Accuracy of radiographic assessment for the diagnosis of invasion depth in small invasive colorectal cancer.

Radiographic findings of 113 submucosally invasive colorectal cancers (CRCs) 10 mm. 47 CRCs had invaded the submucosa superficially while 66 CRCs had invaded deeply. The concordance rate in the assessment of radiology was 90.3% in smooth surface, 92.9% in central barium fleck, 90.3% in fold convergency and 79.6% in eccentric rigidity. Positive predictive value of central barium fleck for deep submucosal invasion was significantly higher in CRCs>10 mm than in those 10 mm. These findings suggest that barium radiography is a procedure which can give useful information in prediction of invasion depth in CRCs

Inflammatory myoglandular colorectal polyps: a case series of nine patients.

Inflammatory myoglandular polyp is an uncommon benign colorectal polyp. We treated nine cases of histologically verified inflammatory myoglandular polyp. The polyps were identified as a pedunculated protrusion located in the distal part of the large intestine. On colonoscopy, eight polyps had a smooth, spherical, and hyperemic surface, accompanied by a patchy mucous exudate. Magnification endoscopy revealed a rugged surface composed of smooth nodules. These colonoscopic findings corresponded to hyperplastic glands with occasional cystic dilation and inflamed stroma with proliferation of smooth-muscle fibers. Inflammatory myoglandular polyp appears to be a distinctive clinical entity, with a unique appearance on colonoscopy.

A case of multicentric gastric carcinoids without hypergastrinemia.

We have encountered an unusual case of gastric carcinoid tumors. Gastroscopic examination of a 71-year-old male patient showed eight smooth protrusions at the greater curvature of the gastric body, some of which had central depressions. Endoscopic ultrasonography demonstrated that the largest tumor (2.6 cm in diameter) was located in the submucosal layer. The patient had a normal serum gastrin level and was negative for antiparietal cell antibody. The patient was also found to have a pituitary tumor, an adenomatous goiter, and bilateral Warthin's tumors of the parotid glands. Histological examination of the resected stomach identified 12 discrete carcinoid tumors. There was no evidence of atrophic gastritis or of endocrine cell micronests. No mutations of the MEN1 gene were found on genomic DNA analysis. Despite the multiplicity of carcinoid tumors, we diagnosed type 3 gastric carcinoid in this patient.

Endosonographic features of Brunner's gland hamartomas which were subsequently resected endoscopically.

BACKGROUND AND STUDY AIMS: Brunner's gland hamartomas are uncommon duodenal submucosal tumors. We aim to describe their morphological characteristics, with particular attention to the endosonographic features. PATIENTS AND METHODS: We reviewed the radiological, endoscopic, endosonographic, and histological findings from six Brunner's gland hamartomas which were completely removed by endoscopic resection. RESULTS: The lesions appeared as broad-based, sessile, or pedunculated submucosal tumors, measuring 0.7 to 2 cm in maximal diameter. Three lesions contained tiny dimple-like depressions on the surface; in one lesion these were only recognized following the use of an endoscopic dye-spraying technique. All the lesions could be safely removed by endoscopic resection after endosonographic confirmation of the layer origin within the submucosa. The internal echo structure of the tumors appeared to be solid echogenic in two, simple cystic in two, and multicystic in the remaining two lesions. In three lesions with an indistinct boundary, some stromal proliferation and solid Brunner's glands were recognized in an area extending from the mucosa to the submucosa. These endosonographic features corresponded to histological findings comprising stromal proliferation and various degrees of solid and cystic glandular Brunner's glands. CONCLUSIONS: Brunner's gland hamartoma is characterized endosonographically by a heterogeneous solid and/or cystic mass within the submucosa.

Is endoscopic ultrasonography indispensable in assessing the appropriateness of endoscopic resection for gastric cancer?

BACKGROUND AND STUDY AIMS: Endoscopic resection is increasingly being used in the treatment of early gastric cancer. The aim of the present study was to investigate the accuracy of pretherapeutic staging techniques for assessing the appropriateness of endoscopic resection. PATIENTS AND METHODS: Both endoscopy and endosonography were carried out at our institution in the treatment of 234 early gastric cancers, with histological confirmation of malignancy following surgical resection (137 lesions) or endoscopic resection (97 lesions). The accuracy in detecting intramucosal cancer with each of the diagnostic procedures was assessed. RESULTS: The accuracy rates for detecting intramucosal cancer using endoscopy and endosonography were calculated as 84 % (197 of 234) and 78 % (182 of 234), respectively. The accuracy tended to be lower in lesions located in the upper third of the stomach, in those measuring 2 cm or more in diameter, and in those with an undifferentiated histology with ulcer fibrosis. However, there were no significant differences in the accuracy rates between endoscopy and endosonography. Precise staging was achieved by endoscopy alone in 103 of 109 differentiated adenocarcinomas without ulcer fibrosis, where the lesions measured less than 2 cm in diameter. CONCLUSIONS: Endoscopic resection is indicated in intramucosal gastric cancer lesions showing differentiated histology, no ulcer fibrosis and a diameter of less than 2 cm. EUS may additionally be used for further evaluation in these patients.

