Background Endoscopic resection (ER) has been accepted as minimally invasive treatment in patients with early gastric cancer (EGC) who have a negligible risk of lymph node metastasis. It has already ...been determined which lesions in differentiated-type EGC present a negligible risk of lymph node metastasis, and ER is being performed for these lesions. In contrast, no consensus has been reached on which lesions in undifferentiated-type (UD-type) EGC present a negligible risk for lymph node metastasis, nor have indications for ER for UD-type EGC been established. Methods We investigated 3843 patients who had undergone gastrectomy with lymph node dissection for solitary UD-type EGC at the Cancer Institute Hospital, Tokyo, and the National Cancer Center Hospital, Tokyo. Seven clinicopathological factors were assessed for their possible association with lymph node metastasis. Results Of the 3843 patients, 2163 (56.3%) had intramucosal cancers and 1680 (43.7%) had submucosal invasive cancers. Only 105 (4.9%) intramucosal cancers compared with 399 (23.8%) submucosal invasive cancers were associated with lymph node metastases. By multivariate analysis, tumor size 21 mm or more, lymphatic-vascular capillary involvement, and submucosal penetration were independent risk factors for lymph node metastasis (P < 0.001, respectively). None of the 310 intramucosal cancers 20 mm or less in size without lymphatic- vascular capillary involvement and ulcerative findings was associated with lymph node metastases (95% confidence interval, 0-0.96%). Conclusion UD-type intramucosal EGC 20 mm or less in size without lymphatic-vascular capillary involvement and ulcerative findings presents a negligible risk of lymph node metastasis. We propose that in this circumstance ER could be considered.
Helicobacter pylori (H. pylori) leads to chronic gastritis and eventually causes gastric cancer. The prevalence of H. pylori infection is gradually decreasing with improvement of living conditions ...and eradication therapy. However, some reports have described cases of H. pylori‐negative gastric cancers (HpNGC), and the prevalence was 0.42–5.4% of all gastric cancers. Diagnostic criteria of HpNGC vary among the different reports; thus, they have not yet been definitively established. We recommend negative findings in two or more methods that include endoscopic or pathological findings or serum pepsinogen test, and negative urease breath test or serum immunoglobulin G test and no eradication history the minimum criteria for diagnosis of HpNGC. The etiology of gastric cancers, excluding H. pylori infection, is known to be associated with several factors including lifestyle, viral infection, autoimmune disorder and germline mutations, but the main causal factor of HpNGC is still unclear. Regarding the characteristics of HpNGC, the undifferentiated type (UD‐type) is more frequent than the differentiated type (D‐type). The UD‐type is mainly signet ring‐cell carcinoma that presents as a discolored lesion in the lower or middle part of the stomach in relatively young patients. The gross type is flat or depressed. The D‐type is mainly gastric adenocarcinoma of the fundic gland type that presents as a submucosal tumor‐like or flat or depressed lesion in the middle and upper part of the stomach in relatively older patients. Early detection of HpNGC enables minimally invasive treatment which preserves the patient's quality of life. Endoscopists should fully understand the characteristics and endoscopic findings of HpNGC.
Background
Totally laparoscopic gastrectomy (TLG), which involves a complete intracorporeal gastric transection and the creation of an anastomosis, has been gradually adopted. However, a potential ...limitation of intracorporeal transection is the lack of tactile feedback, and whether this limitation influences oncological outcomes is unclear. The aim of this study is to evaluate the short- and long-term oncological safety of TLG using endoscopy-guided intracorporeal gastric transection for clinical stage (cStage) I gastric cancer.
Methods
A total of 1875 consecutive patients who underwent laparoscopic gastrectomy for cStage I gastric cancer between January 2007 and March 2015 were enrolled in this study. Marking clips were preoperatively placed and a transection line was determined by perceiving it tactually in laparoscopy-assisted gastrectomy (LAG) or endoscopically in TLG. After propensity score matching, 1366 patients (683 each for LAG and TLG groups) were selected to primarily test the non-inferiority of TLG to that of LAG for relapse-free survival (RFS).
Results
In the propensity-matched population, the 5-year RFS rates of the LAG and TLG groups were 94.3% (95% confidence interval (CI) 92.2–95.8%), and 95.6% (95% CI 93.8–96.9%), respectively. The hazard ratio (TLG/LAG) was 0.77 (95% CI 0.48–1.24,
P
for non-inferiority < 0.01). There were no significant differences in the recurrence profiles. The incidence of the remnant of marking clips or tumor tissue did not differ (LAG: 1.0% vs. TLG: 1.9%,
P
= 0.177).
Conclusions
TLG using preoperative markings and intraoperative endoscopic guidance provides cStage I gastric cancer patients with comparable oncological outcomes to the conventional method.
Background
Based on Japanese guidelines for endoscopic submucosal dissection (ESD) in undifferentiated-type early gastric cancer (UD-EGC), UD-predominant mixed-type (M-UD) EGC is considered high risk ...for lymph node metastasis (LNM). However, differences in LNM risk between pure UD (P-UD) and M-UD remain unclear. This study assessed risk factors for LNM considering differences between P-UD and M-UD and identified pathological features related to the lowest LNM risk.
