卢戈液-美蓝双重染色在早期食管癌诊断中的价值

目的 提高早期食管癌的诊断水平。方法 先用卢戈液染色，再用美蓝染色，比较2次染色后食管病灶着色及范围，大致判断浸润深度，并用超声小探头观察病灶侵犯深度，采用内镜下黏膜切除术和手术治疗。结果 10例患者共11处癌灶，卢戈液染色后9处较好地显示了病灶范围，表现为正常食管黏膜染为棕色，病灶不着色；加用美蓝染色后，11处均清楚地显示了病灶，表现为正常黏膜不染色，病灶黏膜为水蓝色，边界清晰。1例行内镜下食管黏膜切除术切除，8例手术切除。病理结果均为鳞状细胞癌，其中黏膜癌6处，黏膜下癌4处，与其对照，胃镜和超声小探头鉴别黏膜癌和黏膜下癌的准确率均为80％，两者联合的准确率为90％。结论 卢戈液-美蓝染色较单一卢戈液染色，显示早期食管癌病灶及其范围更加清楚，可较准确地判断早期癌的侵犯深度。     

Survival Benefit of Screening for Early Esophageal Carcinoma in Head and Neck Cancer Patients

Abstract: Primary cancer of the head and neck was diagnosed in 676 cases. Systematic endoscopic screening of the upper gastrointestinal tract (including iodine staining of the esophagus) was performed within 1 month of diagnosing head and neck cancer in order to determine the possible presence of a second malignancy- We divided cases in which esophageal cancer was detected into a group in which the initially diagnosed head and neck cancer had been treated curatively and those in which the treatment had been non-curative. A pathological diagnosis of primary esophageal cancer was obtained in 37 cases (5.5%). The incidence of esophageal cancer associated with cancer of the oral cavity or pharynx was significantly higher (10.9%) than in cases with an associated cancer of the larynx or paranasal sinus (1.9%, p<0.05). All but one of the 37 cases detected by screening were asymptomatic and had superficial carcinoma. Of these lesions, 19 Were mucosal carcinomas, 17 submucosal carcinomas and only one an advanced cancer. Twenty-four of these 37 cases had died. The cause of death was head and neck cancer in 17, esophageal cancer in two and other causes in five. The 5-year survival rate of cases in whom the initial head and neck cancer had been treated curatively was 46.7%. The risk of synchronous esophageal cancer associated with cancer of the head and neck is high. Early detection of esophageal cancer at the time of diagnosing cancer of the head and neck and treatment at an early stage is a new strategy for improving the long-term outcome of cases with head and neck cancers associated with esophageal cancer.     

Endoscopic mucosal resection for early esophageal cancer and esophageal dysplasia

BACKGROUND/AIMS: Advances in diagnostic technology have led to increased detection of early esophageal cancer, which is suitable for endoscopic treatment. We performed endoscopic esophageal mucosal resection of such cancer and dysplasia using the endoscopic esophageal mucosal resection tube and evaluated the clinical benefit of this technique. METHODOLOGY: Twenty-nine patients with esophageal mucosal cancer (27 cases with 33 lesions) or dysplasia (2 cases with 2 lesions) diagnosed between September 1992 and March 1998 were assessed endoscopically for the depth and extent of invasion by double staining with toluidine blue and iodine. Endoscopic ultrasonography was also performed to assess the depth of invasion in 22 cases with 22 lesions. RESULTS: The 35 esophageal lesions comprised 27 esophageal carcinomas and 8 areas of dysplasia. Twenty of the 35 lesions were resected en bloc and 15 were resected piecemeal. Subsequent surgery was performed for 5 cases with 7 lesions out of 10 cases with 15 lesions that were histopathologically diagnosed as m3 or more invasive. No recurrence has been detected in 24 evaluable cases (including 1 who died of another disease, 2 in whom surgery could not be performed due to complications, and 3 who refused subsequent surgery). No patients died of esophageal cancer after a mean follow-up period of 30.9 +/- 18.9 months. The 4-year survival rate was 100% in the m2 or less invasive group of 19 cases with 20 lesions, 75% in the m3 or higher invasive group of 5 cases with 8 lesions and 100% in the surgery group of 5 cases with 7 lesions (NS). No serious complications occurred except for 1 patient. Circumferential mucosal resection was done in this patient, resulting in esophageal stenosis, which responded to esophageal dilation. CONCLUSIONS: Esophageal mucosal resection using the endoscopic esophageal mucosal resection tube is safe and beneficial for early esophageal cancer and dysplasia.     