Serrated adenoma in familial adenomatous polyposis: relation to germline APC gene mutation.

BACKGROUND: Serrated adenoma is a precursor of colorectal cancer. AIM: To clarify possible genotype-phenotype correlations of serrated adenomas in familial adenomatous polyposis (FAP). PATIENTS: Eleven patients from eight families with FAP. METHODS: We performed total colonoscopy with multiple biopsies in patients. Neoplasia with a serrated glandular structure was regarded as a serrated adenoma. In each patient, germline mutations of the APC gene were determined. Colonic phenotype was compared with germline mutations of the APC gene. RESULTS: Serrated adenomas were found in three patients. These patients had macroscopic polyps <100 in number. Pedigrees with serrated adenomas had the truncating germline APC mutation at codon 161, 332, or 1556 while in the other pedigrees mutations were found between codons 554 and 1324. CONCLUSIONS: In FAP, serrated adenoma may be a phenotype characteristic of the attenuated form.

Intraoperative enteroscopy detects more lesions but is not predictive of postoperative recurrence in Crohn's disease.

BACKGROUND: The aim of this investigation was to elucidate the clinical value of intraoperative enteroscopy (IOE) for Crohn's disease, and to determine the value of IOE in predicting recurrent disease. METHODS: In this study 27 patients requiring surgery were examined by both preoperative radiography and IOE. The findings obtained by these procedures in the remnant small intestine were compared. In 19 patients, the clinical course and colonoscopic or radiographic findings after surgery were analyzed. RESULTS: Intestinal lesions were identified in 23 patients by IOE, and in 19 patients by radiography. Longitudinal ulcers were equivalently detected by IOE (63%) and radiography (56%), whereas small ulcers and inflammatory polyps were less frequently detected by radiography than by IOE (37% vs 74% and 19% vs 33%, respectively). Neither the presence nor the distribution of IOE findings was related to postoperative recurrence. CONCLUSIONS: Whereas IOE demonstrates small intestinal lesions in detail, the procedure alone cannot predict postoperative recurrence in Crohn's disease.

Predictive value of endoscopic ultrasonography for regression of gastric low grade and high grade MALT lymphomas after eradication of Helicobacter pylori.

BACKGROUND: While a close association between gastric mucosa associated lymphoid tissue (MALT) lymphoma and Helicobacter pylori infection has been established, there are still cases which do not respond to H pylori eradication. AIMS: To investigate the clinicopathological factors which may help predict the therapeutic efficacy of H pylori eradication in gastric MALT lymphoma. PATIENTS: Forty one patients with gastric MALT lymphoma, including low and high grade lesions. METHODS: After endosonographic staging was determined, H pylori was eradicated in all patients, and the subsequent gastric pathological course was then investigated. RESULTS: Complete regression of MALT lymphoma was observed in 29(71%) patients, partial regression in five (12%), and no regression in seven (17%). Twenty six (93%) of 28 MALT lymphomas restricted to the mucosa but only three (23%) of 13 lymphomas which invaded the deep portion of the submucosa or beyond completely regressed. Kaplan-Meier analysis for the probability of complete regression of MALT lymphoma revealed a significant difference between tumours restricted to the mucosa and those invading the submucosa deeply or beyond (p<0.05). Neither the presence of a high grade component, perigastric lymphadenopathy, nor clinical staging prior to eradication correlated with the probability of lymphoma regression. CONCLUSIONS: Assessment of deep submucosal invasion by endosonography is valuable for predicting the efficacy of H pylori eradication in gastric MALT lymphoma.

Cystic submucosal tumors in the gastrointestinal tract: endosonographic findings and endoscopic removal.

BACKGROUND AND STUDY AIMS: The aim of the present study was to describe the endosonographic findings in gastrointestinal cystic submucosal tumors. PATIENTS AND METHODS: The endosonographic and clinicopathological findings in 51 patients with a confirmed diagnosis of cystic submucosal tumors were reviewed. RESULTS: Endosonographically, cystic submucosal tumors were classified into simple cystic, multicystic, and solid cystic tumor types. The simple cystic tumor type was frequently identified in cysts, and rarely in Brunner's gland hamartomas or in heterotopic gastric mucosa. The multicystic tumor type was common in lymphangiomas, followed by gastric cystic malformations, hemangiomas, and Brunner's gland hamartomas. The solid cystic tumor type included duplication cysts, heterotopic gastric mucosa, heterotopic pancreas, myogenic tumors with advanced cystic degeneration, and gastric tuberculomas. Based on the endosonographic findings, 14 lesions were safely treated with endoscopic removal, using in particular the unroofing technique (cutting off the upper part of the tumors) in nine lesions. CONCLUSIONS: Endosonography is a useful diagnostic modality for investigating cystic submucosal tumors.

Natural history of ampullary adenoma in familial adenomatous polyposis: reconfirmation of benign nature during extended surveillance.

