Publications by authors named "Shoichi Yoshimizu"

38 Publications

Long-term outcomes of esophageal squamous cell carcinoma with invasion depth of pathological T1a-muscularis mucosae and T1b-submucosa by endoscopic resection followed by appropriate additional treatment.

Dig Endosc 2021 Oct 2. Epub 2021 Oct 2.

Department of, Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.

Objectives: Endoscopic resection (ER) is indicated for a wide range of superficial esophageal squamous cell carcinomas (ESCCs). We examined the long-term outcomes in patients with pathological (p) invasion of ESCC into the T1a-muscularis mucosae (MM) and T1b-submucosa (SM) after ER, for which data on prognosis are limited.

Methods: Of the 1217 patients with superficial ESCC who underwent ER, 225 patients with a pathological diagnosis of ESCC invasion into the MM, minute submucosal invasion ≤200 µm (SM1), or massive submucosal invasion (SM2) were included. In patients with lymphovascular invasion, droplet infiltration, or SM2 invasion, additional treatments, including chemoradiation (CRT) or esophagectomy with two- to three-field lymph node dissection, were recommended. The median observation period was 66 months (interquartile range 48-91 months).

Results: In total, there were 151, 28, and 46 pT1a-MM, pT1b-SM1, and pT1b-SM2 cases, respectively. Metastatic recurrence was observed in 1.3%, 10.7%, and 6.5% patients with pT1a-MM, pT1b-SM1, and pT1b-SM2 ESCCs, respectively. Of the eight patients with metastatic recurrence, six were successfully treated, and two died of ESCC. The 5-year overall survival rates were 84.1%, 71.4%, and 67.4%, the 5-year relapse-free survival rates were 82.8%, 64.3%, and 65.2%, and the 5-year disease-specific survival rates were 100%, 96.4%, and 99.1% in patients with pT1a-MM, pT1b-SM1, and pT1b-SM2 ESCCs, respectively. Multivariate analysis showed that additional CRT and esophagectomy, and T1b-SM2 were positively and negatively associated with overall survival, respectively.

Conclusions: Endoscopic resection preceding appropriate additional treatments resulted in favorable outcomes. Many cases of metastatic recurrence in this cohort could be successfully treated.
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http://dx.doi.org/10.1111/den.14154DOI Listing
October 2021

Usefulness of Magnifying Endoscopy with Narrow-Band Imaging for Diagnosing Mixed Poorly Differentiated Gastric Cancers.

Digestion 2021 Aug 17:1-8. Epub 2021 Aug 17.

Department of Gastroenterology, Cancer Institute Hospital, Tokyo, Japan.

Introduction: Curative rates of endoscopic treatment for undifferentiated-type early gastric cancer (EGC), particularly mixed poorly differentiated adenocarcinoma (MIXED-POR), are lower than those of endoscopic treatment for the differentiated type. Magnifying endoscopy with narrow-band imaging (ME-NBI) is useful for diagnoses of the histological type. This study aimed to investigate the detection rates of MIXED-POR among undifferentiated-type EGCs using biopsy and ME-NBI in order to improve curative rates through endoscopic treatment.

Methods: We analyzed 267 lesions initially subjected to endoscopic submucosal resection (ESD) and histologically diagnosed as undifferentiated-type EGCs between July 2005 and December 2016 at our hospital. We obtained written informed consent from all participants. Biopsy and ME-NBI findings were compared to distinguish pure signet ring cell carcinoma (PURE-SIG) and MIXED-POR. ME-NBI findings were divided into 2 categories depending on the presence of irregular vessels. Results of biopsy and ME-NBI (combination method) were also analyzed, and detection rates of MIXED-POR and PURE-SIG were evaluated in terms of sensitivity, specificity, and accuracy.

Results: Overall, 114 lesions were analyzed. Fifty-eight lesions (50.9%) were identified as MIXED-POR. With biopsy, the detection rate of MIXED-POR was significantly lower than that of PURE-SIG (p < 0.0001). ME-NBI detected significantly more MIXED-POR with irregular vessels than PURE-SIG (p < 0.0001). The combination method could detect significantly more MIXED-POR than PURE-SIG (p < 0.0001). The sensitivity and accuracy for MIXED-POR diagnosis were significantly higher with the combination method than with biopsy alone (p < 0.0001).

Discussion/conclusion: Combining biopsy and ME-NBI improved the accuracy of pretreatment diagnosis before ESD in undifferentiated-type cancer.
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http://dx.doi.org/10.1159/000517970DOI Listing
August 2021

Outcomes of endoscopic resection for superficial duodenal tumors: 10 years' experience in 18 Japanese high-volume centers.

Endoscopy 2021 Sep 8. Epub 2021 Sep 8.

Cancer Center, School of Medicine, Keio University, Tokyo, Japan.

Background And Study Aim: There is no enough data for endoscopic resection (ER) of superficial duodenal epithelial tumors (SDETs) due to its rarity. There are two main kinds of ER techniques for SDETs: EMR and ESD. In addition, modified EMR techniques, underwater EMR (UEMR) and cold polypectomy (CP), are getting popular. We conducted a large-scale retrospective multicenter study to clarify detailed outcomes of duodenal ER.

Patients And Methods: Patients with SDETs who underwent ER at 18 institutions from January 2008 to December 2018 were included. The rates of en bloc resection and delayed adverse events (AEs) (defined as delayed bleeding or perforation) were analyzed. Local recurrence was analyzed using Kaplan-Meier method.

Results: In total, 3107 patients (including 1017 receiving ESD) were included. En bloc resection rates were 79.1%, 78.6%, 86.8%, and 94.8%, and delayed AE rates were 0.5%, 2.2%, 2.8%, and 7.3% for CP, UEMR, EMR and ESD, respectively. The delayed AE rate was significantly higher for ESD group than non-ESD group among lesions less than 19 mm (7.4% vs 1.9%, p<0.0001), but not among lesions larger than 20 mm (6.1% vs 7.1%, p=0.6432). The local recurrence rate was significantly lower in ESD group than non-ESD group (p<0.001). Furthermore, for lesions larger than 30 mm, the cumulative local recurrence rate at 2 years was 22.6% in non-ESD group compared to only 1.6% in ESD group (p<0.0001).

Conclusions: ER outcomes for SDETs were generally acceptable. ESD by highly experienced endoscopists might be an option for very large SDETs.
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http://dx.doi.org/10.1055/a-1640-3236DOI Listing
September 2021

Usefulness of the l-type Wako antibody J test.

JGH Open 2021 Jun 7;5(6):673-678. Epub 2021 May 7.

Department of Gastroenterology The Cancer Institute Hospital of Japanese Foundation for Cancer Research Tokyo Japan.

Background And Aim: antibody levels in the blood are currently measured using an ELISA. In April 2016, FUJIFILM Wako Pure Chemical Corporation launched the "l-type Wako antibody J" test, which is based on the latex agglutination turbidimetric immunoassay. In this study, we investigated the usefulness of the Wako test.

