Non-ulcerated Lesions Research Articles

An overview of Buruli ulcer in Australia.

Buruli ulcer (BU) is caused by Mycobacterium ulcerans, an environmental pathogen that causes severe skin and soft-tissue necrosis. In Australia, cases of BU are acquired in endemic regions, which include Victoria and Far North Queensland, but those who have visited these regions can present to health practitioners anywhere. This article provides Australian general practitioners with an overview of BU, including its epidemiology, transmission, clinical features, diagnosis and management. BU can manifest as an ulcer or as a non-ulcerated skin lesion, such as a plaque, nodule or oedema. Diagnosis can be achieved with a dedicated Mycobacterium ulcerans polymerase chain reaction (PCR) test performed on a wound swab. Swabs on non-ulcerated disease have a high false negative rate, and a PCR test should be performed on a tissue biopsy to confirm disease. Most cases are managed with prolonged antibiotic therapy - commonly a combination of oral rifampicin and clarithromycin or fluroquinolone (moxifloxacin or ciprofloxacin) - and wound dressings.

Detection of Biofilm Producing Bacteria causing Co-infections with Leishmania Ulcers and their Relation with Matrix metalloproteinase-13 Enzyme

Background: Protozoan parasite causes Cutaneous Leishmaniosis (CL), dermatological disorder. Infected female phlebotomus sand flies spread these parasites. Secondary bacterial infection can worsen tissue damage and scarring. Objectives: In order to accurately ascertain the incidence of secondary bacterial infection caused biofilm formation in cutaneous leishmaniosis, it is imperative to investigate the significant immunological alterations by quantifying the levels of human Matrix metalloproteinase -13 (MMP-13). Materials and Methods: This study included 90 samples (20 controls and 70 CL sufferers). Study participants ranged in age from 3 months to 65 years, including both genders. Human Matrix metalloproteinase -13 measured by ELISA technique. Ulcer exudates were collected with sterile swabs after non-ulcerated lesions scraped. The specimens were cultured on Blood Agar, MacConkey Agar, Mannitol Salt Agar,and Hi Chrom Acinito. Laboratory methods were identified biofilm producing microorganisms. Results: Biofilms- forming secondary bacterial infections were found in 30 (42.8%) of 70 cutaneous Leishmaniosis patients. Bacterial from lesions Acinetobacter baumanni (8) cases (26.6 %), Acinetobacter lwoffi, Crobactor, Klebsiella, Proteus mirabilis, Proteus vulgaris, Pseudomonas Luteola, Raoultella, Serratia, Sphingo, (1) cases (3.3 %) for each spp. Pantoea (2) cases (6.6 %), Pseudomonas fluorescence (3) cases (10 %), and the study found no differences in MMP-13 levels in CL patients (5.7 + 0.2) compared to the control group. Conclusions: This study observed no differences in the average concentration in level of MMP-13 patient with CL compared with control groups.

Detection of Leishmania infantum in a naturally infected horse in an endemic area for Leishmaniasis in Northeast Brazil

Introduction: Leishmaniasis is an anthropozoonosis caused by a protozoan of the genus Leishmania and transmitted by vectors of the species Lutzomyia longipalpis. The disease can present in two forms: the cutaneous form (Cutaneous Leishmaniasis) and the visceral form (Visceral Leishmaniasis). Its main hosts are domestic canids, but it can parasitize other diverse species such as rodents, possums, foxes, non-human primates, edentulous primates, domestic cats, and even equids, although this is infrequent. Study objective: Due to the scarcity of reports on Leishmaniasis in horses. Added to this, taking into account the susceptibility of horses to infection by many species of Leishmania and the fact that the vast majority of cases are asymptomatic, the objective of this study was to report a case of equine leishmaniasis in the state of Pernambuco. Results and discussion: A male horse, of the Manga Larga Machador breed, four years old, residing in the municipality of Bezerros- PE, Northeast of Brazil, was treated. On physical examination, the presence of ulcerated and non-ulcerated nodular lesions was observed on the face close to the masseter muscle, in the ventrodorsal region, and below the humeroradiounar joint. Presence of papules in the neck region. In the blood count, normocytic normochromic anemia, and leukocytosis due to neutrophilia and eosinophilia were observed. In the parasitological diagnosis through immunohistochemistry, the presence of Leishmania sp. amastigotes was observed. As a therapeutic protocol, injectable marbofloxacin was used for this patient at a dosage of 2mg/kg once a day, intramuscularly for 28 days. Conclusion: Horses infected by L. infantum may present dermatological lesions. Therefore, early diagnosis and treatment are recommended, as it is suggested that the use of marbofloxacin provides good results in the regression of skin lesions in these cases. However, more studies are needed to investigate the epidemiology and pathophysiology of this disease in horses.

