Irregular Microvascular Pattern Research Articles

Advanced Diagnostic and Therapeutic Endoscopy for Early Gastric Cancer.

Endoscopy is mandatory to detect early gastric cancer (EGC). When considering the cost-effectiveness of the endoscopic screening of EGC, risk stratification by combining serum pepsinogen values and anti-H. pylori IgG antibody values is very promising. After the detection of suspicious lesions of EGC, a detailed observation using magnifying endoscopy with band-limited light is necessary, which reveals an irregular microsurface and/or an irregular microvascular pattern with demarcation lines in the case of cancerous lesions. Endocytoscopy enables us to make an in vivo histological diagnosis. In terms of the indications for endoscopic resection, the likelihood of lymph node metastasis and technical difficulties in en bloc resection is considered, and they are divided into absolute, expanded, and relative indications. Endoscopic mucosal resection and endoscopic submucosal dissection are the main treatment modalities nowadays. After endoscopic resection, curability is evaluated histologically as endoscopic curability (eCura) A, B, and C (C-1 and C-2). Recent evidence suggests that the outcomes of endoscopic resection for many EGCs are comparable to those of gastrectomy and that endoscopic resection is the gold standard for node-negative early gastric cancers. Personalized medicine is also being developed to overcome the unmet needs in treatments of EGC, for example the further expansion of indications and newer resection techniques, such as full-thickness resection.

Endoscopic Diagnosis Strategy of Raspberry-Shaped Gastric Lesion in Helicobacter Pylori-Uninfected Patient.

We aimed to clarify the endoscopic and clinicopathological features of raspberry-shaped gastric lesions (RSGLs) and to establish an endoscopic diagnostic algorithm for RSGLs. We collected RSGLs from an endoscopic database at our hospital between May 2009 and August 2021. All RSGLs were histopathologically classified and compared based on their endoscopic and clinicopathological characteristics. Sixty-five RSGLs in 54 patients were classified into five histopathological types: gastric adenocarcinoma of foveolar type (GA-FV, n = 43), gastric adenocarcinoma of fundic-gland type (GA-FG, n = 2), gastric adenocarcinoma of fundic-gland mucosa type (GA-FGM, n = 4), hyperplastic polyp (HP, n = 12), and proton pump inhibitor-related lesion (PPI-L, n = 4). All RSGLs exhibited polygonal or curved marginal crypt epithelium (MCE). GA-FV lesions had homogenously reddish (95%) and an irregular microvascular (MV) pattern (91%). GA-FG lesions were heterogeneously reddish with a submucosal tumor shape (100%) and had a regular MV pattern (50%). GA-FGM lesions were homogen+ously reddish (75%) and occasionally had a submucosal tumor shape (50%) with an irregular MV pattern (75%). HPs and PPI-Ls were homogeneously reddish (93%), with linear or dotted MCE (81%) and a regular MV pattern (100%). Our diagnostic algorithm for RSGLs constructed using endoscopic features might be useful for the endoscopic differential diagnosis of RSGLs.

Endoscopic Features of Gastric Epithelial Neoplasm of Fundic Gland Mucosa Lineage

The endoscopic features of gastric epithelial neoplasms of fundic gland mucosa lineage (GEN-FGML) have not been well investigated. We aimed to clarify the endoscopic features of GEN-FGML and differences between gastric adenocarcinoma of the fundic gland type (GA-FG) and fundic gland mucosa type (GA-FGM). A total of 62 GEN-FGML lesions, including 52 GA-FG and 10 GA-FGM, were retrospectively analyzed using endoscopic and clinicopathological findings to provide information of diagnostic value using white light imaging (WLI) and magnifying endoscopy with narrow-band imaging (M-NBI). GA-FG frequently presented with a whitish, submucosal tumor (SMT) shape with dilated vessels with branching architecture and background mucosa without atrophic change in WLI, an indistinct demarcation line (DL), dilatation of the crypt opening and intervening part (IP), and microvessels without distinct irregularity in M-NBI. GA-FGM frequently presented as a reddish, elevated lesion in WLI, with a distinct DL, dilatation of the IP, and an irregular microvascular pattern in M-NBI. As for an M-NBI diagnosis, five GA-FGM lesions met the diagnostic criteria for cancer, whereas none of the GA-FG lesions met the same criteria. We highlight the endoscopic features of GEN-FGML, and the differentiation between GA-FG and GA-FGM might be possible by combination of lesion color and morphology in WLI and M-NBI diagnoses.

