Introduction

There is no consensus on preoperative endoscopic diagnostic methods for superficial nonampullary duodenal tumor (SNADET). We previously reported that texture and color enhanced imaging (TXI) with indigocarmine (ICME-TXI) significantly improved the visibility of SNADET surface structures compared to narrow band imaging (Sci Rep 2022).

Aims & Methods

In this study, we aimed to investigate the diagnostic ability of ICME-TXI. Forty-six consecutive lesions that were endoscopically resected and pathologically neoplastic after prospective ICME-TXI observation for SNADET from March 2021 to November 2022 were included. The components of the surface structure were classified as circular, oval, or others. The presence of both heterogeneity (mixture of components or difficulty in visualization) and size difference (difference of 3 times or more in size with areas of components) were defined as significant findings. Immunohistochemical staining was performed to clarify whether tumor was gastric, intestinal or mixed type. ICME-TXI image and pathological findings were compared. In addition, the diagnostic ability of the lesions was retrospectively evaluated against the Vienna Classification (VCL) C4/5.

Results

Major morphology (Is/ Ip/ IIa/ IIc) = 8/ 2/ 32/ 4, median tumor diameter (mm) = 10 (3-40), location (bulb 9 lesions/ descending 37 lesions), CSP 15 lesions, UEMR 31 lesions, VCL C3 39 lesions, C4/5 7 lesions, gastric/ intestinal/ mixed type=2/ 36/ 8, respectively. 100% of gastric, 0% of intestinal and 37.5% of intestinal type had a circular component. 4 lesions (8.7%) had histopathological findings similar to traditional serrated adenoma (TSA) of the colon and were characterized by an oval component (all were intestinal type, VCL C3). The sensitivity/ specificity/ positive predictive value/ negative predictive value/ accuracy (%) for VCL C4/5 were 57.1/ 94.5/ 66.7/ 92.5/ 89.1.

Conclusion

ICME-TXI revealed fine surface structures, and showed specific findings for a particular histological type similar to TSA. The high specificity and negative predictive value of ICME-TXI for preoperative diagnosis suggest that ICME-TXI may be a new diagnostic modality.

References

1. Okimoto K, Matsumura T, Maruoka D et al. Magnified endoscopy with texture and color enhanced imaging with indigo carmine for superficial nonampullary duodenal tumor: a pilot study. Sci Rep 2022; 12: 10381

Introduction

In the endoscopic diagnosis of superficial nonampullary duodenal epithelial tumor (SNADET), it is not easy to differentiate carcinoma from adenoma. On the other hand, SNADETs can be classified into gastric and intestinal phenotypes of mucin phenotype, and it has been reported that carcinomas of the gastric phenotype in particular show a poor prognosis. If the mucin phenotype can be predicted only by endoscopic findings, it may be possible to estimate the biological malignancy of SNADETs. Then, the following studies were conducted, focusing on it as a new endoscopic diagnosis.

Aims & Methods

The aim of this study was to clarify the endoscopic findings of SNADET in each mucin phenotypes. Between August 2018 and April 2021, 500 cases of suspected SNADET in our hospital were prospectively entered for analysis. Finally, 401 cases with 401 lesions that were treated endoscopically and pathologically diagnosed as SNADET were included and analyzed. Two pathologists with expertise in gastrointestinal pathology performed histological diagnosis according to the Vienna Classification (VCL) and evaluation of mucin phenotypes based on the results of immunostaining for CD10, MUC2, MUC5AC, and MUC6. Each endoscopic finding was compared between gastric and intestinal phenotype, and multivariate analysis was performed using a logistic regression model.

