Differences in diagnostic criteria for esophageal squamous cell carcinoma between Japanese and Western pathologists

Squamous Neoplastic Precursor Lesions of the Esophagus

Clinicopathological and molecular studies have demonstrated that dysplasia is a precancerous and/or neoplastic lesion with malignant potential. Further, it is subclassified into two grades: high-grade and low-grade dysplasia. High-grade dysplasia is a clinically significant lesion requiring resection or ablation. Low-grade dysplasia has a much lower risk of carcinoma; thus, it should be followed by endoscopic surveillance. Because squamous dysplasia may progress to squamous cell carcinoma, periodic endoscopy is useful to detect the lesion in patients with risk factors. Squamous dysplasia is diagnosed histopathologically by evaluating both cytologic and structural changes.

Increased risk of esophageal squamous cell carcinoma in patients with squamous dysplasia: a nationwide cohort study in the Netherlands

Squamous dysplasia is the histological precursor of esophageal squamous cell carcinoma (ESCC). The optimal management for distinct squamous dysplasia grades remains unclear because the corresponding risk of developing ESCC is unknown. We aimed to assess the ESCC risk in patients with esophageal squamous dysplasia in a Western country. This nationwide cohort study included all patients with esophageal squamous dysplasia, diagnosed between 1991 and 2020 in the Dutch nationwide pathology databank (Palga). Squamous dysplasia was divided in mild-to-moderate dysplasia (mild, low-grade, and moderate dysplasia) and higher-grade dysplasia (high-grade dysplasia, severe dysplasia, carcinoma in situ). ESCC were identified in Palga and the Netherlands Cancer Registry. The primary endpoint was diagnosis of prevalent (≤6 months) and incident (>6 months after squamous dysplasia) ESCC. In total, 873 patients (55% male, aged 68 years SD ± 13.2) were diagnosed with esophageal squamous dysplasia, comprising mild-to-moderate dysplasia (n = 456), higher-grade dysplasia (n = 393), and dysplasia not otherwise specified (n = 24). ESCC was diagnosed in 77 (17%) patients with mild-to-moderate dysplasia (49 prevalent, 28 incident ESCC) and in 162 (41%) patients with higher-grade dysplasia (128 prevalent, 34 incident ESCC). After excluding prevalent ESCC, the annual risk of ESCC was 4.0% (95% CI: 2.7-5.7%) in patients with mild-to-moderate dysplasia and 8.5% (95% CI: 5.9-11.7%) in patients with higher-grade dysplasia. All patients with squamous dysplasia, including those with mild-to-moderate dysplasia, have a substantial risk of developing ESCC. Consequently, endoscopic surveillance of the esophageal mucosa or endoscopic resection of dysplasia should be considered for patients with mild-to-moderate dysplasia in Western countries. KEY MESSAGES What is already known on this topic? Squamous dysplasia is the histological precursor of ESCC and is divided in distinct grades, based on the proportion of the squamous epithelium with histopathological abnormalities. In Western countries, the optimal management for distinct squamous dysplasia grades remains unclear because the corresponding risk of developing ESCC is unknown. What this study adds The ESCC risk of patients with squamous dysplasia was increased for all patients with squamous dysplasia in a Western country; 2.1% for patients with mild dysplasia, 5.1% for low-grade dysplasia, and 5.2% for moderate dysplasia. Increasing grades of squamous dysplasia were associated with an increased ESCC risk. How this study might affect research, practice, or policy We recommend that endoscopic follow-up or treatment should be considered in all patients with esophageal squamous dysplasia in Western countries: 1) for patients with mild, low-grade, and moderate dysplasia, endoscopic surveillance with careful inspection with narrow band imaging or dye-based chromoendoscopy of the esophageal mucosa is indicated; and 2) for patients with high-grade dysplasia, severe dysplasia and carcinoma in situ adequate endoscopic staging and in case of suspected neoplasia endoscopic treatment should be performed.

Identification of a nomogram based on long non-coding RNA to improve prognosis prediction of esophageal squamous cell carcinoma

PURPOSE

Esophageal squamous cell carcinoma (ESCC) remains a common aggressive malignancy in the world. Several long non-coding RNAs (lncRNAs) are reported to predict the prognosis of ESCC. Therefore, an in-depth research is urgently needed to further investigate the prognostic value of lncRNAs in ESCC.

