Conventional Endoscopic Biopsy Research Articles

Transoral Ultrasound-Guided Core Biopsy for Minimally Invasive Sampling of Hard-to-Access Oropharyngeal Cancers.

Pathological diagnosis plays a pivotal role in risk classification and personalized treatment planning for patients with oropharyngeal cancers. However, challenges arise in cases involving trismus and tumors with submucosal spread, hindering traditional endoscopic biopsies and open incisional biopsies. In this study, we examined the clinical and pathological data of patients with trismus who underwent transoral ultrasound-guided core biopsy (USCB) for their oropharyngeal tumors, comparing this method with existing diagnostic approaches. Seventeen patients presenting with oropharyngeal tumors and trismus underwent transoral USCB for diagnosis. Of these, 14 patients were diagnosed with squamous cell carcinoma, while the remaining 3 were diagnosed with lymphoma. The procedure resulted in minimal wound size and effective bleeding control through compression, without encountering any complications. In conclusion, transoral USCB emerges as a precise diagnostic tool for patients with oropharyngeal tumors and trismus, offering a valuable adjunct to conventional open and endoscopic biopsies.

A pattern-recognition-based clustering method for non-invasive diagnosis and classification of various gastric conditions.

Conventional endoscopic biopsy tests are not suitable for early detection of the acute onset and progression of peptic ulcer as well as various gastric complications. This also limits its suitability for widespread population-based screening and consequently, many people with complex gastric phenotypes remain undiagnosed. Here, we demonstrate a new non-invasive methodology for accurate diagnosis and classification of various gastric disorders exploiting a pattern-recognition-based cluster analysis of a breathomics dataset generated from a simple residual gas analyzer-mass spectrometry. The clustering approach recognizes unique breathograms and "breathprints" signatures that clearly reflect the specific gastric condition of an individual person. The method can selectively distinguish the breath of peptic ulcer and other gastric dysfunctions like dyspepsia, gastritis, and gastroesophageal reflux disease patients from the exhaled breath of healthy individuals with high diagnostic sensitivity and specificity. Moreover, the clustering method exhibited a reasonable power to selectively classify the early-stage and high-risk gastric conditions with/without ulceration, thus opening a new non-invasive analytical avenue for early detection, follow-up, and fast population-based robust screening strategy of gastric complications in the real-world clinical domain.

Magnifying Endoscopy with Narrow-Band Imaging for Duodenal Neuroendocrine Tumors.

Duodenal neuroendocrine tumors (NETs) are rare subepithelial tumors that arise from the neuroendocrine cells beneath the epithelial layer. However, an accurate histopathological diagnosis is difficult when tissue samples are obtained using conventional endoscopic forceps biopsy alone. This study aimed to evaluate the magnifying endoscopy with narrow-band imaging (ME-NBI) findings of duodenal NETs. We retrospectively analyzed a database of 22 duodenal NETs from 21 patients who underwent ME-NBI between January 2011 and June 2022. The ME-NBI, endosonographic, and histopathologic findings of duodenal NETs were analyzed. Nineteen lesions were located in the bulb, two were located in the superior duodenal angle, and one was located in the second portion of the duodenum. Eighteen lesions (82%) had IIa morphology, and nine (41%) had central depression on the surface. On endoscopic ultrasonography, almost all lesions (20/22, 91%) were located in the second and/or third layers, and the median tumor size was 6 mm. During ME-NBI, the microsurface pattern was regular in 18 lesions (82%) and absent in 4 (18%). The microvascular pattern was regular in 17 lesions (77%), irregular in 4 (18%), and absent in 1 (5%). Thickened subepithelial vessels were observed in 15 (68%) lesions. There was no difference in tumor size according to the presence or absence of thickened subepithelial vessels (6.1 ± 1.8 mm vs. 5.9 ± 3.8 mm, p = 0.860). In conclusion, the characteristic ME-NBI findings of duodenal NETs were regular microsurface and microvascular patterns and the presence of thickened subepithelial vessels. These ME-NBI features may be useful for differentiating duodenal NETs from other duodenal subepithelial lesions.

