2013 Volume 51 Issue 6 Pages 686-694
A 62y.o. male underwent transnasal EGD for upper gastrointestinal cancer screening. In the middle esophagus, rough mucosa with slight redness was observed under white light (WL) though clear identification of the lesion was difficult. It was revealed as a relatively homogenous brownish area under narrow-band imaging (NBI) though lumination was too poor to evaluate the entire lesion. On the oral side of the brownish area, dilated intra-epithelial papillary capillary loops (IPCLs) were recognized as brownish dots, highly suggestive of superficial esophageal cancer (T1a-EP). Pathological finding of the biopsied specimen was high grade intraepithelial neoplasia (HGIN). Endoscopic examination with lugol stain was not performed with the ultrathin scope. These findings were further investigated with a high-resolution magnifying scope in other medical institutes. Depressed lesion at 50mm was identified under WL, in which dilated IPCLs were recognized under NBI. Dilated IPCLs were observed densely on its anal side, and sparsely on its oral side. The boundary of the lesion could be estimated with the distribution of dilated IPCLs. The pattern of dilated IPCLs was diagnosed as type B1, suggesting superficial esophageal cancer (T1a-EP/LPM). Another depressed lesion at 5mm was revealed as a brownish area of dilated IPCLs under NBI in the upper esophagus. The pattern of dilated IPCLs was diagnosed as type A, suggesting HGIN. Both lesions were identified with lugol stain as lugol unstained areas. The lesions were treated with endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) in the middle and upper esophagus, respectively. Pathological diagnosis of the endoscopic resected specimen was SCC, 55×35mm/75×52mm, 0-IIc, pT1a-LPM, INFb, ly0, v0, pHM0, pVM0 and HGIN, 5×3mm/21×14mm, 0-IIb, ly0, v0, pHM0, pVM0 in the middle and upper esophagus, respectively. Observation under NBI was reported to increase the sensitivity of superficial esophageal cancer both under ultrathin and high-resolution magnifying scopes. The specificity of NBI observation depends on the familiarity of the endoscopists, indicating that the learning on NBI findings is important as well as careful observation. Some investigators recommend the usage of lugol stain as well as image-enhanced endoscopy (IEE) to identify tiny lesions of superficial esophageal cancer especially for high risk patients. Recently newly developed ultrathin scopes have been reported to have a resolution compatible with a high resolution standard scope at a short observation distance. Observation with IEE using new ultrathin scopes is expected to improve both the detection and differentiation of superficial esophageal cancer.