Methods: We measured antibody levels using both the ELISA and Wako test in 180 patients who underwent upper gastrointestinal endoscopy at our hospital between September 2017 and February 2019. Ninety patients were infected with . We calculated the diagnostic accuracy, sensitivity, and specificity of each test and the concordance rate between the ELISA and Wako test. If lower limits of 90% confidence intervals (CIs) for each diagnostic validity exceeded the 85% threshold, the usefulness of the diagnostic test was confirmed.

Results: The diagnostic accuracy, sensitivity, and specificity were 94.4% (90% CI, 90.8-97.0%), 94.4% (90% CI, 88.7-97.8%), and 94.4% (90% CI, 88.7-97.8%), respectively, when the Wako test was used, and 94.4% (90% CI, 90.8-97.0%), 88.9% (90% CI, 81.9-93.8%), and 100% (90% CI, 96.0-100%), respectively, when the ELISA was used. The concordance rate between the two tests was high ( = 0.8444).

Conclusions: We confirmed the usefulness of the Wako test, especially when screening for infection, due to its high sensitivity.
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http://dx.doi.org/10.1002/jgh3.12553DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8171153PMC
June 2021

Effect of spraying l-menthol on peristalsis resumption during endoscopic submucosal dissection of gastric tumors.

JGH Open 2021 Jun 6;5(6):653-657. Epub 2021 May 6.

Department of Endoscopy Cancer Institute Hospital Gastroenterology Center Tokyo Japan.

Background And Aim: l-Menthol has smooth muscle-relaxing and antiperistaltic effects. We examined its effectiveness against peristalsis resumption during endoscopic submucosal dissection (ESD) of gastric tumors.

Methods: We retrospectively examined clinical data of 485 patients (501 lesions) who underwent ESD for upper gastrointestinal tumors in 2017. We included 119 patients (127 lesions) in whom peristaltic movement resumed during ESD and l-menthol was applied; 366 patients (374 lesions) without l-menthol application were used as controls. Video recordings were reviewed to determine whether l-menthol suppressed peristalsis resumption.

Results: In cases with l-menthol application, 2 (2.9%), 36 (14.3%), and 89 (71.2%) lesions were found in the upper (U), middle (M), and lower (L) regions, respectively. In the control group, the corresponding values were 66 (17.6%), 215 (57.5%), and 93 (24.9%), respectively. l-Menthol efficacy was observed in 116 of the 127 treated lesions (91.3%), over 90% of which were in the posterior wall of the U region, anterior wall and greater curvature of the M region, and anterior wall and lesser curvature of the L region. The most and least effective areas for l-menthol application were the anterior wall of gastric antrum and posterior wall of the M region, respectively. The mean time from application to peristalsis inhibition was 8.7 s. No adverse effects were observed; perforation and secondary hemorrhage were not significantly different between the groups.

Conclusion: Direct l-menthol application to the submucosal layer during mucosal resection affects smooth muscles and rapidly inhibits peristalsis resumption. Clinically, l-Menthol can be used to suppress peristalsis recurrence during ESD, without adverse effects.
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http://dx.doi.org/10.1002/jgh3.12549DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8171147PMC
June 2021

Ability of artificial intelligence to detect T1 esophageal squamous cell carcinoma from endoscopic videos and the effects of real-time assistance.

Sci Rep 2021 04 8;11(1):7759. Epub 2021 Apr 8.

Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan.

Diagnosis using artificial intelligence (AI) with deep learning could be useful in endoscopic examinations. We investigated the ability of AI to detect superficial esophageal squamous cell carcinoma (ESCC) from esophagogastroduodenoscopy (EGD) videos. We retrospectively collected 8428 EGD images of esophageal cancer to develop a convolutional neural network through deep learning. We evaluated the detection accuracy of the AI diagnosing system compared with that of 18 endoscopists. We used 144 EGD videos for the two validation sets. First, we used 64 EGD observation videos of ESCCs using both white light imaging (WLI) and narrow-band imaging (NBI). We then evaluated the system using 80 EGD videos from 40 patients (20 with superficial ESCC and 20 with non-ESCC). In the first set, the AI system correctly diagnosed 100% ESCCs. In the second set, it correctly detected 85% (17/20) ESCCs. Of these, 75% (15/20) and 55% (11/22) were detected by WLI and NBI, respectively, and the positive predictive value was 36.7%. The endoscopists correctly detected 45% (25-70%) ESCCs. With AI real-time assistance, the sensitivities of the endoscopists were significantly improved without AI assistance (p < 0.05). AI can detect superficial ESCCs from EGD videos with high sensitivity and the sensitivity of the endoscopist was improved with AI real-time support.
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http://dx.doi.org/10.1038/s41598-021-87405-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8032773PMC
April 2021

Clinical outcomes of endoscopic resection of preoperatively diagnosed non-circumferential T1a-muscularis mucosae or T1b-submucosa 1 esophageal squamous cell carcinoma.

Sci Rep 2021 03 22;11(1):6554. Epub 2021 Mar 22.

Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan.

In Japan, preoperatively diagnosed T1a-muscularis mucosae or T1b-submucosa 1 (MM/SM1) esophageal squamous cell carcinoma (ESCC) is a relative indication for endoscopic resection (ER). We evaluated long-term outcomes in patients after ER for non-circumferential ESCC with a preoperative diagnosis of MM/SM1 invasion. We retrospectively reviewed 66 patients with a preoperative diagnosis of non-circumferential MM/SM1 ESCC endoscopically resected between 2010 and 2015. Patients were divided into low- (adequate follow-up) and high-risk (requiring additional treatment) groups for lymph node metastasis according to risk factors (submucosal invasion, lymphovascular invasion, or droplet infiltration) and long-term outcomes were analyzed. Pathological invasion to T1a-lamina propria mucosa, MM/SM1, and T1b-SM2 was seen in 22, 38, and 6 lesions, respectively. Overall, 71.2% patients were classified into the "adequate follow-up" group. Of these, only one patient had a lymph node recurrence, which was successfully treated by additional therapy. The remaining 28.8% patients were classified into the "requiring additional treatment" group, where no recurrences were observed after additional treatments. After a median follow-up of 58.6 months, no deaths happened due to ESCC. The 3- and 5-year overall survival rates were 93.6% and 88.7%, respectively. ER is a valid initial treatment for non-circumferential ESCC with preoperatively diagnosed MM/SM1 invasion.
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http://dx.doi.org/10.1038/s41598-021-85572-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7985298PMC
March 2021

Artificial intelligence diagnostic system predicts multiple Lugol-voiding lesions in the esophagus and patients at high risk for esophageal squamous cell carcinoma.

Endoscopy 2021 Nov 4;53(11):1105-1113. Epub 2021 Feb 4.

Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.

