Superficial Mucosal Layer Research Articles

Comparison of PUCAI Score in Mesalazine-Treated Children with Ulcerative Colitis

Background: Ulcerative colitis is a chronic idiopathic inflammatory bowel disease (IBD) characterized by intestinal inflammation confined to the superficial mucosal layer. Mesalazine, a 5-aminosalicylic acid (5-aminosalicylic, or 5-ASA) compound, is most often used as first-line therapy for mild to moderate ulcerative colitis. The Pediatric Ulcerative Colitis Activity Index (PUCAI) is a non-invasive multi-item measure that has been shown to be valid, reliable, and responsive to short-term changes in several clinical trials and cohort studies. Therefore, this study aims to compare the PUCAI scores in children with ulcerative colitis who received mesalazine therapy to those who did not. Methods: We performed a retrospective database analysis of 12 patients, who were diagnosed with ulcerative colitis at Dr. Kariadi General Hospital, Semarang, Indonesia in a span of 1 year. We included all cases of pediatric patients with ulcerative colitis, then we divided them into 2 groups, the group receiving mesalazine therapy and the group who did not. We monitored the development of PUCAI scores before and after treatment. Results: The number of samples in this study was 12 samples. All sample data were taken based on data from pediatric gastroenterohepatology patients diagnosed with colitis ulcerative based on pathology anatomy results, who were treated in the pediatric ward of RSUP Dr. Kariadi Semarang. From the result of the paired t-test, there was a significant decrease in PUCAI score in patients who received Mesalazine, (p = 0.007), while those who did not receive mesalazine, did not show any significant decrease in PUCAI score. Conclusion: Ulcerative colitis (UC) is a chronic relapsing inflammatory condition. UC is often treated with mesalazine as the first-line treatment. The use of the PUCAI score is an appropriate tool to determine the progression of this disease. Based on the data obtained, the administration of mesalazine therapy in children with ulcerative colitis can improve PUCAI scores compared to children who do not receive mesalazine therapy.

Association between ulcerative colitis and Helicobacter pylori infection: A case-control study

IntroductionUlcerative Colitis (UC), a type of inflammatory bowel disease (IBD), is defined as chronic inflammation of the superficial mucosal layer of the large intestine. In this study, we aimed to investigate the association between Helicobacter pylori (H. pylori) colonization, and UC in Palestine. MethodsA total of 35 Palestinian patients of UC and 105 age-matched and gender-matched controls were retrospectively studied for a period of one year. Diagnosis of ulcerative colitis was based on both colonoscopy and biopsy. The presence of H. pylori in the stomach was evaluated by the H. pylori stool antigen test (HpSA). An interview-based data collection form was filled for all patients with UC before starting the test. ResultsThe overall positivity of H. pylori infection in patients with UC was 14.3%, significantly lower than the control group, 41.9% (odds ratios (OR) = 0.23, 95% confidence intervals (CI): 0.083–0.643, P-value = 0.003). Interestingly, the presence of H. pylori showed no correlation with the extension of UC (P-value = 0.44). Moreover, there were no relationships between the presence of H. pylori and age (P-value = 0.97), gender (P-value = 0.26), smoking (P-value = 0.08), and medication regimen (P-value = 0.80). ConclusionThe rate of H. pylori infection was significantly lower in patients with UC compared with the control group suggesting a protective role of H. pylori against the occurrence of UC.

Association between Ulcerative Colitis and <i>Helicobacter pylori</i> Infection: A Case-Control Study