Results

With regard to pathological evaluation, 289 (72.1%) cases were diagnosed as VCL category 3 and 112 (27.9%) cases were diagnosed as VCL category 4/5. The details of mucin phenotypes in this SNADETs were as follows: 44 pure gastric, 11 gastric predominant, 18 mixed gastrointestinal, 159 intestinal predominant, and 180 pure intestinal phenotypes, respectively, and the percentages of VCL category 4/5 were 63.6%, 54.5%, 38.9%, 30.8% and 16.1%, respectively (P < 0.01, Cochran-Armitage trend test). Compared in the two groups of gastric phenotype (pure gastric and gastric predominant) and intestinal phenotype (pure intestinal and intestinal predominant), there were significant differences in location (from the bulb to the proximal descending part (hereafter, proximal side): 82.2% vs 29.0%, P < 0.01), lesion diameter (20.0 mm vs 15.0 mm, P < 0.05), macroscopic type (Type 0-I: 60.0% vs 14.8%, P < 0.01), redness (present: 68.9% vs 32.8%, P < 0.01), surface structure (closed-loop structure (CLS): 84.4% vs 29.6%, P < 0.01), white opaque substance (WOS) (absent: 51.1% vs 11.0%, P < 0.01). In multivariate analysis, location (proximal side: OR 4.5, 95%CI 1.8-10.9), macroscopic type (Type 0-I: OR 2.5, 95%CI 1.1-5.7), surface structure (CLS: OR 5.4, 95%CI 2.1-13.8), WOS (absent: OR 2.9, 95%CI 1. 3-6.7) were independently and significantly associated with being gastric phenotype of SNADET.

Conclusion

This study showed that SNADETs with gastric and intestinal phenotypes were found to show different endoscopic findings.

Disclosure

There is no conflict of interest in this study.

Introduction

​Endocytoscopy (ECS), an ultrahigh-magnification contact-type endoscopy, enables real-time visualization of gastrointestinal mucosal and neoplastic cells. As a result, ECS enhance diagnostic precision as a form of optical biopsy. However, the reliability of ECS diagnosis is contingent upon adequate staining, which remains a considerable challenge in the stomach due to the abundance of mucus and inflammatory exudates that hinder optimal visualization. Weak vital staining can easily reduce the reliability of ECS diagnosis. Texture and Color Enhancement Imaging (TXI), a digital image enhancement modality developed by Olympus, enhances three key imaging elements—brightness, texture, and color tone—to optimize lesion visualization even under suboptimal staining conditions. Consequently, TXI may augment the diagnostic utility of ECS.

Aims & Methods

The aim of this study was to evaluate whether TXI enhances the diagnostic performance of ECS in early gastric cancer. Twenty-eight patients with 30 gastric cancers scheduled for magnifying endoscopic examination at Nippon Medical School Tama Nagayama Hospital between February 2024 and March 2025 were prospectively enrolled. All ECS procedures were performed with GIF-H290EC (Olympus Co., Tokyo, Japan) and the video processors EVIS X1 (Olympus Co., Tokyo, Japan). For in vivo dyeing, double staining with crystal violet and methylene blue was used. ECS was performed with and without TXI in both cancer and non-cancerous legions. ECS observation is performed by first taking photographs without TXI, and then taking photographs of the same area using the TXI. From each lesion, five ECS images with and without TXI were selected, resulting in a blinded and randomized image catalog (comprising 300 images from 30 gastric cancers and 280 images from 28 non-tumor areas). Two endoscopists independently assessed the images using a numerical rating scale (NRS, 0–10) to evaluate the visibility of nuclear atypia and structural cellular atypia. Diagnostic accuracy was assessed against pathological diagnosis as the gold standard. ECS diagnoses were rendered based on previously established criteria, wherein lesions exhibiting high-grade atypia were classified as cancer (Kaise M, et al. Endoscopy. 2015).

Results

The overall accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for EGC diagnosis by the two endoscopists were 82.5%, 84.3%, 80.7%, 81.3%, and 83.8%, respectively. The rate of interobserver agreement between the two endoscopists was high, with a kappa coefficient of κ = 0.797. Notably, diagnostic accuracy was significantly higher in the TXI images compared to the non-TXI images (85.2% vs. 79.0%, p = 0.0027). While the NRS scores for structural atypia did not differ significantly between the TXI and non-TXI images (4.90 vs. 4.87, p = 0.61), the NRS scores for nuclear atypia were significantly elevated in the TXI images (6.88 vs. 5.88, p < 0.0001).

Conclusion

​The integration of TXI with ECS significantly enhances the visualization of nuclear atypia and improves diagnostic accuracy in the diagnosis of gastric cancer. This synergistic approach facilitates superior optical biopsy capabilities, enhancing its clinical utility in the endoscopic diagnosis of early gastric cancer.