Background: It is known that an esophagus with multiple Lugol-voiding lesions (LVLs) after iodine staining is high risk for esophageal cancer; however, it is preferable to identify high-risk cases without staining because iodine causes discomfort and prolongs examination times. This study assessed the capability of an artificial intelligence (AI) system to predict multiple LVLs from images that had not been stained with iodine as well as patients at high risk for esophageal cancer.

Methods: We constructed the AI system by preparing a training set of 6634 images from white-light and narrow-band imaging in 595 patients before they underwent endoscopic examination with iodine staining. Diagnostic performance was evaluated on an independent validation dataset (667 images from 72 patients) and compared with that of 10 experienced endoscopists.

Results: The sensitivity, specificity, and accuracy of the AI system to predict multiple LVLs were 84.4 %, 70.0 %, and 76.4 %, respectively, compared with 46.9 %, 77.5 %, and 63.9 %, respectively, for the endoscopists. The AI system had significantly higher sensitivity than 9/10 experienced endoscopists. We also identified six endoscopic findings that were significantly more frequent in patients with multiple LVLs; however, the AI system had greater sensitivity than these findings for the prediction of multiple LVLs. Moreover, patients with AI-predicted multiple LVLs had significantly more cancers in the esophagus and head and neck than patients without predicted multiple LVLs.

Conclusion: The AI system could predict multiple LVLs with high sensitivity from images without iodine staining. The system could enable endoscopists to apply iodine staining more judiciously.
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http://dx.doi.org/10.1055/a-1334-4053DOI Listing
November 2021

Efficacy of endoscopic filling with polyglycolic acid sheets and fibrin glue for anastomotic leak after esophageal cancer surgery: identification of an optimal technique.

Esophagus 2021 Jul 8;18(3):529-536. Epub 2021 Jan 8.

Department of Gastroenterology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan.

Background: Anastomotic leak is a potentially life-threatening complication following esophageal cancer surgery. In this study, we aimed to clarify the efficacy of endoscopic filling with polyglycolic acid (PGA) sheets and fibrin glue for anastomotic leak after esophageal cancer surgery.

Methods: Consecutive patients who underwent endoscopic filling with PGA sheets and fibrin glue for anastomotic leak after esophageal cancer surgery between August 2014 and January 2020 were included in the study, with its efficacy retrospectively reviewed. We performed endoscopic filling using two methods: (1) filling the fistula with PGA sheets, followed by the application of a fibrinogen and thrombin solution (conventional method) and (2) filling the fistula with PGA sheets pre-soaked in a fibrinogen solution, followed by the application of a thrombin solution (pre-soak method).

Results: A total of 14 patients underwent endoscopic filling procedures within the study period. The endoscopic filling procedures were successfully performed in all cases and no adverse events associated with the procedures were observed. Fistula closure was obtained in 10 (71%) cases. In the 10 successful cases, the median number of procedures was 1 (range 1-3) and the median time from the first procedure to oral intake was 7.5 days (range 4-36 days). The success rate of the pre-soak method was significantly higher than that of the conventional method (90% vs. 25%, P = 0.041).

Conclusions: Endoscopic filling with PGA sheets and fibrin glue is a safe and effective treatment for the closure of an anastomotic leak. The pre-soak method can achieve successful endoscopic filling.
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http://dx.doi.org/10.1007/s10388-020-00808-8DOI Listing
July 2021

Diagnostic performance in gastric cancer is higher using endocytoscopy with narrow-band imaging than using magnifying endoscopy with narrow-band imaging.

Gastric Cancer 2021 Mar 3;24(2):417-427. Epub 2020 Oct 3.

Department of Gastroenterology, Cancer Institute Hospital (Ringgold ID: 117105), 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.

Background: For diagnosing gastric cancer, differences in the diagnostic performance between endocytoscopy with narrow-band imaging and magnifying endoscopy with narrow-band imaging have not been reported. We aimed to clarify these differences by analyzing diagnoses made by endoscopists in Japan.

Methods: This single-center retrospective cohort study used 106 cancerous and 106 non-cancerous images obtained via both modalities (total, 424 images) for diagnosis. Sixty-one endoscopists with varying experience levels from 45 institutions were included. Diagnostic accuracy, sensitivity, specificity, and positive and negative predictive values were evaluated to determine the diagnostic performance of each modality and compared using the Mann-Whitney U test.

Results: Among all endoscopists, diagnostic accuracy, sensitivity, positive predictive value, and negative predictive value were higher with endocytoscopy with narrow-band imaging than with magnifying endoscopy with narrow-band imaging (percentage [95% confidence interval]: 78.8% [76.4-83.0%] versus 72.2% [69.3-73.6%], p < 0.0001; 82.1% [78.3-85.9%] versus 64.2% [60.4-69.8%], p < 0.0001; 88.7% [82.6-90.7%] versus 78.5% [75.4-85.1%], p = 0.0023; 79.0% [75.3-80.5%] versus 68.5% [66.4-71.6%], p < 0.0001, respectively). In the magnifying endoscopy with narrow-band imaging-trained group, these values were also higher with endocytoscopy with narrow-band imaging than with magnifying endoscopy with narrow-band imaging (p < 0.0001, p = 0.0001, p = 0.0143, and p < 0.0001, respectively). Diagnostic accuracy, sensitivity, and negative predictive value were higher with endocytoscopy with narrow-band imaging than with magnifying endoscopy with narrow-band imaging in the magnifying endoscopy with narrow-band imaging-untrained group (p = 0.0041, p = 0.0049, and p = 0.0098, respectively).

Conclusions: Diagnostic performance was higher using endocytoscopy with narrow-band imaging than using magnifying endoscopy with narrow-band imaging. Our results may help change the technique used to diagnose gastric cancer.
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http://dx.doi.org/10.1007/s10120-020-01125-wDOI Listing
March 2021

Incidence of metachronous cancer after endoscopic submucosal dissection: a comparison between undifferentiated-type and differentiated-type early gastric cancer.

Gastrointest Endosc 2021 03 2;93(3):557-564.e1. Epub 2020 Jul 2.

Department of Gastroenterology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan.

Background And Aims: Endoscopic submucosal dissection (ESD) has become an important and minimally invasive treatment for early gastric cancer (EGC) with a negligible risk of metastasis not only for differentiated-type (D-type) cancer but also for undifferentiated-type (UD-type) cancer. We aimed to investigate the incidence and characteristics of metachronous cancer after ESD for UD-type cancer, which has not yet been elucidated.

Methods: In total, 175 patients who underwent ESD for UD-type EGC were enrolled. For comparison, 350 patients who underwent ESD for D-type EGC during the same period were randomly selected. These patients underwent a follow-up EGD annually. The median observation period was 6.0 years and 5.4 years, respectively.

Results: The annual incidence of metachronous cancer after ESD for UD-type and D-type cancer was .9% and 5.3%, respectively. Among the patients who underwent ESD for UD-type cancer, 30.9% of patients were uninfected with Helicobacter pylori, whereas all patients who underwent ESD for D-type cancer were infected with H pylori. All patients who developed metachronous cancer were infected with H pylori. UD-type metachronous cancer developed more frequently in patients after ESD for UD-type cancer than after ESD for D-type cancer, and the curative resection rate of ESD was significantly lower in these cases.