Introduction: Ulcerative Colitis (UC) is a type of inflammatory bowel disease (IBD) defined as chronic inflammation of the superficial mucosal layer of the large intestine. In this study, we aimed to investigate the association between Helicobacter pylori (H. pylori) infection and UC in Palestine. Methods: A total of 35 Palestinian patients of UC and 105 age-matched and gender-matched controls were retrospectively studied for a period of one year. Ulcerative Colitis diagnosis was based on both colonoscopy and biopsy. The presence of H. pylori in the stomach was tested by stool antigen test (HpSA). An interview-based data collection form was filled for all patients with UC before the test. Results: The overall positivity of H. pylori infection in UC patients was 14.3%, significantly lower than the control group, 41.9% (odds ratios (OR)=0.23, 95% confidence intervals (CI): 0.083-0.643, P -value=0.003). Interestingly, the presence of H. pylori was not correlated with the extension of UC ( P -value=0.44). Moreover, there were no relationships between the presence of H. pylori and age ( P -value=0.97), gender ( P- value=0.26), smoking ( P- value=0.08) and medication regimen ( P -value=0.80). Conclusion: The rate of H. pylori infection was significantly lower in UC patients compared with the control group suggesting a protective role of H. pylori against the occurrence of UC. Funding Information: Our research was funded by An-Najah National University. Declaration of Interests: The authors declare that they have no conflict of interest. Ethics Approval Statement: The study design was based on guidelines of the World Health Organization (WHO), and ethical approval was obtained from the institutional review board (IRB) at An-Najah National University, Nablus, Palestine. An informed consent form was signed by all patients and control group who agreed to participate in the study.

S2334 “Hallelujah Mountain Tumbling in the Loch”: Underwater Endoscopic Mucosal Resection - An Unfolding Strategy

INTRODUCTION: Duodenal adenomas are often found incidentally during upper endoscopy performed for other indications. Duodenal adenomas have the potential for malignant transformation. Therefore, complete excision either surgically or endoscopically is recommended. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are the primary endoscopic techniques for non-ampullary duodenal adenoma resections, however they each have several limitations. Underwater EMR is an emerging technique in which the lumen is filled with water instead of air, allowing the mucosa to float and promoting easier capture of the polyp. Underwater EMR has shown to be effective and safe for colonic polyps. The data about it is safety and efficacy for duodenal adenomas is promising. Here, we present a case of large peri-ampullary polyp that was resected using underwater EMR. CASE DESCRIPTION/METHODS: A 73-year-old female patient with past medical history of coronary artery disease and atrial fibrillation on anticoagulation who was transferred from outside facility for peri-ampullary mass resection. Patient’s anticoagulation was held before the procedure. Esophagoduodenoscopy (EGD) revealed a large multilobulated polyp measuring 3–4 cm in the second part of the duodenum. The polyp was located approximately 1 cm lateral to the major duodenal papilla. The polyp was carefully examined with the radial and linear echoendoscopes. The polyp appeared to originate from the superficial mucosal layer and did not involve deeper structures, submucosa, or the common bile duct. No surrounding lymphadenopathy. Underwater EMR was performed to resect the polyp as described. The duodenal lumen was distended with warm saline. The polyp lifted well into the duodenal lumen and away from the duodenal wall. A 20 mm snare was used to snare the entire lesion and it was completely removed en bloc using a cold snare. No oozing or bleeding at the EMR site was seen. The mucosal defect was closed with one metallic clip. No complications were reported during or after the procedure. Final histology report showed tubular adenoma with low grade dysplasia that was completely resected. DISCUSSION: Underwater EMR is an effective and safe technique for non-ampullary duodenal polyp resection. Prospective studies comparing underwater EMR and conventional techniques for duodenal polyps resection are needed.

P051 MR-enterography with diffusion weighted imaging and apparent diffusion coefficient map for assessing inflammatory bowel disease in children and adolescents