Metachronous squamous cell carcinoma of the esophagus arising after endoscopic mucosal resection

BACKGROUND: Endoscopic mucosal resection (EMR) is being used increasingly to treat early stage esophageal carcinoma. However, the preserved esophageal mucosa may be the source of new lesions. The aims of this study were to analyze the frequency of metachronous esophageal carcinoma after EMR and to determine whether minute iodine unstained areas often associated with squamous cell carcinoma develop into carcinoma. METHODS: Eighty-two patients with esophageal squamous cell carcinoma who underwent EMR were studied. Based on the iodine staining pattern at initial EMR, they were divided into those with uniform (group U) and scattered (group S) types of background mucosa. Patients were followed by endoscopy with iodine staining (group U: median 39 months, range 12 to 71 months; group S: median 38 months, range 14 to 68 months). RESULTS: In total, 12 (14.6%) of 82 patients were found to have metachronous esophageal carcinoma during follow-up, including 6 (37.5%) of 16 patients in group S. The cumulative proportion of metachronous carcinoma-free subjects was significantly lower in group S than group U (p = 0.0048). CONCLUSIONS: Primary esophageal carcinoma develops frequently in patients who have undergone EMR for esophageal squamous carcinoma. The high frequency of metachronous carcinoma may be attributed to field carcinogenesis. Careful long-term endoscopic observation is required for patients who undergo EMR for esophageal carcinoma, especially those with scattered-type iodine staining of the background mucosa.     

碘染色在食管癌高发区直接内镜普查中的应用和效果

目的 研究碘染色在食管癌高发区直接内镜普查中的应用和效果以及对比碘染色前后癌和异型增生的发现率。方法 在高发现场对3022例40—69岁人群进行内镜检查，观察并记录食管黏膜颜色、形态和黏膜下血管纹理，碘染色后再观察其颜色变化，并行组织括检。结果 经活检组织学诊断，并发现食管癌131例，中度和重度异型增生659例。碘染色前后发现食管癌分别为57例、111例，发现中度和重度异型增生154例、505例。统计学上差异有显著性意义。结论 内镜检查中碘染色可明显提高浅表食管癌和异型增生的发现率。     

A New Classification System for Early Carcinomas of the Esophagus

Abstract: Carcinomas of the esophagus have a higher degree of malignancy than gastric carcinomas. Likewise, the therapeutic response of esophageal cancer patients to radical surgery has been poor because a thoracotomy and/or laparotomy are required. Since the advent of the iodine staining technique for the detection of esophageal carcinoma, the diagnosis of small, thin lesions limited to the mucosa ha become endoscopically possible. Progress in diagnostic techniques has thus resulted in the detection of increasing numbers of early carcinomas. Recent advances in techniques for the endoscopic mucosectomy of early esophageal carcinomas have similarly contributed to an increasing trend towards early detection and endoscopic resection. As mucosectomy is indicated for the treatment of small, thin lesions without lymh node metastases, a new endoscopic classification system has become necessay, to insure improved diagnostic accuracy.     