A case of early gastric cancer in a patient with gastric juvenile polyposis diagnosed by magnifying endoscopy and resected by endoscopic submucosal dissection

Gastric juvenile polyposis (GJP) is frequently associated with the development of gastric cancer. However, there are no reports of gastric cancer in patients with GJP diagnosed using magnifying endoscopy with narrow-band imaging (M-NBI) and successfully treated by endoscopic submucosal dissection (ESD). A 50-year-old woman was referred to our hospital. Conventional white-light endoscopy revealed numerous aggregated polyps with reddish and whitish areas in the gastric cardia. M-NBI revealed a regular microvascular pattern (MVP) and regular microsurface pattern (MSP) in the reddish area of the lesion, and they were diagnosed as non-cancerous polyps. There was a clear demarcation line between the reddish and whitish areas, with irregular MVP plus irregular MSP in the whitish area, which was diagnosed as early gastric cancer. The horizontal extent of the cancer was precisely identified using M-NBI, and the en bloc resection of cancerous lesions was performed using ESD. Histopathological examination of the resected specimen showed that the reddish area comprised a hyperplastic foveolar epithelium. Conversely, the whitish area was diagnosed as a well-differentiated adenocarcinoma. The cancer was limited to the mucosa, lymphovascular invasion was negative, and horizontal and vertical margins were free from cancerous tissue. According to surveillance endoscopy, there has been no recurrence 11years after ESD. This is the first report demonstrating that M-NBI is useful for making a precise diagnosis of cancer in juvenile polyposis and that ESD can be an option for the treatment of such a cancer.

Magnifying endoscopy with narrow-band imaging is useful in differentiating gastric cancer from matched adenoma in white light imaging

This study assessed the effect of magnifying endoscopy with narrow-band imaging (M-NBI) on the endoscopic differential diagnosis between intramucosal gastric carcinomas and adenomas with matched characteristics. Associations between magnified endoscopic findings and pathological high-grade cellular and architectural atypia were also investigated. In total, the records of 50 adenomas and 50 intramucosal well-differentiated adenocarcinomas matched by tumor size (≥ 20 mm or < 20 mm), shape (depression or non-depression), and color (red or non-red) were extracted. Fourteen endoscopists diagnosed adenoma or cancer in the 100 cases with conventional white light imaging (C-WLI), then did the same with C-WLI + M-NBI.The cancer diagnostic sensitivity, specificity, and accuracy were assessed. The sensitivity of C-WLI + M-NBI for cancer diagnosis was 79.9% compared to 71.6% with C-WLI (p < 0.001). There were no significant differences in specificity (40.1% vs. 36.3%, p = 0.296) and accuracy (55.9% vs. 58.1%, p = 0.163). High-grade cytological or architectural atypia was diagnosed more often with irregular microvascular pattern (IMVP) or microsurface pattern (IMSP), respectively, than the low-grade forms. In conclusion, IMVP and IMSP correlate with high-grade cytological and architectural atypia. M-NBI is useful in differentiating intramucosal carcinoma from adenoma and can reduce underdiagnosis of cancer.

Linked Color Imaging and Blue Laser Imaging for the Diagnosis of Superficial Non-Ampullary Duodenal Epithelial Tumors

