Endoscopic criteria to evaluate tumor response of rectal cancer to neoadjuvant chemoradiotherapy using magnifying chromoendoscopy.

BACKGROUND AND AIMS: Precise endoscopic assessment of complete response to neoadjuvant chemoradiotherapy before surgery is important for optimizing surgical and non-surgical treatment. We prospectively evaluated the accuracy of the newly proposed endoscopic criteria to identify complete response, using magnifying chromoendoscopy. METHODS: New endoscopic criteria were created to define endoscopic complete response, near complete response and incomplete response, using magnifying chromoendoscopy. The criteria contained notable endoscopic findings, including shape of the scar, state of the ulcer, finding of white moss, presence of residual protruded nodules, regenerated pits of the scar, presence of neoplastic pit patterns, and extension of rectal wall. Seventy-nine patients with rectal cancer who received neoadjuvant chemoradiotherapy were prospectively evaluated 1-3 days before resection. Diagnostic accuracy to identify pathological complete response and interobserver agreement among a supervising colonoscopist and two trainees were investigated. RESULTS: Pathological complete response was obtained in 17 patients (21.5%). The diagnostic accuracy of endoscopic complete response was 85%, with a sensitivity of 47%, specificity of 97%, positive predictive value of 80% and negative predictive value of 77%. The kappa-value for interobserver agreement across 3 doctors was 0.57 (standard error, 0.74; 95% confidence interval, 0.39-0.76). CONCLUSION: The newly proposed endoscopic criteria using magnifying chromoendoscopy achieved excellent diagnostic accuracy to determine good responders to neoadjuvant chemoradiotherapy in rectal cancer, with fair interobserver agreement. The criteria could be clinically useful to select patients for non-surgical management.

Advantages of magnifying narrow-band imaging for diagnosing colorectal cancer coexisting with sessile serrated adenoma/polyp.

BACKGROUND AND AIM: In the present study, we investigated the advantages of narrow-band imaging (NBI) for efficient diagnosis of sessile serrated adenoma/polyp (SSA/P). The main objective of this study was to analyze the characteristic features of cancer coexisting with serrated lesion by carrying out NBI. METHODS: We evaluated 264 non-malignant serrated lesions by using three modalities (conventional white light colonoscopy, magnifying chromoendoscopy, and magnifying NBI). Of the evaluated cancer cases with serrated lesions, 37 fulfilled the inclusion criteria. RESULTS: In diagnosing non-malignant SSA/P, an expanded crypt opening (ECO) under magnifying NBI is a useful sign. One hundred and twenty-five lesions (87%) of observed ECO were, at the same time, detected to have type II open pit pattern, which is known to be a valuable indicator when using magnifying chromoendoscopy. ECO had high sensitivity of 80% for identifying SSA/P, with 62% specificity and 83% positive predictive value (PPV). In detecting the cancer with SSA/P, irregular vessels under magnifying NBI were frequently observed with 100% sensitivity and 99% specificity, 86% PPV and 100% negative predictive value. CONCLUSIONS: A focus on irregular vessels in serrated lesions might be useful for identification of cancer with SSA/P. This is an advantage of carrying out magnifying NBI in addition to being used simultaneously with other modalities by switching, and observations can be made by using wash-in water alone. We can carry out advanced examinations for selected lesions with irregular vessels. To confirm cancerous demarcation and invasion depth, a combination of all three aforementioned modalities should be done.

Endoscopic evaluation of clinical response after preoperative chemoradiotherapy for lower rectal cancer: the significance of endoscopic complete response.