Methods
This single-center, retrospective study included 1425 patients with UD-EGC treated with surgical resection between April 2005 and May 2017. We divided patients into those with and without LNM and compared background characteristics and post-operative pathological results between groups. Patients were further stratified based on depth, tumor diameter, ulcerative findings, lymphatic invasion, vascular invasion, and histological type to clarify post-operative pathological features associated with the lowest LNM risk.
Results
When comparing background characteristics and post-operative pathological results, multivariate analysis showed that, in patients with LNM, tumor diameters were significantly larger, and there were higher rates of submucosal invasion, lymphatic invasion, and M-UD histological type. In patients with absence of ulcerative findings, absence of lymphatic invasion, and absence of vascular invasion, no LNM occurred among those with intramucosal P-UD tumor diameters of 1–40 mm (1–20 mm: 95% confidence interval CI, 0–5.5%; 21–40 mm: 95% CI, 0–6.1%).
Conclusions
Intramucosal P-UD EGC patients with absence of ulcerative findings, absence of lymphatic invasion, absence of vascular invasion, and tumor diameters of ≤ 40 mm did not show LNM. We suggest expanding indications for ESD to include these patients.
Epstein‐Barr virus‐positive gastric cancer (EBVGC) comprises approximately 9% of all gastric cancers and is associated with a low prevalence of lymph node metastasis (LNM). Given that limited data ...concerning LNM in EBV‐related early GC are available, EBV status is not considered an indicator for endoscopic submucosal dissection (ESD). In this review, we focused on pT1 EBVGC and on gastric carcinoma with lymphoid stroma (GCLS), and discuss expanded ESD indications and curative resection criteria. In pT1b EBVGC, the incidence of LNM was low (6/180 patients, 3.3%; 95% confidence interval CI 1.2–7.1), especially in lymphovascular invasion‐negative EBVGC (1/109 patients, 0.9%). No patients with pT1a EBVGC had LNM (0/38 patients, 0%; 95% CI 0–7.6), even those who did not meet the current curative ESD criteria. Although the frequency of LNM in GCLS was low (5.0–10.6%), the incidence of LNM in non‐EBV GCLS was relatively high (10.0–20.0%); therefore, EBV status can be considered a more important factor than GCLS. In summary, the clinicopathological characteristics of EBVGC differ from those of conventional GC, and EBV negativity is a risk factor for LNM in early GC. Therefore, patients in this group are likely to be promising candidates for ESD, and we recommend that EBV status evaluation be included in early GC treatment guidelines.
Since the indications for endoscopic submucosal dissection have been expanded to include undifferentiated-type early gastric cancers, improvements in preoperative diagnostic ability have been an area ...of research. There are also concerns about the impact on the diagnosis of Helicobacter pylori infection. Based on our previous studies, in undifferentiated-type early gastric cancers, magnifying endoscopy with narrow-band imaging is useful for delineating the demarcation regardless of the tumor size. Additionally, inflammatory cell infiltration appears to be a cause of misdiagnosis, suggesting that the resolution of inflammation could contribute to the accurate diagnosis of demarcations. As such, the accuracy of demarcation in eradicated and uninfected cases is higher than that in non-eradicated cases. The common features of the endoscopic findings were discoloration under white-light imaging and a predominance of sites in the lower and middle regions. The uninfected group was characterized by smaller tumor size, flat type, more extended intervening parts in magnifying endoscopy with narrow-band imaging, and pure signet ring cell carcinoma. In contrast, the eradication and non-eradication groups were characterized by larger tumor size, depressed type, and wavy microvessels in magnifying endoscopy with narrow-band imaging. In this comprehensive review, as described above, we discuss the diagnosis of demarcation of undifferentiated-type early gastric cancers, undifferentiated-type early gastric cancers that developed following H. pylori eradication, and H. pylori-uninfected undifferentiatedtype early gastric cancers, with a focus on studies with self-examination and endoscopic findings and describe the future direction. (Gut Liver 2024;18:209-217)
Endoscopic resection (ER) of superficial adenocarcinoma of the esophagogastric junction (AEGJ) has been shown to be safe and effective. However, long-term data in patients undergoing ER for ...superficial AEGJ in Japan are still limited. The aim of this study was to determine the effect of ER on survival and occurrence of metachronous cancer of patients with superficial AEGJ.
A retrospective analysis of patients who underwent or endoscopic submucosal dissection (ESD) for superficial AEJG in 13 centers in Japan was performed. The patients were classified as either low risk or high risk for lymph node metastasis based on histologic features. The incidence of metachronous AEGJ as well as overall survival and disease-specific survival rates were calculated.