Background and Objective: This study aimed to evaluate endoscopic findings using linked color imaging (LCI) and blue laser imaging (BLI) and to determine a diagnostic predictor for duodenal adenocarcinomas. Methods: All consecutive patients who underwent endoscopic resection for superficial non-ampullary duodenal epithelial tumors (SNADETs) between October 2012 and June 2019 were enrolled in this study. Two highly experienced endoscopists investigated six morphological findings using both white light imaging and LCI and three magnifying endoscopic findings using magnifying BLI (M-BLI). Results: A total of 90 patients with 110 SNADETs, including 87 adenocarcinomas and 23 adenomas, were analyzed in this study. Among the non-magnifying endoscopic findings, the presence of reddish color, orange color on LCI (orange color sign), lobulation, depression, and marginally white opaque substance were found significantly more frequently in adenocarcinomas than in adenomas (p = 0.015, p < 0.001, p = 0.048, p < 0.001, and p = 0.007, respectively). Among the magnifying endoscopic findings, a mixed microsurface pattern (MSP), irregular MSP, and irregular microvascular pattern were found significantly more frequently in adenocarcinomas than in adenomas (p < 0.001, p < 0.001, and p = 0.002, respectively). In the multivariate analysis of all endoscopic findings associated with adenocarcinoma, orange color sign (odds ratio [OR] 10.46; 95% confidence interval [CI]: 1.42–77.08; p = 0.021), mixed MSP (OR 4.66; 95% CI: 1.02–21.40; p = 0.048), and irregular MSP (OR 13.11; 95% CI: 1.41–121.99; p = 0.024) were independent predictors of adenocarcinoma. Conclusions: The presence of orange color sign on LCI and mixed/irregular MSP on M-BLI were independent diagnostic predictors that were frequently observed in duodenal adenocarcinoma.

Usefulness of vessel plus surface classification system for the diagnosis of early gastric cancer after Helicobacter pylori eradication.

BackgroundIt has been reported that it is sometimes difficult to make a diagnosis of gastric cancer detected after Helicobacter pylori (H. pylori) eradication. Therefore, we conducted a study to determine the usefulness of magnifying endoscopy using vessel plus surface classification system for making a diagnosis of early gastric cancer after H. pylori eradication.MethodUsefulness of the markers of the vessel plus surface classification system for diagnosing gastric cancer using magnifying endoscopy with narrow-band imaging was investigated for gastric cancer detected after H. pylori eradication (H. pylori-eradicated group) vs. H. pylori-positive gastric cancer (H. pylori-positive group).Results85 lesions were included in this study. The H. pylori-eradicated group comprised 27 lesions, whereas the H. pylori-positive group comprised 58 lesions. As for magnified endoscopic findings based on the vessel plus surface classification system, the respective positivity rates in the H. pylori-eradicated group vs. those in the H. pylori-positive group were as follows: demarcation line, 100% (27/27) vs. 100% (58/58); irregular microvascular pattern, 100% (27/27) vs. 100% (58/58); and irregular microsurface pattern, 78% (21/27) vs. 95% (55/58). There was no significant difference in the positivity rates of the demarcation line and irregular microvascular pattern between the groups. The positivity rate of the irregular microsurface pattern was significantly lower in the H. pylori-eradicated group than in the H. pylori-positive group (P=0.03).ConclusionWe presume that the microvascular pattern is more useful than the microsurface pattern as a diagnostic marker in cases of gastric cancer detected after H. pylori eradication.

Clinicopathological and Endoscopic Features of Raspberry-Shaped Gastric Cancer in Helicobacter pylori-Uninfected Patients

Background: Gastric adenocarcinoma of foveolar type (GA-FV) is a raspberry-shaped gastric cancer (RSGC) and garners much attention as H. pylori (Hp)-uninfected gastric cancer. However, the classification and clinicopathological and endoscopic features of RSGCs in Hp-uninfected patients are poorly defined. We designed a new histopathological classification of RSGC and compared them via endoscopic and clinicopathological characteristics. Summary: From 996 patients with early gastric cancers resected by endoscopy in our hospital, we studied 24 RSGC lesions from 21 (2.4%) Hp-uninfected patients. RSGCs were classified into 3 histological types as follows: GA-FV (n = 19), gastric adenocarcinoma of fundic gland type (GA-FG, n = 2), and gastric adenocarcinoma of fundic gland mucosa type (GA-FGM, n = 3). Most of the lesions were found at the greater curvature of the upper or middle third of the stomach. GA-FV lesions were homogeneously reddish and frequently accompanied with a whitish area around the tumor and an irregular microvascular (MV) pattern; these features were confirmed histopathologically by the presence of homogeneous neoplastic foveolar epithelium with foveolar hyperplasia around the tumors. GA-FG lesions might be heterogeneously reddish with a submucosal tumor shape and regular MV pattern; these were confirmed by the presence of covered or mixed nonneoplastic epithelium on deeper regions of tumors. GA-FGM lesions might be homogeneously reddish and occasionally had a submucosal tumor shape and irregular MV pattern; these were confirmed by the presence of homogeneous neoplastic foveolar epithelium on deeper regions of the tumors. Key Messages: RSGCs in Hp-uninfected patients are classified into 3 histopathological types. For accurate diagnosis of RSGCs, it may be necessary to fully understand endoscopic features of these lesions based on these histological characteristics and to take a precise biopsy.