OBJECTIVE: Surgical or endoscopic papillectomy may be one of the therapeutic strategies for patients with familial adenomatous polyposis (FAP). To determine whether prophylactic papillectomy is necessary for FAP, we investigated the natural history of the ampullary adenoma in FAP. METHODS: Eighteen subjects with FAP were surveyed by duodenoscopy with biopsy for >10 yr. Endoscopic appearance, histological findings, and immunohistochemical stainings for Ki-67 of ampulla were compared between initial and final endoscopic examinations. RESULTS: The endoscopic grade in the ampulla remained unchanged in 16 subjects, whereas in two subjects an increase in the endoscopic grade was noted. In two subjects adenoma developed from an endoscopically and histologically normal ampulla. The histological grade of dysplasia increased in three of 12 subjects who initially had adenoma. The labeling index for Ki-67 was not different between initial and final examinations. CONCLUSIONS: These data suggest that most ampullary adenoma of patients with FAP is static and that aggressive endoscopic or surgical removal is unnecessary for the adenoma.

Endoscopic ultrasound features of protein-losing gastropathy with hypertrophic gastric folds.

BACKGROUND AND STUDY AIMS: We aim to clarify the endoscopic ultrasound (EUS) features of protein-losing gastropathy with hypertrophic gastric folds (PLGH), including Ménétrier's disease. PATIENTS AND METHODS: We analyzed the EUS and histologic findings in five patients who underwent both endoscopic ultrasonography and endoscopic resection. RESULTS: Histologically, we diagnosed one patient as having acute gastritis, three patients as having Ménétrier's disease, and the remaining patient as having hypertrophic lymphocytic gastritis (HLG). Helicobacter pylori was recognized in all but one patient. At EUS every patient was found to have giant gastric folds (13 to 20 mm in diameter), resulting from echogenic thickening of the mucosal layer with or without cystic components. Two patients who underwent eradication therapy of H. pylori showed both clinical and morphologic resolution. CONCLUSIONS: Echogenic thickening of the mucosal layer may be a characteristic EUS feature of protein-losing gastropathy with hypertrophic gastric folds, and H. pylori may be one of the causative agents.

Multilocular pyogenic hepatic abscess complicating ascaris lumbricoides infestation.

A 74-year-old man was admitted to our hospital with frequent right flank pain. The multiple multilocular hepatic abscesses were revealed by computed tomography. Radiographs following a barium meal showed a linear filling defect in the ileum consistent with ascariasis. One day after treatment with pyrantel pamoate, an Ascaris was passed in the stool. The pyogenic hepatic abscesses gradually healed with both antibiotics and continuous drainage. After 2 months, he was discharged. In this case, the pyogenic hepatic abscesses were thus considered to have been caused by an inflammation which spread through the portal vein.

Crohn's disease of aphthous type: serial changes in intestinal lesions.

In Crohn's disease (CD), aphthous lesions are regarded as possible precursors of typical intestinal involvement. To determine the natural course of intestinal lesions in CD of aphthous type, the clinical course of 10 patients was retrospectively investigated during a period ranging from 6 to 16 years after diagnosis. The criterion for inclusion was confirmed aphthous lesions within the gastrointestinal tract with histologically verified epithelioid granuloma. The degrees of aphthous lesions in the small intestine and the colon were graded by small bowel radiography, barium enema examination and colonoscopy. Five patients developed typical CD during a period ranging from 0.8-3.3 years. The site of involvement was the ileum in three patients, the colon in one patient and both the ileum and the colon in one patient. Typical small intestinal CD occurred in four of seven patients with marked aphthous lesions of the small intestine, whereas colonic CD occurred in two of eight patients with such aphthous lesions of the colon. These findings suggest that CD of aphthous type is not necessarily a precursor of clinically overt disease. This may especially be the case for colonic aphthous lesions.

Depressed adenoma of the duodenum in patients with familial adenomatous polyposis: endoscopic and immunohistochemical features.

BACKGROUND: Depressed neoplastic lesions of the colorectum have been specified in patients with familial adenomatous polyposis (FAP). The aim of this study was to characterize endoscopic, histologic, and immunohistochemical features of depressed adenoma of the duodenum in patients with FAP. METHODS: Duodenoscopy was performed on 25 patients with FAP, and the neoplastic nonampullary lesions were classified as polypoid or depressed adenomas. The grade of dysplasia, the proliferative activity determined by Ki-67 labeling index (LI), and the grade of p53 expression were compared between polypoid and depressed neoplasia. RESULTS: Ten subjects had depressed nonampullary adenoma, whereas polypoid adenoma was found in the remaining 15 subjects. Moderate dysplasia was more frequent in depressed adenoma than in polypoid adenoma (70% vs. 27%, P = 0.04). Whereas p53 expression was not different between the two adenoma groups, the LI was significantly higher in depressed adenoma than in polypoid adenoma (59.7 +/- 9.5 vs. 47.5 +/- 10.7, P < 0.01). CONCLUSIONS: Depressed adenoma of the duodenum is a distinctive phenotype of duodenal neoplasm in patients with FAP. The high proliferative activity of depressed adenoma suggests that there may be a need to survey FAP patients with such lesions intensively.