Digestive Endoscopy 2014; 26 (Suppl. 2): 16–22
doi: 10.1111/den.12282
Endoscopic diagnosis and treatment of non-ampullary superficial duodenal tumors
Diagnostic algorithm of magnifying endoscopy with narrow band imaging for superficial non-ampullary duodenal epithelial tumors Daisuke Kikuchi, Shu Hoteya, Toshiro Iizuka, Ryusuke Kimura and Mitsuru Kaise Department of Gastroenterology, Toranomon Hospital, Tokyo, Japan Background and Aim: A novel diagnostic algorithm for magnifying endoscopy with narrow band imaging (ME-NBI) for superficial non-ampullary duodenal epithelial tumors (SNADET) is needed because of diagnostic difficulties. Methods: In the present study, ME-NBI images taken prior to endoscopic treatment were retrospectively analyzed to investigate the relationship between ME-NBI findings and pathological findings. Lesions displaying a single surface pattern were classified as monotype, and those displaying multiple surface patterns as mixed type. Surface pattern was classified as preserved, micrified, or absent. In addition, vascular pattern was classified as absent, network, intrastructural vascular (ISV), or unclassified. Results: According to the revised Vienna classification, 100% (23/23) of mixed-type lesions were category 4/5 tumors, whereas
INTRODUCTION
S
URGICAL TREATMENT FOR non-ampullary duodenal tumor can be invasive, especially because pancreaticoduodenectomy is done in advanced cases. Compared with gastric, esophageal, and colorectal cases, endoscopic treatment for superficial non-ampullary duodenal epithelial tumors (SNADET), even those in the early stage, is associated with a high risk of complications, some of them serious, and demonstrates the hazardous nature of endoscopic treatment for SNADET.1 Against this background, individual lesions should be treated according to their pathology, and endoscopic diagnosis is essential for determining a proper treatment strategy. Although many studies have investigated the utility of magnifying endoscopy with narrow band imaging (ME-NBI) for early esophageal,2–5 gastric,6,7 and colorectal8 cancers, only a few ME-NBI studies have been done on SNADET. In cliniCorresponding: Daisuke Kikuchi, Department of Gastroenterology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo 105-8470, Japan. Email: [email protected] Received 6 December 2013; accepted 10 February 2014.
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approximately 50% (10/23) of monotype lesions were category 3 tumors. In the monotype lesions, the probability of category 4/5 tumor was 100% (2/2) in lesions with an unclassified vascular pattern, 64.3% (9/14) in lesions with an ISV pattern, 33.3% (1/3) in lesions with an absent pattern, and 25.0% (1/4) in lesions with a network pattern.
Conclusion: These findings suggest the possibility of developing an effective diagnostic algorithm for ME-NBI for SNADET by determining their surface pattern and vascular pattern. Key words: endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), magnifying endoscopy, narrow band imaging (NBI), superficial non-ampullary duodenal epithelial tumor (SNADET)
cal practice, we often encounter a gap between diagnosis and postoperative pathological findings in cases of SNADET when the diagnosis is made in accordance with the diagnostic criteria for early gastric or colorectal cancers. It is therefore necessary to develop a diagnostic algorithm specific to duodenal cases. This article reports on the utility of an ME-NBI-based diagnostic algorithm newly developed for the diagnosis of SNADET.
METHODS Patients and endoscopists
O
F 56 PATIENTS with SNADET (56 lesions) treated by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) at Toranomon Hospital between August 2010 and November 2013, 46 lesions from 46 patients who underwent ME-NBI were examined. Three physicians (DK, TI, and RK) specialized in endoscopy retrospectively examined ME-NBI images to determine the association between endoscopic findings and histopathological diagnosis. Two of the three are board-certified endoscopists of the Japan Gastroenterological Endoscopy Society.
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
Digestive Endoscopy 2014; 26 (Suppl. 2): 16–22
NBI magnification for duodenal tumors 17
Figure 1 Mixed-type lesion. A flat elevated lesion (12 mm) is visible in the second portion of the duodenum. Its surface pattern is preserved in one region (yellow line) and is absent in another region (red line). After endoscopic mucosal resection, the lesion was diagnosed as a category 4-2 tumor.