Endoscopic ultrasound-guided fine-needle biopsy in patients with unexplained diffuse gastrointestinal wall thickening.

Background and study aims Endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) is recommended after non-diagnostic biopsy in gastrointestinal wall thickening, although the performance of currently available FNB needles in this setting is unknown. We aimed to assess the diagnostic accuracy and safety of EUS-FNB and to evaluate the "T" wall staging in malignant pathology. Patients and methods This was a single center retrospective study that included all consecutive patients undergoing EUS-FNB for diffuse gastrointestinal wall thickening with at least one previous negative conventional endoscopic biopsy between January 2016 and November 2019. EUS-FNB was performed using linear-array echoendoscopes with slow-pull/fanning technique. Tissue acquisition was done with 19- or 22-gauge biopsy needles. Samples were included in formalin without rapid on-site evaluation and submitted for histopathological processing. The final diagnosis was based on conclusive histology or absence of evidence of disease progression after follow-up at least 6 months. Results Twenty-nine patients (21 men), with a median age of 68 (IQR: 56–77), were included. EUS-FNB was technically feasible and the sample quality was adequate for full histological assessment in all patients (100 %). Sensitivity, specificity, positive and negative predictive values, and overall accuracy for diagnosis of malignancy were 95.5 %, 100 %, 100 %, 83.3 %, and 96.3 %, respectively. In patients with malignant disease, the samples obtained allowed detection of signs of deep layer infiltration (“histological staging”) in 17 of 21 cases (81 %). No adverse events were noted. Conclusions The EUS-FNB technique demonstrated excellent diagnostic performance and safety in the study of unexplained diffuse gastrointestinal wall thickening. Histological staging was obtained in a high percentage of samples.

Diagnostic Value of EUS-Guided Fine-Needle Aspiration Biopsy for Gastric Linitis Plastica with Negative Endoscopic Biopsy.

Due to the tendency of gastric linitis plastica (GLP) to cause extensive submucosal infiltration, a superficial endoscopic biopsy sometimes yields no evidence of malignancy, hindering definite diagnosis. The present study was a single-center retrospective analysis of 54 consecutive patients diagnosed with GLP between 2016 and 2020 to evaluate EUS-guided fine-needle aspiration (EUS-FNA) biopsy outcomes in patients with negative endoscopic biopsy findings. A pathological GLP diagnosis was achieved by endoscopic biopsy in 40 patients (74.1%). EUS-FNA biopsy with a 22-gauge needle was performed in 13 of the remaining 14 patients, and GLP diagnosis was confirmed in 10 patients, with a median of three needle passes. The remaining four patients were laparoscopically diagnosed with GLP. The diagnostic ability of EUS-FNA biopsy for GLP was 76.9%, and EUS-FNA biopsy contributed to GLP diagnosis in 18.5% (10/54) of all cases. None of the 13 patients exhibited EUS-FNA biopsy-related adverse events. Univariable and multivariable analyses revealed an absence of superficial ulcerations as a predictor of false-negative endoscopic biopsy findings in patients with GLP. These results suggest EUS-FNA biopsy as a minimally invasive and safe alternative diagnostic modality for GLP in cases where conventional endoscopic biopsy fails to verify malignancy, although prospective studies with larger cohorts are warranted to confirm these findings.

