnifying endoscopy with narrow-band imaging in the magnifying endoscopy with narrow-band imaging-untrained group (p = 0.0041, p = 0.0049, and p = 0.0098, respectively). CONCLUSIONS: Diagnostic performance was higher using endocytoscopy with narrow-band imaging than using magnifying endoscopy with narrow-band imaging. Our results may help change the technique used to diagnose gastric cancer.

Feasibility of using narrow band imaging international colorectal endoscopic classification for diagnosing colorectal neoplasia in China: A multicenter pilot observational study.

OBJECTIVE: We aimed to investigate whether Chinese endoscopists without narrow-band imaging (NBI) experiences could achieve high accuracy in the real-time diagnosis of colorectal polyps using NBI International Colorectal Endoscopic (NICE) classification after web-based training. METHODS: Altogether 15 endoscopists from five centers with no NBI experiences followed a short, web-based training program on the NICE classification and took web-based test. Their performances were compared with 15 matched experienced endoscopists with no NBI experience who received no NBI training. These 15 trained endoscopists then made real-time diagnoses of colorectal neoplasia. A logistic regression was used to assess potential predictors of diagnostic performance. RESULTS: Compared with those who received no training, trained endoscopists achieved comparable overall accuracy (85.3% vs 83.1%, P = 0.408) and accuracy at a high-confidence level (87.0% vs 86.0%, P = 0.670), but had a higher confidence rate (86.1% vs 83.7%, P = 0.004) for the diagnosis of neoplasia. Real-time diagnostic accuracy, sensitivity and specificity were 94.3% (95% confidence interval [CI] 91.5%-96.2%), 96.2% (95% CI 93.4%-97.9%) and 85.3% (95% CI 74.8%-92.1%) at high-confidence level. The high-confidence level was the strongest predictor of real-time diagnostic accuracy (odds ratio 12.66, P < 0.001). CONCLUSIONS: Web-based training can improve the confidence level of endoscopists in accurately diagnosing colorectal polyps using the NICE classification. Chinese endoscopists can achieve high accuracy in diagnosing colorectal neoplasia at a high confidence level (ClinicalTrials ID: NCT02033980).

The Diagnostic Performance for Colorectal Neoplasms Using Magnified Endoscopy Differs between Experts and Novice Endoscopists: A Post Hoc Analysis.

INTRODUCTION: Magnified endoscopy is difficult for novice endoscopists because it requires both knowledge and skill of endoscopic diagnosis. The aim of this study was to examine the diagnostic performance of novice endoscopists on determining the invasive depth of colorectal neoplasms and compare it with that of experts. METHODS: The present study was conducted as a post hoc analysis. Thirty expert and 30 novice endoscopists who use magnifying endoscopy (narrow-band imaging [NBI] and pit pattern analysis) were recruited for the online survey. Novice endoscopist was defined as one who has <5 years of experience in magnifying endoscopy. Three outcomes were assessed: (a) diagnostic accuracy of both novice and expert endoscopists in determining the depth of invasion; (b) additional diagnostic accuracy of novice endoscopists in determining the depth of invasion with magnifying NBI or pit pattern compared with nonmagnifying white light imaging (WLI); (c) difference in confidence on diagnosis among each modality between novice and expert endoscopists. RESULTS: The area under the curve (AUC) of expert endoscopists was significantly higher than that of novice endoscopists. The AUC of the pit pattern was significantly higher than that of WLI regardless of lesion characteristics as determined by novice endoscopists. The proportion of answers with high confidence was significantly higher with expert endoscopists than with novice endoscopists. CONCLUSIONS: Aside from learning basic diagnosis of colorectal neoplasms, magnifying endoscopy may have substantial clinical benefit for novice endoscopists.

Reliability of Japan Narrow-Band Imaging Expert Team Classification for the Diagnosis of Colorectal Neoplasms: A Pilot Study.