References

Kaise M, Ohkura Y, Iizuka T, Kimura R, Nomura K, Kuribayashi Y, et al. Endocytoscopy is a promising modality with high diagnostic accuracy for gastric cancer. Endoscopy. 2015;47:19–25.

Introduction

Balloon dilation is sometimes required to prevent stricture after esophageal endoscopic submucosal dissection (ESD), but the procedure is performed frequently and there is a risk of perforation.

Aims & Methods

In this study, we investigated whether intensive triamcinolone (TA) injection after extensive esophageal ESD can prevent stricture while avoiding balloon dilation. Thirty-one lesions in 31 patients with post ESD ulcers more than 3/4 circumference and confirmed scarring from December 2017 to February 2023 were included in this study. The total circumferential resection was defined as group A, the other group as group B, and stricture was defined as the inability to pass an endoscope of normal diameter (8.9-10.2 mm). All patients underwent TA immediately after ESD. Basically, after ESD, weekly TA injection was performed in group A, and no additional injection/ weekly or bi-weekly TA injection was performed in group B, depending on the endoscopists’ judgement. The primary endpoint was the percentage of patients who required balloon dilation, and the secondary endpoints were the stricture rate and the number of TA injections.

Results

Group A (8 patients, 8 lesions) and Group B (23 patients, 23 lesions). Morphology (IIa/IIb/IIc) 0/1/7, 1/4/18. Histological type (squamous cell carcinoma / Barrett's esophageal adenocarcinoma) 7/1, 22/1, and en bloc resection rate was 100% in both groups. No perforation was observed in either group. Three consecutive patients (37.5%) in the early stage of group A and three consecutive patients (13.0%) in early stage of group B were treated with oral steroids. The length of resection (mm) (median (range)) were 55 (40-80) and 50 (40-120), respectively, and the circumferential length (mm) was 30 (20-50) in group A. The longest observation period until the presence of stricture was 15 (1-38)/11 (1-37) months, respectively. The percentage of balloon dilation required and the stricture rate (n (%)) were both 0 (0) in group A and 1 (4.3) in group B. The number of TA injections was 8 (3-12) and 1 (1-3), significantly higher in group A (p < 0.01. Mann-Whitney U test). One case in group B required balloon dilation because of difficulty in coming to the hospital due to poor ADL after a subcircumferential resection, and the additional injection was performed 3 weeks after ESD, later than scheduled.

Conclusion

Intensive TA injection based on weekly or bi-weekly was effective in preventing stricture after extensive esophageal ESD, and could avoid balloon dilation even in cases with circumferential resection.

Introduction

Recent advances in high definition endoscopy have increased the diagnostic accuracy for superficial non- ampullary duodenal epithelial tumors (SNADETs). Appropriate endoscopic categorization of these tumors as low grade adenoma (LGA)/high grade adenoma (HGA)/adenocarcinoma (AC) is of extreme importance to plan appropriate management. We report the accuracy and feasibility of a novel ‘Simple Scoring System’ (SSS) for SNADETs to differentiate LGA from HGA/AC.​

Aims & Methods

The aim of this prospective study was to evaluate the accuracy of SSS for diagnosis of SNADETs and to assess the feasibility of its understanding and usage among beginner and expert gastroenterologists. SSS includes four sections which are evaluated and scored: 1. Tumor diameter (10-20mm: +1, >20mm: +2); 2. Color on white light imaging (redness: +1); the presence/absence of irregular surface pattern by magnifying endoscopy using narrow band imaging (ME-NBI) (Present: +1); 4. The presence/absence of irregular vascular pattern on ME- NBI (Present: +1). The score is on a 5-point scale. A score of 3 or more is diagnosed as HGA/AC. Study 1: 319 SNADETs were preoperatively evaluated with SSS from June 2019 to February 2022 and were compared with postoperative pathological results. Diagnostic accuracy according to histological type (gastric, intestinal, or mixed gastrointestinal) was also evaluated. Study 2: Diagnostic accuracy of 20 lesions (10 LGA and 10 HGA/AC lesions) selected randomly were compared before and after a lecture on SSS for 26 expert and beginner gastroenterologists in 7 hospitals. Experts were defined as those with minimum 5 years of endoscopic experience and 3 years of experience with magnifying endoscopy. A total of 4 images of each lesion (white light imaging; indigo carmine; ME-NBI distant view; ME-NBI near view) were presented for evaluation. T test was used to analyze the pre and post lecture outcomes.