Diagnostic value of probe-based confocal laser endomicroscopy versus conventional endoscopic biopsies of non-muscle invasive bladder tumors: a pilot study

Purpose The standard procedure for diagnostics and follow-up for non-muscle invasive bladder cancer (NMIBC) is cystoscopy in the outpatient clinic. Suspicious lesions are biopsied for histopathological assessment. This pilot study aimed to evaluate the ability of Confocal Laser Endomicroscopy (CLE) to rule out High Grade Urothelial Carcinoma (HGUC) to select patients for in-office fulguration. Materials and methods We performed a prospective non-randomized, single surgeon study. Intraoperative CLE was performed independently by the surgeon and a blinded on-site uropathologist. Following the procedure, a CLE evaluation was performed by another blinded urologist. Lesions were classified as normal/inflammatory, Low Grade Urothelial Carcinoma (LGUC) or HGUC. With the histological evaluations as the gold standard we calculated sensitivity, specificity, PPV and NPV for HGUC and the accuracy for each CLE assessor. The primary outcome was the NPV for HGUC for the surgeon. Results Twelve patients with a total of 34 lesions were included. Six lesions were flat and 28 were exophytic. On histopathology, 25 lesions were classified as normal/inflammatory or LGUC, while nine were classified as HGUC. For the surgeon, the uropathologist and the second urologist, the sensitivity was 44%, 78% and 22%, respectively. Specificities for the three observers were 84%, 68% and 96%. This corresponded to PPVs for HGUC of 50%, 47% and 67% and NPV for HGUC of 81%, 89% and 77%. Conclusions In our hands the NPV of CLE is not high enough for it to be considered an alternative to histopathological assessment of bladder lesions.

Magnifying endoscopy with narrow-band image for diagnosing diffuse type of gastric antral vascular ectasia in cirrhotic patients.

Gastric antral vascular ectasia (GAVE) and portal hypertensive gastropathy (PHG) can cause gastrointestinal bleeding in cirrhotic patients. Distinguishing diffuse-type GAVE and severe PHG is important but difficult by conventional endoscopy and endoscopic biopsy. The aim of this study is to evaluate the value of magnifying endoscopy with narrow-band image for diagnosing diffuse-type GAVE in cirrhotic patients. From January 2010 to December 2013, cirrhotic patients with diffuse red spots of stomach in suspicion of diffuse-type GAVE on conventional endoscopy in a tertiary medical center were included. The detection of diffuse red spots on magnifying endoscopy with narrow-band image (NBI) was classified into ring-pattern which suggested GAVE and mosaic-pattern which suggested non-GAVE. The golden diagnosis of GAVE was based on histological criteria of GAVE score ≥3 by any one of two endoscopic sessions. Total 27 cirrhotic patients were included. Twenty-two patients reached the diagnosis of GAVE and five patients were diagnosed of non-GAVE by histology. The diagnostic rate of conventional endoscopy was 81.5% (22/27). The positive rate of initial endoscopic biopsy was 77.2%. On magnifying endoscopy with NBI, the sensitivity, specificity, positive, negative predicted rate and accuracy of ring-pattern for the diagnosis of GAVE were 100, 90, 96.4, 100 and 97.3%. Kappa coefficient of inter-observer agreement for differentiating the ring and mosaic-pattern was 0.92. The efficacy and accuracy of magnifying endoscopy with NBI for diagnosing diffuse-type GAVE in cirrhotic patients have been demonstrated. It can avoid repeated endoscopy to confirm diagnosis and obviate the invasive biopsy in cirrhotic patients.

Correlation study on 18F-FDG PET/CT metabolic characteristics of primary lesion with clinical stage in lung cancer.