INTRODUCTION: Magnifying narrow-band imaging (NBI) is a beneficial modality for the prediction of histology in colonoscopy. The Japan NBI Expert Team (JNET) classification has been established based on the results of online surveys of the diagnostic accuracy of histological features. However, the reliability of the JNET classification has not been examined. The aim of this study was to evaluate the degree of interobserver agreement for JNET classification among endoscopists when evaluating colonic lesions. METHODS: We analyzed a total of 246 colonic lesions in this interpretation test. Each lesion image was subsequently reviewed by 3 experienced endoscopists and then classified based on 4 established JNET categories and indeterminate categories between fixed categories. The primary endpoint was the interobserver agreement rate for evaluation of endoscopic findings using the JNET classification. RESULTS: The complete concordance (defined as 3 out of 3 observer agreement) rate was 73% (179/246), while the partial concordance (defined as 2 out of 3 observer agreement) rate was 26% (64/246). Therefore, concordance of at least 2 out of 3 was achieved in 99% of all the lesions and disagreement of the 3 endoscopists was found in only 1% (3/246). Fleiss's kappa coefficient (κ) was 0.72 for all cases, which represents moderate interobserver agreement for observers. DISCUSSION/CONCLUSION: Our study highlights the reliability of the JNET classification for colonic neoplastic lesions among experienced endoscopists and demonstrates acceptable interobserver agreement. Further studies validating the clinical applicability of JNET classification are required among endoscopists with a variety of expertise in several clinical settings.

Accuracies of Endoscopic Diagnosis of Helicobacter pylori-Gastritis: Multicenter Prospective Study Using White Light Imaging and Linked Color Imaging.

INTRODUCTION: The diagnosis of Helicobacter pylori infection status with white light imaging (WLI) is difficult. We evaluated the accuracies of using WLI and linked color imaging (LCI) for diagnosing H. pylori-active gastritis in a multicenter prospective study setting. METHODS: Patients who underwent esophagogastroduodenoscopy were prospectively included. The image collection process was randomized and anonymous, and the image set included 4 images with WLI or 4 images with LCI in the corpus that 5 reviewers separately evaluated. Active gastritis was defined as positive when there was diffuse redness in WLI and crimson coloring in LCI. The H. pylori infection status was determined by the urea breath test and the serum antibody test. Cases in which both test results were negative but atrophy or intestinal metaplasia was histologically confirmed were defined as past infections. The primary endpoint was the diagnostic accuracies of WLI and LCI, and the secondary endpoint was inter-observer agreement. RESULTS: Data for 127 patients were analyzed. The endoscopic diagnostic accuracy for active gastritis was 79.5 (sensitivity of 84.4 and specificity of 74.6) with WLI and 86.6 (sensitivity of 84.4 and specificity of 88.9) with LCI (p = 0.029). LCI significantly improved the accuracy in patients with past infections over WLI (36.8 in WLI and 78.9 in LCI, p < 0.01). The κ values were 0.59 in WLI and 0.70 in LCI. CONCLUSIONS: LCI is useful for endoscopic diagnosis of H. pylori-active or inactive gastritis, and it is advantageous for patients with past infections of inactive gastritis.

Narrow band imaging in head and neck unknown primary carcinoma: A systematic review and meta-analysis.

OBJECTIVE: To estimate the diagnostic performance of Narrow Band Imaging (NBI) in patients with cervical metastasis from head and neck squamous cell carcinoma of unknown primary (SCCUP) origin. METHODS: PubMed, Embase, and Scopus databases were systematically scrutinized up to July 1, 2019, looking for studies that encompassed the NBI in the SCCUP diagnostic work up. The main inclusion criteria for eligible articles for the meta-analysis were non-evidence of primary tumor after physical examination and conventional cross-section imaging before NBI assessment and the availability of complete data on the diagnostic accuracy of NBI. A set of random-effects model meta-analyses was then performed following the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. RESULTS: Five studies, conducted between January 2003 and September 2016, comprising 169 patients imaged with NBI, were included in the meta-analysis. The pooled sensitivity and specificity of NBI in patients with head and neck SCCUP was 0.83 (99% CI, 0.54-0.95) and 0.88 (99% CI, 0.55-0.97), respectively. The positive and negative likelihood ratios were 6.38 (99% CI, 1.6-25.44) and 0.06 (99% CI, 0.005-0.86). The pooled diagnostic odds ratio (DOR) was 82.15 (99% CI, 7.06-955). The overall detection rate of NBI was 0.35 (99% CI, 0.18-0.53), which allowed localization the primary tumor in 61 out of 169 patients, otherwise not detected by the usual diagnostic work-up. CONCLUSIONS: Current available evidence suggests that NBI has a considerable diagnostic accuracy in patients affected by head and neck SCCUP. Laryngoscope, 130:1692-1700, 2020.