Results

Study 1: The overall diagnostic accuracy was 258/319 (80.8%), sensitivity 80.7%, and specificity 81.2%. Diagnostic accuracy for each tissue type was 83.3% for gastric type, 80.3% for intestinal type, and 100% for mixed type. Study 2: The mean diagnostic accuracy before and after the lecture changed from 71% to 79% overall, 70% to 81% for HGA/AC, 72% to 78% for LGA. Diagnostic accuracy of both experts (13) and beginners (13) improved significantly (p value expert: <0.01, beginner: <0.01) after the lecture.

Conclusion

SSS can be understood and used easily. It is an accurate method to diagnose SNADETs endoscopically.

Introduction

Linked color imaging (LCI), a unique image-enhanced endoscopy technique, expands the color range to enhance the recognition of subtle mucosal differences, facilitating early lesion detection. Recently, the advantage of LCI in cancer visibility and detection has been reported especially in Helicobacter pylori (H. pylori)-negative gastric cancer including cases post-eradication.¹ However, the correlations between the color of LCI’s visualized mucosa and histological findings have not been thoroughly investigated.

Aims & Methods

This study aimed to investigate relationships between color values and histological findings visualized by LCI in H. pylori-negative gastric cancer.
Thirty-two patients with H. pylori-negative, differentiated-type intramucosal gastric cancer (≤20 mm) who underwent endoscopic submucosal dissection were retrospectively reviewed. Images captured with LCI and white light imaging (WLI) were analyzed using the CIE1976 (L^*a^*b^*) color space, as defined by the International Commission on Illumination (CIE).² Three regions of interest, each measuring 10 × 10 pixels, were set on the malignant tumor and adjacent mucosa to the border. The values of a^*(red-green) and b^* (yellow-blue) and the color difference (ΔE), which represents the overall difference between the two colors, were calculated. Histopathological evaluation using Hematoxylin-Eosin stained specimens was performed to highlight the demarcation between cancerous and noncancerous mucosa in a width of 1.0 mm inside and outside the lesion. Vascular density, glandular density, mucosal thickness, and the degrees of intestinal metaplasia (IM) were measured. Vascular density was calculated as the percentage of the occupied blood vessels in an area up to 200 μm from the surface. And the proportion of IM relative to the glands was measured and classified as the severe IM (≥60%), moderate IM (≥30% and <60%), or mild IM (<30%) groups.

Results

LCI significantly increased ΔE between the cancer and surrounding mucosa compared with WLI (P < 0.001); however, no significant differences in Δa^* and Δb^* were observed between LCI and WLI. Moderate correlations were observed between LCI a^* values and vascular density (ρ = 0.39, P < 0.001) and between LCI b^* values and the proportion of IM (ρ = −0.49, P < 0.001). Furthermore, the vascular density of cancer in the 0−100 μm depth showed a moderate correlation with the LCI a^* values (ρ = 0.41, P < 0.001). Severe IM significantly decreased the LCI b^* values compared with mild and moderate IM (P = 0.02, P < 0.001).

Conclusion

LCI quantitatively visualizes the superficial vascularity of cancer lesions and the presence of IM of the background mucosa in H. pylori-negative patients. It is a potential noninvasive tool for gastric cancer risk stratification and early detection.

References

1. Kato M, Ono S, Kawada K et al. Diagnostic performance of linked color imaging for gastric cancer by Helicobacter pylori infection status: a subanalysis of the large-scale, multicenter randomized controlled trial LCI-FIND. Helicobacter 2024; 29: e1308.
2. Kuehni RG. Color-tolerance data and the tentative CIE 1976 L a b formula. J Opt Soc Am 1976; 66: 497–500.

Disclosure

Shoko Ono has received lecture and/or consulting fees from Fujifilm.