BACKGROUND: Endoscopy has been considered as the gold standard for the assessment of gastrointestinal inflammation, however, it can only evaluate superficial mucosal layers. Crohn's disease could cause transmural inflammation in any part of the gastrointestinal tract. As a result, stenosis, perforation, and internal/external fistula formation can complicate with this inflammation, and assessing the inflammatory activity of the bowel wall, not limited to the superficial intestinal mucosa, would lead to the proper diagnosis as well as management to minimize complication in patients with inflammatory bowel disease (IBD). Small bowel inflammation can be evaluated by both magnetic resonance imaging (MRI) and computed tomography (CT), and they have shown similar accuracy and sensitivity for the detection of active inflammation. Recent studies have addressed the utility of Diffusion Weighted Imaging (DWI) and apparent diffusion coefficient (ADC) map in adult, while there have been few studies using these modalities in children and adolescents. The aim of this study was to explore the usefulness of ADC values in children with IBD. METHODS: Children and adolescents with IBD that required MR-enterography (free-breathing axial DWI with 2 b (0 and 800 s/mm2) was included) for the assessment of small intestinal lesion at a Japanese children's hospital were retrospectively reviewed. A total of 14 children and adolescents with IBD (12 CD and 2 UC), aged 5 to 23 years who had undergone MR-enterography from 2017 to 2018. Mean restricted ADC (r-ADC) value was obtained in a set of value (3 points of thickened bowel wall in all patients [n = 14]). Also, mean non-restricted ADC (nr-ADC) value was obtained from normal bowel wall as well as r-ADC described above. Fourteen age-matched control patients that had undergone MR-enterography were identified. In addition, mean ADC value of non-IBD patients (ni-ADC) was obtained from normal intestinal wall as a control group (e.g., neuroblastoma, n = 14). These values were compared using t-test. P < 0.05 were considered to indicate statistical significance. RESULTS: The r-ADC values were significantly lower than the nr-ADC values (1.118 ± 0.271 × 10−3 mm2/s vs 2.119 ± 0.252 × 10−3 mm2/s; P < 0.01). However, there was no significant difference between ni-ADC and nr-ADC (2.15 ± 0.217 × 10−3 mm2/s vs 2.119 ± 0.2519 × 10−3 mm2/s; P = 0.556). CONCLUSION(S): DWI and ADC map were useful in locating actively inflamed bowel segments. MR-enterography with DWI and ADC map appeared an excellent modality to assess intestinal inflammation that can be repeatedly used without radiation exposure, even in pediatric patients. Further studies to investigate for the threshold of ADC value that can be used for children with IBD should be considered.

Sub-periosteal peri-implant augmented layer technique for horizontal bone augmentation at implant placement.

In the present study, a novel surgical technique, namely the sub-periosteal peri-implant augmented layer (SPAL), to increase hard and soft tissue dimensions at the most coronal portion of an implant will be thoroughly described. The surgical buccal access at the time of implant placement first consisted of a split-thickness flap to raise the most superficial mucosal layer, followed by the elevation of the periosteal layer which was detached from the buccal cortical bone plate (BCBP). A full-thickness flap was elevated on the oral aspect. A xenograft was used to fill the space between the periosteal layer and the BCBP, and the periosteal layer was sutured to the oral flap. The mucosal layer was coronally advanced and sutured to submerge both the graft and the implants. At implant uncovering at 4 months, an increase in the thickness (>2 mm) of the buccal peri-implant tissues was observed. A free gingival graft was used to enhance the dimensions of buccal keratinized mucosa. The SPAL technique may represent a surgical option for the horizontal augmentation of peri-implant tissue thickness.

Role of Narrow Band Imaging in Relation to Stroboscopy and White Light Laryngoscopy in Diagnosis of Benign Nonvascular Glottic Lesions

ABSTRACT Objective To evaluate the role of narrow band imaging (NBI) in detecting benign nonvascular glottic lesions. Materials and methods Our study is a retrospective and prospective analysis of 247 patients with suspected benign glottic lesions who presented to our voice clinic over a 6-month duration. Patients were diagnosed on stroboscopy (by the first author) and divided into three groups consisting of leukoplakia, sulci, and cysts. A white light (WL) laryngoscopy and NBI examination was performed by an independent laryngologist (not an author) followed by a comparative analysis. The final gold standard for diagnosis was microlaryngoscopy with or without histopathology. Sensitivity of each modality for diagnosis of the three groups was calculated. Results The NBI is more sensitive for diagnosing leukoplakia. Stroboscopy is more sensitive for diagnosing sulcus. Conclusion Small vocal fold lesions may be missed on WL laryngoscopy. Stroboscopy helps in the diagnosis of structural glottic lesions affecting mucosal wave pattern. Many studies have shown that NBI light highlights the vasculature in superficial mucosal and subepithelial layers. This study is an analysis of the value of NBI in detecting relatively avascular glottic lesions, such as leukoplakia, sulci, and cysts. How to cite this article Nerurkar NK, Shedge AE, Gupta HK, Arya AA. Role of Narrow Band Imaging in Relation to Stroboscopy and White Light Laryngoscopy in Diagnosis of Benign Nonvascular Glottic Lesions. Int J Phonosurg Laryngol 2017;7(1):1-5.