Comparative study of magnifying narrow-band imaging and conventional white light endoscopy in the diagnosis of Helicobacter pylori status after eradication therapy.

Predicting Helicobacter pylori (Hp) status by endoscopic finding would be useful in recent clinical condition that the use of proton-pump inhibitors, anti-platelet, and anti-coagulant have become widespread. We aimed to elucidate the diagnostic accuracy of magnifying narrow-band imaging (M-NBI) endoscopy in distinguishing Hp status in patients with or without history of successful Hp eradication and compare this accuracy to the diagnostic accuracy of conventional white light (WL) endoscopy.Two hundred seven endoscopic examinations before and after Hp eradication were performed in prospective 163 patients. Endoscopic images by using the M-NBI and conventional WL were stored electronically and randomly allocated to 2 readers for evaluation. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were assessed by reference to Hp status assessed by conventional clinical test.Sensitivity, specificity, PPV, NPV, and accuracy for predicting Hp status for the conventional WL was 72.2%, 75.5%, 72.2%, 75.5%, and 73.9% for the first reader; 86.6%, 57.3%, 64.1%, 82.9%, and 71.0% for the second reader. On the other hand, sensitivity, specificity, PPV, NPV, and accuracy for predicting Hp status for the M-NBI was 96.9%, 93.6%, 93.1%, 97.1%, and 95.2% for the first reader; 92.8%, 93.6%, 92.8%, 93.6%, and 93.2% for the second reader, respectively. The diagnostic accuracy of M-NBI was significantly higher than that of WL (P < .0001 for both readers). Inter-observer agreement of M-NBI (k = 0.83) was also better than that of WL (k = 0.53).M-NBI was capable of distinguishing Hp status before and after eradication therapy.

The utility of narrow band imaging in endoscopic diagnosis of laryngopharyngeal reflux.

OBJECTIVE: This study assessed the utility of narrow band imaging (NBI) in patients with symptoms of laryngopharyngeal reflux (LPR) and tried to quantitatively evaluate the signs found under the NBI Laryngoscope. METHODS: Patients with and without LPR symptoms completed reflux symptom index (RSI) questionnaires prior to enrolment. The throat was examined by standard white light endoscopy followed by NBI. LPR status was determined using the reflux finding score and the RSI. Laryngoscope images and videos from 70 subjects with LPR and 70 control subjects without LPR were obtained. Features seen only by NBI were compared between the two groups. Then the RGB values of the throat mucosa of the two groups were measured by Photoshop software, and finally statistical analysis was performed. RESULTS: In total, 140 patients were eligible for final analysis (LPR group mean age = 50.0, 47 males; control group mean age = 44.8, 45 males). A significantly higher proportion of patients with LPR had increased vascularity, green spots, contact ulcers and granulomas. Of these, increased vascularity and green spots can only be found under NBI, and the prevalence rates in the LPR group were found to be 92.8% and 88.6% (P < 0.05), respectively. In the control group, the prevalence rates of increased vascularity and green spots were 21.4% and 7.1%, respectively (P < 0.05). The RGB value of the LPR group was generally higher than that of the control group. The difference is statistically significant (P < 0.05). CONCLUSION: LPR presents vascularity and green spots with high specificity and sensitivity under NBI which can play a role in the auxiliary diagnosis of LPR.