Introduction

The prevalence of Helicobacter pylori (H.pylori) positive patients has gradually decreased in Japan due to eradication therapy, and H.pylori-uninfected gastric cancer (HPUGC) is expected to increase relatively. Recently, HPUGC, such as gastric adenocarcinoma of fundic-gland type (GAFG), gastric adenocarcinoma of foveolar-type (GAFV), adenocarcinoma of differentiated type (DGA) and signet ring cell carcinoma (SRCC) has been increasingly reported. Since the detection and endoscopic diagnosis of HPUGC is considered to be difficult [1]. The effective observation methods in screening endoscopy to detect HPUGC. In this context, a new image enhancement technology called Texture and Color Enhancement Imaging (TXI; Olympus Medical Systems Corporation) which optimizes the three elements: structure (texture) enhancement, color tone, and brightness correction was developed in 2020. There have been several reports on the usefulness of TXI for the detection and endoscopic diagnosis of mucosal atrophy or gastric neoplasm [2-6]. However, the usefulness of TXI for the detection of HPUGC has been investigated.

Aims & Methods

The aim of the study is to investigate whether the visibility of HPUGC improved using TXI and NBI compared with WLI as a single-center retrospective clinical study. We enrolled 40 HPUGC lesions endoscopically imaged with WLI, TXI-1, TXI-2, and NBI in our facility between October 2020 and March 2023. In addition, the visibility of HPUGCs was analyzed for each factor, such as histological type, coloration, and macroscopic type. Ten endoscopists (5 experts and 5 non-experts) evaluated the images, and visibility changes were scored by endoscopists as follows: 5, improved; 4, somewhat improved; 3, equivalent; 2, somewhat decreased; and 1, decreased. The total visibility score of ≥40 in all endoscopists and /≥20 in each of the 5 endoscopists was defined as improved visibility, 21-39/11-19 as unchanged visibility, and 20≤/10≤ as decreased visibility. The intraclass correlation coefficients (ICC) were calculated and evaluated for inter-rater agreement.

Results

The histological types were classified as GAFG (n=24), GAFV (n=9), DGA (n=4), and SRCC (n=3). There were 17 reddish lesions and 23 whitish lesions. In the macroscopic type, there were type 0-Ⅰ (n=11), type 0-Ⅱa (n=13), type 0-Ⅱb (n=11), and type 0-Ⅱc (n=5) lesions. The visibility improvement rate for all endoscopists in all HPUGCs was TXI-1: 55%, TXI-2: 29.7%, and NBI: 7.5%. The overall ICCs were TXI-1: 0.86, TXI-2: 0.84, and NBI: 0.90, which were almost perfect. GAFG (all/experts/trainees: 79/54/79%) and SRCC (all/experts/trainees: 67/67/67%) showed improved visibility with TXI-1. In contrast, GAFV and DGA did not improve the visibility. The whitish lesions (all/experts/trainees: 74/52/74%) showed improved the visibility with TXI-1, but the reddish lesions did not improve visibility. Among the macroscopic type , type 0-Ⅱa (overall/experts/trainees: 85/54/85%) and type 0-Ⅱb (overall/experts/trainees: 73/64/73%) showed improved visibility with TXI-1. The all ICCs of each factor were above 0.7, which indicated generally good correlations.

Conclusion

The usefulness of TXI-1 compared with WLI led to the improved visibility of the whitish lesions such as GAFG and SRCC for both experts and trainees when evaluated subjectively and objectively.

References

1. Ishibashi, F., et al., Exploring quality indicators for the detection of Helicobacter pylori-naïve gastric cancer: a cross-sectional nationwide survey. Clinical Endoscopy, 2023. Apr 4. doi: 10.5946/ce.2022.167.
2. Abe, S., et al., Emerging texture and color enhancement imaging in early gastric cancer. Dig Endosc, 2022. 34(4): p. 714-720.
3. Sugimoto, M., et al., Efficacy of high-vision transnasal endoscopy using texture and colour enhancement imaging and narrow-band imaging to evaluate gastritis: a randomized controlled trial. Ann Med, 2022. 54(1): p. 1004-1013.
4. Abe, S., et al., Visibility of early gastric cancer in texture and color enhancement imaging. DEN Open, 2022. 2(1): p. e46.
5. Ishikawa, T., et al., Efficacy of Texture and Color Enhancement Imaging in visualizing gastric mucosal atrophy and gastric neoplasms. Sci Rep, 2021. 11(1): p. 6910.
6. Kawasaki, A., et al., Usefulness of third-generation narrow band imaging and texture and color enhancement imaging in improving visibility of superficial early gastric cancer: A study using color difference. DEN Open, 2022. 3(1): p. e186.