Conclusions: Metachronous cancers developed only in H pylori-infected patients in this cohort. Although metachronous cancer incidence was significantly less frequent in patients after ESD for UD-type cancer, the curative resection rate of ESD was significantly lower. Routine surveillance should be conducted more carefully after ESD for UD-type cancer, especially in H pylori-infected patients.
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http://dx.doi.org/10.1016/j.gie.2020.06.067DOI Listing
March 2021

Clinicopathological features and risk factors for lymph node metastasis in early-stage non-ampullary duodenal adenocarcinoma.

J Gastroenterol 2020 Aug 12;55(8):754-762. Epub 2020 Jun 12.

Department of Gastroenterology, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan.

Background: Management strategies for primary non-ampullary duodenal adenocarcinoma (NADAC) in early stage are not well established given its low incidence. This study aimed to elucidate clinicopathological features of early NADAC, including risk for lymph nodal metastasis (LNM).

Methods: In total, 166 patients with early NADAC underwent initial treatment at our institution between 2006 and 2019, of whom 153 had intramucosal (M-) and 13 had submucosal (SM-) NADAC. These endoscopic and pathological features were retrospectively analyzed. Risk factors for LNM were evaluated in 46 early NADAC patients who underwent surgery with lymph node dissection.

Results: Compared with M-NADAC, SM-NADAC was significantly more frequently located at the proximal side of the papilla, with mixed elevated and depressed macroscopic type, histologically poorly differentiated tumor and lymphovascular invasion (LVI) (85% vs. 47%, P = 0.009; 54% vs. 5%, P < 0.001; 23% vs. 0%, P < 0.001; and 46% vs. 0%, P < 0.001, respectively). The frequency of LNM was significantly higher in SM-NADAC than in M-NADAC (5/12, 42% vs. 0/34, 0%; P < 0.001). In SM-NADAC, the frequency of LNM was higher in poorly differentiated than in well to moderately differentiated tumors (3/3, 100% vs. 2/9, 22%) and higher in tumors with LVI than in those without LVI (3/5, 60% vs. 2/7, 29%). Regarding invasion depth, 2 of 4 patients with SM invasion (400 ≤ × < 500 µm) showed LNM. However, in this study, no patients developed very shallow SM invasion (0 < × < 400 µm).

Conclusions: SM-NADAC showed high LNM risk. Surgical treatment with regional lymph node dissection is recommended as a treatment strategy for SM-NADAC.
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http://dx.doi.org/10.1007/s00535-020-01696-6DOI Listing
August 2020

Artificial intelligence-based diagnostic system classifying gastric cancers and ulcers: comparison between the original and newly developed systems.

Endoscopy 2020 12 5;52(12):1077-1083. Epub 2020 Jun 5.

Tada Tomohiro Institute of Gastroenterology and Proctology, Saitama, Japan.

Background: We previously reported for the first time the usefulness of artificial intelligence (AI) systems in detecting gastric cancers. However, the "original convolutional neural network (O-CNN)" employed in the previous study had a relatively low positive predictive value (PPV). Therefore, we aimed to develop an advanced AI-based diagnostic system and evaluate its applicability for the classification of gastric cancers and gastric ulcers.

Methods: We constructed an "advanced CNN" (A-CNN) by adding a new training dataset (4453 gastric ulcer images from 1172 lesions) to the O-CNN, which had been trained using 13 584 gastric cancer and 373 gastric ulcer images. The diagnostic performance of the A-CNN in terms of classifying gastric cancers and ulcers was retrospectively evaluated using an independent validation dataset (739 images from 100 early gastric cancers and 720 images from 120 gastric ulcers) and compared with that of the O-CNN by estimating the overall classification accuracy.

Results: The sensitivity, specificity, and PPV of the A-CNN in classifying gastric cancer at the lesion level were 99.0 % (95 % confidence interval [CI] 94.6 %-100 %), 93.3 % (95 %CI 87.3 %-97.1 %), and 92.5 % (95 %CI 85.8 %-96.7 %), respectively, and for classifying gastric ulcers were 93.3 % (95 %CI 87.3 %-97.1 %), 99.0 % (95 %CI 94.6 %-100 %), and 99.1 % (95 %CI 95.2 %-100 %), respectively. At the lesion level, the overall accuracies of the O- and A-CNN for classifying gastric cancers and gastric ulcers were 45.9 % (gastric cancers 100 %, gastric ulcers 0.8 %) and 95.9 % (gastric cancers 99.0 %, gastric ulcers 93.3 %), respectively.

Conclusion: The newly developed AI-based diagnostic system can effectively classify gastric cancers and gastric ulcers.
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http://dx.doi.org/10.1055/a-1194-8771DOI Listing
December 2020

Performance of a computer-aided diagnosis system in diagnosing early gastric cancer using magnifying endoscopy videos with narrow-band imaging (with videos).

Gastrointest Endosc 2020 Oct 15;92(4):856-865.e1. Epub 2020 May 15.

AI Medical Service Inc., Tokyo, Japan; Tada Tomohiro Institute of Gastroenterology and Proctology, Saitama, Japan.

Background And Aims: The performance of magnifying endoscopy with narrow-band imaging (ME-NBI) using a computer-aided diagnosis (CAD) system in diagnosing early gastric cancer (EGC) is unclear. Here, we aimed to clarify the differences in the diagnostic performance between expert endoscopists and the CAD system using ME-NBI.

Methods: The CAD system was pretrained using 1492 cancerous and 1078 noncancerous images obtained using ME-NBI. One hundred seventy-four videos (87 cancerous and 87 noncancerous videos) were used to evaluate the diagnostic performance of the CAD system using the area under the curve (AUC), accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). For each item, comparisons were made between the CAD system and 11 experts who were skilled in diagnosing EGC using ME-NBI with clinical experience of more than 1 year at our hospital.

Results: The CAD system demonstrated an AUC of 0.8684. The accuracy, sensitivity, specificity, PPV, and NPV were 85.1% (95% confidence interval [95% CI], 79.0-89.6), 87.4% (95% CI, 78.8-92.8), 82.8% (95% CI, 73.5-89.3), 83.5% (95% CI, 74.6-89.7), and 86.7% (95% CI, 77.8-92.4), respectively. The CAD system was significantly more accurate than 2 experts, significantly less accurate than 1 expert, and not significantly different from the remaining 8 experts.

Conclusions: The overall performance of the CAD system using ME-NBI videos in diagnosing EGC was considered good and was equivalent to or better than that of several experts. The CAD system may prove useful in the diagnosis of EGC in clinical practice.
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http://dx.doi.org/10.1016/j.gie.2020.04.079DOI Listing
October 2020

Detecting early gastric cancer: Comparison between the diagnostic ability of convolutional neural networks and endoscopists.