内镜下碘染色用于江苏淮安地区食管疾病筛查1983例研究

目的探讨内镜下碘染色在食管癌高发区的食管早癌内镜筛查中的重要临床价值。 方法2014至2016年在江苏省淮安市清浦区武墩镇及盐河镇等对1983例40～60岁人群进行食管癌内镜筛查,对比碘染色前后食管黏膜颜色和形态的变化,并对黏膜染色异常者行活检病理检查。 结果740例患者共835处病灶接受食管组织活检,有273例于碘染色前发现(白光状态下),碘染色后再发现562例。其中碘染后新发现5例黏膜内癌,205例各种异型增生,2组比较差异有统计学意义(P<0.05),表明碘染色后食管癌及癌前病变的检出率明显高于染色前。 结论内镜下食管黏膜碘染色可明显提高筛查过程中食管癌及癌前病变的检出率,且因其价格低廉,操作简单,值得临床推广应用。     

Endoscopic diagnosis of early carcinoma of the esophagus using Lugol's solution.

Small esophageal lesions, particularly intraepithelial cancers, are extremely difficult to detect. We used Lugol's iodine solution with panendoscopic examination to detect the presence and spread of small squamous cell carcinomas of the esophagus. Serial histologic specimens of the surgically removed esophagus from 32 patients with Lugol's combined endoscopic diagnosis of early esophageal carcinoma were examined to determine the correlation between endoscopic and histologic findings. All of the early staged carcinomas clearly remained unstained by Lugol's solution. We believe that the application of Lugol's solution will greatly aid in instances when a suspicious mucosal lesion is noted, when the margin of the lesion is unclear, or when there is suspicion that a mucosal lesion may have been overlooked.     

EARLY DETECTION OF HYPOPHARYNGEAL CANCER BY NARROW‐BAND IMAGING

Twelve years ago, a presently 66‐year‐old male underwent resection of esophageal cancer. He was followed up with annual endoscopy, which in April of 2005 found and by endoscopic mucosal resection removed two small, low‐grade carcinomas of less than 10 mm from his hypopharynx. Before the development of narrow‐band imaging, such early stage cancer could not have been detected. Now, narrow‐band imaging is useful for screening high‐risk groups.     

MICROVASCULAR PATTERNS OF ESOPHAGEAL MICRO SQUAMOUS CELL CARCINOMA ON MAGNIFYING ENDOSCOPY

Background: Recently, esophageal microcancers have been frequently diagnosed and are receiving increasing attention as initial findings of cancer. We examined whether the clinicopathological features and microvascular patterns of esophageal microcancers on magnifying endoscopy are useful for diagnosis. Methods: Magnifying endoscopy was performed to examine the histopathological features of 55 esophageal cancers measuring ≤10 mm in diameter (34 small cancers, 16 microcancers, and five supermicrocancers). Results: Although some lesions were detected only on iodine staining, most were detected on conventional endoscopic examination. Most small cancers and microcancers were m1 or m2; some were m3 or sm2. Supermicrocancers were dysplasia or m1 cancer. As for the microvascular pattern, most m1 and m2 cancers showed type 3 vessels, while most submucosal cancers showed type 4 vessels. Conclusions: Microvascular patterns on magnifying endoscopy are useful for the differential diagnosis of benign and malignant esophageal cancers and for estimating the depth of tumor invasion. The shape of small lesions is often altered considerably by biopsy. Residual tumor may persist unless the basal layer of the lesion is included in biopsy specimens, even in microcancers. Consequently, endoscopic mucosal resection, without biopsy, is being performed in increasing numbers of patients with lesions suspected to be cancer on the basis of their microvascular patterns.     

Endoscopic resection of superficial esophageal squamous-cell carcinomas: Western experience