18F-FDG PET/CT metabolic characteristics provide the crucial biologic and molecular information for tumors. To explore the relationships between 18F-FDG PET/CT derived parameters such as maximum standardized uptake value (SUV<inf>max</inf>), metabolic tumor volume (MTV), total lesion glycolysis (TLG) of primary tumor and clinical stage in different histopathologic subtypes of lung cancer. A total of 97 newly diagnosed lung cancer patients (69 males, 28 females; average age 65.1 years) with pathologically proven were retrospectively analyzed, who had undergone 18F-FDG PET/CT scan before treatment from September 2016 to November 2017. SUV<inf>max</inf>, MTV and TLG of primary tumor were measured. Clinical stage was mainly determined by 18F-FDG PET/CT, in conjunction with conventional imaging and endoscopic biopsy. Mann-Whitney U test, χ2 test, Spearman correlation test and ROC curve analysis were used for statistical analysis. There were 53 adenocarcinomas (AC), 28 squamous carcinomas (SCC), 13 small cell carcinomas (SCLC), one adenosquamous carcinoma, one mucoepidermoid carcinoma, and one sarcomatoid carcinoma in 97 patients. Both AC and SCLC revealed more cases in stage IV than in stage I-III (P<0.01). There was no significant difference in four stages of SCC (P>0.05). Metabolic parameters of SCC were higher than AC including SUV<inf>max</inf>, MTV and TLG (P<0.01). SCLC showed a higher value than AC in TLG (P<0.05). No significant differences were found between AC and SCLC in SUV<inf>max</inf> and MTV, also between SCC and SCLC in SUV<inf>max</inf>, MTV and TLG (P>0.05). MTV and TLG except SUV<inf>max</inf> were positively correlated with stage in AC (P≤0.001). Only MTV showed a positive correlation with stage in SCC (P<0.05). Whereas there were no definitive relationships between metabolic parameters and stage in SCLC (P>0.05). AC with a higher MTV (MTV≥5.965 cm3) indicated a significantly higher rate of distant metastasis than those with a lower MTV (77.5% (31/40) vs. 30.8% (4/13), χ2=9.553, P<0.01), as well as AC with a higher TLG (TLG≥46.922) than those with a lower TLG (88.5% (23/26) vs. 44.4% (12/27), χ2=11.422, P<0.01). Histopathologic subtypes have a significant influence on the relationships between MTV/TLG not SUV<inf>max</inf> of primary foci and stage in lung cancer. Primary MTV/TLG is related to clinical stage closely in AC, and a higher MTV/TLG results in a higher risk of distant metastasis.

TRUS applications in anal and rectal diseases

Transrectal ultrasound (TRUS), sometimes named endoanal ultrasound, is performed with dedicated endoprobes and in the hands of an experienced user, can represent an indispensable tool in evaluation of anal fistulae and abscesses in the perianal and – rectal region plus staging of anal and rectal cancer. The spatial resolution of TRUS is unsurpassed, however, MRI or CT should be used to provide a complementary overview of the entire region. The anal canal constitutes the distal approximately 4 cm of the bowel system and represents the transition between mucosal lining in the rectum and squamous cell lining of the skin. The ultrasound appearance is dominated by the change in anatomy of the muscular layers of the wall which in this small segment is made up solely of the circular, concentric muscles representing the internal and external anal sphincter. The anal canal is divided into 3 levels relating to the sphincter muscles. In rectum 5 distinctive layers corresponding to the underlying anatomy can be identified with TRUS and correlated to disease. TRUS guided intervention by means of biopsy or drainage can be performed with a rigid US probe as well as with flexible echoendoscopes. The rigid US probe with an end-fire design is optimal for endo-rectal interventions and in most cases can visualize the entire rectum including perirectal structures. With use of a dedicated needle guide mounted on the probe this technique enables precise puncture of most rectal or perirectal target seen on TRUS. TRUS guided biopsy of rectal masses is an important supplement to the conventional endoscopic biopsy if the latter technique does not provide the final diagnosis. Indications are staging of rectal cancer or suspicions of local recurrence. In these cases, a TRUS guided biopsy of the rectal masse with a 1.2 mm needle (18 gauge automatic or semi-automatic biopsy systems) can provide a deep tissue sample that often results in a final histologic diagnosis. In addition, TRUS guided biopsy is an obvious technique to provide histologic or cytologic information about enlarged lymph nodes or other suspicious perirectal masses. TRUS guided drainage of perianal and deep pelvis abscesses or other fluid collections is a safe approach and effective treatment in cases where the transabdominal percutaneous access cannot be utilized because of overlying structures. This technique provides an alternative to other access routes such as transvaginal, transgluteal or transperineal technique Smaller abscesses can often be treated with needle aspiration followed by saline irrigation, whereas larger abscesses may require continuous drainage through a catheter, which can be inserted with Seldinger technique. A preprocedure CT examination of the lower abdomen is recommended to visualize the exact location and size of the abscess in order to optimize drainage strategy.