Dig Endosc 2021 Jan 2;33(1):141-150. Epub 2020 Jun 2.

AI Medical Service Inc, Tokyo, Japan.

Objectives: Detecting early gastric cancer is difficult, and it may even be overlooked by experienced endoscopists. Recently, artificial intelligence based on deep learning through convolutional neural networks (CNNs) has enabled significant advancements in the field of gastroenterology. However, it remains unclear whether a CNN can outperform endoscopists. In this study, we evaluated whether the performance of a CNN in detecting early gastric cancer is better than that of endoscopists.

Methods: The CNN was constructed using 13,584 endoscopic images from 2639 lesions of gastric cancer. Subsequently, its diagnostic ability was compared to that of 67 endoscopists using an independent test dataset (2940 images from 140 cases).

Results: The average diagnostic time for analyzing 2940 test endoscopic images by the CNN and endoscopists were 45.5 ± 1.8 s and 173.0 ± 66.0 min, respectively. The sensitivity, specificity, and positive and negative predictive values for the CNN were 58.4%, 87.3%, 26.0%, and 96.5%, respectively. These values for the 67 endoscopists were 31.9%, 97.2%, 46.2%, and 94.9%, respectively. The CNN had a significantly higher sensitivity than the endoscopists (by 26.5%; 95% confidence interval, 14.9-32.5%).

Conclusion: The CNN detected more early gastric cancer cases in a shorter time than the endoscopists. The CNN needs further training to achieve higher diagnostic accuracy. However, a diagnostic support tool for gastric cancer using a CNN will be realized in the near future.
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http://dx.doi.org/10.1111/den.13688DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7818187PMC
January 2021

Artificial intelligence-based detection of pharyngeal cancer using convolutional neural networks.

Dig Endosc 2020 Nov 1;32(7):1057-1065. Epub 2020 Apr 1.

AI Medical Service Inc., Tokyo, Japan.

Objectives: The prognosis for pharyngeal cancer is relatively poor. It is usually diagnosed in an advanced stage. Although the recent development of narrow-band imaging (NBI) and increased awareness among endoscopists have enabled detection of superficial pharyngeal cancer, these techniques are still not prevalent worldwide. Nevertheless, artificial intelligence (AI)-based deep learning has led to significant advancements in various medical fields. Here, we demonstrate the diagnostic ability of AI-based detection of pharyngeal cancer from endoscopic images in esophagogastroduodenoscopy.

Methods: We retrospectively collected 5403 training images of pharyngeal cancer from 202 superficial cancers and 45 advanced cancers from the Cancer Institute Hospital, Tokyo, Japan. Using these images, we developed an AI-based diagnostic system with convolutional neural networks. We prepared 1912 validation images from 35 patients with 40 pharyngeal cancers and 40 patients without pharyngeal cancer to evaluate our system.

Results: Our AI-based diagnostic system correctly detected all pharyngeal cancer lesions (40/40) in the patients with cancer, including three small lesions smaller than 10 mm. For each image, the AI-based system correctly detected pharyngeal cancers in images obtained via NBI with a sensitivity of 85.6%, much higher sensitivity than that for images obtained via white light imaging (70.1%). The novel diagnostic system took only 28 s to analyze 1912 validation images.

Conclusions: The novel AI-based diagnostic system detected pharyngeal cancer with high sensitivity. It could facilitate early detection, thereby leading to better prognosis and quality of life for patients with pharyngeal cancers in the near future.
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http://dx.doi.org/10.1111/den.13653DOI Listing
November 2020

Application of artificial intelligence using convolutional neural networks in determining the invasion depth of esophageal squamous cell carcinoma.

Esophagus 2020 07 24;17(3):250-256. Epub 2020 Jan 24.

AI Medical Service Inc., Toshima, Tokyo, Japan.

Objectives: In Japan, endoscopic resection (ER) is often used to treat esophageal squamous cell carcinoma (ESCC) when invasion depths are diagnosed as EP-SM1, whereas ESCC cases deeper than SM2 are treated by surgical operation or chemoradiotherapy. Therefore, it is crucial to determine the invasion depth of ESCC via preoperative endoscopic examination. Recently, rapid progress in the utilization of artificial intelligence (AI) with deep learning in medical fields has been achieved. In this study, we demonstrate the diagnostic ability of AI to measure ESCC invasion depth.

Methods: We retrospectively collected 1751 training images of ESCC at the Cancer Institute Hospital, Japan. We developed an AI-diagnostic system of convolutional neural networks using deep learning techniques with these images. Subsequently, 291 test images were prepared and reviewed by the AI-diagnostic system and 13 board-certified endoscopists to evaluate the diagnostic accuracy.

Results: The AI-diagnostic system detected 95.5% (279/291) of the ESCC in test images in 10 s, analyzed the 279 images and correctly estimated the invasion depth of ESCC with a sensitivity of 84.1% and accuracy of 80.9% in 6 s. The accuracy score of this system exceeded those of 12 out of 13 board-certified endoscopists, and its area under the curve (AUC) was greater than the AUCs of all endoscopists.

Conclusions: The AI-diagnostic system demonstrated a higher diagnostic accuracy for ESCC invasion depth than those of endoscopists and, therefore, can be potentially used in ESCC diagnostics.
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http://dx.doi.org/10.1007/s10388-020-00716-xDOI Listing
July 2020

Pretreatment diagnosis factors associated with overtreatment with surgery in patients with differentiated-type early gastric cancer.

Sci Rep 2019 10 25;9(1):15356. Epub 2019 Oct 25.

Department of Gastroenterology, Cancer Institute Hospital, 3-10-6 Ariake, Koto-ku, Tokyo, 135-8550, Japan.

This study aimed to clarify the pretreatment factors associated with overtreatment with surgery in patients with differentiated-type early gastric cancer. This single-centre, retrospective study included 781 patients with differentiated-type early gastric cancer treated by surgical resection between April 2005 and May 2017. Postoperative pathological results were used to divide patients into the accurate surgical indication group and overtreatment with surgery group; the groups were compared with respect to accurate diagnosis and misdiagnosis based on tumour diameter (≤30 mm or >30 mm), diagnosis of depth, diagnosis of ulcerative findings, and diagnosis of main histology. There were 224 patients in the overtreatment with surgery group. Multivariate analysis revealed significant differences in misdiagnosis of tumour diameter, misdiagnosis of depth, misdiagnosis of ulcerative findings, and misdiagnosis of main histology between the accurate surgical indication group and overtreatment with surgery group. Significant factors for pretreatment misdiagnosis leading to overtreatment in differentiated-type early gastric cancer were tumour diameter, depth, and main histology. It may be acceptable to perform endoscopic resection for patients with pretreatment tumour diameter ≤30 mm, mucosal invasion of pretreatment depth, and undifferentiated-type cancers containing differentiated-type components of pretreatment histology because this reduces overtreatment with surgery.
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http://dx.doi.org/10.1038/s41598-019-51952-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6814734PMC
October 2019

Convolutional Neural Network for Differentiating Gastric Cancer from Gastritis Using Magnified Endoscopy with Narrow Band Imaging.