Manchas de Wischnewsky em casos de hipotermia fatal em bovinos

ABSTRACT: Wischnewsky spots (WS) are hemorrhagic, non-erosive, and non-ulcerative lesions that affect the gastric mucosa. They are considered common in the stomachs of humans who have died from hypothermia and are rarely described in other animal species. This study describes the occurrence of WS in cattle that had died of hypothermia in two cities in the state of Mato Grosso do Sul. Two properties were visited, and three cattle were necropsied by the team from the Pathological Anatomy Laboratory of the Federal University of Mato Grosso do Sul (LAP-UFMS). The epidemiological conditions and clinical signs of the cattle examined on both properties were similar. The deaths occurred on days when there was a sudden drop in environmental temperature, with continuous rain for more than 24 hours. During the visits, the most affected live cattle were found in sternal decubitus, with their heads resting on their flanks, or laterally in a comatose state, with nystagmus and a rectal temperature below 32°C. Macroscopically, there were multifocal to coalescent red and black areas on the mucosal surface of the abomasums of the three cattle necropsied, mainly at the apex of the folds, oval or punctate in shape, measuring 0.1 to 1.0cm in diameter. Microscopically, these dark areas corresponded to areas of rarefaction of the mucosal epithelial cells associated with hemorrhage and the frequent deposition of golden-brown pigment (hematin) in the extracellular medium. The diagnosis of hypothermia in cattle was based on epidemiology, clinical-pathological examination, and the exclusion of differential diagnoses. The lesions found in the abomasum of cattle that had died from hypothermia were compatible with WS, highlighting the importance of recognizing them in cases of cattle deaths in which this condition is suspected.

Leishmania species and clinical characteristics of Pacific and Amazon cutaneous leishmaniasis in Ecuador and determinants of health-seeking delay: a cross-sectional study

BackgroundCutaneous Leishmaniasis (CL) affects up to 5.000 people in Ecuador each year. L. guyanensis and L. braziliensis are the most common of the eight CL-causing Leishmania species. Earlier CL research concentrated on the easily accessible Pacific region. This study aims to describe the Leishmania species in Pacific and Amazon ecoregions, to analyze regional differences in CL patient clinical presentation, and to identify determinants of health-seeking delay.MethodsAll cases in this cross-sectional study were diagnosed using smear slide microscopy, PCR, or both. Cytochrome B gene sequencing was used to identify the causative Leishmania species in qPCR-positive samples.ResultsThis study included 245 patients, with 154 (63%) infected in the Pacific region and 91 (37%) infected in the Amazon. Causative Leishmania species were identified in 135 patients (73% of qPCR positives). L. guyanensis was identified in 76% (102/135) of the samples and L. braziliensis in 19% (26/135). The Pacific region had a low prevalence of 6% (5/89) of L. braziliensis. For the first time, we report L. guyanensis from the central Amazon, L. braziliensis from the northern Pacific, and L. lainsoni from both the central Amazon and northern Pacific. Amazon cases had a longer median health-seeking delay in months (2.0, IQR 3.0) than Pacific cases (1.0, IQR 1.5). Prolonged health-seeking delay was associated with older age, Amerindian ethnicity, infection at lower altitudes, non-ulcerative lesions, and lesions on the lower limbs.ConclusionsIn the Pacific region, health-seeking delay is relatively short and L. braziliensis prevalence remains low. Limited access to health care and stigma might explain the prolonged health-seeking delay in the Amazon. We recommend larger studies on the distribution of Leishmania species in Amazon CL cases and additional regional research into diagnostic test accuracy. Furthermore, the determinants of health-seeking delay in Ecuador should be investigated further.