PURPOSE: The management of rectal cancer is a significant oncologic challenge because rectal cancer has a poor prognosis among the various types of colorectal cancer. There have been several recent reports on a nonoperative approach for advanced lower rectal cancer, and this may be best for local disease control. However, objective evaluation of tumor response after preoperative chemoradiotherapy has not been standardized. The purpose of this study is to evaluate our method of endoscopic evaluation of complete response. METHODS: This is a retrospective chart review. All patients received a long course of preoperative chemoradiotherapy (5-fluorouracil-based chemotherapy and 45-50.4 Gy) followed by radical surgical resection from May 2005 to March 2012 in The Cancer Institute Hospital of Japanese Foundation for Cancer Research. One hundred fifty-seven patients were reviewed consecutively. Criteria for endoscopic complete response were defined with a focus on the degree of ulcer healing and pit pattern without magnification. RESULTS: Endoscopic CR (E-CR) evaluation with our definitions reflected histopathologic response evaluation with an accuracy of 91.7 %, sensitivity of 27.8 %, specificity of 100 %, positive predictive value (PPV) of 100 %, and negative predictive value (NPV) of 91.4 % (p < 0.001). Our criteria of E-CR led all cases of y-clinical CR (ycCR) to pathological CR. CONCLUSIONS: Endoscopic evaluation focused on the degree of ulcer healing, and pit pattern without magnification is useful for judging ycCR.

Thienopyridine derivatives as risk factors for bleeding following high risk endoscopic treatments: Safe Treatment on Antiplatelets (STRAP) study.

BACKGROUND AND STUDY AIMS: The optimal method of perioperative management of antiplatelet agents during endoscopic procedures that carry a high risk of bleeding is still controversial. The aim of this study was to evaluate the safety of continuing aspirin treatment during these procedures in an Asian population. PATIENTS AND METHODS: A multicenter, prospective, observational cohort study was conducted at six high volume endoscopy centers in Japan. The study included patients at high risk of thromboembolism who were regularly taking antiplatelet agents (e. g. thienopyridine derivatives and aspirin). Enrolled patients continued their aspirin therapy, and underwent endoscopic procedures that had a high risk of bleeding for treatment of lesions in the upper and lower gastrointestinal tracts. The primary end point was the rate of major bleeding complications after endoscopic procedures. RESULTS: The study was terminated in accordance with predetermined safety criteria because 7 of 28 consecutive patients experienced major bleeding complications (25.0 %; 95 % confidence interval 10.7 % - 44.9 %). All major bleeding complications occurred following endoscopic submucosal dissection (ESD; 6 stomach, 1 colon). Univariate analysis showed that postoperative administration of thienopyridine derivatives was the only significant factor associated with postoperative bleeding (P = 0.01). Subanalysis of gastric ESD (23 lesions in 19 patients) confirmed that the administration of thienopyridine derivatives (P = 0.01) and that of multiple agents (P = 0.02) were the significant factors. All bleeding complications (postoperative day 11.2 ±â€Š3.5) occurred after resuming thienopyridine derivative therapy postoperatively (postoperative day 2.3 ±â€Š2.4). CONCLUSION: In Asian patients taking thienopyridine derivatives with aspirin, cautious postoperative care is necessary for those undergoing endoscopic procedures that are associated with a high risk of bleeding, especially gastric ESD. Continuation of aspirin alone during these endoscopic procedures may be acceptable. STUDY REGISTRATION: UMIN000009176.

Successful use of endoscopic argon plasma coagulation for hemorrhagic radiation cystitis: a case report.

Hemorrhagic radiation cystitis is an example of a typical radiotherapy-induced adverse event. However, the optimal treatment for hemorrhagic radiation cystitis is not known. There are limited data regarding the use of argon plasma coagulation for hemorrhagic radiation cystitis. Here, we present the use of argon plasma coagulation using a gastrointestinal endoscope to treat hemorrhagic radiation cystitis. The patient was a 75-year-old male patient with hemorrhagic radiation cystitis due to external beam irradiation for prostate adenocarcinoma. Six years after radiotherapy, the patient presented with macroscopic hematuria over the preceding 4 months, and laboratory investigations revealed a low hemoglobin level. The hematuria was not controlled with 2 days of bladder irrigation using normal saline. Thus, argon plasma coagulation using an upper gastrointestinal endoscope was considered for treatment of the hemorrhagic radiation cystitis. The cystoscopic examination revealed diffuse radiation cystitis with oozing telangiectasia and coagula. All of the bleeding sites and telangiectasia were coagulated using argon plasma coagulation. Following treatment, the patient's clinical symptoms improved and did not recur. The hemoglobin level also recovered. No complications associated with the treatment were observed during the 6-month follow-up period. Thus, argon plasma coagulation using a gastrointestinal endoscope is a safe and effective treatment for hemorrhagic radiation cystitis.

