Endoscopic features with associated histological and molecular alterations in serrated polyps with dysplasia: Retrospective analysis of a tertiary case series.

BACKGROUND: Serrated polyps are incompletely understood lesions and include serrated sessile lesion (SSL) without or with dysplasia and traditional serrated adenoma (TSA). AIMS: We investigated prevalence and characteristics of serrated lesions, especially SSL with dysplasia (mixed polyps). METHODS: This retrospective study analyzed data from consecutive patients referred for colonoscopy at a tertiary care center. Endoscopic and histopathological characteristics of identified lesions were studied. SSLs with dysplasia were molecularly analyzed for mutations and microsatellite instability. RESULTS: Among 1147 patients, a total of 436 polyps were found, including 288 adenomas (66.1 %) and 114 serrated lesions (SLDR 26.2 %). PDR was 34.5 % and ADR was of 30.2 %. Serrated lesions included 75 hyperplastic polyps (17.2 %), 24 SSLs without dysplasia (5.5 %), 6 SSLs with dysplasia (mixed polyps) (1.4 %) and 9 TSA (2.1 %). The mixed polyps were evaluated molecularly: these analyses found no KRAS mutation, a single NRAS mutation in one lesion, the Val600Glu BRAF mutation in four lesions in both their serrated non-dysplastic and dysplastic areas, and microsatellite instability in four lesions, limited to the dysplastic areas. CONCLUSION: Our single-center experience confirms the high prevalence of serrated lesions, a part of which are SSL with dysplasia. These lesions seem to carry specific molecular alterations.

Diffuse xanthoma in early esophageal cancer: A case report.

BACKGROUND: Gastrointestinal xanthomas are asymptomatic and infrequent non-neoplastic lesions that commonly occur in the stomach with Helicobacter pylori-associated gastritis and rarely in the esophagus. To date, there have been no reports of esophageal xanthoma combined with esophageal cancer. Herein, we present the first case in the literature of a diffuse xanthoma complicated with early esophageal cancer. Moreover, this combination makes the endoscopic diagnosis difficult if it is not in mind. CASE SUMMARY: A 68-year-old man visited our department with a 2-mo history of epigastric discomfort. He underwent surgery for gastric cancer 6 years ago. Esophagogastroduodenoscopy showed a semi-circumferential irregular yellowish-colored and granular lesion in the esophagus (30-35 cm from the incisors). Using magnifying endoscopy with narrow band imaging, aggregated minute and yellowish-colored spots with tortuous microvessels on the surface were observed, and background coloration was clearly seen in the lesion. As endoscopic biopsy suggested a histologically high-grade dysplasia; the lesion was completely resected en bloc by endoscopic submucosal dissection (ESD). The resected specimen was confirmed to be a squamous cell carcinoma in situ with extensive foamy cells in the superficial mucosal layer. Immunohistochemically, the observed foamy cells were strongly positive for CD68, which is characteristic of xanthoma. The clinical course was favorable, and no recurrence was observed 2 years and 7 mo after ESD. CONCLUSION: Diffuse xanthoma concurrent with early esophageal cancer is extremely rare. The characteristic endoscopic features may assist endoscopists in diagnosing similar lesions.

Endoscopic features and associated histology of an basaloid squamous cell carcinoma of the esophagus at the very early stage.

