Recent developments in endoscopic diagnosis have enabled gastrointestinal endoscopists and otolaryngologists to detect pharyngeal carcinoma at an early stage. Because patients with superficial pharyngeal carcinoma have backgrounds similar to those of patients with esophageal squamous cell carcinoma, focusing on such high-risk group is important for efficient surveillance. Many patients with superficial pharyngeal carcinoma can be treated with endoscopic resection with minimal invasiveness; however, adverse events such as laryngeal edema may occur. At present, there are no definite criteria for the indication of endoscopic treatment; however, the risk of metastasis in patients with superficial pharyngeal carcinoma is being studied owing to clinical data of patients with lymph node metastasis after treatment. Pharyngeal carcinoma can often be completely cured by neck dissection after neck lymph node metastasis is found.
Adult T-cell leukemia/lymphoma (ATLL) is a peripheral T-cell malignancy caused by human T-cell leukemia virus type 1 (HTLV-1). The clinical characteristics of ATLL are very heterogeneous, and ATLL is a systemic disease with an unfavorable prognosis. It is difficult to perform gastrointestinal (GI) endoscopy in all ATLL patients due to the poor condition of some ATLL patients. However, we observed that the characteristic endoscopic findings of the GI tract of ATLL patients consist of multiple mucosal protrusions and ulcers, GI wall thickening, and the presence of similar macroscopic findings in various GI organs such as the stomach and colon. The endoscopist should organize current classification methods and endoscopic findings to assist in the diagnosis of ATLL, because patients with ATLL have heterogeneous GI lesions as part of the systemic disease of ATLL. We searched PubMed for articles published between 1965 and 2020 using the terms “adult T-cell leukemia/lymphoma” and “gastrointestinal tract”. We also review endoscopic and characteristic findings of ATLL infiltration in the GI tract.
Background and Aims: We previously showed that the performance of artificial intelligence (AI) in diagnosing deep (≥1mm) submucosally invasive (T1b) colorectal cancer was relatively good after training with non-magnified white light images (sensitivity 80％, specificity 87％). However, the “region of interest” (ROI) within the image that was responsible for the AI diagnosis is a black box. Recently, the class activation mapping (CAM) technique has been developed, enabling identification of the ROI within the image that AI utilized for making the diagnosis. In this study, we aimed to investigate features of the ROI selected by AI using CAM and clarify the similarities and differences between AI and endoscopists.
Methods: We selected endoscopic digital images that were used for training or validation of our AI system in our previous study, comprising histologically proven T1b colorectal cancers (n＝114, 0-Ⅰs 69, 0-Ⅱa 39, 0-Ⅱc 6; maximum diameter 16.5±13.4mm). The application of CAM was limited to a maximum of two images per lesion from which T1b cancer was diagnosed. The CAM images were generated on ResNet50, and the ROI defined by AI was depicted in red. Two expert colonoscopists rated characteristics of the ROI following discussion. The outcome measures were concordance of the ROI defined by AI with the ROI defined by expert endoscopists, and endoscopic features analyzed by AI, including color (red or non-red), surface morphology (depressed, flat, protruding), presence of bleeding, and fold convergence. Concordance of the ROI defined by AI and the ROI that was defined by expert endoscopists was rated by concordance area and classified into excellent (≥75％), fair (≥25％ <75％) and poor (<25％).
Results: CAM images were successfully generated for all 226 images. The level of concordance between the ROI defined by AI and the ROI that was defined by expert endoscopists was excellent in 39％, fair in 34％ and poor in 27％. In images showing poor concordance, the ROI defined by AI was distant from the T1b cancer. After excluding lesions with poor concordance, the vast majority (91％) of the ROI defined by AI was concordant with the ROI containing endoscopists’ identification of red color, and a small proportion (21％) of the ROI defined by AI revealed bleeding. Among the lesions detected by AI, the surface morphology was depressed in 39％, flat in 5％ and protruding in 57％. Fold convergence was observed in 34％ of the ROI defined by AI.