Risk factors for bleeding after endoscopic submucosal dissection of colorectal neoplasms.

AIM: To investigate the risk factors for delayed bleeding following endoscopic submucosal dissection (ESD) treatment for colorectal neoplasms. METHODS: We retrospectively reviewed the medical records of 317 consecutive patients with 325 lesions who underwent ESD for superficial colorectal neoplasms at our hospital from January 2009 to June 2013. Delayed post-ESD bleeding was defined as bleeding that resulted in overt hematochezia 6 h to 30 d after ESD and the observation of bleeding spots as confirmed by repeat colonoscopy or a required blood transfusion. We analyzed the relationship between risk factors for delayed bleeding following ESD and the following factors using univariate and multivariate analyses: age, gender, presence of comorbidities, use of antithrombotic drugs, use of intravenous heparin, resected specimen size, lesion size, lesion location, lesion morphology, lesion histology, the device used, procedure time, and the presence of significant bleeding during ESD. RESULTS: Delayed post-ESD bleeding was found in 14 lesions from 14 patients (4.3% of all specimens, 4.4% patients). Patients with episodes of delayed post-ESD bleeding had a mean hemoglobin decrease of 2.35 g/dL. All episodes were treated successfully using endoscopic hemostatic clips. Emergency surgery was not required in any of the cases. Blood transfusion was needed in 1 patient (0.3%). Univariate analysis revealed that lesions located in the cecum (P = 0.012) and the presence of significant bleeding during ESD (P = 0.024) were significantly associated with delayed post-ESD bleeding. The risk of delayed bleeding was higher for larger lesion sizes, but this trend was not statistically significant. Multivariate analysis revealed that lesions located in the cecum (OR = 7.26, 95%CI: 1.99-26.55, P = 0.003) and the presence of significant bleeding during ESD (OR = 16.41, 95%CI: 2.60-103.68, P = 0.003) were independent risk factors for delayed post-ESD bleeding. CONCLUSION: Location in the cecum and significant bleeding during ESD predispose patients to delayed post-procedural bleeding. Therefore, careful and additional management is recommended for these patients.

Diagnosis of laterally spreading tumors (LST) in the rectum and selection of treatment: characteristics of each of the subclassifications of LST in the rectum.

BACKGROUND: In recent years, endoscopic submucosal dissection (ESD) has often been used for the treatment of laterally spreading tumors (LST) of the rectum. The present study was carried out with the aim of clarifying the characteristics of each of the subtypes of LST in the rectum that are often treated by ESD. PATIENTS AND METHODS: This study involved 141 rectal LST that were initially treated at our hospital between March 2005 and December 2010 and whose endoscopic images and histopathological specimens could be re-examined. The LST were divided into LST-G-H (homogeneous type), LST-G-MIX (nodular mixed type), LST-NG-F (flat type) and LST-NG-PD (pseudo-depressed type) type lesions, and tumor diameter and depth of invasion of each of these tumor types were investigated. RESULTS: Regarding the depth of invasion, the proportion of submucosa-massive (SM-m) lesions was high in the LST-NG-PDtumors, even among tumors measuring <20 mm in diameter; both the rate of cancer and proportion of SM-m lesions were significantly higher in the LST-NG-PD tumors than in the LST-NG-F tumors (P < 0.05). In both LST-NG-MIX and LST-NG-PD tumors, the proportion of SM-m lesions was significantly higher in the lower rectum than in the upper rectum (P < 0.05). CONCLUSION: For LST of the rectum (particularly of the lower rectum), it is necessary to carefully select the treatment considering LST subclass and tumor diameter from the standpoint of the presence of malignancy, quality of life, and prognosis of patients.