Endoscopic observation Preoperative endoscopic observation of subjects sedated with pethidine hydrochloride was carried out using a GIF H260Z gastrointestinal videoscope (Olympus Co., Tokyo, Japan). After conventional endoscopic observation of lesion size, surface regularity, and tone, ME-NBI was done to carefully examine the surface pattern of the lesions at low to medium magnification and the vascular structure by gradually increasing the magnification.
Classification by magnifying endoscopy Three physicians who were blinded to patient information and pathological diagnosis examined the ME-NBI images (conventional endoscopic images and endoscopic ultrasound images were excluded). They divided all the lesions into two
surface types as follows. Lesions displaying a single surface pattern were classified as monotype (Fig. 1) and those displaying multiple surface patterns as mixed type (Fig. 2). When individual diagnoses of monotype or mixed type differed among the raters, the final diagnosis was decided by a majority. Surface pattern of the lesions was classified as preserved, micrified, or absent. (i) Preserved: each mucosal structure is clearly maintained in the lesion; some mucosal structure may be fringed by a white entity such as a white opaque substance9 or milky-white sign,10 regardless of size, arrangement, and configuration (Fig. 3). (ii) Micrified: size is less than half of the mucosal structure seen in the surrounding area, despite the mucosal structure being well maintained (Fig. 4). (iii) Absent: the lesion has an unclear or absent mucosal structure (Fig. 5).
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
18
D. Kikuchi et al.
Digestive Endoscopy 2014; 26 (Suppl. 2): 16–22
Figure 2 Monotype lesion. A depressed lesion (15 mm) is visible in the second portion of the duodenum. Its surface pattern is absent overall and there is a network vascular pattern (yellow line). After endoscopic mucosal resection, the lesion was diagnosed as a category 3 tumor.
Figure 3 Lesion displaying a preserved surface pattern on magnifying endoscopy with narrow band imaging.
Vascular pattern of lesions was divided into four patterns as follows. When microvessels were visible, the most frequent vascular pattern was used to classify the lesions. (i) Absent: no microvessels visible (Fig. 6). (ii) Network: vasculature of regular networks (Fig. 7). (iii) Intrastructural vascular (ISV): dilated or tortuous vessels within the mucosal structure (Fig. 8). (iv) Unclassified: patterns other than those described in (i)–(iii) (Fig. 9). When individual diagnoses differed among the raters, the final diagnosis of surface pattern and vascular pattern was made by consensus.
Figure 4 Lesion displaying a micrified surface pattern on magnifying endoscopy with narrow band imaging.
Endoscopic treatment Indication for treatment was an atypical lesion suspected as a category 4/5 tumor according to the revised Vienna classification11 on biopsy or endoscopic observation. Operators determined the indication for EMR or ESD in a comprehensive manner based on the size and location of the lesion and the operability of endoscopy. Details of the EMR and ESD procedures are described elsewhere.1 Briefly, the lesion was elevated by a local injection of glyceol (Chugai Pharmaceutical Co., Tokyo, Japan) or hyaluronic acid. In EMR, snare excision was carried out. In ESD, the circumference of the
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
Digestive Endoscopy 2014; 26 (Suppl. 2): 16–22
NBI magnification for duodenal tumors 19
Figure 5 Lesion displaying an absent surface pattern on magnifying endoscopy with narrow band imaging.
Figure 7 Lesion displaying a network vascular pattern on magnifying endoscopy with narrow band imaging.
Figure 6 Lesion displaying an absent vascular pattern on magnifying endoscopy with narrow band imaging.
Figure 8 Lesion displaying an intrastructural vascular pattern on magnifying endoscopy with narrow band imaging.
lesion was excised with a Dual Knife (Olympus Optical, Tokyo, Japan), followed by injection of glycerol into the submucosal layer for en bloc resection.
Statistical analysis
Pathological examination Resected specimens were fixed with formalin and cut into 2-mm sections. In the case of a piecemeal resection, specimens were reconstructed prior to examination. Pathologically, SNADET were classified as category 3, 4, or 5 tumors in accordance with the revised Vienna classification.11 In the present study, pathological diagnoses were made by board-certificated pathologists of the Japanese Society of Pathology, who were blinded to endoscopic diagnosis.