RESULTS

From the training set, we identified a eight-lncRNA signature (including AP000487, AC011997, LINC01592, LINC01497, LINC01711, FENDRR, AC087045, AC137770) which separated the patients into two groups with significantly different overall survival (hazard ratio, HR = 3.79, 95% confidence interval, 95% CI [2.56-5.62]; P < 0.001). The signature was applied to the validation set (HR = 2.73, 95%CI [1.65-4.53]; P < 0.001) and showed similar prognostic values. Stratified, univariate and multivariate Cox regression analysis indicated that the signature was an independent prognostic factor for patients with ESCC. A nomogram based on the lncRNAs signature, age, grade and stage was developed and showed good accuracy for predicting 1-, 3- and 5-year survival probability of ESCC patients. We found a strong correlation between the gene significance for the survival time and T stage. Eight modules were constructed, among which the key module most closely associated with clinical information was identified.

CONCLUSIONS

Our eight-lincRNA signature and nomogram could be practical and reliable prognostic tools for esophageal squamous cell carcinoma.

METHODS

We downloaded the lncRNA expression profiles of ESCC patients from Gene Expression Omnibus (GEO) and The Cancer Genome Atlas (TCGA) datasets and separated to training and validation cohort. The univariate, least absolute shrinkage and selection operator (LASSO) and multivariate Cox regression analysis were used to identify a lncRNA-based signature. The predictive value of the signature was assessed using the Kaplan-Meier method, receiver operating characteristic (ROC) curves and area under curve (AUC). Weighted gene co-expression network analysis (WGCNA) was applied to predict the intrinsic relationship between gene expressions. In addition, we further explored the combination of clinical information and module construction.

The expression of podoplanin protein is a diagnostic marker to distinguish the early infiltration of esophageal squamous cell carcinoma

The esophageal squamous cell carcinoma (ESCC) is usually develped from low-grade intraepithelial neoplasia (LGIEN) and high-grade intraepithelial neoplasia (HGIEN) to infiltrative squamous cell carcinoma. Till now, it remains hard to screen for infiltration at earlier stages, especially the differentiation between HGEIN and early infiltrative carcinoma. The purpose of this study is to determine a role of podoplanin in differentiating between HGEIN and early infiltrative squamous cell carcinoma. Totally 133 patients pathologically diagnosed with early ESCC and/or precancerous lesions were enrolled.The EnVision two-step IHC staining technique was applied using the monoclonal mouse anti-human Podoplanin antibody (clone number: D2-40). The expressions of PDPN protein on the basal layer of squamous epithelium lesions could be divided into three different patterns: complete type, incomplete (non-continuous) type, or missing type. A diagnosis of HGEIN can be made if the basal layer showed non-continuous or complete expression of PDPN and a diagnosis of early infiltration can be made if the expression of PDPN is completely missing. Our study confirmed that PDPN was a potential biomarker to identify the presence of early infiltrative squamous cell carcinoma.

The importance of the concept and histological criteria of "intraepithelial squamous cell carcinoma" of the esophagus: in comparison between Western and Japanese criteria

BACKGROUND

There are differences in the histological diagnostic criteria for early stage gastrointestinal carcinoma between Western and Japanese pathologists. Western histological criteria of carcinoma are "presence of stromal invasion of neoplastic cells", while Japanese criteria are "the degree of cytological and structural abnormality of neoplastic cells, regardless of stromal invasion". The aim of the present study is to clarify and review the present status of the Western and Japanese histological criteria of early stage esophageal squamous cell carcinoma (SCC) and also to clarify their significance and accuracy.

METHODS

Twenty-nine Polish, German, and Japanese pathologists participated in this study. A total of 18 histological slides of biopsy, endoscopic submucosal dissection (ESD), and surgical resection of esophageal squamous lesions were diagnosed using a virtual slide system.

RESULTS

Most of noninvasive (intraepithelial) carcinomas diagnosed by Japanese pathologists were diagnosed as high- or low-grade dysplasia (intraepithelial neoplasia) or reactive atypia by the majority of Polish and German pathologists. Diagnoses of not only high-grade dysplasia but also low-grade dysplasia or reactive lesion by Western criteria were given for many biopsy specimens of cases in which the corresponding ESD or surgical specimens showed definite stromal invasion.

CONCLUSION

There still exist differences in the histological diagnostic criteria for early stage esophageal carcinoma between Western and Japanese pathologists. The Japanese diagnostic criteria could improve agreement of diagnoses between biopsy and resected specimens of esophageal SCC. Moreover, diagnostic approaches using Western criteria may cause delay in the early diagnosis and treatment of esophageal SCC.