Clinical Usefulness of the VS Classification System Using Magnifying Endoscopy with Blue Laser Imaging for Early Gastric Cancer.

Background Blue laser imaging (BLI) enables the acquisition of more information from tumors' surfaces compared with white light imaging. Few reports confirm the validity of magnifying endoscopy (ME) with BLI (ME-BLI) for early gastric cancer (EGC). We aimed to assess the detailed endoscopic findings from EGCs using ME-BLI. Methods We enrolled 386 consecutive patients with 417 EGCs that were diagnosed using ME-BLI and resected by endoscopic submucosal dissection. Using the VS classification system, three highly experienced endoscopists (HEEs) and three less experienced endoscopists (LEEs) evaluated the demarcation line (DL), microsurface pattern (MSP), and microvascular pattern (MVP) within the endoscopic images of EGCs obtained using ME-BLI, assigning high-confidence (HC) or low-confidence (LC) levels. We investigated the clinicopathological features associated with each confidence level. Results The HEEs' evaluations determined the presence of DL in 99%, irregular MSP in 96%, and irregular MVP in 96%, and the LEEs' evaluations determined the presence of DL in 98%, irregular MSP in 95%, and irregular MVP in 95% of the EGCs. When DL was present, HC levels in the Helicobacter pylori- (H. pylori-) eradicated group and noneradicated group were evident in 65% and 89%, a difference that was significant (p < 0.001). Conclusions In the diagnosis of EGC with ME-BLI, the VS classification system with ME-NBI can be applied, but identifying the DL after H. pylori was difficult.

Gastric adenocarcinoma of the fundic gland (chief cell-predominant type): A review of endoscopic and clinicopathological features.

Gastric adenocarcinoma of the fundic gland (chief cell-predominant type, GA-FG-CCP) is a rare variant of well-differentiated adenocarcinoma, and has been proposed to be a novel disease entity. GA-FG-CCP originates from the gastric mucosa of the fundic gland region without chronic gastritis or intestinal metaplasia. The majority of GA-FG-CCPs exhibit either a submucosal tumor-like superficial elevated shape or a flat shape on macroscopic examination. Narrow-band imaging with endoscopic magnification may reveal a regular or an irregular microvascular pattern, depending on the degree of tumor exposure to the mucosal surface. Pathological analysis of GA-FG-CCPs is characterized by a high frequency of submucosal invasion, rare occurrences of lymphatic and venous invasion, and low-grade malignancy. Detection of diffuse positivity for pepsinogen-I by immunohistochemistry is specific for GA-FG-CCP. Careful endoscopic examination and detailed pathological evaluation are essential for early and accurate diagnosis of GA-FG-CCP. Nearly all GA-FG-CCPs are treated by endoscopic resection due to their small tumor size and low risk of recurrence or metastasis.

Preclipping fixation EMR to achieve sufficient surgical margin and negative resection

A 55-year-old man underwent 3-point pre-clipping around a 15-mm ascending colon polyp and conventional EMR for a 12-mm transverse colon polyp. Because magnified narrow-band imaging revealed a slight irregular microvascular pattern at the center depressed area, this ascending colon polyp might have contained a malignant part with high risk for slight submucosal invasion (Fig. 1A) (Video 1, available online at www.giejournal.org). Preclipping to reach the muscular layer was performed (Fig. 1B), and 4 mL of saline solution was injected to ensure ample gripping (Fig. 1C).

Gastric adenocarcinoma of fundic gland type: Five cases treated with endoscopic resection

Recently, a new disease entity termed gastric adenocarcinoma of fundic gland type (GA-FG) was proposed. We treated five cases of GA-FG with endoscopic submucosal dissection. All tumors were small and located in the upper third of the stomach. Four tumors were macroscopically identified as 0-IIa and one was identified as 0-IIb. Narrow-band imaging with magnifying endoscopy showed an irregular microvascular pattern in 2 cases and a regular microvascular pattern in the remainder. All tumors arose from the deep layer of the lamina propria mucosae and showed submucosal invasion. Lymphatic invasion was seen only in one case, while no venous invasion was recognized. All tumors were positive for pepsinogen-I and MUC6 by immunohistochemistry. None showed p53 overexpression, and the labeling index of Ki-67 was low in all cases. All cases have been free from recurrence or metastasis. Herein, we discussed the clinicopathological features of GA-FG in comparison with past reports.