Endoscopic Resection of Early Gastric Cancer and Pre-Malignant Gastric Lesions.

Early gastric cancer comprises gastric malignancies that are confined to the mucosa or submucosa, irrespective of lymph node metastasis. Endoscopic resection is currently pivotal for the management of such early lesions, and it is the recommended treatment for tumors presenting a very low risk of lymph node metastasis. In general, these lesions consist of two groups of differentiated mucosal adenocarcinomas: non-ulcerated lesions (regardless of their size) and small ulcerated lesions. Endoscopic submucosal dissection is the technique of choice in most cases. This procedure has high rates of complete histological resection while maintaining gastric anatomy and its functions, resulting in fewer adverse events than surgery and having a lesser impact on patient-reported quality of life. Nonetheless, approximately 20% of resected lesions do not fulfill curative criteria and demand further treatment, highlighting the importance of patient selection. Additionally, the preservation of the stomach results in a moderate risk of metachronous lesions, which underlines the need for surveillance. We review the current evidence regarding the endoscopic treatment of early gastric cancer, including the short-and long-term results and management after resection.

Non-Ulcerated and Ulcerated Necrotizing Sialometaplasia: Report of an Additional Case and Literature Review.

Necrotizing sialometaplasia (NS) is a rare, self-limiting, necrotizing inflammatory lesion, often involving the minor salivary glands of the palate. NS occurs often in men (60%) older than 45 years. Commonly, it presents as an ulcerative lesion, measuring 1 to 3cm in diameter, with an evolution time of a few weeks or days, simulating malignancy. However, in some instances, the mucosal surface is intact, thus emphasizing the importance of considering NS in the differential diagnosis of oral ulcerative and non-ulcerative lesions. To date, 12 cases of non-ulcerated NS in the palate have been reported. Here, we report a 50-year-old male patient who presented a non-ulcerated, asymptomatic, nodular swelling 3 months ago, located on the hard palate, clinically suggesting salivary gland tumor or lymphoproliferative disorder. After biopsy, a diagnosis of non-ulcerated NS was established. After 4 weeks, the lesion evolved with complete resolution. After literature review, notably, unlike ulcerated NS, the non-ulcerated NS affected patients a decade younger (33 years vs. 45 years), with marked female predilection (83% vs. 40%) and not uncommon bilateral presentation (33% vs. 10%). NS should be considered in the differential diagnosis of ulcerative and non-ulcerative lesions affecting the palate.

Predictive accuracy of elevated mitotic rate on lymph node positivity and recurrence in thin melanomas.

Mitotic rate (MR) is considered an important prognostic factor for melanoma but is not currently used for staging because its nuanced effect is not yet well-delineated. We sought to determine if T category-specific MR is predictive of sentinel lymph node (SLN) positivity, recurrence, and melanoma-specific mortality (MSM). A retrospective review of patients with primary cutaneous melanoma from 1994 to 2020 at a single academic center was performed. Patient demographics and tumor characteristics were recorded. MR was considered elevated for each AJCC8-defined T category if it was ≥2 mitoses/mm2 for T1, ≥4 mitoses/mm2 for T2, ≥6 mitoses/mm2 for T3, or ≥7 mitoses/mm2 for T4. Statistical analysis was performed to assess the predictive accuracy of MR on selected outcomes while controlling for ulceration. Data from 2,984 patients with complete records were analyzed. Along with Breslow thickness and ulceration, elevated MR was associated with higher risk of MSM (HR 1.816, P=0.0001). There was no difference among patients with ulcerated T1 or T2 tumors regardless of MR, but those with non-ulcerated T1 or T2 tumors and elevated MR were more likely to have positive SLNs (P<0.0001 and P=0.0043, respectively) and recurrence (P=0.0007 and P=0.0004, respectively) compared to counterparts with low MR. There were no notable differences for T3 or T4 tumors based on MR. Elevated MR is associated with SLN positivity and recurrence in thin melanomas, independent of ulceration. SLN biopsy should therefore be strongly considered for patients with non-ulcerated lesions <0.8mm thick if the MR is ≥2 mitoses/mm2.