BACKGROUND: Basaloid squamous cell carcinoma of the esophagus (BSCCE) is generally detected at advanced stage and the prognosis is poorer than advanced conventional esophageal squamous cell carcinoma. Therefore, early detection is a critical to improve patients' survival. However, only a few cases of early BSCCE have been reported and the endoscopic features of early BSCCE are not well described. We herein report the endoscopic features and associated histology of an early BSCCE limited within the mucosal lamina propria (m2). To our knowledge, this is the earliest BSCCE reported to date. CASE PRESENTATION: A 62-year-old male patient was admitted to our hospital because of epigastric pain for 3 months. White light endoscopy revealed a flat lesion with mild sloping at the periphery. The lesion was covered with leukoplakia, and normal vascular network could not be seen in the lesion. Magnifying endoscopy with narrow-band imaging showed abnormal intra-papillary capillary loop categorized as type B1 according to the classification of the Japan Esophageal Society. Iodine staining revealed a less-stained lesion. The lesion was completely resected through endoscopic submucosal dissection. Histopathologically, tumor cells, which were limited within the mucosal lamina propria, formed solid nests and lobule structures, with ribbon-like arrangement of sparse cytoplasm and round to ovoid hyperchromatic nuclei. A final diagnosis of early BSCCE was established. CONCLUSIONS: This is the earliest BSCCE reported to date. The prominent lesion with a gentle rising slope and less-staining or abnormal stain might be initial feature of early BSCCE.

Neurofibromatosis type 1-associated multiple rectal neuroendocrine tumors: A case report and review of the literature.

Neurofibromatosis type 1 (NF-1) is commonly associated with benign or malignant tumors in both the central and peripheral nervous systems. However, rare cases of NF-1-associated multiple rectal neuroendocrine tumors have been reported. This report describes a case of a 39 year old female with NF-1 and intermittent hematochezia as a primary symptom. Physical examination showed multiple subcutaneous nodules and café au lait spots with obvious scoliosis of the back. Imaging examinations and colonoscopy found malformation of the left external iliac vein and multiple gray-yellow nodules with varying sizes and shapes in the rectal submucosal layer. Histological and immunohistochemical results suggested multiple rectal neuroendocrine tumors, a rare disease with few appreciable symptoms and a particularly poor prognosis. The patient with NF-1 presented here had not only multiple rectal neuroendocrine neoplasms but also vascular malformations, scoliosis and other multiple system lesions. This case therefore contributes to improving clinical understanding, diagnosis and treatment of related complications for patients with NF-1 who present with associated medical conditions.

Validation study for development of the Japan NBI Expert Team classification of colorectal lesions.

BACKGROUND AND AIM: The Japan narrow-band imaging (NBI) Expert Team (JNET) was organized to unify four previous magnifying NBI classifications (the Sano, Hiroshima, Showa, and Jikei classifications). The JNET working group created criteria (referred to as the NBI scale) for evaluation of vessel pattern (VP) and surface pattern (SP). We conducted a multicenter validation study of the NBI scale to develop the JNET classification of colorectal lesions. METHODS: Twenty-five expert JNET colonoscopists read 100 still NBI images with and without magnification on the web to evaluate the NBI findings and necessity of the each criterion for the final diagnosis. RESULTS: Surface pattern in magnifying NBI images was necessary for diagnosis of polyps in more than 60% of cases, whereas VP was required in around 90%. Univariate/multivariate analysis of candidate findings in the NBI scale identified three for type 2B (variable caliber of vessels, irregular distribution of vessels, and irregular or obscure surface pattern), and three for type 3 (loose vessel area, interruption of thick vessel, and amorphous areas of surface pattern). Evaluation of the diagnostic performance for these three findings in combination showed that the sensitivity for types 2B and 3 was highest (44.9% and 54.7%, respectively), and that the specificity for type 3 was acceptable (97.4%) when any one of the three findings was evident. We found that the macroscopic type (polypoid or non-polypoid) had a minor influence on the key diagnostic performance for types 2B and 3. CONCLUSION: Based on the present data, we reached a consensus for developing the JNET classification.

Use of an abdominal obstetric binder in colonoscopy: A randomized, prospective trial.