OBJECTIVES: Endoscopic resection of esophageal squamous-cell neoplasia with curative intent appears to be an alternative treatment to radical surgery when the malignant neoplasia is intraepithelial or limited to the mucosal layer, since the risk for lymph-node metastases is very low. In contrast to Japan, there has so far been only limited experience in Europe and the United States with endoscopic resection in such cases. In the present observational study, we report on the largest prospective series so far in Western countries of patients with early squamous-cell cancer or carcinoma in situ, who were treated using endoscopic resection therapy. METHODS: Between December 1997 and November 2001, 115 patients with a suspicion of early squamous cancer were referred for local endoscopic therapy. A total of 39 patients (mean age 61.4 +/- 10.2 yr) with early esophageal carcinoma (n = 29) and carcinoma in situ (Cis) (n = 10) fulfilled the criteria for local endoscopic therapy and were treated using endoscopic resection. Ten patients had Cis (group A), 19 had mucosal cancer (group B), and 10 had submucosal cancer (group C). All patients in group C were inoperable or had refused surgery. RESULTS: A total of 94 resections were performed. Nine of the 10 patients in group A (90%), 19 of the 19 in group B (100%), and 8 of the 10 in group C (80%) achieved a complete response during a mean follow-up period of 29.7 +/- 14.3 months. Tumor-related deaths occurred in three patients (one in group B, who was inoperable; two in group C, who refused surgery). No major complications such as perforation or bleeding requiring blood transfusion occurred. Minor complications were seen in six patients (15%)-three with minor bleeding after endoscopic resection and three with esophageal stenoses, who were successfully treated using injection therapy or dilatation. Calculated 5-yr survival was 90% in group A, 89% in group B, and 0% in group C. CONCLUSIONS: Endoscopic resection appears to be an effective and safe method of curative treatment in patients with Cis and mucosal squamous-cell carcinomas of the esophagus. The preferred method in patients with submucosal cancer should be esophagectomy or chemoradiotherapy, whenever possible.     

Superficial Esophageal Carcinoma: Evaluation by Endoscopic Ultrasonography

Objectives: The aim of this study was to evaluate the usefulness of endoscopic ultrasonography (EUS) in the staging of superficial esophageal carcinoma (SEC). Methods: We examined the histopathologic findings of 28 patients with SEC which was confirmed in the postoperative histologic evaluation. The EUS results preoperatively estimated were compared with them. Results: There were nine patients with mucosal carcinoma (two intraepithelial carcinomas and seven carcinomas limited to the mucosal layer) and 19 patients with submucosal carcinoma. The mucosal carcinomas revealed no lymph node metastasis or vessel permeation, whereas the submucosal carcinomas revealed lymph node metastasis (71%) and vessel permeation (lymphatic, 58%, vascular, 21%). The accuracy rates of depth of invasion by EUS were mucosa, 67% (6/9); submucosa, 79% (15/19); and total, 75% (21/28). EUS could not detect microinvasion to the submucosa. The overall accuracy rate of EUS in the evaluation of periesophagogastric lymph node metastasis was 72%: sensitivity 58% and specificity 85%. Conclusions: It has been clinically proved important to differentiate mucosal carcinoma from submucosal carcinoma in the staging of SEC, and EUS is recommended in differentiating between them.     

The utility of endoscopic screening for patients with esophageal or head and neck cancer

In a series of 378 patients with esophageal carcinoma, 43 patients with head and neck carcinoma were divided into two groups: 30 patients without symptoms whose esophageal or head and neck second primary carcinomas were incidentally detected by an endoscopic examination for the second carcinoma (group 1) and 13 patients with symptoms whose esophageal or head and neck second primary carcinomas were detected by routine examinations (group 2). Regarding the second primary carcinomas, the incidence of stage 0-I and curability were significantly higher in group 1 than in group 2 (p < 0.001 and p < 0.05 respectively). The 5-year overall survival rates of patients with the second primary carcinomas were significantly higher in group 1 (60.4%) than in group 2 (0%) (p < 0.01). We suggest that a routine endoscopic screening of the upper aerodigestive tract in patients with esophageal carcinoma or head and neck carcinoma contributes to the improvement of the prognosis and the patient's quality of life.     

Evaluation of FDG-PET imaging for the detection of gastrointestinal tract cancer in patients with suspected lung cancer]

This study evaluated 18F-FDG-PET imaging for the detection of gastrointestinal tract cancer in patients with suspected lung cancer. A total of 351 patients who had abnormal lung shadows and who underwent whole-body FDG-PET between June 1998 and January 2006 were retrospectively entered for analysis. Gastrointestinal tract cancers were subsequently found in 15 patients (4.3%) who had been found to have lung diseases consisting of 7 inflammatory changes, 6 lung cancers, and 2 metastatic lung carcinomas, 9 colon cancers, 4 gastric cancers, and 2 esophageal cancers. Five patients (2 colon cancers, 2 gastric cancers, and 1 esophageal cancer) had early stage carcinoma. In this study, FDG-PET was useful not only for the diagnosis and staging of lung cancer, but also for the detection of unexpected gastrointestinal tract cancers. FDG-PET may be most suitable for cancer screening.     