Histological changes in the vulva and vagina from ovariectomised rats undergoing oestrogen treatment.

The purpose of this study was to assess the histological changes occurring in the vagina and vulva in ovariectomised female rats, as well as the response to the administration of injectable oestrogens. We used 30 female Wistar white rats, distributed as follows: group 1 - the control group, group 2 - the operated but untreated rats, and groups 3, 4 and 5 - operated rats, to which oestrogenic treatment was administered (Estradiol, Estradurin, Sintofolin) at a dosage of 0.2 mg/rat/day. After 14 days of treatment, all animals were sacrificed and vaginal and vulvar biopsies were taken from all groups. In group 2, we encountered structural changes of the vaginal mucosa, with severe atrophy and alterations in the thickness of the vagina and vulva. In groups 3, 4 and 5 we found marked hyperplasia of the vaginal and vulvar epithelium, eosinophilic and mast cell infiltration in the chorion. Our study proves that the histopathological changes during anoestrus after administration of oestrogens are cell hyperplasia, thickening of the superficial mucosal layer, eosinophilic and mast cells infiltrations, and chorionic congestion. Furthermore, we demonstrated that Estradiol therapy induces the most evident histological changes when compared to synthetic oestrogens such as Estradurin or Sintofolin.

Analysis of microvascular density in early gastric carcinoma using magnifying endoscopy with narrow-band imaging.

Background and study aims: Intramucosal vascular density differs between differentiated and undifferentiated type gastric carcinomas. This study aimed to evaluate the microvascular density characteristics of these two types of carcinoma using magnifying endoscopy with narrow-band imaging (ME-NBI). Patients and methods: In total, 42 differentiated and 10 undifferentiated types were evaluated. The microvessels observed using ME-NBI were extracted from stored still images and the microvascular density in the two carcinoma types was analyzed. Histological vascular density in resected specimens was also evaluated using CD34 immunostaining. Results: There were significant differences between the microvascular density in the differentiated and undifferentiated types of carcinoma (10.02 ± 4.72 % vs 4.02 ± 0.40 %; P < 0.001) using ME-NBI. Vascular density assessed histologically also differed significantly between differentiated and undifferentiated types in both the whole mucosal (5.81 ± 3.17 % vs 3.25 ± 1.21 %) and the superficial mucosal layers (0 – 100 μm) (6.38 ± 3.73 % vs 3.66 ± 1.46 %). However, the vascular density in the surrounding non-carcinomatous mucosa assessed using ME-NBI and histologically, was significantly lower in the differentiated than in the undifferentiated types (P < 0.001). There was good agreement between ME-NBI and histologically assessed microvascular density in both the whole (r = 0.740; P < 0.001) and superficial mucosal layers (r = 0.764; P < 0.001). White opaque substance (WOS) was seen in eight patients who had the differentiated type carcinoma. In almost all cases with WOS, the appearance of the carcinoma was discolored. Conclusions: There was a close relationship between ME-NBI assessed microvascular density and histologically assessed vascular density in the mucosal layer. Microvascular density differed significantly between the differentiated and undifferentiated types of carcinoma assessed using ME-NBI.

NBI Optical Filters in Minimally Invasive Medical Devices

The integration of the narrow band imaging (NBI) technique in highly miniaturized minimally invasive medical devices is presented. NBI provides a more reliable sensing performance for in vivo studies on tissues as compared to approaches based on white light illumination. NBI uses a selective filtered light with peak transmission at 415 (blue) and 540 nm (green). The blue light improves the visualization of the superficial mucosal layer, while the deeper penetration of the green light highlights the vascular patterns of the subepithelial vessels. The optical filters are based on a multilayer thin-film stack, using the Fabry–Perot configuration with titanium dioxide (TiO2) and silicon dioxide (SiO2). The blue light-emitting diode (LED) combined with the blue filter results in a maximum central wavelength at 414 nm, full-width half-maximum (FWHM) of 19 nm and maximum relative transmittance of 21%. The green LED combined with the green filter yields maximum peak intensity at 536 nm, FWHM of 30 nm, and maximum relative transmittance of 35%. RF-sputtering was used for the deposition of NBI optical filters. The refractive index and extinction coefficient of the TiO2 and SiO2 thin films were characterized and the green and blue filter designs were experimentally validated.