Data were analyzed using the unpaired t-test, chi-squared test, or Mann–Whitney U-test as appropriate. P-value
doi: 10.1111/den.12282
Endoscopic diagnosis and treatment of non-ampullary superficial duodenal tumors
Diagnostic algorithm of magnifying endoscopy with narrow band imaging for superficial non-ampullary duodenal epithelial tumors Daisuke Kikuchi, Shu Hoteya, Toshiro Iizuka, Ryusuke Kimura and Mitsuru Kaise Department of Gastroenterology, Toranomon Hospital, Tokyo, Japan Background and Aim: A novel diagnostic algorithm for magnifying endoscopy with narrow band imaging (ME-NBI) for superficial non-ampullary duodenal epithelial tumors (SNADET) is needed because of diagnostic difficulties. Methods: In the present study, ME-NBI images taken prior to endoscopic treatment were retrospectively analyzed to investigate the relationship between ME-NBI findings and pathological findings. Lesions displaying a single surface pattern were classified as monotype, and those displaying multiple surface patterns as mixed type. Surface pattern was classified as preserved, micrified, or absent. In addition, vascular pattern was classified as absent, network, intrastructural vascular (ISV), or unclassified. Results: According to the revised Vienna classification, 100% (23/23) of mixed-type lesions were category 4/5 tumors, whereas
INTRODUCTION
S
URGICAL TREATMENT FOR non-ampullary duodenal tumor can be invasive, especially because pancreaticoduodenectomy is done in advanced cases. Compared with gastric, esophageal, and colorectal cases, endoscopic treatment for superficial non-ampullary duodenal epithelial tumors (SNADET), even those in the early stage, is associated with a high risk of complications, some of them serious, and demonstrates the hazardous nature of endoscopic treatment for SNADET.1 Against this background, individual lesions should be treated according to their pathology, and endoscopic diagnosis is essential for determining a proper treatment strategy. Although many studies have investigated the utility of magnifying endoscopy with narrow band imaging (ME-NBI) for early esophageal,2–5 gastric,6,7 and colorectal8 cancers, only a few ME-NBI studies have been done on SNADET. In cliniCorresponding: Daisuke Kikuchi, Department of Gastroenterology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo 105-8470, Japan. Email: [email protected] Received 6 December 2013; accepted 10 February 2014.
bs_bs_banner
16
approximately 50% (10/23) of monotype lesions were category 3 tumors. In the monotype lesions, the probability of category 4/5 tumor was 100% (2/2) in lesions with an unclassified vascular pattern, 64.3% (9/14) in lesions with an ISV pattern, 33.3% (1/3) in lesions with an absent pattern, and 25.0% (1/4) in lesions with a network pattern.
Conclusion: These findings suggest the possibility of developing an effective diagnostic algorithm for ME-NBI for SNADET by determining their surface pattern and vascular pattern. Key words: endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), magnifying endoscopy, narrow band imaging (NBI), superficial non-ampullary duodenal epithelial tumor (SNADET)
cal practice, we often encounter a gap between diagnosis and postoperative pathological findings in cases of SNADET when the diagnosis is made in accordance with the diagnostic criteria for early gastric or colorectal cancers. It is therefore necessary to develop a diagnostic algorithm specific to duodenal cases. This article reports on the utility of an ME-NBI-based diagnostic algorithm newly developed for the diagnosis of SNADET.
METHODS Patients and endoscopists
O
F 56 PATIENTS with SNADET (56 lesions) treated by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) at Toranomon Hospital between August 2010 and November 2013, 46 lesions from 46 patients who underwent ME-NBI were examined. Three physicians (DK, TI, and RK) specialized in endoscopy retrospectively examined ME-NBI images to determine the association between endoscopic findings and histopathological diagnosis. Two of the three are board-certified endoscopists of the Japan Gastroenterological Endoscopy Society.
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
Digestive Endoscopy 2014; 26 (Suppl. 2): 16–22
NBI magnification for duodenal tumors 17
Figure 1 Mixed-type lesion. A flat elevated lesion (12 mm) is visible in the second portion of the duodenum. Its surface pattern is preserved in one region (yellow line) and is absent in another region (red line). After endoscopic mucosal resection, the lesion was diagnosed as a category 4-2 tumor.