Diagnostic value of blue laser imaging combined with magnifying endoscopy for precancerous and early gastric cancer lesions.

BACKGROUND/AIMS: Blue laser imaging (BLI) is a new technique for detailed examination of upper gastrointestinal lesions. This study aimed to evaluate the diagnostic value of BLI combined with magnifying endoscopy for precancerous and early gastric cancer lesions. MATERIALS AND METHODS: A total of 249 gastric lesions detected via conventional white light endoscopy (WLE) based on assessments of mucosal shape and color were included in this study. The accuracy of diagnosis of precancerous or early cancer lesions white light magnification alone, BLI-contrast magnification, and BLI-bright magnification was determined according to the VS criteria. RESULTS: For white light magnification alone, BLI-contrast magnification, and BLI-bright magnification, the concordance rates for lesions were 76.7%, 85.1%, and 86.7%, respectively, and the Kappa values were 0.571, 0.730, and 0.760, respectively. For the screening of high-grade intraepithelial neoplasia or early gastric cancer, the diagnostic sensitivities of white light magnification alone, BLI-contrast magnification, and BLI-bright magnification were 72.0%, 92.0%, and 92.0%, respectively; the specificities were 95.5%, 98.2%, and 99.1%, respectively; the consistencies were 93.2%, 97.6%, and 98.4%, respectively; and the Kappa values were 0.642, 0.871, and 0.911, respectively. For diagnoses of high-grade intraepithelial neoplasia or early gastric cancer, the concordance between endoscopic and pathological diagnosis was significantly higher for BLI-contrast and BLI-bright magnification than for white light magnification alone (p<0.05). CONCLUSION: BLI combined with magnifying endoscopy may improve diagnostic accuracy for early gastric cancer and precancerous lesions.

Narrow-Band Imaging for Detection of Neoplasia at Colonoscopy: A Meta-analysis of Data From Individual Patients in Randomized Controlled Trials.

BACKGROUND & AIMS: Adenoma detection rate (ADR) is an important quality assurance measure for colonoscopy. Some studies suggest that narrow-band imaging (NBI) may be more effective at detecting adenomas than white-light endoscopy (WLE) when bowel preparation is optimal. We conducted a meta-analysis of data from individual patients in randomized controlled trials that compared the efficacy of NBI to WLE in detection of adenomas. METHODS: We searched MEDLINE, EMBASE, and Cochrane Library databases through April 2017 for randomized controlled trials that assessed detection of colon polyps by high-definition WLE vs NBI and from which data on individual patients were available. The primary outcome measure was ADR adjusted for bowel preparation quality. Multilevel regression models were used with patients nested within trials, and trial included as a random effect. RESULTS: We collected data from 11 trials, comprising 4491 patients and 6636 polyps detected. Adenomas were detected in 952 of 2251 (42.3%) participants examined by WLE vs 1011 of 2239 (45.2%) participants examined by NBI (unadjusted odds ratio [OR] for detection of adenoma by WLE vs NBI, 1.14; 95% CI, 1.01-1.29; P = .04). NBI outperformed WLE only when bowel preparation was best: adequate preparation OR, 1.07 (95% CI, 0.92-1.24; P = .38) vs best preparation OR, 1.30 (95% CI, 1.04-1.62; P = .02). Second-generation bright NBI had a better ADR than WLE (second-generation NBI OR, 1.28; 95% CI, 1.05-1.56; P = .02), whereas first-generation NBI did not. NBI detected more non-adenomatous polyps than WLE (OR, 1.24; 95% CI, 1.06-1.44; P = .008) and flat polyps than WLE (OR, 1.24; 95% CI, 1.02-1.51; P = .03). CONCLUSIONS: In a meta-analysis of data from individual patients in randomized controlled trials, we found NBI to have a higher ADR than WLE, and that this effect is greater when bowel preparation is optimal.