A retrospective study of endoscopic resection for 368 patients with early esophageal squamous cell carcinoma or precancerous lesions

BACKGROUND

To retrospectively investigate the clinicopathological features and prognosis of early esophageal squamous cell neoplasm (ESCN) treated with endoscopic resection (ER), especially, to compare the prognosis in patients with sm2 cancer and non-sm2 cancer.

METHODS

From 2007 to 2013, 368 patients were included in our analysis.

RESULTS

The patients were 252 (68.5 %) men and 116 (31.5 %) women with a median age of 61 (range 16-84 years) years. Hyperplasia, mild dysplasia, moderate dysplasia, severe dysplasia, m1, m2, m3, sm1, and sm2 were diagnosed in 47 (12.8 %), 27 (7.3 %), 34 (9.2 %), 61 (16.6 %), 54 (14.7 %), 38 (10.3 %), 63 (17.1 %), 12 (3.3 %), and 32 (8.7 %) cases. The mean (range) follow-up time was 29 (0-84) months. The cumulative overall 1-, 3-, and 5-year metachronous esophageal lesion rates were 4.1, 12.9, and 32.6 %. The incidence of lymph node or distant metastasis was 1.54 % in m3, 6.25 % in sm2, and 0 in other subgroups. The overall 1-, 3-, and 5-year survival rates were 99.5, 97.3, and 87.5 %. There was significant difference between sm2 and non-sm2 patients in metastatic rate (P = 0.021); however, no difference existed between m3 patients and sm2 patients (P = 0.252). The difference of metachronous esophageal lesion (P = 0.401) and survival (P = 0.634) between sm2 and non-sm2 patients was not obvious.

CONCLUSIONS

Our study showed that ER was an effective and relatively safe treatment for superficial ESCN. ER is still appropriate in select sm2 patients. To monitor the second primary cancer in sm2 is necessary during the follow-up.

Clinical Outcomes of Endoscopic Submucosal Dissection for Early Esophageal Squamous Cell Neoplasms: A Retrospective Single-Center Study in China

Aims. To retrospectively analyze the clinical outcomes for a large number of endoscopic submucosal dissections (ESDs) in early esophageal squamous cell neoplasms (ESCNs) at the First Affiliated Hospital of Nanjing Medical University. Patients and Methods. From January 2010 to February 2014, 296 patients (mean age 61.4 years, range 31–85 years; 202 men) with 307 early ESCNs (79 intramucosal invasive esophageal squamous cell carcinomas (ESCCs) and 228 high-grade intraepithelial neoplasia (HGIN) cases) were included from a total of 519 consecutive patients who were treated by esophageal ESD at our hospital. The primary end points of the study were rates of en bloc resection and complete resection. Secondary end points were complications, residual and recurrence rates, and mortality during follow-up. Results. The en bloc resection rate and complete resection rate were 93.5% and 78.2%, respectively. Complications included strictures (8.4%), perforations (1.0%), and bleedings (0.7%). Twenty-seven (9.1%) patients experienced residual and 18 (6.1%) patients experienced recurrence during a mean follow-up period of 30 months. Thirteen patients died from causes unrelated to ESCC, and no cancer-related death was observed. Conclusions. Our study showed that ESD is a successful and relatively safe treatment for intramucosal invasive ESCC and HGIN, fulfilling the criteria of lymph node negative tumors. This should encourage clinicians to select ESD performed by experienced operators as a potential or even preferred treatment option for lesions amenable to endoscopic treatment.

The Molecular Analysis of Breast Cancer Utilizing Targeted Nanoparticle Based Ultrasound Contrast Agents