Prospective cohort study by InspECT on safety and efficacy of electrochemotherapy for cutaneous tumors and metastases depending on ulceration.

Electrochemotherapy (ECT) is an effective local treatment for cutaneous tumors. The aim of this study was to compare the effectiveness of ECT in ulcerated vs. non-ulcerated tumors and investigate the effect on tumor-associated symptoms. Twenty cancer centers in the International Network for Sharing Practices on Electrochemotherapy (InspECT) prospectively collected data. ECT was performed following ESOPE protocol. Response was evaluated by lesion size development. Pain, symptoms, performance status (ECOG-Index) and health status (EQ-5D questionnaire) were evaluated. 716 patients with ulcerated (n = 302) and non-ulcerated (n = 414) cutaneous tumors and metastases were included (minimum follow-up of 45days). Non-ulcerated lesions responded to ECT better than ulcerated lesions (complete response 65% vs. 51%, p = 0.0061). Only 38% (115/302) with ulcerated lesions before ECT presented with ulcerated lesions at final follow-up. Patients with ulcerated lesions reported higher pain and more severe symptoms compared to non-ulcerated lesions, which significantly and continuously improved following ECT. In non-ulcerated lesions however, pain spiked during the treatment. No serious adverse events were reported. ECT is a safe and effective local treatment for cutaneous tumors. While ECT improves symptoms especially in patients with ulcerated lesions, data suggest the implementation of a perioperative pain management in non-ulcerated lesions during ECT.

Leishmania (Viannia) braziliensis replicates in mouse bone marrow

Leishmaniasis is a neglected disease caused by species of the protozoan Leishmania. Leishmania (Viannia) braziliensis causes the cutaneous and mucocutaneous forms of the disease. Experimental cutaneous infection of mice is one of the most important preclinical research models of leishmaniasis. Here, we investigated the course of infection in mice inoculated with two reference strains of L. (V.) braziliensis (MHOM/BR/00/BA788 strain [BA] and MHOM/BR/94/H-3227 strain [CE]). Although both parasite strains induced detectable footpad lesions, BA-infected mice developed small non-ulcerated lesions that self-healed, whereas CE-infected mice developed small non-ulcerated lesions that did not regress. The parasites were detected in the footpad lesions, lymph nodes draining the site of inoculation, spleen, and bone marrow of mice infected with BA or CE parasites at 6 and 25 weeks post-inoculation. These data indicate that L (V.) braziliensis-infected mice harbor parasites that spread, even when these animals do not display overt lesions. In addition, this is the first report of the presence of the parasite in the bone marrow of mice inoculated with L. (V.) braziliensis.

Compound Endoscopic Morphological Features for Identifying Non-Pedunculated Lesions ≥20 mm with Intramucosal Neoplasia.