Metagenomic Characterization of Microbial Communities In Situ Within the Deeper Layers of the Ileum in Crohn's Disease.

Background & AimsMicrobial dysbiosis and aberrant host–microbe interactions in the gut are believed to contribute to the development and progression of Crohn’s disease (CD). Microbiome studies in CD typically have focused on microbiota in feces or superficial mucosal layers of the colon because accessing DNA from deeper layers of the bowel is challenging. In this study, we analyzed the deep tissue microbiome in patients who underwent surgical resection of the small intestine.MethodsParaffin blocks were obtained from 12 CD patients undergoing ileocecal resection, and healthy ileum samples (inflammatory bowel disease–free controls) were obtained from 12 patients undergoing surgery for right-sided colon cancer. Diseased and healthy-appearing ileum was identified using microscopy, and paraffin blocks were macrodissected using a core needle to specifically isolate DNA. Illumina Whole Genome Sequencing was used for microbial sequence identification and subsequent taxonomic classification using the PathSeq tool.ResultsWe observed significant differences between the microbiome of CD samples vs inflammatory bowel disease–free controls, including depletion of Bacteroidetes and Clostridia. Notably, microbial composition at the phyla level did not differ markedly between healthy and diseased areas of CD patients. However, we observed enrichment of potentially pathogenic organisms at the species level.ConclusionsOur study showed dysbiosis within deeper layers of the ileum of CD patients, specifically enrichment of enterotoxigenic Staphylococcus aureus and an environmental Mycobacterium species not described previously. Future studies with larger cohort sizes are warranted to confirm these findings. Studies would benefit from effective microbial DNA extraction methods from paraffin sections and host nucleic acid depletion approaches to increase microbial read coverage.

Clinicopathological features of alpha-fetoprotein producing early gastric cancer with enteroblastic differentiation.

AIMTo investigate clinicopathological features of early stage gastric cancer with enteroblastic differentiation (GCED).METHODSWe retrospectively investigated data on 6 cases of early stage GCED and 186 cases of early stage conventional gastric cancer (CGC: well or moderately differentiated adenocarcinoma) who underwent endoscopic submucosal dissection or endoscopic mucosal resection from September 2011 to February 2015 in our hospital. GCED was defined as a tumor having a primitive intestine-like structure composed of cuboidal or columnar cells with clear cytoplasm and immunohistochemical positivity for either alpha-fetoprotein, Glypican 3 or SALL4. The following were compared between GCED and CGC: age, gender, location and size of tumor, macroscopic type, ulceration, depth of invasion, lymphatic and venous invasion, positive horizontal and vertical margin, curative resection rate.RESULTSSix cases (5 males, 1 female; mean age 75.7 years; 6 lesions) of early gastric cancer with a GCED component and 186 cases (139 males, 47 females; mean age 72.7 years; 209 lesions) of early stage CGC were investigated. Mean tumor diameters were similar but rates of submucosal invasion, lymphatic invasion, venous invasion, and non-curative resection were higher in GCED than CGC (66.6% vs 11.4%, 33.3% vs 2.3%, 66.6% vs 0.4%, 83.3% vs 11% respectively, P < 0.01). Deep submucosal invasion was not revealed endoscopically or by preoperative biopsy. Histologically, in GCED the superficial mucosal layer was covered with a CGC component. The GCED component tended to exist in the deeper part of the mucosa to the submucosa by lymphatic and/or venous invasion, without severe stromal reaction. In addition, Glypican 3 was the most sensitive marker for GCED (positivity, 83.3%), immunohistochemically.CONCLUSIONEven in the early stage GCED has high malignant potential, and preoperative diagnosis is considered difficult. Endoscopists and pathologists should know the clinicopathological features of this highly malignant type of cancer.

Advanced gastrointestinal endoscopic imaging for inflammatory bowel diseases.

