Introduction

Accurate endoscopic diagnosis of colorectal polyps is essential for determining appropriate treatment strategies. The Japan NBI Expert Team (JNET) classification and pit pattern diagnosis are used for diagnosis, but their comparative diagnostic performance in real-world clinical settings remains unclear, particularly between experts and non-experts.

Aims & Methods

This post-hoc analysis aimed to evaluate the diagnostic accuracy of both classification across different levels of expertise using data from a prospective multicenter trial. We conducted a post-hoc analysis of the deTXIon trial¹ , a randomized controlled trial conducted at eight Japanese institutions between March and October 2023. From the per-protocol set, we analyzed colorectal lesions that had both JNET classification and pit pattern diagnosis with confirmed histopathology. JNET classification categorizes lesions into Type 1 (corresponding to hyperplastic polyps [HPs] and sessile serrated lesions [SSLs]), Type 2A (low-grade adenomas), Type 2B (high-grade adenomas or superficial submucosal invasive cancer), and Type 3 (deep submucosal invasive cancer). Pit pattern classification included Type II ( HPs/SSLs ), Type III_S/III_L/IV (low-grade adenomas), Type V_I low-grade (high-grade adenoma), and Type V_I high-grade/V_N (submucosal invasive cancer). We calculated sensitivity (Sen), specificity (Spe), positive predictive value (PPV), and negative predictive value (NPV) for each classification stratified by endoscopist expertise and lesion size.

Results

A total of 1,617 colorectal lesions with a median size (IQR) of 2(1-4) mm were included in this analysis. Histopathological examination revealed that 71.5% (1,156/1,617) were low-grade adenomas, 1.0% (16/1,617) were high-grade adenomas or cancer, 19.3% were HPs (312/1,617), and 8.2% (133/1,617) were SSLs. For JNET Type 1 lesions, diagnostic accuracy was comparable between experts (Sen: 82.8%, Spe: 95.9%, PPV: 88.3%, NPV: 93.7%) and non-experts (Sen: 81.7%, Spe: 93.4%, PPV: 83.1%, NPV: 92.8%). Similarly, for JNET Type 2A, both groups showed high diagnostic performance (experts: Sen 93.8%, Spe 81.0%, PPV: 92.6%, NPV: 83.8%; non-experts: Sen 91.5%, Spe 78.3%, PPV: 90.3%, NPV: 80.6%).
In contrast, pit pattern diagnosis experts showed higher performances, particularly for Type II (experts: Sen 80.9%, Spe 96.3%, PPV: 89.0%, NPV: 93.1%; non-experts: Sen 57.9%, Spe 92.8%, PPV: 76.0%, NPV: 84.8%). The diagnostic performance for small lesions (≤5mm) was consistently high with JNET classification (Type 1: Sen 79.5%, Spe 94.3%; Type 2A: Sen 93.7%, Spe 79.2%), while pit pattern diagnosis showed lower performance (Type II: Sen 70.8%, Spe 94.5%; Type III_S/III_L/IV: Sen 93.6%, Spe 79.5%), for these lesions among non-experts.

Conclusion

JNET classification demonstrates comparable diagnostic performance between expert and non-expert endoscopists, likely due to its standardized and intuitive visual criteria. Pit pattern diagnosis shows experience-dependent performance differences, suggesting that NBI-based assessment may be more suitable for routine clinical practice, especially for diminutive lesions.

References

1. Toyoshima N, Mizuguchi Y, Takamaru H,et al. The Efficacy of Texture and Color Enhancement Imaging Observation in the Detection of Colorectal Lesions: A Multicenter, Randomized Controlled Trial (deTXIon Study). Gastroenterology. 2025 in press

Disclosure

These authors disclose the following: Yutaka Saito, Masashi Misawa, Shin-ei Kudo, and Toshio Uraoka have received lecture fees from Olympus
Corporation. The remaining authors disclose no conflicts.

Introduction

Colorectal cancer is one of the most prevalent cancers with an estimated 1.8 million newly developed cases and 0.9 million cancer-related deaths in 2020.Resection of adenomatous polyps decreases the incidence and mortality of colorectal cancer. Narrow-band imaging (NBI) and linked color imaging (LCI) are the most predominantly conducted image-enhanced endoscopy using short-wavelength light but their usefulness in screening and surveillance colonoscopy remains controversial.