Endoscopic observation Preoperative endoscopic observation of subjects sedated with pethidine hydrochloride was carried out using a GIF H260Z gastrointestinal videoscope (Olympus Co., Tokyo, Japan). After conventional endoscopic observation of lesion size, surface regularity, and tone, ME-NBI was done to carefully examine the surface pattern of the lesions at low to medium magnification and the vascular structure by gradually increasing the magnification.
Classification by magnifying endoscopy Three physicians who were blinded to patient information and pathological diagnosis examined the ME-NBI images (conventional endoscopic images and endoscopic ultrasound images were excluded). They divided all the lesions into two
surface types as follows. Lesions displaying a single surface pattern were classified as monotype (Fig. 1) and those displaying multiple surface patterns as mixed type (Fig. 2). When individual diagnoses of monotype or mixed type differed among the raters, the final diagnosis was decided by a majority. Surface pattern of the lesions was classified as preserved, micrified, or absent. (i) Preserved: each mucosal structure is clearly maintained in the lesion; some mucosal structure may be fringed by a white entity such as a white opaque substance9 or milky-white sign,10 regardless of size, arrangement, and configuration (Fig. 3). (ii) Micrified: size is less than half of the mucosal structure seen in the surrounding area, despite the mucosal structure being well maintained (Fig. 4). (iii) Absent: the lesion has an unclear or absent mucosal structure (Fig. 5).
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
18
D. Kikuchi et al.
Digestive Endoscopy 2014; 26 (Suppl. 2): 16–22
Figure 2 Monotype lesion. A depressed lesion (15 mm) is visible in the second portion of the duodenum. Its surface pattern is absent overall and there is a network vascular pattern (yellow line). After endoscopic mucosal resection, the lesion was diagnosed as a category 3 tumor.
Figure 3 Lesion displaying a preserved surface pattern on magnifying endoscopy with narrow band imaging.
Vascular pattern of lesions was divided into four patterns as follows. When microvessels were visible, the most frequent vascular pattern was used to classify the lesions. (i) Absent: no microvessels visible (Fig. 6). (ii) Network: vasculature of regular networks (Fig. 7). (iii) Intrastructural vascular (ISV): dilated or tortuous vessels within the mucosal structure (Fig. 8). (iv) Unclassified: patterns other than those described in (i)–(iii) (Fig. 9). When individual diagnoses differed among the raters, the final diagnosis of surface pattern and vascular pattern was made by consensus.
Figure 4 Lesion displaying a micrified surface pattern on magnifying endoscopy with narrow band imaging.
Endoscopic treatment Indication for treatment was an atypical lesion suspected as a category 4/5 tumor according to the revised Vienna classification11 on biopsy or endoscopic observation. Operators determined the indication for EMR or ESD in a comprehensive manner based on the size and location of the lesion and the operability of endoscopy. Details of the EMR and ESD procedures are described elsewhere.1 Briefly, the lesion was elevated by a local injection of glyceol (Chugai Pharmaceutical Co., Tokyo, Japan) or hyaluronic acid. In EMR, snare excision was carried out. In ESD, the circumference of the
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
Digestive Endoscopy 2014; 26 (Suppl. 2): 16–22
NBI magnification for duodenal tumors 19
Figure 5 Lesion displaying an absent surface pattern on magnifying endoscopy with narrow band imaging.
Figure 7 Lesion displaying a network vascular pattern on magnifying endoscopy with narrow band imaging.
Figure 6 Lesion displaying an absent vascular pattern on magnifying endoscopy with narrow band imaging.
Figure 8 Lesion displaying an intrastructural vascular pattern on magnifying endoscopy with narrow band imaging.
lesion was excised with a Dual Knife (Olympus Optical, Tokyo, Japan), followed by injection of glycerol into the submucosal layer for en bloc resection.
Statistical analysis
Pathological examination Resected specimens were fixed with formalin and cut into 2-mm sections. In the case of a piecemeal resection, specimens were reconstructed prior to examination. Pathologically, SNADET were classified as category 3, 4, or 5 tumors in accordance with the revised Vienna classification.11 In the present study, pathological diagnoses were made by board-certificated pathologists of the Japanese Society of Pathology, who were blinded to endoscopic diagnosis.
Data were analyzed using the unpaired t-test, chi-squared test, or Mann–Whitney U-test as appropriate. P-value