Simple SummaryPiecemeal endoscopic mucosal resection (EMR) has proved to be an excellent resection technique for large colorectal polyps. However, a key limitation is the inaccurate histologic assessment of the sample in cases where there is invasion of the submucosa. Thus piecemeal EMR should be avoided if submucosal invasion is suspected. Furthermore, both western and eastern scientific societies have recently recommended that treatment should be based on optical diagnosis (ideally with magnification) which estimates the histology endoscopically. However, experience with magnification in western countries is limited. This study primarily aims to develop a classification system based on endoscopic features to identify intramucosal neoplasia (absence of submucosal invasion) in non-pedunculated lesions ≥20 mm assessed by western endoscopists with narrow band imaging (NBI) and without magnification. We observed that non-ulcerated LST-granular type and LST-non-granular flat elevated lesions represent 58.8% of all non-pedunculated lesions ≥20 mm and are associated with a low risk of submucosal invasion (3.8%). Therefore, we suggest these lesions be treated by piecemeal EMR. In the remaining lesions further diagnostic techniques such as magnifying endoscopy or en bloc resection should be considered.Background: The major limitation of piecemeal endoscopic mucosal resection (EMR) is the inaccurate histological assessment of the resected specimen, especially in cases of submucosal invasion. Objective: To classify non-pedunculated lesions ≥20 mm based on endoscopic morphological features, in order to identify those that present intramucosal neoplasia (includes low-grade neoplasia and high-grade neoplasia) and are suitable for piecemeal EMR. Design: A post-hoc analysis from an observational prospective multicentre study conducted by 58 endoscopists at 17 academic and community hospitals was performed. Unbiased conditional inference trees (CTREE) were fitted to analyse the association between intramucosal neoplasia and the lesions’ endoscopic characteristics. Result: 542 lesions from 517 patients were included in the analysis. Intramucosal neoplasia was present in 484 of 542 (89.3%) lesions. A conditional inference tree including all lesions’ characteristics assessed with white light imaging and narrow-band imaging (NBI) found that ulceration, pseudodepressed type and sessile morphology changed the accuracy for predicting intramucosal neoplasia. In ulcerated lesions, the probability of intramucosal neoplasia was 25% (95%CI: 8.3–52.6%; p < 0.001). In non-ulcerated lesions, its probability in lateral spreading lesions (LST) non-granular (NG) pseudodepressed-type lesions rose to 64.0% (95%CI: 42.6–81.3%; p < 0.001). Sessile morphology also raised the probability of intramucosal neoplasia to 86.3% (95%CI: 80.2–90.7%; p < 0.001). In the remaining 319 (58.9%) non-ulcerated lesions that were of the LST-granular (G) homogeneous type, LST-G nodular-mixed type, and LST-NG flat elevated morphology, the probability of intramucosal neoplasia was 96.2% (95%CI: 93.5–97.8%; p < 0.001). Conclusion: Non-ulcerated LST-G type and LST-NG flat elevated lesions are the most common non-pedunculated lesions ≥20 mm and are associated with a high probability of intramucosal neoplasia. This means that they are good candidates for piecemeal EMR. In the remaining lesions, further diagnostic techniques like magnification or diagnostic +/− therapeutic endoscopic submucosal dissection should be considered.

Gastric Cancer screening – does it exist or not? - literature review

INTRODUCTION AND PURPOSE: Gastric cancer (GC) is one of the biggest healthcare problem in the world. Despite the fact that the incidence of this cancer has decreased recently, GC is on the fifth place of causes of morbidity and on the second place of causes of mortality. Therefore, some countries such as Japan and South Korea have decided to establish and develop screening methods to detect GC as early as it is possible and to begin early treatment. DESCRIPTION OT THE STAGE OF KNOWLEDGE: There are many types of screening methods such as: markers of atrophy- serum-pepsinogen test and low serum gastrin-17 concentration, barium photofluorography of mucosa or endoscopy. Upper gastrointestinal endoscopy has the highest detection rate in high-incidence areas, compared to other screening methods, because upper endoscopy makes it possible to highlight changes such as flat and non-ulcerative lesions, which are usually invisible in barium examination. An alternative to screening is the massive eradication of Helicobacter pylori. Occasionally some countries recommend genetic testing and prophylactic gastrectomy. CONCLUSIONS: Despite the high incidence of GC in Asian countries, there is still a lack of data on the cost-effectiveness of mass screening for GC. The main factor influencing the profitability of screening tests for GC is the cost of upper gastrointestinal endoscopy. Moreover, the value and usefulness of the GC screening program remains controversial in many countries.

Miltefosine for the treatment of cutaneous leishmaniasis-A pilot study from Ethiopia.