BACKGROUND AND AIMS: Various methods have been reported as aids to cecal intubation. This study aimed to prospectively investigate whether an abdominal obstetric binder (AOB) used during pregnancy and attached to the patients' abdomen during colonoscopy could facilitate effective colonoscopic insertion. METHODS: This was a prospective study of 451 consecutive outpatient colonoscopies performed by a single experienced endoscopist. The recruited patients were randomly separated into two groups that received colonoscopy either with (Group A) or without an AOB attached (Group B). The cecal intubation time, cecal intubation length of the colonoscope, use of manual pressure, position change of each patient, and the number of patients with abdominal distension were collected for comparison. RESULTS: A total of 451 patients (224 in Group A and 227 in Group B) were ultimately included in this study. In Group A, cecal intubation time and cecal intubation length of colonoscope (CIL) were significantly reduced (P < 0.001). The patients had significantly fewer position changes and manual pressure in Group A (P < 0.001). Significantly less abdominal distension was reported by patients in Group A (P < 0.001). CONCLUSIONS: During colonoscopy, the application of an AOB provided a significantly faster and more effective colonoscope insertion.

Correlation of endoscopic images and histological findings of a high grade dysplasia developed in a gastric xanthoma.

Gastric neoplasia developed in a xanthoma is very rare. We herein report a high grade dysplasia (HGD) arising in a gastric xanthoma removed by endoscopic submucosal dissection (ESD). A 57-year-old man was referred to our hospital for removal of rectal polyps. During surveillance esophago-gastro-duodenoendoscopy before polypectomy, an irregularly shaped gastric xanthoma with unusual color was found in the stomach. Although, magnifying narrow band imaging showed no typical neoplastic vessel or surface pattern on the surface and endoscopic biopsies revealed no tumor, diagnostic ESD was performed because of its irregular shape and unusual color for a commonly seen xanthoma. Histologically, a high grade dysplasia, 6 mm×6 mm in size, was detected within a gastric xanthoma. This is the first report of correlation of endoscopic images and histological findings of a HGD in a gastric xanthoma.

A modified endoscopic submucosal dissection for a superficial hypopharyngeal cancer: a case report and technical discussion.

BACKGROUND: Adequate working space and a clear view for the dissected lesion are crucial for endoscopic submucosal dissection (ESD). Pharyngeal ESD requires that an otorhinolaryngologist creates working space by lifting the larynx with a curved laryngoscope. However, many countries do not have this kind of curved laryngoscope, and the devices could interfere with endoscope because of the narrow space of the pharynx. To overcome these issues, we used a transparent hood (Elastic Touch, slit and hole type, M (long), Top company, Tokyo Japan) instead of the curved laryngoscope to create adequate working space by pushing the larynx, and pharyngeal ESD could be done by gastroenterologists. CASE PRESENTATION: A 64-year-old male patient was admitted to our hospital because of chronic persistent swallowing dysfunction for 2 years. Oesophagogastroduodenoscopy showed a superficial hypopharyngeal cancer in the right pyriform sinus. We used a transparent hood (Elastic Touch, slit and hole type, M (long), Top company, Tokyo Japan) instead of the curved laryngoscope to create adequate working space by pushing the larynx, and dental floss tied to a haemoclip was applied to create counter traction during ESD. The lesion was pathologically confirmed as superficial squamous cell carcinoma and resected completely. CONCLUSIONS: This is the first report of modified ESD for a superficial hypopharyngeal cancer. The modified ESD enables early pharyngeal superficial cancer to be removed completely under endoscope by gastroenterologist.

Traction using a clip-with-line is a preferred method for trainees in performing esophageal endoscopic submucosal dissection: an animal model study.

BACKGROUND: The optimal operative process of esophageal endoscopic submucosal dissection (ESD), especially for the beginners, is not established. In this study, the clip-with-line method, the tunneling method and the conventional method for esophageal ESD were compared in a training course on live pigs. METHODS: 15 trainee endoscopists were randomized into three groups, the clip-with-line method group, the tunneling method group, and the conventional method group. Each trainee performed four esophageal ESDs on live pigs with one of the specified methods, assisted by a senior endoscopist. The procedural time and speed, the en bloc resection rates, adverse events, and self-completion rates were recorded, and learning curves were drawn. RESULTS: The procedural time in the clip-with-line group was significantly shorter than those in the tunneling and the conventional method group (47.4 ± 9.0 min versus 67.0 ± 15.1 min and 67.0 ± 11.8 min, p = 0.000). The clip-with-line method had the lowest rates of perforation and muscle layer injury among the three methods. The en bloc resection rates and self-completion rates were similar among the three groups. Learning curves analysis showed the clip-with-line method was the easiest one for the trainees to master. CONCLUSIONS: The clip-with-line method shortened procedural time for trainees, and was associated with lower rates of adverse events. This method is preferred for endoscopists in their learning periods for esophageal ESD.