Gastrointestinal luminal endoscopy is of paramount importance for diagnosis, monitoring and dysplasia surveillance in patients with both, Crohn's disease and ulcerative colitis. Moreover, with the recent recognition that mucosal healing is directly linked to the clinical outcome of patients with inflammatory bowel disorders, a growing demand exists for the precise, timely and detailed endoscopic assessment of superficial mucosal layer. Further, the novel field of molecular imaging has tremendously expanded the clinical utility and applications of modern endoscopy, now encompassing not only diagnosis, surveillance, and treatment but also the prediction of individual therapeutic responses. Within this review, we describe how novel endoscopic approaches and advanced endoscopic imaging methods such as high definition and high magnification endoscopy, dye-based and dye-less chromoendoscopy, confocal laser endomicroscopy, endocytoscopy and molecular imaging now allow for the precise and ultrastructural assessment of mucosal inflammation and describe the potential of these techniques for dysplasia detection.

Lymphangiomatous Lesions of the Gastrointestinal Tract: A Clinicopathologic Study and Comparison Between Adults and Children

Lymphangiomatous lesions involving the gastrointestinal (GI) tract remain incompletely characterized, and their clinical and histopathologic features have not been systematically evaluated. The distinction between a primary lymphatic malformation (lymphangioma) and a dilation of existing lymphatics (lymphangiectasia) is of clinical significance, since lymphangiectasia may occur in the setting of lymphatic obstruction due to an unsampled malignancy. We describe clinical and morphologic features of lymphangiomas of the GI tract in adult and pediatric populations and contrast them with lymphangiectasia. We performed a retrospective review of adult and pediatric lymphangiomas and lymphangiectasia involving the GI tract. Thirty-six cases of lymphangioma and lymphangiectasia were retrieved, and clinical presentation and histologic features were compared. Lymphangiomas had distinct clinical presentations in adults and children, with adult lesions being more frequently asymptomatic and more frequently involving the superficial mucosal layers of the GI tract. Microscopically, lymphangiomas mostly consisted of confluent dilated spaces with a smooth muscle component. This appearance differed from lymphangiectasia, which lacked a complete distinct endothelial or smooth muscle lining and diffusely involved the mucosa and submucosa. Morphologic features of GI tract lymphangiomas can be reliably distinguished from lymphangiectasia by clinical and pathologic characteristics.

Gastroduodenal Intussusception and Biochemical Pancreatitis Due to a Gastric Hyperplastic Polyp: A Case Report

Introduction: Gastroduodenal intussusceptions represent less than 10% of intussusceptions. Common etiologies include benign and malignant intestinal neoplasms. We present a rare case of a gastroduodenal intussusception caused by a hyperplastic gastric polyp. Case Report: A 76-year-old man with history of coronary artery disease presented to the emergency room with a 1-day history of abdominal pain and emesis. His medications included ticlopidine and aspirin for a bare metal stent that was placed 6 months ago. Laboratory studies were notable for mildly elevated liver tests and lipase, which peaked at 3,663. Computed tomography (CT) of the abdomen demonstrated gastric antral wall thickening without evidence of pancreatitis. Esophagogastroduodenoscopy (EGD) revealed a large, fungating, and multi-lobulated gastric polyp that was at least 10 cm in width. Endoscopic ultrasound demonstrated a polyp involving the superficial and deep mucosal layers of the gastric wall. Stack biopsies confirmed the presence of a hyperplastic gastric polyp without dysplasia. Further resection could not be performed due to the patient’s current use of ticlopidine and aspirin. Endoscopic resection was recommended 5 days after stopping anticoagulation and the patient was discharged home. The following day, he returned with worsening symptoms, and a repeat CT of the abdomen showed a gastroduodenal intussusception with gastric outlet obstruction secondary to the gastric mass acting as lead point. The lipase continued to be elevated without radiographic evidence of pancreatitis. The intussusception was endoscopically reduced by pulling the polyp back into the stomach using a through-the-scope 15-mm controlled radial expansion (CRE) balloon inflated beyond the lead point. Because of the high likelihood of recurrence, we attempted endoscopic resection of the polyp. Due to the broad-base and size of the lesion, we were only able to complete partial resection. We used an endoloop prior to resecting each of multiple pieces with a hot snare. The polyp was reduced in size by greater than 50% with the longest protruding piece being less than 3 cm in length. The patient has had no recurrence of symptoms or intussusception for over 6 months. Discussion: There are few documented cases of gastroduodenal intussusception in adults. We present a unique case of intermittent gastroduodenal intussusception and biochemical pancreatitis due to a large gastric polyp that was managed endoscopically with complete resolution of symptoms. To our knowledge, this is the first reported case of a large hyperplastic gastric polyp causing gastroduodenal intussusception and biochemical pancreatitis treated with endoscopic management alone.