Dig Dis Sci 2020 05 4;65(5):1355-1363. Epub 2019 Oct 4.

AI Medical Service Inc., Arai Building 2F, 1-10-13 Minami Ikebukuro, Toshima-ku, Tokyo, 171-0022, Japan.

Background: Early detection of early gastric cancer (EGC) allows for less invasive cancer treatment. However, differentiating EGC from gastritis remains challenging. Although magnifying endoscopy with narrow band imaging (ME-NBI) is useful for differentiating EGC from gastritis, this skill takes substantial effort. Since the development of the ability to convolve the image while maintaining the characteristics of the input image (convolution neural network: CNN), allowing the classification of the input image (CNN system), the image recognition ability of CNN has dramatically improved.

Aims: To explore the diagnostic ability of the CNN system with ME-NBI for differentiating between EGC and gastritis.

Methods: A 22-layer CNN system was pre-trained using 1492 EGC and 1078 gastritis images from ME-NBI. A separate test data set (151 EGC and 107 gastritis images based on ME-NBI) was used to evaluate the diagnostic ability [accuracy, sensitivity, positive predictive value (PPV), and negative predictive value (NPV)] of the CNN system.

Results: The accuracy of the CNN system with ME-NBI images was 85.3%, with 220 of the 258 images being correctly diagnosed. The method's sensitivity, specificity, PPV, and NPV were 95.4%, 71.0%, 82.3%, and 91.7%, respectively. Seven of the 151 EGC images were recognized as gastritis, whereas 31 of the 107 gastritis images were recognized as EGC. The overall test speed was 51.83 images/s (0.02 s/image).

Conclusions: The CNN system with ME-NBI can differentiate between EGC and gastritis in a short time with high sensitivity and NPV. Thus, the CNN system may complement current clinical practice of diagnosis with ME-NBI.
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http://dx.doi.org/10.1007/s10620-019-05862-6DOI Listing
May 2020

Feasibility of further expansion of the indications for endoscopic submucosal dissection in undifferentiated-type early gastric cancer.

Gastric Cancer 2020 03 5;23(2):285-292. Epub 2019 Sep 5.

Department of Gastroenterology, Cancer Institute Hospital, 3-10-6 Ariake, Koto-ku, Tokyo, 135-8550, Japan.

Background: Based on Japanese guidelines for endoscopic submucosal dissection (ESD) in undifferentiated-type early gastric cancer (UD-EGC), UD-predominant mixed-type (M-UD) EGC is considered high risk for lymph node metastasis (LNM). However, differences in LNM risk between pure UD (P-UD) and M-UD remain unclear. This study assessed risk factors for LNM considering differences between P-UD and M-UD and identified pathological features related to the lowest LNM risk.

Methods: This single-center, retrospective study included 1425 patients with UD-EGC treated with surgical resection between April 2005 and May 2017. We divided patients into those with and without LNM and compared background characteristics and post-operative pathological results between groups. Patients were further stratified based on depth, tumor diameter, ulcerative findings, lymphatic invasion, vascular invasion, and histological type to clarify post-operative pathological features associated with the lowest LNM risk.

Results: When comparing background characteristics and post-operative pathological results, multivariate analysis showed that, in patients with LNM, tumor diameters were significantly larger, and there were higher rates of submucosal invasion, lymphatic invasion, and M-UD histological type. In patients with absence of ulcerative findings, absence of lymphatic invasion, and absence of vascular invasion, no LNM occurred among those with intramucosal P-UD tumor diameters of 1-40 mm (1-20 mm: 95% confidence interval [CI], 0-5.5%; 21-40 mm: 95% CI, 0-6.1%).

Conclusions: Intramucosal P-UD EGC patients with absence of ulcerative findings, absence of lymphatic invasion, absence of vascular invasion, and tumor diameters of ≤ 40 mm did not show LNM. We suggest expanding indications for ESD to include these patients.
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http://dx.doi.org/10.1007/s10120-019-01003-0DOI Listing
March 2020

Phenotypic variations of gastric neoplasms in familial adenomatous polyposis are associated with endoscopic status of atrophic gastritis.

Dig Endosc 2020 May 31;32(4):547-556. Epub 2019 Oct 31.

Department of Gastroenterology, The Cancer Institute Hospital of Japanese Foundation for Cancer Research (JFCR), Tokyo, Japan.

Background And Aim: Gastric neoplasms (GN), including gastric adenoma and carcinoma, are well known as extracolonic manifestations of familial adenomatous polyposis (FAP). We aimed to investigate the clinicopathological features of GN in FAP patients and to clarify their relationship with the endoscopic status of the background mucosa.

Methods: We analyzed the records of 39 patients who were diagnosed with FAP and underwent esophagogastroduodenoscopy between April 2005 and July 2016. Patients were divided into two groups according to atrophic gastritis (AG) status. Endoscopic findings of GN and background mucosa, and histopathological findings, including phenotypic expression of GN and mutation locus of adenomatous polyposis coli (APC) gene, were evaluated.

Results: Gastric neoplasms were more predominant in the AG-positive group than in the AG-negative group (6/9, 66.7% vs 7/30, 23.3%; P = 0.039). Of 36 GN detected in 13 patients, six GN in five patients were followed and 30 GN in eight patients were endoscopically resected and analyzed. GN in the AG-negative group frequently showed whitish color, were located in the proximal stomach, and presented the gastric immunophenotype compared to GN in the AG-positive group. All GN were intramucosal lesions and were curatively resected regardless of AG status. APC germline mutations were identified in 32 patients. In patients with GN, a significantly higher number of mutation loci were among exons 10-15 (codons 564-1465).

Conclusion: Clinicopathological characteristics and phenotypic expressions of GN in FAP patients depend on background mucosa status with or without AG. These findings are useful for detecting GN in FAP patients.
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http://dx.doi.org/10.1111/den.13512DOI Listing
May 2020

Endoscopic features of esophageal adenocarcinoma derived from short-segment versus long-segment Barrett's esophagus.

J Gastroenterol Hepatol 2020 Feb 1;35(2):211-217. Epub 2019 Sep 1.

Department of Gastroenterology, Cancer Institute Hospital, Tokyo, Japan.

Background And Aim: The study aims to clarify the endoscopic features and clinicopathological differences in superficial Barret's esophageal adenocarcinoma (s-BEA) derived from short-segment Barrett's esophagus (SSBE) and long-segment Barrett's esophagus (LSBE).

Methods: We reviewed data of 130 patients (141 lesions) with pathologically confirmed s-BEA (SSBE: 95 patients and 95 lesions; LSBE: 35 patients and 46 lesions). We analyzed endoscopic and clinicopathological features of s-BEA in patients with SSBE and LSBE.