Endoscopic Submucosal Dissection of Superficial Esophageal Neoplasms Is Feasible and Not Riskier for Patients with Liver Cirrhosis.

BACKGROUND: Esophageal endoscopic submucosal dissection (ESD) has rarely been reported for the treatment of cirrhotic patients. AIM: To report the results of ESD treatment of superficial esophageal neoplasms (SENs) for cirrhotic patients. METHODS: Forty patients with 50 consecutive SENs undergoing 46 sessions of ESD were retrospectively reviewed. The cirrhotic group included eight patients (11 SENs) with liver cirrhosis consisting of six patients classified as Child-Pugh class A liver cirrhosis and two patients classified as class B liver cirrhosis. Four patients (6 SENs) had coexisting esophageal varices. Parameters were compared between the cirrhotic patients and the non-cirrhotic controls (32 patients, 39 SENs). RESULTS: Platelet counts of the cirrhotic group were significantly lower, while international normalized ratio was significantly higher. When the cirrhotic group and non-cirrhotic group were compared, the mean tumor length (4 vs. 3.7 cm, p = 0.56) and median procedure time (15.1 vs. 11.5 min/cm2, p = 0.30) were similar. The en bloc resection rates were 81.8 and 89.7 % (p = 0.60). Within the cirrhotic group, both lesions without en bloc resection were patients with esophageal varices. The rates of submucosal disease for the cirrhotic group and non-cirrhotic groups were 54.5 and 25.6 % (p = 0.064), respectively, while the R0 resection rates were 77.8 and 94.3 % (p = 0.16), respectively. The two lesions without R0 resection in cirrhotic group had positive vertical but not horizontal margins due to submucosal invasion. Intraprocedural bleeding occurred more frequently in cirrhotic patients than non-cirrhotic patients (18.2 vs. 0 %, p = 0.045). None of the patients suffered from esophageal perforation, postoperative bleeding, or death that was related to the ESD. CONCLUSION: Esophageal ESD seems to be safely and can be effectively performed on cirrhotic patients, particularly those without severe liver dysfunction.

Narrow-band imaging (NBI) magnifying endoscopic classification of colorectal tumors proposed by the Japan NBI Expert Team.

Many clinical studies on narrow-band imaging (NBI) magnifying endoscopy classifications advocated so far in Japan (Sano, Hiroshima, Showa, and Jikei classifications) have reported the usefulness of NBI magnifying endoscopy for qualitative and quantitative diagnosis of colorectal lesions. However, discussions at professional meetings have raised issues such as: (i) the presence of multiple terms for the same or similar findings; (ii) the necessity of including surface patterns in magnifying endoscopic classifications; and (iii) differences in the NBI findings in elevated and superficial lesions. To resolve these problems, the Japan NBI Expert Team (JNET) was constituted with the aim of establishing a universal NBI magnifying endoscopic classification for colorectal tumors (JNET classification) in 2011. Consensus was reached on this classification using the modified Delphi method, and this classification was proposed in June 2014. The JNET classification consists of four categories of vessel and surface pattern (i.e. Types 1, 2A, 2B, and 3). Types 1, 2A, 2B, and 3 are correlated with the histopathological findings of hyperplastic polyp/sessile serrated polyp (SSP), low-grade intramucosal neoplasia, high-grade intramucosal neoplasia/shallow submucosal invasive cancer, and deep submucosal invasive cancer, respectively.