BackgroundCutaneous leishmaniasis (CL) in Ethiopia, caused by Leishmania aethiopica, is often severe and hard to treat compared to CL caused by other species elsewhere. Miltefosine is the only oral anti-leishmanial drug, with a favorable side-effect profile compared to routinely available sodium stibogluconate (SSG), but evidence about its use for L. aethiopica is lacking.Methodology and principal findingsIn an observational cohort study, treatment outcomes, safety and adherence among CL patients who required systemic treatment and received miltefosine for 28 days in Boru Meda Hospital and University of Gondar Hospital were studied. Patient cure was defined as 100% flattening for non-ulcerated lesions and 100% flattening and 100% re-epithelization for ulcerated lesions. Outcomes were documented for day 28, 90 and 180, both per site, and pooled, adjusting for site as a fixed effect with effect coding. Among 94 included patients (32 in Gondar, 62 in Boru Meda), median lesion duration was 12 months, median size six cm, and mucosal involvement (46.8%) and diffuse (30.9%) lesions were common. Adherence to miltefosine was good, and side-effects were tolerable. Initial outcomes at day 28 were promising, with 68.8% and 94.0% of patients having good improvement or cure in Gondar and Boru Meda respectively. In Boru Meda, outcomes were good with 72.7% and 72.9% cure at day 90 and day 180 respectively. In Gondar, results were less promising, with only 12.5% and 26.7% cure at day 90 and day 180, although confidence intervals were wide. In pooled estimates, 48.7% of patients reached cure at day 180, and 32.3% relapsed. Outcomes were better in Boru Meda Hospital, for smaller lesions and for mucosal lesions.Conclusions/SignificanceBased on miltefosine’s good initial response, tolerable side-effects, tablet-form, we propose to include miltefosine for future clinical trials using extended treatment schedules, combination therapy, or targeting specific subgroups.Trial registrationClinicalTrials.gov NCT04004754.

Comparison of endoscopic and pathological findings of the upper gastrointestinal tract in transplant candidate patients undergoing hemodialysis or peritoneal dialysis treatment: a review of literature

BackgroundDyspepsia is a common disorder in kidney transplant recipients, and the risk of post-transplant complications is increased in candidates with upper gastrointestinal disease. We evaluated gastrointestinal lesions of kidney transplant candidates on dialysis.MethodsIn this study, endoscopic and pathological findings in hemodialysis (HD) and peritoneal dialysis (PD) patients with gastrointestinal symptoms on the waiting list were compared.ResultsThe most common non-ulcerous lesions in the endoscopic examination were gastritis (62.3%), erosive gastritis (38.7%), duodenal erosion or duodenitis (18.9%) and esophagitis (13.2%). The ulcerous lesion was present in only 3 patients. Gastroesophageal reflux disease, ulcerated lesion and non-ulcerated lesion rates were similar in both dialysis groups. Histopathological examination revealed Helicobacter pylori (HP) positivity in 28.3% of patients. HP positivity rate was significantly higher in PD patients than in HD patients (38.7% vs. 13.6%, p = 0.046). Chronic gastritis (75.5%) was the most common pathological finding. HP positivity rate was 37.5% in patients with chronic gastritis, but HP was negative in patients without chronic gastritis. In multivariate analysis, male gender, urea and albumin levels were associated with the presence of pathological chronic gastritis. The presence of gastritis, total cholesterol and ferritin levels were found significant for HP positivity. A total cholesterol > 243 mg/dL was significantly related to an increased risk of the presence of HP positivity.ConclusionsGastrointestinal lesions and HP infection are common in dialysis patients. Dialysis modality may affect the frequency of some lesions. It may be useful to have an endoscopic examination before entering the transplant waiting list for all candidates.

A firm mass of the maxillary gingiva

A firm mass of the maxillary gingiva

EPITHELIAL-MYOEPITHELIAL CARCINOMA OF MINOR SALIVARY GLANDS: A CASE REPORT

Epithelial-myoepithelial carcinoma (EMC) is a rare biphasic low-grade malignant tumor accounting for less than 0.5% of all salivary gland tumors. We report a case of a 65-year-old Afrodescendant female presenting a painful nonulcerated nodular lesion on the mouth floor, with approximately 5.0 × 2.5 cm. An incisional biopsy was performed, and the specimen revealed proliferation of double-layered duct-like structures composed of clear myoepithelial and luminal cells within a hyalinized stromal, with a thin peripheral fibrous capsule. Immunohistochemical analysis showed outer ductal cells positive for α–smooth muscle actin and AE1/AE3 cytokeratin panel. The diagnosis was EMC. The patient was referred to a head and neck surgery service for proper management, and no recurrence or metastatic disease was observed so far. EMC histologic features frequently resemble other more aggressive salivary gland malignant tumors, such as adenoid cystic carcinoma. The correct diagnosis, based on morphologic and immunohistochemical criteria, is essential to assure the proper management of the tumor.