Results: The distribution of lesions according to macroscopic findings were as follows (s-BEA in SSBE vs LSBE): flat type (0-IIb), 3.2% (3/95) vs 32.6% (15/46) (P < 0.001); accompanied type 0-IIb, 2.1% (2/95) vs 21.7% (10/46) (P < 0.001); and complex type (0-I + IIb, 0-IIa + IIc, etc.), 30.5% (29/95) vs 50.0% (23/46) (P = 0.025). Complex-type s-BEAs had high incidences of T1b invasions and poorly differentiated components (simple type: 22.5% [20/89] and 18.0% [16/89]; complex type: 59.6% [31/52] and 44.2% [23/52], P < 0.001 and P = 0.002, respectively). In SSBE, 72.6% (69/95) of lesions were located at the right anterior wall (P = 0.01). All flat-type or depressed-type lesions derived from SSBE were identified as reddish areas, whereas only 65.2% (15/23) from LSBE were identified as reddish areas (P < 0.001).

Conclusions: In LSBE, flat-type, accompanied-type 0-IIb, and complex-type lesions were significantly more prevalent. Furthermore, complex-type s-BEAs tended to have T1b invasions and poorly differentiated components. S-BEAs in LSBE should be more carefully evaluated on endoscopic appearance including flat-type and complex-type lesions than in SSBE.
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http://dx.doi.org/10.1111/jgh.14827DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7027738PMC
February 2020

Additive Effect of Magnifying Endoscopy with Narrow-Band Imaging for Diagnosing Mixed-Type Early Gastric Cancers.

Dig Dis Sci 2020 02 31;65(2):591-599. Epub 2019 Jul 31.

Department of Gastroenterology, Cancer Institute Hospital, 3-10-6 Ariake, Koto-ku, Tokyo, 135-8550, Japan.

Background: Pretreatment biopsy may not correctly diagnose mixed-type early gastric cancers. Despite reports on the usefulness of magnifying endoscopy with narrow-band imaging in diagnosing early gastric cancers, no reports exist on differences in magnifying endoscopy with narrow-band imaging findings between differentiated-type-predominant mixed-type and undifferentiated-type-predominant mixed-type early gastric cancers.

Aim: This study aimed to clarify differences in magnifying endoscopy with narrow-band imaging findings and investigate the additive effect of combining magnifying endoscopy with narrow-band imaging and biopsy findings for pretreatment histological-type diagnosis.

Methods: Patients undergoing endoscopic submucosal dissection as initial treatment between April 2005 and March 2017 participated in this retrospective study. There were 156 differentiated-type-predominant mixed-type and 36 undifferentiated-type-predominant mixed-type lesions. We extracted the most significant magnifying endoscopy with narrow-band imaging findings of differentiated-type-predominant mixed-type and undifferentiated-type-predominant mixed-type lesions using multivariate analysis and compared the accuracy, sensitivity, and specificity between pretreatment biopsy alone and a combination of biopsy and magnifying endoscopy with narrow-band imaging findings.

Results: Significant magnifying endoscopy with narrow-band imaging findings was fine network pattern in differentiated-type-predominant and corkscrew pattern in undifferentiated-type-predominant mixed-type lesions. Accuracy, sensitivity, and specificity were significantly higher with combined biopsy and magnifying endoscopy with narrow-band imaging findings than with pretreatment biopsy alone.

Conclusions: The study results demonstrated the additive effect of magnifying endoscopy with narrow-band imaging with biopsy for diagnosing mixed-type early gastric cancers. This study may be beneficial in routine practice because it indicates a possibility of reducing additional surgery after endoscopic submucosal resection because of incorrect diagnosis of histological type.
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http://dx.doi.org/10.1007/s10620-019-05762-9DOI Listing
February 2020

Enterochromaffin-like cell neuroendocrine tumor associated with parietal cell dysfunction.

Gastrointest Endosc 2019 11 2;90(5):841-845.e1. Epub 2019 Jul 2.

Department of Gastroenterology, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan.

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http://dx.doi.org/10.1016/j.gie.2019.06.029DOI Listing
November 2019

Efficacy of novel sedation using the combination of dexmedetomidine and midazolam during endoscopic submucosal dissection for esophageal squamous cell carcinoma.

Esophagus 2019 07 1;16(3):285-291. Epub 2019 Apr 1.

Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan.

Background: Endoscopic submucosal dissection (ESD) is the preferred treatment for esophageal squamous cell carcinoma (ESCC). However, ESD can be difficult when patients move due to insufficient sedation. We conducted a prospective confirmatory single arm study to evaluate the efficacy of using dexmedetomidine (DEX) in combination with midazolam as a novel sedation for ESD.

Methods: Endoscopic submucosal dissection was performed without intubation in 65 patients. The primary outcome was the proportion of patients who did not move or require restraint during ESD, compared to historical control of ESD performed under midazolam sedation. Secondary outcomes included the frequency of complications and self-report questionnaires from patients and endoscopists.

Results: Restraint was not required in 97% of patients sedated using the combination of DEX and midazolam. Depressed respiration, low blood pressure, and bradycardia occurred in 23, 37, and 26% of patients, respectively. All patients recovered without severe complication. Occurrence of low blood pressure and bradycardia were higher, while respiratory depression was lower for the combination group than for the historical control group. The amount of midazolam used was significantly lower than in the control. Of note, 94% of patients had no painful sensations, with 3 reporting chest pain and 3 having a recollection of the procedure. Endoscopists were satisfied with the sedation in 94% of cases. All lesions were resected in en bloc fashion, without perforation.

Conclusions: The combination of DEX and midazolam provided effective sedation for ESD for ESCC.
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http://dx.doi.org/10.1007/s10388-019-00666-zDOI Listing
July 2019

[Endoscopic Diagnosis Using Artificial Intelligence].

Gan To Kagaku Ryoho 2019 Mar;46(3):412-417

Dept. of Gastroenterology, The Cancer Institute, Japanese Foundation for Cancer Research.

Image recognition using artificial intelligence(AI)has developed dramatically with innovative technologies such as machine learning and deep learning. Currently, it is considered that AI has exceeded human ability in image recognition. In the field of endoscopic diagnosis, development of computer-aided diagnosis(CAD)systems using AI is progressing. The CAD is expected to help endoscopists improve detection and characterization of polyp, cancer, and inflamation in all digestive area. Some CAD systemes showing ability better than endoscopists have been reported. It may be well applicable to daily clinical practice as real time endoscopic diagnosis in the near future.
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March 2019

A suitable marking method to achieve lateral margin negative in endoscopic submucosal dissection for undifferentiated-type early gastric cancer.

Endosc Int Open 2019 Feb 30;7(2):E274-E281. Epub 2019 Jan 30.

Department of Gastroenterology, Cancer Institute Hospital, Tokyo, Japan.