Sa1463 Is Fundoplication Necessary With Per-Oral Endoscopic Myotomy (POEM)?

Reflux esophagitis after ESD procedure in a patient with early well differentiated adenocarcinoma located at EGJ. There was neither patient complain on reflux symptom nor endoscopic finding of reflux esophagitis before procedure (A). Narrow band imaging revealed irregular microvascular pattern (B). ESD was performed and a half of circumferential extent of mucosal defect was created (C). Follow-up endoscopy revealed complete mucosal healing after 1 month of medication (D), however, on further follow-up of 6 month (E) and 1 year (F), reflux esophagitis was demonstrated with negative biopsy finding.

An efficient diagnostic strategy for small, depressed early gastric cancer with magnifying narrow-band imaging: a post-hoc analysis of a prospective randomized controlled trial

We previously reported that magnifying narrow-band imaging (M-NBI) is a high-performance diagnostic tool for small, depressed gastric cancer. However, an efficient diagnostic strategy using endoscopic findings has not been fully elucidated. To identify the endoscopic findings that contribute to accurate diagnosis of small, depressed gastric cancer and to propose the ideal diagnostic approach to such lesions. Post-hoc analysis of a prospective, randomized, controlled trial. Nine hospitals. Three hundred fifty-three patients with small, depressed gastric lesions. In the M-NBI group (n = 177), cancer diagnosis was made with diagnostic criteria including a demarcation line (DL) and an irregular microvascular pattern (IMVP). In the conventional white-light imaging (C-WLI) group (n = 176), diagnostic criteria were both an irregular margin and a spiny depressed area. In the C-WLI group, M-NBI was performed after C-WLI diagnosis. The diagnostic performance of each criterion in M-NBI alone, C-WLI, and M-NBI after C-WLI was investigated. M-NBI after C-WLI ultimately showed the best diagnostic performance in each diagnostic criterion. In M-NBI after C-WLI, evaluation of DL is technically easier than that of IMVP, and DL alone had a high sensitivity (95%) and negative predictive value (99%). The IMVP in M-NBI after C-WLI had a high sensitivity and specificity (95% and 96%, respectively) for diagnosis of cancer. Lesions were limited to the small, depressed type. For a diagnosis using M-NBI after C-WLI, identification of DL is the first step, and subsequent inspection of IMVP diagnosed by DL is an efficient strategy.

Enhanced magnifying endoscopy for differential diagnosis of superficial gastric lesions identified with white-light endoscopy

Various techniques using magnifying endoscopy (ME) and chromoendoscopy are being developed to enhance images of gastrointestinal tumor. The aim of this study was to evaluate the diagnostic performance of ME enhanced by acetic acid-indigo carmine mixture (ME-AIM) and ME enhanced with narrow-band imaging (ME-NBI) for differential diagnosis of superficial gastric lesions identified with conventional white-light endoscopy (WLE). Patients with superficial gastric lesions picked up with WLE were enrolled in the study. ME-NBI and ME-AIM were used to further characterize the lesions. All images of the lesions were evaluated by four skilled endoscopists blinded to the clinical data. The microarchitectural patterns in the lesions were analyzed with reference to the "VS classification" system. A total of 643 lesions (mean diameter, 7 mm) from 508 patients (316 men, 192 women; mean age, 63 years) were evaluated. Pathologically, 24 of the 643 lesions were diagnosed as gastric cancer; the others were noncancerous lesions. For diagnosis of gastric cancer, the negative predictive value of each of the three magnified findings (irregular microvascular pattern, irregular microsurface pattern, and demarcation line) was high (nearly 100 %). According to the "VS classification" system, either ME-NBI or ME-AIM had a higher specificity (99.5 % or 99.4 % vs. 89.5 %, P < 0.001) and accuracy (99.2 % or 98.9 % vs. 89.0 %, P < 0.001) than WLE, and ME-AIM was not superior to ME-NBI for identifying carcinoma. Enhanced ME is useful for correctly diagnosing early gastric cancer, and in contrast with ME-AIM, ME-NBI is a more feasible and efficient method for clinical practice.