Aims & Methods

Our aim in this study was to investigate the superiority of LCI over NBI for ADR.
This is an open-label, two-arm, parallel, 1:1, multicenter, randomized, controlled, right-sided colonoscopy study and included patients who underwent colonoscopy at six endoscopy centers in Japan from November 2020 through November 2023. The patients were randomly assigned to undergo a proximal-sided colonoscopy (cecum and ascending colon) with LCI or 2G-NBI followed by WLI. The primary outcome included the ADR and secondary outcomes involved polyp detection rate (PDR), polyp miss rate, and adenoma miss rate. This study was registered on November 4, 2020, in the Japan Registry of Clinical Trials (jRCT1012200007).

Results

During the study period, 1,655 patients were randomly assigned to the LCI group (828 patients, primary LCI followed by secondary WLI) and the 2G-NBI group (827 patients, primary 2G-NBI followed by secondary WLI), and 776 patients in the LCI group and 752 patients in the 2G-NBI groups were finally analyzed. The ADRs were 26.7% and 23.4% and the PDRs were 32.6% and 28.9% in primary LCI and 2G-NBI, respectively, with no statistically significant differences in ADR and PDR between groups (P = 0.14 and P = 0.12). However, multivariate regression analysis revealed primary LCI observation as an independent predictor for reducing PDR in the secondary WLI (Odds ratio [OR]: 0.72, 95% confidence interval [CI]: 0.53−0.97, P = 0.029). Moreover, polyp analysis demonstrated that miss rates of adenomas and polyps were significantly lower in the LCI group than in the NBI group (OR: 0.54, 95% CI: 0.39−0.76 in adenoma; OR: 0.59, 95% CI: 0.44−0.78 in polyp).

Conclusion

LCI is not superior to 2G-NBI in ADR and PDR in a clinical right-sided colonoscopy setting. However, LCI significantly reduced miss rates of adenomas and polyps.

Disclosure

Naohisa Yoshida has received lecture and/or consulting fees from Fujifilm and Olympus; Shoko Ono has received lecture and/or consulting fees from Fujifilm and Olympus; Momoko Tsuda has received lecture and/or consulting fees from Fujifilm; Nobuaki Yagi have received lecture and/or consulting fees from Fujifilm and Olympus; Mototsugu Kato has received lecture and/or consulting fees from Fujifilm. The remaining authors disclose no conflicts.

Introduction

There is a widespread agreement that age is a significant predictor of impaired response to nutritional support. For the same amount of protein and energy provided, the increase in weight and fat-free mass is significantly lower in older persons. This is generally attributed to anabolic resistance, and impaired absorption is usually considered non-existent/irrelevant. Nevertheless, in older rats gradual changes of the intestinal mucosa were observed, including reductions in villus height/width and density, which reduce absorption. Despite this, the aging influence on human intestinal mucosa is a matter of debate, and the lack of knowledge is partially explained by the exclusion criteria of older patients from most research protocols.

Aims & Methods

We aimed to evaluate potential histological and ultrastructural changes associated with aging that may reflect reduced absorption in older people.
The present single-center study is observational and prospective. Younger (18-45 years) and older (≥70 years) adults referred for upper endoscopy for reasons unrelated with intestinal alterations were included and underwent duodenal biopsies. Those biopsies were analyzed for histological, histomorphometric and ultrastructural changes. Histologic analysis was performed using optical microscopy with hematoxylin–eosin staining observed by two pathologists, including one expert gastrointestinal pathologist. All samples were analyzed for the presence of mucosal atrophy according to the adapted Marsh–Oberhuber classification and histomorphometric evaluation of duodenal villi length in micrometers, with at least two villi being measured through the use of an automatic scale. For transmission electron microscopy, duodenal fragments were fixed in 3% glutaraldehyde in cacodylate buffer (0.1 M, pH 7.4) overnight at 4 °C. The fixed fragments were rinsed and post-fixed in 1.0% osmium tetroxide for 1 h in the same buffer and dehydrated in graded ethanol passages. The fragments were embedded in a mixture of Epon and Araldite after two 15-min passages in propylene oxide. Thin sections, cut on a ultramicrotome with a diamond knife, were stained on the grid with uranyl acetate and lead citrate and examined with a electron microscope.

Results

A total of 84 patients were included (38 men/46 women), 33 with 18-45 years and 50 with ≥70 years. There were no duodenal endoscopic or microscopic changes apart from mucosal atrophy that was evident in one older adult. The median villi length was 0.35 mm (0.23-0.43 mm) in older persons, lower than in younger adults (0.65 mm; 0.37-0.79 mm) (p<0.01). On ultrastructural evaluation, the enterocytes of older group showed several changes suggesting compromise of the normal cell physiology. These changes were not observed in younger adults, who displayed normal cell architecture with regular microvilli structure and normal organelles.