Effectiveness of endoscopic mucosal resection with submucosal saline injection technique for superficial squamous carcinomas of the esophagus

BACKGROUND: Intraepithelial cancers (m1 cancer) and cancers that penetrate the basement membrane but do not approach the muscularis mucosae (m2 cancer) do not have lymph node metastasis and thus can be removed completely with mucosal resection. Therefore, in this study, the effectiveness of endoscopic mucosal resection with submucosal saline injection for removal of superficial esophageal cancers was investigated prospectively. METHODS: Twenty-five superficial esophageal cancers in 21 patients were removed with submucosal saline injection. When it was thought that a tumor had not been completely resected en bloc, it was removed completely in piecemeal fashion. Endoscopy was repeated 1, 3, 6, 12 months or more after endoscopic resection. RESULTS: All superficial esophageal cancers were completely removed: 18 (72%) en bloc and 7 (28%) by piecemeal resection. No recurrence was found during a mean observation period of 2.0 years (range 0.8 to 3.6) after resection. Bleeding occurred in 5 cases (24%) during or after resection but was successfully treated with the endoscopic alginate or thrombin spray technique. There was no perforation. CONCLUSION: Endoscopic mucosal resection with submucosal saline injection is effective for removal of superficial cancers of the esophagus.     

Risk factors of lymph node metastasis in T1 esophageal squamous cell carcinoma

Background and Aim: To perform endoscopic mucosal resection (EMR) for T1 esophageal cancer, it is essential to estimate the lymph node status exactly. In order to evaluate the feasibility of EMR for esophageal cancers, we evaluated the clinicopathological features of T1 esophageal squamous carcinomas with an emphasis on the risk factors and distribution patterns of lymph node metastasis. Methods: From 1994 to 2006, a total of 200 patients with T1 esophageal carcinoma were treated surgically in our institution. Among them, clinicopathological features were evaluated for 197 consecutive patients with T1 squamous cell carcinoma. Results: The frequency of lymph node involvement was 6.25% (4/64) in mucosal cancers and 29.3% (39/133) in submucosal cancers (P < 0.001). In patients with M1 (n = 32) and M2 (n = 14) cancers, no lymph node metastasis was found. In multivariate analysis, size larger than 20 mm, endoscopically non‐flat type, and endo‐lymphatic invasion were significant independent risk factors for lymph node metastasis. The differentiation of tumor cell was not a risk factor for lymph node metastasis. Conclusions: We suggest that EMR may be attempted for flat superficial squamous esophageal cancers smaller than 20 mm. After EMR, careful histological examination is mandatory.     

Histologic results of EMR for esophageal lesions diagnosed as high-grade intraepithelial squamous neoplasia by endoscopic biopsy

BACKGROUND: Biopsy specimens obtained from esophageal lesions detected in endoscopic screening with iodine staining have often been diagnosed as high-grade intraepithelial squamous neoplasia (WHO 2000). However, a management strategy for such lesions has not been established. The purpose of this study was to perform EMR for such lesions and to determine the actual tumor stage in patients with complete resection and the outcomes after EMR. PATIENTS: During the study period, 51 patients were found to have esophageal lesions diagnosed as high-grade intraepithelial squamous neoplasia by using endoscopic iodine staining in biopsy specimens. All of the patients underwent EMR, and resected specimens were reviewed microscopically. RESULTS: Histologic examination of totally resected specimens revealed that 12 (23.5%) of the 51 patients had tumor invasion of the lamina propria mucosae and that 4 (7.8%) had tumor invasion of the muscularis mucosae. The remaining 35 patients (68.6%) were confirmed to have high-grade intraepithelial squamous neoplasia. The invasive focus in all of the 16 lesions of invasive squamous-cell carcinoma was surrounded by high-grade intraepithelial squamous neoplasia. After a median of 23 months of follow-up, there were two recurrences, and those patients required second EMR. CONCLUSIONS: Histologic results suggested that high-grade intraepithelial squamous neoplasia of the esophagus has characteristics of carcinoma in the preinvasive stage. EMR should be performed for esophageal lesions diagnosed by endoscopic biopsy as high-grade intraepithelial squamous neoplasia, not only because of its probable malignant potential but also because more than 30% of such lesions are actually invasive carcinoma.     