A total of 372 patients who underwent ER were included, in which 277 patients were low risk and 95 high risk for lymph node metastasis. Five-year cumulative incidences of local recurrence were 13% and .5% in the EMR and ESD groups, respectively (P < .01). Six AEGJ deaths were observed in the high-risk group and none in the low-risk group. The 5-year overall survival rates in the low-risk group without additional treatment, the high-risk group with additional treatment, and the high-risk group without additional treatment were 93.9%, 77.7%, and 81.6%, respectively. The 5-year disease-specific survival rates in the 3 groups were 100%, 94.4%, and 92.8%, respectively. The 5-year cumulative incidence of metachronous AEGJ in 316 patients without additional treatment was 1.1%.
Favorable long-term outcomes with ER were observed in patients with AEGJ who met the low-risk criteria for lymph node metastasis. ESD was a reasonable and effective treatment in Japanese patients.
Diagnosis using artificial intelligence (AI) with deep learning could be useful in endoscopic examinations. We investigated the ability of AI to detect superficial esophageal squamous cell carcinoma ...(ESCC) from esophagogastroduodenoscopy (EGD) videos. We retrospectively collected 8428 EGD images of esophageal cancer to develop a convolutional neural network through deep learning. We evaluated the detection accuracy of the AI diagnosing system compared with that of 18 endoscopists. We used 144 EGD videos for the two validation sets. First, we used 64 EGD observation videos of ESCCs using both white light imaging (WLI) and narrow-band imaging (NBI). We then evaluated the system using 80 EGD videos from 40 patients (20 with superficial ESCC and 20 with non-ESCC). In the first set, the AI system correctly diagnosed 100% ESCCs. In the second set, it correctly detected 85% (17/20) ESCCs. Of these, 75% (15/20) and 55% (11/22) were detected by WLI and NBI, respectively, and the positive predictive value was 36.7%. The endoscopists correctly detected 45% (25-70%) ESCCs. With AI real-time assistance, the sensitivities of the endoscopists were significantly improved without AI assistance (p < 0.05). AI can detect superficial ESCCs from EGD videos with high sensitivity and the sensitivity of the endoscopist was improved with AI real-time support.
In Japan, preoperatively diagnosed T1a-muscularis mucosae or T1b-submucosa 1 (MM/SM1) esophageal squamous cell carcinoma (ESCC) is a relative indication for endoscopic resection (ER). We evaluated ...long-term outcomes in patients after ER for non-circumferential ESCC with a preoperative diagnosis of MM/SM1 invasion. We retrospectively reviewed 66 patients with a preoperative diagnosis of non-circumferential MM/SM1 ESCC endoscopically resected between 2010 and 2015. Patients were divided into low- (adequate follow-up) and high-risk (requiring additional treatment) groups for lymph node metastasis according to risk factors (submucosal invasion, lymphovascular invasion, or droplet infiltration) and long-term outcomes were analyzed. Pathological invasion to T1a-lamina propria mucosa, MM/SM1, and T1b-SM2 was seen in 22, 38, and 6 lesions, respectively. Overall, 71.2% patients were classified into the "adequate follow-up" group. Of these, only one patient had a lymph node recurrence, which was successfully treated by additional therapy. The remaining 28.8% patients were classified into the "requiring additional treatment" group, where no recurrences were observed after additional treatments. After a median follow-up of 58.6 months, no deaths happened due to ESCC. The 3- and 5-year overall survival rates were 93.6% and 88.7%, respectively. ER is a valid initial treatment for non-circumferential ESCC with preoperatively diagnosed MM/SM1 invasion.
Objectives
The prognosis for pharyngeal cancer is relatively poor. It is usually diagnosed in an advanced stage. Although the recent development of narrow‐band imaging (NBI) and increased awareness ...among endoscopists have enabled detection of superficial pharyngeal cancer, these techniques are still not prevalent worldwide. Nevertheless, artificial intelligence (AI)‐based deep learning has led to significant advancements in various medical fields. Here, we demonstrate the diagnostic ability of AI‐based detection of pharyngeal cancer from endoscopic images in esophagogastroduodenoscopy.
Methods
We retrospectively collected 5403 training images of pharyngeal cancer from 202 superficial cancers and 45 advanced cancers from the Cancer Institute Hospital, Tokyo, Japan. Using these images, we developed an AI‐based diagnostic system with convolutional neural networks. We prepared 1912 validation images from 35 patients with 40 pharyngeal cancers and 40 patients without pharyngeal cancer to evaluate our system.
Results
Our AI‐based diagnostic system correctly detected all pharyngeal cancer lesions (40/40) in the patients with cancer, including three small lesions smaller than 10 mm. For each image, the AI‐based system correctly detected pharyngeal cancers in images obtained via NBI with a sensitivity of 85.6%, much higher sensitivity than that for images obtained via white light imaging (70.1%). The novel diagnostic system took only 28 s to analyze 1912 validation images.
Conclusions
The novel AI‐based diagnostic system detected pharyngeal cancer with high sensitivity. It could facilitate early detection, thereby leading to better prognosis and quality of life for patients with pharyngeal cancers in the near future.
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