Current clinical management of gastrointestinal stromal tumor.

Gastrointestinal stromal tumors (GISTs) are the most common malignant subepithelial lesions (SELs) of the gastrointestinal tract. They originate from the interstitial cells of Cajal located within the muscle layer and are characterized by over-expression of the tyrosine kinase receptor KIT. Pathologically, diagnosis of a GIST relies on morphology and immunohistochemistry [KIT and/or discovered on gastrointestinal stromal tumor 1 (DOG1) is generally positive]. The prognosis of this disease is associated with the tumor size and mitotic index. The standard treatment of a GIST without metastasis is surgical resection. A GIST with metastasis is usually only treated by tyrosine kinase inhibitors without radical cure; thus, early diagnosis is the only way to improve its prognosis. However, a GIST is usually detected as a SEL during endoscopy, and many benign and malignant conditions may manifest as SELs. Conventional endoscopic biopsy is difficult for tumors without ulceration. Most SELs have therefore been managed without a histological diagnosis. However, a favorable prognosis of a GIST is associated with early histological diagnosis and R0 resection. Endoscopic ultrasonography (EUS) and EUS-guided fine needle aspiration (EUS-FNA) are critical for an accurate diagnosis of SELs. EUS-FNA is safe and effective in enabling an early histological diagnosis and adequate treatment. This review outlines the current evidence for the diagnosis and management of GISTs, with an emphasis on early management of small SELs.

Residual carcinoma cells after chemoradiotherapy for esophageal squamous cell carcinoma patients: striving toward appropriate judgment of biopsy.

In esophageal squamous cell carcinoma (ESCC) patients who are treated with chemoradiotherapy (CRT), identification of the presence or absence of residual or recurrent carcinoma is usually pivotal in their clinical management. In addition, the extent of carcinoma invasion into the esophageal wall could determine the clinical outcome of these patients following CRT. Therefore, in this study, we evaluated the response to CRT both macroscopically and histologically in a consecutive series of 42 ESCC patients receiving neoadjuvant chemoradiotherapy following curative esophageal resection at Tohoku University Hospital between August 2011 and December 2012. The histological grading of tumor regression was as follows: grade 3, markedly effective (no viable residual tumor cells); grade 2, moderately effective (residual tumor cells in less than one-third of the tumor); grade 1, slightly effective (1b, residual tumor cells in one-third to two-thirds of the tumor; 1a, residual tumor cells in more than two-thirds of the tumor); and grade 0, ineffective. In this study, we selected grade 2 and 1b cases because they might show a complete response with definitive CRT. We evaluated the presence of any residual in situ lesions and tumor depth in detail. The grading of tumor regression in primary sites was as follows: grade 3 (7 cases), grade 2 (16 cases), grade 1b (13 cases), and grade 1a (6 cases). The concordance rate between macroscopic and histopathological evaluation on the depth of the tumor was 40% (17/42). Among 29 cases (grade 2 and grade 1b), intraepithelial lesions were not detected in 17 cases, and tumor nests were not detected in the lamina propria mucosae in 9 cases. The results of this study highlight the difficulties of detecting residual carcinoma cells using conventional endoscopic biopsy in patients who have received CRT. Therefore, when residual cancer is clinically suspected in patients who have received CRT, the biopsy specimen should be obtained from the deep layer of the esophagus whenever possible. Additionally, close follow-up is required using positron emission tomography/computed tomography, endoscopy, and other radiological evaluations.