p53 and Ki-67 in Barrett's carcinoma: is there any value to predict recurrence after circumferential endoscopic mucosal resection?

BACKGROUND: There are situations in which the specimens obtained after endoscopic mucosal resection of superficial adenocarcinoma arising from Barrett's esophagus are not adequate for histopathological assessment of the margins. In these cases, immunohistochemistry might be an useful tool for predicting cancer recurrence. AIM: To evaluate the value of p53 and Ki-67 immunohistochemistry in predicting the cancer recurrence in patients with Barrett's esophagus-related cancer referred to circumferential endoscopic mucosal resection. METHODS: Mucosectomy specimens from 41 patients were analyzed. All endoscopic biopsies prior to endoscopic mucosal resection presented high-grade dysplasia and cancer was detected in 23 of them. Positive reactions were considered the intense coloration in the nuclei of at least 90% of the cells in each high-power magnification field, and immunostaining could be classified as superficial or diffuse according to the mucosal distribution of the stained nuclei. RESULTS: Endoscopic mucosal resection samples detected cancer in 21 cases. In these cases, p53 immunohistochemistry revealed a diffuse positivity for the great majority of these cancers (90.5% vs. 20%), and Ki-67 showed a diffuse pattern for all cases (100% vs. 30%); conversely, patients without cancer revealed a superficial or negative pattern for p53 (80% vs. 9.5%) and Ki-67 (70% vs. 0%). During a mean follow-up of 31.6 months, 5 (12.2%) patients developed six episodes of recurrent cancer. Endoscopic mucosal resection specimens did not show any significant difference in the p53 and Ki-67 expression for patients developing cancer after endoscopic treatment. CONCLUSIONS: p53 and Ki-67 immunohistochemistry were useful to confirm the cancer; however, they had not value for predicting the recurrent carcinoma after circumferential endoscopic mucosal resection of Barrett's carcinoma.     

Transthoracal partial resection or local excision of small esophageal carcinoma with a radical mediastinal lymphadenectomy--proposal of limited operation for postoperative quality of life

BACKGROUND/AIMS: Controversy remains regarding which treatment should be employed for superficial esophageal cancer. The treatment modalities for such superficial cancers vary from a local excision, including an endoscopic mucosal resection (EMR) to an extended radical esophagectomy (three-field lymphadenectomy). In the current report, we proposed the use of either a transthoracal partial resection or local excision of the esophagus with a radical mediastinal lymphadenectomy for the patients with small superficial esophageal squamous cell carcinoma, in order to perform effective radical cancer surgery and maintain the quality of life (QOL) of the patients. METHODOLOGY: Surgical procedures: After thoracotomy and detaching of the esophagus from the surrounding tissues, the proximal and distal resection lines were determined by careful palpation of the clips within the esophagus which had been placed during the preoperative endoscopic examination. Thereafter, a mediastinal lymph node dissection, including the bilateral recurrent nerve nodes and paratracheal nodes, was performed. After this procedure, intrathoracic esophageal end-to-end anastomosis was performed in the ordinary manner. We performed this procedure on three patients with small localized esophageal cancer. RESULTS: Operations were safely performed on these three patients and postoperative quality of life was almost satisfactory. CONCLUSIONS: Transthoracal partial resection or local excision with a radical mediastinal lymphadenectomy was useful for the patients with small localized esophageal carcinoma.