Magnifying endoscopy with narrow-band imaging is useful in the differential diagnosis between low-grade adenoma and early cancer of superficial elevated gastric lesions

The usefulness of magnifying gastroscopy has been reported in differentiating between benign and malignant gastric mucosal lesions. However, there have been no studies of the usefulness of magnifying endoscopy with narrow-band imaging (M-NBI) in the diagnosis of superficial (non-polypoid) elevated lesions of the stomach. In this study, we investigated the ability of M-NBI to differentiate between cancer and adenoma in superficial elevated lesions of the stomach. We examined 93 consecutive superficial elevated lesions of the stomach. We defined the endoscopic criteria for early cancer as red coloring using conventional white light imaging (C-WLI), and an irregular microvascular pattern with a demarcation line, or irregular microsurface pattern with a demarcation line, using M-NBI. We determined the sensitivity, specificity and accuracy of C-WLI and M-NBI in the diagnosis of these 93 lesions. The sensitivity, specificity, and accuracy (95 % confidence interval) of C-WLI versus M-NBI were 64 % (52-76 %) versus 95 % (90-100 %), 94 % (86-100 %) versus 88 % (77-99 %), and 74 % (66-83 %) versus 92 % (86-98 %), respectively. Sensitivity and accuracy were significantly higher for M-NBI than C-WLI. M-NBI appears to be useful in differentiating between cancerous and adenomatous superficial elevated lesions of the stomach.

Magnifying endoscopy with narrow-band imaging helps determine the management of gastric adenomas

There are no clear clinical criteria for the management of gastric lesions diagnosed as adenomas (Vienna classification category 3) by pre-treatment biopsy. In the present study, we examined the feasibility of magnifying endoscopy with narrow-band imaging (ME-NBI) in discriminating early gastric cancers (Vienna classification category 4 or 5) from adenomas in lesions diagnosed as adenomas by pre-treatment biopsy. This was a single-center cross-sectional retrospective study at a tertiary referral center. One hundred thirty-seven consecutive cases of gastric lesions diagnosed as adenomas in pre-treatment forceps biopsy were examined with conventional non-magnifying endoscopy under white light, non-magnifying chromoendoscopy, and ME-NBI. We investigated the association between the final pathological diagnoses (carcinoma or adenoma) and the following factors: lesion size (mm), color (red or white), macroscopic type (depressed or others), presence of ulceration, and positive ME-NBI finding. The presence of an irregular microvascular pattern or an irregular microsurface pattern with a demarcation line between the lesion and the surrounding area was regarded as a positive ME-NBI finding. Lesion size was significantly larger in carcinomas than adenomas (P=0.005). Depressed lesion (P=0.011), red color (P<0.001), and positive ME-NBI finding (P<0.001) were significant predictive factors for carcinoma. Multivariate logistic regression confirmed that red color (odds ratio [OR] 3.04, 95% confidence interval [CI] 1.26-7.34, P=0.14) and a positive ME-NBI finding (OR 13.68, 95% CI 5.69-32.88, P<0.001) were independent predictive factors for carcinomas. A positive ME-NBI finding was the strongest predictive factor. ME-NBI is useful in planning the management of lesions diagnosed as adenomas by pre-treatment forceps biopsy.

ENDOSCOPICALLY TREATED CRONKHITE-CANADA SYNDROME ASSOCIATED WITH MINUTE INTRAMUCOSAL GASTRIC CANCER: AN ANALYSIS OF MOLECULAR PATHOLOGY