Diagnosis of vocal cord leukoplakia: The role of a novel narrow band imaging endoscopic classification.

OBJECTIVES: The purpose of this study was to introduce a new narrow band imaging (NBI) endoscopic classification for the diagnosis of vocal cord leukoplakia. STUDY DESIGN: Case series. METHODS: From January 2010 to February 2018, a total of 120 cases of vocal cord leukoplakia were enrolled in this study. The NBI endoscopic system was used to examine the vocal cords. Each lesion was observed by NBI endoscopy and evaluated according to the detailed morphologic findings of intraepithelial papillary capillary loop (IPCL). The superficial IPCL patterns were classified into six types (types I-VI). The differential diagnosis abilities of NBI classification for benign and malignant leukoplakia were investigated. RESULTS: Out of the 120 cases of vocal cord leukoplakia, 81% (97 of 120) related to benign lesions (including inflammation, epithelial proliferation, hyperkeratosis, dyskeratosis, mild dysplasia, and moderate dysplasia); the remaining 19% (23 of 120) consisted of malignant lesions (including severe dysplasia, carcinoma in situ, and invasive carcinoma). The accuracy of differential diagnosis for vocal cord leukoplakia using NBI endoscopy was up to 90.8% (109 of 120), significantly higher than that of white light imaging (70.0%, 84 of 120) (χ2 = 16.536, P = 0.000). The sensitivity, specificity, and positive and negative predictive values of the diagnosis for malignant vocal cord leukoplakia under the NBI endoscope were 82.6%, 92.8%, 73.1%, and 95.7%, respectively. There is relatively good consistency between the NBI endoscopic diagnosis and pathological diagnosis (kappa = 0.718, P = 0.000). CONCLUSION: The new NBI endoscopic classification of vocal cord leukoplakia can improve the accuracy of distinguishing benign and malignant leukoplakia. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:429-434, 2019.

Intraoperative Margin Control in Transoral Approach for Oral and Oropharyngeal Cancer.

OBJECTIVES: Piecemeal resection provides an innovative conceptual tool for margins surveillance because it entails the intraoperative evaluation of the whole resection margins and not just sample points, which should result in a better control of deep margins compared to en bloc resection. Although it is recognized that the intraoperative use of narrow band imaging (NBI) results in a better control of superficial margins, in this exploratory study we investigated whether NBI and piecemeal resection could be used in combination to improve margin control at both superficial and deep levels. Because piecemeal resection is based on frozen section analysis, we wanted to verify its reliability compared to definitive histological examination. METHODS: The status of resection margins in a group of patients with oral and oropharyngeal cancers treated with NBI and laser CO2 piecemeal resection (group 1) was compared with that of an historical group of patients (group 2) treated with NBI and conventional en bloc resection. In group 1, sensitivity, specificity, and positive and negative predictive values were used to verify the rate of concordance between frozen section and definitive histology. RESULTS: The difference between deep positive margins in the two groups was statistically significant (P = 0.042). The high sensitivity and specificity (94.6% and 94.7%, respectively) of frozen section analysis also demonstrated its reliability in the examination of larger samples corresponding to the whole margin. CONCLUSION: Even if our findings are limited by the small number of patients, we are confident that the combined use of NBI and piecemeal resection could represent an attractive surgical strategy to improve margin control. LEVEL OF EVIDENCE: 2b Laryngoscope, 129:1810-1815, 2019.

Narrow Band Imaging Endoscopy of the Nasopharynx for Malignancy: An Inter- and Intraobserver Study.