Via mucosa incision EUS-guided sampling for the diagnosis of conventional endoscopic biopsy-negative gastric wall thickening

Abnormal thickened lesions of the gastric wall are usually covered with normal mucosa. Conventional endoscopic biopsies often do not yield sufficient positive histological results for clinical treatment. To increase the rate of diagnosis of conventional endoscopic biopsy-negative gastric wall thickening, we used an endoscopic submucosal dissection (ESD)-like sampling method under endoscopic ultrasound (EUS) guidance to obtain tissue of gastric wall-thickening lesions. Between 2012 and 2016, patients with gastric wall thickening (as identified by computed tomography (CT), EUS or other imaging methods that showed no positive findings in repeating conventional endoscopic biopsy) underwent via mucosa incision EUS-guided sampling. Final diagnosis was determined after surgical or biopsy pathology. A total of 10 patients with gastric wall thickening were included in this study. Eight cases received definite results, whereas in two cases the biopsy results were ambiguous and in these two patients poorly differentiated adenocarcinoma was determined by postoperative pathology. The results of the cases presented in this study demonstrated that via mucosa incision EUS-guided sampling provided a complementary option for the diagnosis of conventional endoscopic biopsy-negative gastric wall thickening.

Usefulness of endoscopic ultrasound-guided fine needle aspiration in the diagnosis of hepatic, gallbladder and biliary tract Lesions.

Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) of the liver is a safe procedure in the diagnosis and staging of hepatobiliary malignancies with a minimal major complication rate. EUS-FNA is useful for liver lesions poorly accessible to other imaging modalities of the liver. EUS-guided FNA of biliary neoplasia and malignant biliary stricture is superior to the conventional endoscopic brushing and biopsy.

Mo1634 The Accuracy of Probe-Based Confocal Endomicroscopy Versus Conventional Endoscopic Biopsies for the Diagnosis of Superficial Gastric Neoplasia

Probe type confocal laser endomicroscopy (pCLE) allows real-time in vivo histologic evaluation of gastrointestinal mucosal lesions. Although pCLE has been used for various GI disorders, the significance of pCLE for gastric lesions is largely unknown. We compared the accuracy of conventional endoscopic forceps biopsy and pCLE for diagnosis of superficial gastric neoplasia prior to endoscopic resection.

The accuracy of probe-based confocal endomicroscopy versus conventional endoscopic biopsies for the diagnosis of superficial gastric neoplasia (with videos)

Probe-based confocal laser endomicroscopy (pCLE) allows real-time in vivo histologic evaluation of GI mucosal lesions. Although pCLE has been used for various GI disorders, the significance of pCLE for gastric lesions is largely unknown. We compared the accuracy of conventional endoscopic forceps biopsy and pCLE for the diagnosis of superficial gastric neoplasia before endoscopic resection. Prospective comparative study. Single tertiary referral center. This study involved 54 superficial gastric neoplasias in 46 patients. Accuracy of in vivo and offline pCLE diagnosis and interobserver agreement. pCLE was performed before endoscopic resection of superficial gastric neoplasias previously diagnosed by endoscopic biopsy. The overall accuracy of endoscopic, in vivo pCLE, and offline pCLE diagnosis was compared with postendoscopic resection histopathology. Endoscopic resection was performed on 54 lesions. On final histopathology, there were 3 non-neoplastic lesions, 19 gastric dysplasias, 22 differentiated adenocarcinomas, and 10 undifferentiated adenocarcinomas. The overall agreement with the final histopathology was substantial for conventional biopsies (κ = 0.617) and excellent for in vivo pCLE (κ = 0.824) (P < .001). The overall accuracy for the diagnosis of adenocarcinoma was 91.7% for pCLE and 85.2% for conventional biopsies (P = .065). The combined accuracy of conventional endoscopic biopsies and pCLE was 98.1%. The interobserver agreement for offline pCLE diagnosis was excellent (κ = 0.931). Single-center study, small sample size. Our study showed that pCLE can provide an accurate diagnosis for superficial gastric neoplasia. pCLE has the potential to compensate for the inherent limitations of a conventional endoscopic biopsy.