Gastroesophageal Junction Cancer

Cancers of the gastroesophageal junction (GEJ) remain challenging malignancies to treat effectively. The GEJ represents the transition between esophagus and stomach, and approaching GEJ cancers as “esophageal” or as “gastric” cancers, a priori will run risk for excluding some more appropriate therapeutic options based on actual location. Gastroesophageal junction cancers are increasing in incidence, in particular at the distal esophageal and gastric cardia locations. They may be discovered in an early stage on upper GI endoscopy, but when presenting with dysphagia symptoms they are often of more advanced stage. Endoscopic resection options are limited to non-ulcerated T1 lesions, and surgical resection as only therapy is accepted for nodal-negative T1 or T2 disease. All other mid-stage GEJ cancers should be considered for multimodality therapy and should undergo a formal and complete multidisciplinary evaluation process before any therapy is started. While the proper approach remains debated, most often trimodality therapy with preoperative chemoradiation followed by resection is being offered, as it offers the greatest likelihood for complete pathologic response and survival benefit but requires a shorter preoperative treatment duration. Perioperative chemotherapy remains acceptable as well, based on the patient’s tolerance for related toxicity. The Siewert classification with 3 subtypes of GEJ cancers, based on the relationship of the tumor’s epicenter to the gastric cardia, remains useful for planning resection approach and extent as well as reconstruction technique. Type I (proximal GEJ) tumors require esophageal resection with mediastinal and retrogastric lymphadenectomy; reconstruction most often involves a gastric tube pull-up. Type III (distal GEJ) lesions are gastric cancers that require total or proximal gastrectomy with D2 dissection; reconstruction often utilizes Roux-Y esophagojejunostomy, but may include small bowel interposition for proximal gastrectomy too. Best approaches to type II lesions (of the cardia) remain debated; complete resection through esophagectomy (as type I) or transhiatal esophagogastrectomy (as in type III with appropriate proximal extension) remain acceptable, as long as complete resection and proper extent lymphadenectomy are performed. Minimally invasive approaches (versus open), patient comorbidity, individual tumor extent and surgeon’s experience should determine the best individual choice for operative approach. Surgeons engaging in GEJ cancer care should be familiar with all aspects of multidisciplinary and operative treatment planning, and should be able to offer the most appropriate resection choice for the patient’s best benefit. This review contains 2 figures, 3 tables, and 100 references. Key words: adenocarcinoma, gastrectomy, gastroesophageal junction, laproscopy, lymphadenectomy, metastasis, minimally invasive esophagectomy

Gastroesophageal Junction Cancer

Cancers of the gastroesophageal junction (GEJ) remain challenging malignancies to treat effectively. The GEJ represents the transition between esophagus and stomach, and approaching GEJ cancers as “esophageal” or as “gastric” cancers, a priori will run risk for excluding some more appropriate therapeutic options based on actual location. Gastroesophageal junction cancers are increasing in incidence, in particular at the distal esophageal and gastric cardia locations. They may be discovered in an early stage on upper GI endoscopy, but when presenting with dysphagia symptoms they are often of more advanced stage. Endoscopic resection options are limited to non-ulcerated T1 lesions, and surgical resection as only therapy is accepted for nodal-negative T1 or T2 disease. All other mid-stage GEJ cancers should be considered for multimodality therapy and should undergo a formal and complete multidisciplinary evaluation process before any therapy is started. While the proper approach remains debated, most often trimodality therapy with preoperative chemoradiation followed by resection is being offered, as it offers the greatest likelihood for complete pathologic response and survival benefit but requires a shorter preoperative treatment duration. Perioperative chemotherapy remains acceptable as well, based on the patient’s tolerance for related toxicity. The Siewert classification with 3 subtypes of GEJ cancers, based on the relationship of the tumor’s epicenter to the gastric cardia, remains useful for planning resection approach and extent as well as reconstruction technique. Type I (proximal GEJ) tumors require esophageal resection with mediastinal and retrogastric lymphadenectomy; reconstruction most often involves a gastric tube pull-up. Type III (distal GEJ) lesions are gastric cancers that require total or proximal gastrectomy with D2 dissection; reconstruction often utilizes Roux-Y esophagojejunostomy, but may include small bowel interposition for proximal gastrectomy too. Best approaches to type II lesions (of the cardia) remain debated; complete resection through esophagectomy (as type I) or transhiatal esophagogastrectomy (as in type III with appropriate proximal extension) remain acceptable, as long as complete resection and proper extent lymphadenectomy are performed. Minimally invasive approaches (versus open), patient comorbidity, individual tumor extent and surgeon’s experience should determine the best individual choice for operative approach. Surgeons engaging in GEJ cancer care should be familiar with all aspects of multidisciplinary and operative treatment planning, and should be able to offer the most appropriate resection choice for the patient’s best benefit. This review contains 2 figures, 3 tables, and 100 references. Key words: adenocarcinoma, gastrectomy, gastroesophageal junction, laproscopy, lymphadenectomy, metastasis, minimally invasive esophagectomy