OBJECTIVE: To assess interobserver agreement and intraobserver reproducibility when assessing the nasopharynx for malignancy under white light and narrow band imaging endoscopy because the decision to biopsy hinges on the examiner's perceived chance of malignancy. METHODS: An interobserver and intraobserver agreement study utilizing white light and narrow band endoscopic images of the nasopharynx. The setting was an academic referral hospital. Participants were 156 adults with suspected nasopharyngeal carcinoma who underwent white light and narrow band imaging endoscopy and biopsy. Images of the nasopharynges were subsequently scored for malignancy by four otolaryngologists. The nasopharynx was scored on 4-point scales under white light and narrow band imaging endoscopy for the likelihood of malignancy or abnormality, respectively. RESULTS: Intraclass correlation coefficients for intraobserver agreement for nasopharyngeal malignancy for four observers under white light were 0.86, 0.89, 0.79 and 0.88 (mean 0.855), respectively; and under narrow band imaging they were 0.64, 0.68, 0.64, and 0.66 (mean 0.655), respectively (all P values < 0.001). The coefficient for interobserver reliability under white light was 0.79 (95% confidence interval [CI] 0.76-0.82; P < 0.001), which indicated strong agreement. The coefficient for interobserver reliability under narrow band imaging was 0.56 (95% CI 0.50-0.61; P < 0.001), which indicated moderate agreement. CONCLUSIONS: Intraobserver and interobserver agreement for nasopharyngeal malignancy was strong on white light endoscopy but only moderate on narrow band imaging endoscopy. Agreement may be improved by adopting a standard set of assessment guidelines, including an objective detailed morphological analysis under white light and vasculature analysis under narrow band imaging. LEVEL OF EVIDENCE: 2a Laryngoscope, 129:1374-1379, 2019.

The usefulness of the NBI - narrow band imaging for the larynx assessment.

Narrow band imaging (NBI) by enhancing the contrast between the mucosal epithelium and submucosal vessels facilitates diagnosis of precancerous and cancerous lesions, as well as hypertrophic lesions such as laryngeal papillomatosis. Narrow band imaging (NBI) is an optical technique based on the modification of white light by the use of special optical filters. Every change in the microvascular architecture of the mucosa is classified according to Ni's classification (2011). The use of NBI improves sensitivity and specificity of assessment of laryngeal lesions and allows more precise assessment of the status of surgical margins of early-stage and locally-advanced laryngeal cancers managed in endoscopic laser cordectomy.

Effects of Training and Feedback on Accuracy of Predicting Rectosigmoid Neoplastic Lesions and Selection of Surveillance Intervals by Endoscopists Performing Optical Diagnosis of Diminutive Polyps.

BACKGROUND & AIMS: Real-time differentiation of diminutive polyps (1-5 mm) during endoscopy could replace histopathology analysis. According to guidelines, implementation of optical diagnosis into routine practice would require it to identify rectosigmoid neoplastic lesions with a negative predictive value (NPV) of more than 90%, using histologic findings as a reference, and agreement with histology-based surveillance intervals for more than 90% of cases. METHODS: We performed a prospective study with 39 endoscopists accredited to perform colonoscopies on participants with positive results from fecal immunochemical tests in the Bowel Cancer Screening Program at 13 centers in the Netherlands. Endoscopists were trained in optical diagnosis using a validated module (Workgroup serrAted polypS and Polyposis). After meeting predefined performance thresholds in the training program, the endoscopists started a 1-year program (continuation phase) in which they performed narrow band imaging analyses during colonoscopies of participants in the screening program and predicted histological findings with confidence levels. The endoscopists were randomly assigned to groups that received feedback or no feedback on the accuracy of their predictions. Primary outcome measures were endoscopists' abilities to identify rectosigmoid neoplastic lesions (using histology as a reference) with NPVs of 90% or more, and selecting surveillance intervals that agreed with those determined by histology for at least 90% of cases. RESULTS: Of 39 endoscopists initially trained, 27 (69%) completed the training program. During the continuation phase, these 27 endoscopists performed 3144 colonoscopies in which 4504 diminutive polyps were removed. The endoscopists identified neoplastic lesions with a pooled NPV of 90.8% (95% confidence interval 88.6-92.6); their proposed surveillance intervals agreed with those determined by histologic analysis for 95.4% of cases (95% confidence interval 94.0-96.6). Findings did not differ between the group that did vs did not receive feedback. Sixteen endoscopists (59%) identified rectosigmoid neoplastic lesions with NPVs greater than 90% and selected surveillance intervals in agreement with those determined from histology for more than 90% of patients. CONCLUSIONS: In a prospective study following a validated training module, we found that a selected group of endoscopists identified rectosigmoid neoplastic lesions with pooled NPVs greater than 90% and accurately selected surveillance intervals for more than 90% of patients over the course of 1 year. Providing regular interim feedback on the accuracy of neoplastic lesion prediction and surveillance interval selection did not lead to differences in those endpoints. Monitoring is suggested, as individual performance varied. ClinicalTrials.gov no: NCT02516748; Netherland Trial Register: NTR4635.