Conclusions: Most of the ROIs identified by AI were concordant with ROIs defined by experienced endoscopists, although AI may diagnose T1b colorectal cancer using different features of the ROI. Since a quarter of ROIs were present within normal mucosa, annotation of the image that the image should be reviewed by expert endoscopists may improve the diagnostic accuracy of AI for T1b colorectal cancer.
A 34-year-old woman presented epigastric pain. Upper endoscopy revealed diffuse distribution of nodular and flat elevations and depressed areas similar to atrophic epithelium in the gastric body. Pathologic examination of the initial biopsy specimens did not lead to a definitive diagnosis. Her symptom was refractory to a proton pump inhibitor. Re-examination by upper endoscopy five years after the initial endoscopy showed expansion of the lesion, and pathologic examination of a biopsy specimen from the lesion revealed deposition of a collagen band below the gastric epithelium which was consistent with collagenous gastritis. Steroid pulse therapy rapidly relieved the clinical symptom. Follow-up endoscopy and biopsy 3.4 years later demonstrated histological remission.
[Case] A male in his 70s was being followed for walled-off pancreatic necrosis subsequent to acute pancreatitis. A computerized tomography (CT) scan obtained six months previously showed no lesions. Upper gastrointestinal endoscopy at the current visit revealed a submucosal tumor of about 2 cm in size at the gastric cardia. Since the tumor could not be differentially diagnosed by imaging and tended to become larger, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed, and an inflammatory myofibroblastic tumor was diagnosed. The tumor was completely resected by laparoscopy and partial gastrectomy. Histopathologically, the final diagnosis was intermediate malignant primary retroperitoneal inflammatory myofibroblastic tumor. There has been no recurrence 18 months after the surgery.
[Discussion] We encountered a case in which a gastric submucosal tumor detected by upper gastrointestinal endoscopy, and EUS-FNA was useful for establishing the preoperative diagnosis of an inflammatory myofibroblastic tumor.
A 44-year-old woman presented to our hospital with fever, abdominal pain, and diarrhea. We administered treatment for acute colitis of the ascending colon, but she did not respond to the treatment. Total colonoscopy (TCS) showed multiple ulcers extending from the terminal ileum to the rectum, while esophagogastroduodenoscopy showed nonspecific findings. Histopathological examination of biopsy specimens from the lesions revealed noncaseating epithelioid cell granulomas, and Crohnʼs disease (CD) was suspected. Because laboratory data showed increased liver enzyme levels and amylase concentration, and eosinophilia, liver biopsy and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of the pancreas were performed. Histopathological examination revealed granulomatous hepatitis and pancreatitis with eosinophilic infiltration caused by peripheral eosinophilia as extraintestinal manifestations of CD. After administering infliximab (5 mg/kg), TCS showed no ulcers, and the extraintestinal manifestations improved. We report a rare case of suspected CD in which the onset of multiple extraintestinal manifestations of CD was diagnosed in the early phase, and disease progression of CD could be assessed.
A 63-year-old woman underwent lower gastrointestinal endoscopy at a local clinic, which revealed a 25-mm-sized 0-Ⅱa lesion in the cecum. Biopsy examination revealed a well-to-moderately differentiated adenocarcinoma, and the patient was referred to our hospital for medical treatment. Narrow-band imaging magnified observation revealed a glandular duct with an uneven caliber; it also revealed an abnormal blood vessel running in two ridges of redness, in which the abnormal blood vessel was more prominent in areas with strong redness. On magnified observation with crystal violet, the two red ridges were found to have type VI irregular pits and the surrounding surface ridges were found to have type Ⅱ pits. Based on the above findings, we diagnosed intramucosal cancer associated with a sessile serrated lesion and performed endoscopic submucosal dissection. The pathological diagnosis was a 4 mm×3 mm mucosal cancer and 3 mm×2 mm submucosal cancer against the background of a sessile serrated lesion. Since the submucosal layer infiltrated the part containing poorly differentiated components, additional surgery was performed. No residual cancer or tumor components or lymph node metastasis was observed. This was an interesting case where cancerous changes were observed in two places in a single lesion with submucosal infiltration.