Usefulness of sodium hyaluronate solution in colorectal endoscopic mucosal resection.

BACKGROUND: In endoscopic mucosal resection (EMR), it is essential to inject submucosal fluid to prevent complications and ensure safe and complete en bloc resection of tumors. Sodium hyaluronate (SH) solution, which is effective in forming and maintaining a mucosal lift and is innocuous to mucosal tissue, is considered a useful injection solution for endoscopic submucosal dissection, a procedure associated with a high risk of perforation. This study was undertaken to assess the usefulness of this solution in EMR. METHODS: Ninety-four patients with colorectal tumors of ≤20 mm in diameter were enrolled for this study and randomized to a SH solution group (0.2% two-fold diluted MucoUp) or to a normal saline group (control). Ease of EMR was primarily assessed based on ease of submucosal injection, ease of snaring and injection time. RESULTS: SH solution was superior to normal saline for ease of submucosal injection (57 ± 0.7 vs 50 ± 0.7; P < 0.05), and it showed better results for ease of snaring with less variability (63 ± 0.8 vs 51 ± 1.0; P < 0.05). The mean injection time was similar between the two groups (3.0 ± 9.0 s and 3.0 ± 2.7 s, respectively). Post-procedural hemorrhage occurred in 7% patients (3/46) injected with SH solution and in 6% of patients (3/48) in the control group; there was no significant difference between the groups. CONCLUSIONS: Use of two-fold diluted MucoUp facilitated colorectal EMR.

Treatment strategy for rectal carcinoids: a clinicopathological analysis of 229 cases at a single cancer institution.

BACKGROUND AND AIM: A treatment strategy for tumors with only venous invasion and characteristics of small rectal carcinoids with metastasis have not been clearly documented. The present study aims to determine the risk factors for lymph node metastasis and to elucidate characteristics of small tumors with metastasis. METHODS: We investigated a total of 229 patients with rectal carcinoids. The relationship between each clinicopathological variable and the presence of lymph node metastasis was evaluated. RESULTS: Tumor size (larger than 10 mm), presence of central depression, depth of tumor invasion, lymphatic invasion, and venous invasion were significantly associated with the incidence of lymph node metastasis (P < 0.001). Multivariate analysis revealed that tumor size (odds ratio: 63.3, P < 0.001) and venous invasion (odds ratio: 40.9, P < 0.001) were independently predictive of lymph node metastasis. In 204 patients with small (no larger than 10 mm) tumors, 10 patients had lymph node metastasis. All 10 tumors had low proliferation values indicated by mitosis and Ki-67 index. Multivariate analysis for the 204 patients revealed that only venous invasion was independently associated with metastasis (odds ratio: 40.1, P < 0.001). Five-year disease free survival rates of the total patients with metastasis and without metastasis were 81.1% and 95.5%, respectively (P < 0.001, log-rank test). CONCLUSIONS: Venous invasion as well as tumor size and lymphatic invasion indicates high malignant potential to metastasize to lymph node and would provide useful information in considering the addition of radical surgery. Postoperative pathological examinations of specimens obtained by local resection are very important to avoid underestimation.

Re-epithelialization of squamous epithelium for a radiation-induced rectal ulcer while giving an ecabet sodium enema.

The present patient developed a severe rectal ulcer more than 1 month after having received external beam radiation therapy for prostate cancer. Surveillance endoscopy every 3 months demonstrated healing of this rectal ulcer using a novel therapy. He was given enemas with ecabet sodium, which provides physical protection and promotes healing by increasing prostaglandin E(2), and this process induced squamous metaplasia that halted the progression of the ulcer of radiation proctitis as a late-phase reaction. Intrapapillary capillary loops were visualized with magnified narrow band imaging at the healing ulcer site as seen via the esophagus and, moreover, demonstrated histologically.