Role of narrow-band imaging in detection of head and neck unknown primary squamous cell carcinoma.

OBJECTIVES/HYPOTHESIS: There is no general consensus on what kind of examination to include in an optimal detection strategy for head and neck squamous cell carcinomas of unknown primary (SCCUPs). This study investigates the role of narrow-band imaging (NBI) in their identification. STUDY DESIGN: Case series. METHODS: Twenty-nine consecutive patients affected by SCCUPs were referred at two academic institutions. Selection criteria were: 1) lymph node cytology positive for squamous cell carcinoma (SCC); 2) no evidence of any primary at white light (WL); 3) negative contrast-enhanced computed tomography (CT) and/or magnetic resonance imaging, and positron emission tomography-CT; and 4) no contraindication to general anesthesia. Each patient underwent office-based NBI panendoscopy. If a suspicious area was identified, a biopsy was performed for histological confirmation. When no suspicious area was detected in the office, patients underwent WL and NBI under general anesthesia. If this examination was still negative, bilateral tonsillectomy and base of the tongue (BOT) mucosectomy were performed. RESULTS: Office-based NBI identified 10 SCCs (34.5%), one in the nasopharynx, three in the tonsil, four in the BOT, and two in the supraglottis. In only one (3.5%) NBI-negative patient was a primary found in the BOT. In one (3.5%) we found an NBI suspicious area during panendoscopy under general anesthesia, but histology did not confirm this finding after BOT mucosectomy. Seventeen (58.6%) patients remained as having true SCCUPs. NBI sensitivity, specificity, positive, negative predictive values, and accuracy were 91%, 95%, 91%, 95%, and 90%, respectively. CONCLUSIONS: In the present study, office-based NBI increased the detection rate of head and neck SCCUPs by 34.5% and should be strongly recommended as an adjunctive tool in their diagnostic workup. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:2060-2066, 2018.

NBI utility in the pre-operative and intra-operative assessment of oral cavity and oropharyngeal carcinoma.

PURPOSE: Despite advances in the surgical management of head and neck squamous cell carcinoma, the identification of synchronous lesions, precancerous lesions around the main tumor, or the unknown primary in the case of neck metastasis remains a problem, as these lesions may be invisible to the naked eye or with standard white light (WL) endoscopy. However, the advent of tools such as narrow-band imaging (NBI) could help the clinician. The purpose of this study was to assess the impact of NBI during the pre-operative and intra-operative stages of management of oral and oropharyngeal cancers. MATERIALS AND METHODS: NBI was used pre-operatively in 47 patients with oral or oropharyngeal squamous cell carcinoma to identify the involvement of adjacent subsites, multifocality, synchronous lesions or an unknown primary. NBI was used intra-operatively in 30 patients to better define the tumor limits and guide the resection. The advantage of NBI versus WL endoscopy was analyzed by calculating the true and false positive rate pre-operatively, and the need for resection enlargements, histology of the enlargement, and the rate of clear margins at definitive histology, intra-operatively. RESULTS: Pre-operatively, the diagnostic gain of NBI was 8.5%, allowing identification of three synchronous tumors and one unknown primary. Intra-operatively, NBI improved the definition of tumor limits in 67.7% of cases, with resection enlargements showing dysplasia and carcinoma in 8 and 12 patients, respectively; we obtained 74.2% negative margins at histology. CONCLUSIONS: NBI could represent an added value in the pre-operative and intra-operative assessment of oral cavity and oropharyngeal carcinoma.