Conclusion

Aging is associated with histological, histomorphometric and ultrastructural changes in the intestinal mucosa that can be linked with reduced absorptive capacity. Besides anabolic resistance, this could be a reason for the reduced response to nutritional support found in older citizens.

References

1. Soenen S, Rayner CK, Jones KL, et al. The ageing gastrointestinal tract. Curr Opin Clin Nutr Metab Care. 2016 Jan;19(1):12-8.
2. Patel BA, Patel N, Fidalgo S, et al. Impaired colonic motility and reduction in tachykinin signalling in the aged mouse. Exp Gerontol 2014; 53:24 – 30.
3. Saffrey MJ. Aging of the mammalian gastrointestinal tract: a complex organ system. Age 2014; 36:9603.
4. Ren WY, Wu KF, Li X, et al. Age-related changes in small intestinal mucosa epithelium architecture and epithelial tight junction in rat models. Aging Clin Exp Res 2014; 26:183 – 191.
5. Thomson AB. Small intestinal disorders in the elderly. Best Pract Res Clin Gastroenterol. 2009;23(6):861-74.
6. Nalapareddy K, Zheng Y, Geiger H. Aging of intestinal stem cells. Stem Cell Reports. 2022 Apr 12;17(4):734-740.

Introduction

Hepatocellular carcinoma (HCC) is the sixth most common malignancy and the third leading cause of cancer-related deaths globally, with increasing incidence and mortality rates. Most patients are diagnosed at advanced stages, missing the opportunity for radical treatment. Sorafenib, a tyrosine kinase inhibitor, is the first-line treatment for advanced HCC; however, drug resistance typically develops within 6 months. Therefore, elucidating the mechanisms of sorafenib resistance and identifying new therapeutic targets are of significant importance. Our study focuses on the role and mechanism of Ribonucleotide Reductase M2 (RRM2) in sorafenib resistance in HCC.

Aims & Methods

The primary objective of this study is to investigate the role of RRM2 in sorafenib resistance in HCC and explore its underlying mechanisms. We aim to clarify whether RRM2 regulates aerobic glycolysis via the HIF-1α/HK2 pathway, thereby affecting sorafenib sensitivity. Our methods include:

• Analyzing RRM2 expression in HCC tissues and its correlation with clinical outcomes, such as disease-free survival (DFS) and overall survival (OS).
• Establishing sorafenib-resistant HCC cell lines (LM3-SR and SMMC7721-SR) and manipulating RRM2 expression using lentiviral vectors for knockdown and overexpression.
• Conducting in vitro experiments to assess the effects of RRM2 on cell proliferation, apoptosis, glycolysis, and sorafenib sensitivity using assays such as CCK8, flow cytometry, and Seahorse analysis.
• Performing in vivo studies using a nude mouse xenograft model to evaluate the impact of RRM2 knockdown on tumor growth and sorafenib efficacy.
• Utilizing RNA-seq, Western blot, PCR, and other techniques to investigate the molecular mechanisms, including the potential regulation of HIF-1α and HK2 by RRM2.

Results

• Clinical Correlation: RRM2 expression was significantly higher in HCC tissues compared to adjacent normal tissues. Higher RRM2 levels were associated with shorter DFS and OS in HCC patients.
• In Vitro Findings: RRM2 knockdown in sorafenib-resistant HCC cells (LM3-SR and SMMC7721-SR) increased sensitivity to sorafenib, as evidenced by reduced cell viability and increased apoptosis. Additionally, RRM2 knockdown decreased glycolysis, as indicated by reduced lactate production and glucose uptake. Conversely, RRM2 overexpression in HCC cells promoted resistance to sorafenib and enhanced glycolysis.
• Molecular Mechanisms: RRM2 regulated the expression of glycolytic enzymes, particularly HK2, through the HIF-1α pathway. Knockdown of RRM2 reduced HIF-1α and HK2 expression, while overexpression of HIF-1α or HK2 could reverse the effects of RRM2 knockdown on glycolysis and sorafenib sensitivity.
• In Vivo Validation: In a nude mouse xenograft model, RRM2 knockdown enhanced the inhibitory effects of sorafenib on tumor growth, as demonstrated by reduced tumor volume and increased apoptosis.

Conclusion

Our study demonstrates that RRM2 plays a crucial role in sorafenib resistance in HCC by regulating aerobic glycolysis via the HIF-1α/HK2 pathway. Targeting RRM2 or its downstream pathways may represent a promising strategy to overcome sorafenib resistance and improve therapeutic outcomes in HCC patients. Future work will focus on further elucidating the molecular mechanisms and exploring the potential clinical applications of RRM2 as a therapeutic target.

Disclosure

The authors declare that they have no conflict of interest.