The vulnerable Indian one rupee coin

Coins are the most commonly ingested foreign body encountered in the pediatric population, with a peak incidence between 6 months and 3 years of age. Although some ingested coins may be aspirated, most coins pass through the alimentary tract without causing any complications. Coins in the esophagus causing symptoms require immediate removal. The management of asymptomatic coins has been a perplexing problem to the clinicians for decades. We recently managed an interesting case of an impacted Indian one rupee coin in the esophagus of a 13-year-old girl, by performing a simple yet novel technique, by using a conventional flexible endoscopic biopsy forceps. Further, reviewing the literature we inferred that the rounded, stainless steel Indian one rupee coin with a diameter of 25 mm, by itself seems to be vulnerable for impaction in the esophagus and therefore needs to be promptly addressed even if asymptomatic.

A pediatric non-protein losing Menetrier's disease successfully treated with octreotide long acting release

Pediatric Menetrier's disease (MD) is an uncommon, acute, self-limited hypertrophic gastropathy characterized by enlarged gastric folds associated with epithelial hyperplasia and usually accompanied by protein losing gastropathy. Gastric cytomegalovirus infection is found in one third of MD children and its treatment is often associated with remission. Diagnosis often requires full-thickness biopsy due to inability to detect typical histological findings with conventional endoscopic biopsy. We report an uncommon case of non self-limited pediatric MD needing endoscopic mucosal resection for diagnosis which was then successfully treated with octreotide long-acting release (LAR). To the best of our knowledge, this is the first pediatric MD case successfully treated with octreotide LAR. Our experience suggests octreotide LAR as treatment for refractory MD before gastrectomy.

‘Whole gut remote endoscopy’: a novel protocol for luminal imaging using combined small bowel and colon capsule endoscopy

IntroductionConventional endoscopy is uncomfortable, undignified, may require sedation and incur complications. Yet most procedures provide reassurance rather than identify relevant abnormalities. A sensitive diagnostic tool which is simpler, safer, less...

Esophageal squamous papillomatosis

Esophageal squamous papillomatosis is rare and has been associated with gastroesophageal reflux and recurrent respiratory papillomatosis. We report a case of extensive esophageal papillomatosis, no airway involvement and a slowly progressive clinical course with progressive strictures and ultimately fatal squamous cell carcinoma. In-situ hybridization performed on biopsy specimens was negative for high-risk human papilloma virus types. Due to the paucity of reported cases, little is conclusively known about the etiology, natural course and best clinical management of this disease. Human papilloma virus has been linked to some, but not all, cases, and the clinical course has been reported to vary from spontaneous regression to malignant transformation. Surveillance for malignancy by conventional endoscopic biopsies or computed tomography scan appears to have low sensitivity. This case illustrates the difficulties in clinical management and establishing a definite etiology in esophageal squamous papillomatosis.

Diagnosis of primary early gastric lymphoma. Usefulness of endoscopic mucosal resection for histologic evaluation

Eight patients thought to have primary early gastric lymphoma were studied to evaluate the usefulness of endoscopic mucosal resection for the diagnosis of reactive lymphoid hyperplasia (RLH) or malignant lymphoma. In these patients, conventional endoscopic forceps biopsy did not provide a definite histologic diagnosis. Endoscopic ultrasonography (EUS) demonstrated that the disease was limited to the mucosa and the submucosa in all patients, without any paragastric lymph node involvement, so endoscopic mucosal resection was performed to obtain specimens large enough to include the submucosa. As a result, primary early gastric lymphoma was diagnosed in five patients, for whom subsequent gastrectomy confirmed the diagnosis. The authors recommend that endoscopic mucosal resection be performed in patients thought to have primary early gastric lymphoma and for whom a definite diagnosis can not be made by conventional endoscopic forceps biopsy.