Narrow band imaging improves observer reliability in evaluation of upper aerodigestive tract lesions.

OBJECTIVES/HYPOTHESIS: Visualization by endoscopy is essential in the diagnosis of upper aerodigestive tract lesions. Recent studies showed that narrow band imaging (NBI) increases the diagnostic potential of conventional white light imaging (WLI) by highlighting the superficial vessels. The objective of this study was to evaluate whether the use of NBI would influence inter- and intraobserver agreement while making diagnostic decisions using rigid endoscopy of the upper aerodigestive tract. STUDY DESIGN: Retrospective study. METHODS: One hundred routinely collected pictures of laryngeal, hypopharyngeal, and oropharyngeal lesions were used. Rigid endoscopies and patient data collection were performed according to standard protocol. Twelve observers, grouped in different levels of experience, assessed all lesions twice with a 2 to 4 week interval. Fleiss and Cohen's kappa (κ) values were calculated to assess inter- and intraobserver agreement. RESULTS: Overall interobserver agreement increased from κ = 0.34 to κ = 0.40 by adding NBI to WLI (WLI and WLI + NBI, respectively). In experienced observers, an improvement from κ = 0.39 to κ = 0.43 was observed; in less-experienced observers an improvement from κ = 0.30 to κ = 0.37 was observed. Overall intraobserver agreement increased from moderate (κ = 0.54) to substantial (κ = 0.63) with addition of NBI. Intraobserver agreement for less-experienced observers improved remarkably when WLI was combined with NBI (κ = 0.51 vs. κ = 0.67). CONCLUSIONS: Addition of NBI during rigid endoscopies of the upper aerodigestive tract led to improvement of both inter- and intraobserver agreement. LEVEL OF EVIDENCE: 4 Laryngoscope, 126:2276-2281, 2016.

Intentional examination of esophagus by narrow-band imaging endoscopy increases detection rate of cervical inlet patch.

Foci of heterotopic gastric mucosa have been identified at different sites in the human body and the most common location is the proximal esophagus which is referred to as cervical inlet patch (CIP). The true prevalence of CIP varies and it is usually incidental findings during endoscopy. Because CIP is always asymptomatic, it was believed to be of little clinical relevance. However, emerging studies have described the acid-secreting characteristics of heterotopic gastric mucosa and associations of CIP with gastroesophageal reflux disease (GERD). In addition, complications such as stricture, fistula, infection, mucosal hyperplasia, and malignant transformation have been reported. In this study, we investigated the prevalence of CIP, its associations with clinical manifestations, and the effect of intentional screening upper esophagus by magnifying endoscopy-narrow-band imaging (ME-NBI) system. Consecutive healthy adults who underwent panendoscopy were separated into two groups. Patients in group I (n = 471) were examined by an endoscopist who intended to find CIPs by ME-NBI. Patients in group II (n = 428) were examined by two endoscopists who were unaware of the study and performed white-light imaging endoscopy. Participants provided questionnaires on GERD-related symptoms. Higher CIP prevalence (11.7% vs. 1.9%, P < 0.0001) and longer duration of esophageal examination (mean ± standard deviation, 17.50 ± 12.40 vs. 15.24 ± 10.78 seconds, P = 0.004) were noted in group I than in group II. Analyzing group I patients revealed the higher prevalences of reflux symptoms (32.7% vs. 18.3%, P = 0.013) and erosive esophagitis (43.6% vs. 25.5%, P = 0.005) in patients with CIP than in those without. CIP was not associated with globus or dysphagia symptoms. More small CIPs (< 5 mm) were detected by ME-NBI than by white-light imaging (85.3% vs. 41.4%, P = 0.001). In conclusion, CIP prevalence was not low under intentional ME-NBI examination of the upper esophagus. The clinical relevance of CIP and its association with GERD require further investigation.