Ultrastructural alterations in field carcinogenesis measured by enhanced backscattering spectroscopy.

Optical characterization of biological tissue in field carcinogenesis offers a method with which to study the mechanisms behind early cancer development and the potential to perform clinical diagnosis. Previously, low-coherence enhanced backscattering spectroscopy (LEBS) has demonstrated the ability to discriminate between normal and diseased organs based on measurements of histologically normal-appearing tissue in the field of colorectal (CRC) and pancreatic (PC) cancers. Here, we implement the more comprehensive enhanced backscattering (EBS) spectroscopy to better understand the structural and optical changes which lead to the previous findings. EBS provides high-resolution measurement of the spatial reflectance profile P(rs) between 30 microns and 2.7 mm, where information about nanoscale mass density fluctuations in the mucosa can be quantified. A demonstration of the length-scales at which P(rs) is optimally altered in CRC and PC field carcinogenesis is given and subsequently these changes are related to the tissue's structural composition. Three main conclusions are made. First, the most significant changes in P(rs) occur at short length-scales corresponding to the superficial mucosal layer. Second, these changes are predominantly attributable to a reduction in the presence of subdiffractional structures. Third, similar trends are seen for both cancer types, suggesting a common progression of structural alterations in each.

Mixed adenoneuroendocrine carcinoma (MANEC) of the esophagogastric junction predominantly consisting of poorly differentiated neuroendocrine carcinoma

A 68-year-old man presented with a rapidly growing mass at the esophagogastric junction. The tumor was initially biopsied and diagnosed as well-differentiated Barrett’s carcinoma. Subsequently the tumor was resected with endoscopic submucosal dissection (● Fig.1). On histopathological examination, the tumor showed two distinct components with abrupt transition (● Fig.2). The part of the tumor in the superficial mucosal layer was a well-differentiated adenocarcinoma, resembling common Barrett’s carcinoma. The underlying component consisted of a poorly differentiated small round blue cell tumor that made up about 80% of the entire tumor mass. On immunohistochemistry this component was strikingly positive for synaptophysin and showed a Ki67 proliferation rate of >95%, which confirmed it as poorly differentiated neuroendocrine carcinoma. Within the adenocarcinoma, only a scattering of synaptophysin-positive cells were visible. The results for CK7were exactly the opposite as the adenocarcinoma was strongly positive for it and the neuroendocrine carcinoma almost negative (● Fig.3), with the neuroendocrine carcinoma infiltrating at least the lower third of the submucosal layer (sm3) and reaching the basal resection margin. Therefore, according to the current World Health Organization (WHO) criteria the final pathological diagnosiswaspoorly differentiatedmixed adenoneuroendocrine carcinoma (MANEC) of the esophagogastric junction. MANECs are exceedingly rare, because of which there are no recommended therapeutic strategies; however, according to WHO, surgery is the treatment of choice [1]. These tumors often occur, as in our case, in association with Barrett’s carcinoma, but combinations with squamous cell carcinoma have also been reported [2,3]. It is believed that MANECs have a slightly better prognosis than pure neuroendocrine carcinomas in the same location, but which unfortunately is very poor (<6 months overall survival rate [4]). In conclusion, clinicians should have a high index of suspicion for MANEC in cases with a diagnosis of Barrett’s carcinoma when a rapidly growing tumor is reported.