There have been no reports of Cronkhite-Canada syndrome (CCS) associated gastric cancer resected with endoscopy because it is very difficult to identify small cancers that are candidates for endoscopic resection. We report a case of CCS with gastric cancer treated with endoscopic submucosal dissection, and we evaluate the molecular pathological analysis of malignant transformation in patients with CCS. A 74-year-old man had an advanced rectal cancer and gastrointestinal polyposis after presenting with hypoproteinemia, partial hair loss and atrophic nails as well as hyperpigmentation on the hands. He was diagnosed as having CCS. On upper endoscopy, a 7 mm discolored polyp with an irregular microvascular pattern revealed by magnified narrow-band imaging (NBI) was identified in gastric diffuse CCS polyposis. This lesion was treated with endoscopic submucosal dissection and diagnosed as a flat, elevated-type, mucosal well-differentiated tubular adenocarcinoma without lymphatic or venous infiltration, and with tumor-free margins. Microsatellite instability was detected in both the cancer and the surrounding CCS polyps. Mucin-histochemical analysis of the cancer area showed the complete intestinal type, and thus may have differentiated the CCS polyps from that of the common gastric hyperplastic polyps. This case illustrates that a clue to detecting small cancers may be to look for the discolored lesion among reddish CCS polyposis and thereafter to observe the irregular vascular pattern with NBI endoscopy. From the viewpoint of genetic alterations, patients with CCS polyps are considered to be at high risk for developing gastric cancer, and therefore careful follow-up examinations are necessary for the early detection of malignancies.

Nasopharyngeal carcinoma detected by narrow-band imaging endoscopy

The aim of the study was to investigate the novel endoscopic findings in nasopharyngeal carcinoma (NPC) under narrow-band imaging (NBI) and to determine the reliability of screening NPC by NBI. A total of 79 adults underwent nasopharyngeal biopsy. We proposed five distinctly different findings that need to be examined by NBI: Type I: brownish spots, Type II: irregular microvascular pattern (IMVP), Type III: light crests, Type IV: side-difference, Type V: presence of either IMVP or side-difference, of which last three (Type III-V) were a new concept. The results of NPC diagnosis by detecting NBI Type V pattern, the false positive, false negative, sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 6.7%, 2.9%, 97.1%, 93.3%, 91.7%, 97.7%, and 94.9%, respectively. On the other hand, there was a higher prevalence of Type I and IV patterns in T1 category NPC. The nasopharyngeal endoscopy coupled with NBI was able to provide a rapid, convenient, and highly reliable screening for high-risk populations.

A Prospective Study for Differential Diagnosis of Gastric Small Depressive Lesions By Narrow Band Imaging (NBI) Combined with Magnifying Endoscopy

Background: The high-resolution endoscopy has increased opportunities of detecting small depressive lesion (SDL) in the stomach. However, accurate diagnosis of SDLs by conventional endoscopic examination has been difficult. Then, the number of biopsy specimen has increased to confirm the histological diagnosis. The following characteristic findings by a magnifying endoscopy are considered to be useful for differential diagnosis of neoplastic lesions; a clear demarcation line (DL) between the cancerous and non-cancerous area and an irregular microvascular pattern (IMVP). However, magnifying image by conventional white light image (WLI) is still difficult to diagnose SDLs correctly. Narrow band imaging (NBI) combined with magnifying endoscopy clearly enhanced the visualization of surface structure and microvascular architecture compared to conventional WLI, then, more accurate diagnosis of SDL is expected by NBI. Aims: The primary aim of this study was to compare the real-time diagnostic accuracy for gastric SDLs (<10 mm) between magnifying NBI and magnifying WLI. Subjects and Methods: Written informed consent was obtained from all the patients who receive routine endoscopic examination. Among them, patients in whom gastric SDLs were identified during the examination were enrolled, and examination with magnifying WLI followed by magnifying NBI for all SDLs was performed. Experienced endoscopists evaluated the visibility of DL and IMVP and classified them into 3 phases: visible, invisible or illegible. SDLs were diagnosed according to the combination of the visibility of DL and IMVP. The real-time diagnosis was used in this study. Diagnostic accuracy and time required for diagnosis in both methods were compared. Results: Total of 60 lesions of 56 patients were enrolled, but 3 lesions were excluded; one was not obtained biopsy specimen, one could not be examined sufficiently due to bleeding, one was not small (>10 mm). Finally, 57 lesions were analyzed in this study. Lesions were consisted of 30 cancers and 27 benign lesions. Diagnostic accuracy and sensitivity were 79% and 70% in NBI respectively. They were significantly higher than those of WLI (44%; p=0.0001, 33%; p=0.0005). Diagnostic specificity was higher with NBI (89%) than with WLI (67%), but it was not statistically significant. Time required for diagnosis was equivalent between two methods. Conclusion: To make accurate diagnosis for gastric SDLs, magnifying NBI is useful modality compared to conventional WLI. Both DL and IMVP are significant endoscopic findings to do it.