Delineating undifferentiated-type early gastric cancer (UD-type EGC) from noncancerous areas is difficult. Therefore, the lateral margin negative (LM-) resection rate of endoscopic submucosal dissection (ESD) is lower for UD-type EGC than for differentiated-type EGC. This study aimed to retrospectively evaluate the effectiveness of the marking methods with circumferential biopsies in ESD for UD-type EGC. We analyzed the clinical outcomes of ESD in 127 patients with UD-type EGC between April 2013 and 2017. We performed diagnostic delineation of cancerous areas using magnifying endoscopy with narrow-band imaging, and four or more circumferential biopsies approximately 5 mm apart from the estimated lesion border were obtained to confirm noncancerous areas. The markings were placed on the circumferential biopsy scars, and a mucosal incision line was made outside the markings. Median size of the tumors and ESD specimens was 12 and 35 mm, respectively. En-bloc resection rate was 100 % (127/127), and LM- and curative resection rates were 97.6 % (124/127) and 80.3 % (102/127), respectively. Circumferential biopsy in preoperative esophagogastroduodenoscopy has successfully identified the misdiagnosis of cancerous areas of four patients (3.2 %), with three (2.4%) achieving LM- resection. LM + resection was pathologically identified in three patients (2.4 %), with all undergoing non-curative resection due to > 20-mm tumor. The proportion of patients with the shortest distance ≥ 5 mm from the lesion edge to the specimen edge was 88.2 % (112/127). Our marking methods with circumferential biopsies may reduce LM + resections in ESD for UD-type EGC.
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http://dx.doi.org/10.1055/a-0812-3222DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6353714PMC
February 2019

Prospective feasibility study for single-tracer sentinel node mapping by ICG (indocyanine green) fluorescence and OSNA (one-step nucleic acid amplification) assay in laparoscopic gastric cancer surgery.

Gastric Cancer 2019 07 3;22(4):873-880. Epub 2019 Jan 3.

Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.

Background: The double-tracer method has been established for sentinel node (SN) mapping in gastric cancer surgery. However, there remain several unresolved issues that prevent its widespread use in clinical practice. In this study, we aimed to demonstrate the feasibility of single-tracer SN mapping in laparoscopic surgery for gastric cancer, using indocyanine green (ICG) fluorescence imaging with a one-step nucleic acid amplification (OSNA) assay intraoperatively.

Methods: Patients with clinical T1N0M0 gastric adenocarcinoma preoperatively were considered for inclusion if they had a single primary lesion 4 cm or less in maximal diameter. Immunohistochemical staining with the anti-cytokeratin 19 antibody was performed on preoperative biopsy specimens, and patients with faint positive reactions were excluded. Intraoperatively, single-tracer SN biopsy with ICG fluorescence imaging was performed, followed by laparoscopic gastrectomy with modified D1+ or D2 lymph node dissection.

Results: Twenty eligible patients underwent SN biopsy and laparoscopic gastrectomy. SNs were identified in 17 cases (85%), with a median number of three SNs per patient. The median times for SN mapping and OSNA assay were 19 and 35 min, respectively. OSNA assay detected one metastatic lymph node, but all other nodes were negative. No adverse effects were observed in relation to SN mapping.

Conclusions: Single-tracer SN mapping by ICG fluorescence imaging with intraoperative diagnosis by OSNA assay is feasible and safe. SNs can be identified in most patients, without producing false-negative results. Further clinical trial to demonstrate the sensitivity is ongoing.
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http://dx.doi.org/10.1007/s10120-018-00919-3DOI Listing
July 2019

Efficacy and safety of endoscopic resection for gastric tube cancer after surgical resection of esophageal squamous cell carcinoma.

Esophagus 2019 04 1;16(2):194-200. Epub 2019 Jan 1.

The Cancer Institute Hospital of JFCR, 3-8-31 Ariake, Koto, Tokyo, 135-8550, Japan.

Background: Gastric tube cancers (GTCs) are found frequently, even as the surgical outcomes of esophageal cancer improve. Diagnosing and treating early gastric tube cancer endoscopically has therefore become very important.

Aims: This study aimed to evaluate the clinical characteristics and outcomes of endoscopic resection for GTC.

Methods: We analyzed 29 patients (33 lesions) with metachronous GTC who underwent endoscopic resection from April 2005 to August 2016 and evaluated their clinical characteristics and the short-term outcomes of endoscopic resection.

Results: All of the cases were identified by periodic examinations. The lesions were found a median of 6.5 years after surgery (range 9 months-19 years), with six lesions found more than 10 years later. Among the total of 33 lesions, 28 resulted in curative resections (85%), and five were non-curative resections because of lymphovascular invasion, submucosal deep invasion, histological type, and size. None had received additional treatment or had a local recurrence thus far. Regarding the complications, delayed perforation occurred in a case (3%) and precordial skin burn occurred in four cases (12%).

Conclusion: The safety and efficacy of endoscopic resection for gastric tube cancer were evaluated. Additionally, it is important to continue annual endoscopy even 5 years or more after esophageal surgery.
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http://dx.doi.org/10.1007/s10388-018-00653-wDOI Listing
April 2019

Differences in upper gastrointestinal neoplasm detection rates based on inspection time and esophagogastroduodenoscopy training.

Endosc Int Open 2018 Oct 8;6(10):E1190-E1197. Epub 2018 Oct 8.

Division of Gastroenterology, Cancer Institute Hospital, Tokyo, Japan.

 Esophagogastroduodenoscopy (EGD) has utility in early detection of upper gastrointestinal (UGI) neoplasms. However, previous studies report shorter inspection times and inexperienced endoscopists contribute to overlooking gastric neoplasms. We investigated neoplasm detection rates according to inspection time and extent of EGD training. In this retrospective observational study, we reviewed routine EGDs for 3,925 consecutive cases between October 2014 and March 2015. We divided the endoscopists into three groups based on median inspection time during EGD without undergoing biopsy. Using cut-off median inspection times of 7 and 10 minutes, three, five, and eight endoscopists were classified into the fast, moderate, and slow groups, respectively. We compared detection rates according to inspection time and the extent of EGD training. The median inspection time among all endoscopists was 9.3 minutes (range, 6.6 - 12.0 min). The detection rate for UGI neoplasms was as follows: fast group, 3.6%; moderate group, 3.3 %; and slow group, 3.1 % (  = 0.807). The median inspection time was significantly shorter among the intensive training ≥ 1-year group than among the < 1-year group (< 1-year: median 6.3 min; range 8.2 - 13.9 min, ≥ 1-year: median 8.9 min; range 6.4 - 11.4 min,  < 0.001). The detection rate for UGI neoplasms was significantly higher among the intensive training ≥ 1-year group than among the < 1-year group (< 1-year: 2.2 %; ≥ 1-year: 3.7 %, OR = 1.65, 95 % CI: 1.02 - 2.68,  = 0.041). There was no association between inspection times and neoplasm detection rates. The quality of EGD, as measured by neoplasm detection rates, may be improved by ≥ 1-year of intensive training.
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http://dx.doi.org/10.1055/a-0655-7382DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6175677PMC
October 2018
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