Evaluation of microvascular density in Barrett's associated neoplasia

Angiogenesis has an important role in the carcinogenesis of esophageal adenocarcinoma, however, the diagnostic and prognostic utility of microvascular density counts have not been clinically established. The aim of this study is to assess the correlation between microvascular density and disease progression of non-dysplastic Barrett's esophagus, low-grade dysplasia, high-grade dysplasia and invasive carcinoma in the superficial aspects of the tissue. Archival histological specimens from two referral centers for Barrett's esophagus and esophageal cancer were selected for review. A total of 160 regions marked according to histological grade were assessed with digitally interactive software to measure microvascular density. This was quantified in three levels: 0–50, 50–100 and 100–150 μm. In the areas of gastric cardia, Barrett's esophagus, low-grade dysplasia, high-grade dysplasia and cancer, microvascular density was significantly different (P<0.0001) among the five groups in the most superficial 150 μm of the mucosa. Furthermore, when examining the pairwise difference between the groups, there was a significant difference between cancer and each of the lower grades of histology (P<0.05) and between high-grade dysplasia and each of the lower grades of histology (P<0.05). These statistically significant differences were preserved in examining the depth at the most superficial 50 μm. We have used digital pathology to demonstrate a significant and stepwise increase in microvascular density, which supports the hypothesis that angiogenesis has a key role in Barrett's carcinogenesis. Furthermore, the differences in the most superficial mucosal layers are consistent with findings of increased vascularity by depth-restricted imaging modalities.

Human Calmodulin-Like Protein CALML3: A Novel Marker for Normal Oral Squamous Mucosa That Is Downregulated in Malignant Transformation

Oral cancer is often diagnosed only at advanced stages due to a lack of reliable disease markers. The purpose of this study was to determine if the epithelial-specific human calmodulin-like protein (CALML3) could be used as marker for the various phases of oral tumor progression. Immunohistochemical analysis using an affinity-purified CALML3 antibody was performed on biopsy-confirmed oral tissue samples representing these phases. A total of 90 tissue specimens were derived from 52 patients. Each specimen was analyzed in the superficial and basal mucosal cell layers for overall staining and staining of cellular subcompartments. CALML3 was strongly expressed in benign oral mucosal cells with downregulation of expression as squamous cells progress to invasive carcinoma. Based on the Cochran-Armitage test for trend, expression in the nucleus and at the cytoplasmic membrane significantly decreased with increasing disease severity. Chi-square test showed that benign tissue specimens had significantly more expression compared to dysplasia/CIS and invasive specimens. Dysplasia/CIS tissue had significantly more expression than invasive tissue. We conclude that CALML3 is expressed in benign oral mucosal cells with a statistically significant trend in downregulation as tumorigenesis occurs. CALML3 may thus be a sensitive new marker for oral cancer screening.

Improving risk stratification in superficial (T1) gastroesophageal adenocarcinoma: Association of the intestinal phenotype (MUC2 positive) with prognosis.

33 Background: An increasing proportion of esophageal and gastroesophageal junction adenocarcinomas (EAC) are limited to the superficial mucosal layer (stage classification T1) at the time of diagnosis. Intramucosal lesions (stage classification T1a) are increasingly managed with endoscopic resection due to their relatively low risk of nodal metastasis and favorable prognosis compared to those with submucosal invasion (stage classification T1b). At esophagectomy, however, the majority of T1b EAC are node-negative; conversely, a small proportion of T1a EAC will have nodal metastasis at esophagectomy and/or develop recurrent disease. Additional prognostication tools, such as tumor biomarker panels, are needed to optimize treatment algorithms. Known to carry prognostic significance in other tumors, we evaluated mucin protein expression to determine whether the mucin phenotype in early EAC was associated with survival outcomes. Methods: We classified 141 induction naive, resected, T1 EAC as intestinal-, gastric- or ductal-type depending on the expression pattern of gastrointestinal mucins (MUC2, MUC5AC, MUC6 and MUC1) determined by immunohistochemistry (IHC) on tissue microarrays. CDX2 expression was assessed by IHC and EGFR amplification was assessed by in situ hybridization. The association between survival and mucin subtypes was determined in univariate and multivariate analyses. Results: The intestinal phenotype (MUC2+) is associated with poor prognosis in T1b (HR 2.1, 95%CI 1.1-4.0) and node negative T1 EAC (HR 2.5, 95%CI 1.1-5.7) after adjusting for other significant prognostic factors. Intestinal type EAC also showed accelerated time to first recurrence in these subgroups. The colloid histologic subtype and CDX2 expression were positively associated with MUC2 expression, but EGFR amplification was not. Conclusions: The mucin phenotype may serve as a useful adjunct to conventional risk assessment for optimizing therapy for potentially resectable, superficial EAC.