A new exploration of white globe appearance (WGA) in ulcerative lesions.

White globe appearance (WGA), a small white lesion with a globular shape that can be clearly visualized by magnifying endoscopy with narrow-band imaging (ME-NBI), was reported to be a reliable marker of early gastric cancer (EGC). However, we found that this endoscopic presentation could also be seen in non-cancerous tissues, especially in ulcerative lesions. This study aimed to further investigate the diagnostic value of WGA in differentiating non-cancerous lesions from EGC in ulcer-type cases. We retrospectively reviewed 54cases of EGC and 155 cases of non-cancerous lesions in this study, all of which had endoscopic imaging data of ME-NBI scanning and pathological data of biopsy or resected specimens. The correlation of the prevalence of WGA and ulcerative lesions, as well as the characteristics of WGA between the 2 groups were analyzed in this study. WGA was more common in ulcerative lesions (27.6 %, 21/76) than in non-ulcerative lesions (3.8 %, 5/133) (p < 0.001) in our study. In the ulcerative cases, no significant difference in prevalence of WGA was observed between EGC and non-cancerous lesions (p = 0.532). Compared with WGA in EGC, WGA in non-cancerous lesions tended to show the characteristic of tree-branch-like vessels on globular shape (p < 0.001). WGA is more likely to occur in ulcerative lesions, and the presence of WGA alone cannot distinguish EGC from non-cancerous lesions in ulcer-type cases. In WGA-positive tissue, tree-branch-like vessels of globular shape may provide a certain clinical value in diagnosis of non-cancerous lesions or EGC.

MIRROR OF UPPER GASTROINTESTINAL ENDOSCOPIC FINDINGS IN LUMBINI PROVINCIAL HOSPITAL

Background: Upper Gastro Intestinal (UGI) endoscopy is a common and important procedure for UGI problems. In Nepal, especially to this region, there have not been many scientific studies about the pattern of diseases seen on UGI endoscopy. This study aimed to enlist patterns of upper GI endoscopic findings done in Lumbini Provincial Hospital.&#x0D; Methods: This was a retrospective study of 200 consecutive patients who underwent UGI endos­copy from August 2017 to February 2018. Data were retrieved retrospectively from prospectively maintained data in computer-based systems and analyzed with SPSS-20.&#x0D; Results: A total of 200 patients underwent UGI Endoscopy during the study period. Among them, females were 110 (55.0%) and males were 90(45.0%). The mean age of the study population was 46.3% (SD, 17.75). The pain abdomen was the most common indication for UGI endoscopy with 166 cases (83.0%) followed by gastrointestinal bleeding with 22 cases (11.0%). Benign lesions were seen in most of the cases which include non-ulcerative lesions 117(58.5%) and ulcerative benign lesions 72(36%). Malignancies found in 7(3.5%) cases and normal findings in 4 cases.&#x0D; Conclusions: This study outlines the most common indications for upper GI endoscopy in our set up and disease patterns in those patients. This study will be helpful for an epidemiological