The environment in the duodenal mucosa has changed due to the increase in the eradication rate of Helicobacter pylori and the improvement of gastric acid secretion. In addition, due to the development of endoscopic equipment and technology, the detection of duodenal lesions has recently been increasing. Many duodenal lesions are detected in the descending part of the duodenum; however, duodenal lesions may also be present in the transverse part and ascending part. The transverse and ascending parts of the duodenum are referred to as the deep duodenum, which is sometimes difficult to reach with routine esophagogastroduodenoscopy (EGD). The deep duodenum can be observed by balloon-assisted endoscopy (BAE) and capsule endoscopy (CE), and it is expected that the chances of observation of the deep duodenum will increase more and more as new operations of the upper gastrointestinal endoscope are devised. Although the deep duodenum should be observed as much as possible by routine EGD, it is difficult to reach this part of the duodenum in many cases. Therefore, it is necessary to clarify the purpose of each examination and select the appropriate modality.
The Stag Beetle Knife （SB Knife） was put to practical use in 2013 as the first scissors-type knife allowing steady tissue incision for endoscopic submucosal dissection (ESD) in the world. It enables safe and easy resection without the need for large manipulation of the endoscope by grasping the target tissue with the open-close operations of the tip of the knife and applying the high-frequency currentvisually confirming the dissection plane.
Several variations of the SB Knife have been developed including the Jr type and Jr2 type for colorectal ESD, the Short type for exfoliation in esophageal ESD, the Standard type for exfoliation in gastric ESD, the GX type for gastric ESD and the type for Laparoscopy and Endoscopy Cooperative Surgery. These knives are especially useful for handling in the narrow space of the colorectum and esophagus, and in cases associated with severe submucosal fibrosis that mandates more accurate and shaper dissection. These SB knives can overcome situations in which it is difficult to complete ESD with the conventional devices.
The SB Knife will contribute to make ESD procedures globally propagated as a standard therapeutic option. Because it can resect the target tissue without large manipulation of the tip of the endoscope, even novice endoscopists can safely use and handle the SB Knife.
Objectives: The endoscopic pressure study integrated system (EPSIS) is a novel diagnostic tool for gastroesophageal reflux disease (GERD) by monitoring intragastric pressure (IGP). Evaluation of the lower esophageal sphincter (LES) function may be achieved endoscopically by utilizing this newly developed diagnostic tool. This study aimed to evaluate the association between EPSIS results and gastroesophageal reflux-related diseases, e.g., erosive esophagitis (EE) and Barrett’s esophagus (BE).
Methods: This was a retrospective, single-center study. All patients who underwent EPSIS between November 2016 and July 2018 were included. EPSIS was performed during esophagogastroduodenoscopy with a dedicated electronic device and a through-the-scope catheter. The maximum IGP (IGP-max) and IGP waveform pattern (flat or uphill) were recorded with this system. Evaluation of an EE and BE was based on the Los Angeles classification and Prague classification, respectively.
Results: A total of 104 patients were enrolled; 29 (28％) had EE and 42 (40％) had BE. Patients with EE had lower IGP-max values (16.0 vs 18.8 mmHg, P＝0.01) and an EPSIS flat pattern was seen more frequently (82.8％ vs 37.3％, P < 0.001). Similarly, patients with BE displayed a lower IGP-max (15.7 vs 19.6 mmHg, P < 0.001) and presented with an EPSIS flat pattern in a higher proportion (69％ vs 37.1％, P < 0.001). These differences remained significant on multivariate analysis.
Conclusions: The EPSIS, as a novel diagnostic tool, was shown to exhibit a relation with EE and BE, implying that EPSIS is a promising modality to evaluate gastroesophageal refluxrelated diseases and LES function endoscopically.