This study was structured to challenge the hypothesis that nano-sized particulates could be molecularly targeted and bound to the prognostic and predictive HER-2/neu cell membrane receptor to elicit detectable changes in ultrasound response from human breast cancer cells. SKBR-3 human breast cancer cells were enlisted to test the efficacy of the particle conjugation strategy used in this study and ultimately, to provide conclusive remarks regarding the validity of the stated hypothesis. A characterization-mode ultrasound (CMUS) system was used to apply a continuum mechanics based, two-step inversion algorithm to reconstruct the mechanical material properties of four cell/agarose test conditions upon three independent test samples. The four test conditions include: Herceptin® conjugated iron oxide nanoparticles bound to cells (HER-con), Herceptin® bound to cells (HER), iso-type matched antibody conjugated iron oxide nanoparticles bound to cells (ISO-con), and Cold Flow Buffer mixed with agarose (CFB). The statistical analysis of these ultrasound results supported the ability to differentiate between HER-2/neu positive SKBR-3 cells that have been successfully tagged with Herceptin® conjugated iron oxide particles to those that have not demonstrated particle binding. These findings serve as promising proof-of-concept data for the development of a quantitative histopathologic evaluation tool directed towards both in situ and in vivo applications. The ultimate goal of this research is to exploit the molecular expression of the HER-2/neu protein to offer rapid, quantitative ultrasound information concerning the malignancy rating of human breast tissue employing tumor targeting nanoparticle based ultrasound contrast agents. When fully developed, this could potentially help 32,000–63,000 women efficiently find their proper treatment strategy to fight and win their battle against breast cancer.

Abnormal cell proliferation in the p75NTR-positive basal cell compartment of the esophageal epithelium during squamous carcinogenesis

The low affinity neurotrophin receptor p75NTR is known to be expressed in the mitotically quiescent basal layer (BL) of the normal esophageal epithelium. The aim of the present study was to detect oncogenic changes in the p75NTR-positive BL during esophageal squamous carcinogenesis. The normal epithelium (NE), low-grade intraepithelial neoplasia (LGN), high-grade intraepithelial neoplasia (HGN), and esophageal squamous carcinoma (SCC), in which invasion was limited to the muscularis mucosa, were obtained from surgically removed esophagi. The expression of p75NTR, the proliferation marker ki67, hTERT, p53, and p63 was examined immunohistochemically. The expression of p75NTR was detected in these tissues with average staining indexes (number of stained cells/100 nucleated cells; SI) of 1.00, 0.99, 0.81, and 0.73, respectively. The expression of ki67 in the BL significantly increased with the progression from LGN to HGN. The expression of hTERT and p53 significantly increased with the progression from NE to LGN, and then increased in a stepwise manner in HGN and SCC, with SI (hTERT/p53) of 0.10/0.11, 0.32/0.45, 0.50/0.72, and 0.65/0.61, respectively. The expression of p63 showed no significant difference among NE, LGN, HGN, and SCC, with SI of 0.82, 0.77, 0.85, and 0.87, respectively. A correlation was observed between the expression of ki67 and p53 (P = 0.005), while a negative correlation was found between p75NTR and hTERT (P = 0.01). Our results demonstrated that phenotypic changes from quiescent to active proliferation in the p75NTR-positive BL occurred during the progression from LGN to HGN. The altered expression of hTERT and p53 in the BL was detected in LGN, which suggested that additional oncogenic events that disrupt mitotic regulation in the p75NTR-positive quiescent BL may play a crucial role in malignant transformation. Further investigations using the isolation and tracing of p75NTR-positive cells in precancerous epithelia may provide us with a better understanding of squamous carcinogenesis.

Comparative study of Western and Japanese criteria for biopsy-based diagnosis of gastric epithelial neoplasia

BACKGROUND

In Western countries, gastric cancer (GC) is diagnosed when there is histological evidence of invasion into the lamina propria or beyond the submucosa. In Japan and some other countries, however, diagnosis of GC is based on the degree of structural and cytological abnormality of tumor glands. The aim of the present study was to compare the accuracy of the Western and Japanese criteria for diagnosis of GC.

METHODS

The study included 233 consecutive patients with a postoperative diagnosis of submucosal invasive GC who underwent gastrectomy or endoscopic submucosal dissection. All pretreatment biopsy specimens were independently reviewed by two experts in gastrointestinal pathology employing both the Western and Japanese diagnostic criteria. Diagnostic agreement between pretreatment biopsy specimens and the corresponding resected specimens was evaluated, together with the interobserver agreement for each of the criteria.

RESULTS

On the basis of the Western and Japanese criteria, the pretreatment biopsy diagnosis was noncancerous (including dysplasia) in 44 lesions and 1 lesion, respectively. Diagnostic accuracy based on biopsy was 81.1% for the Western criteria and 99.5% for the Japanese criteria (P < 0.001). Interobserver agreement based on the Western and Japanese criteria was 73.8% and 96.5%, respectively (P < 0.001). Invasion into the submucosa was detected by biopsy in only 25 cases.

CONCLUSIONS

The Japanese criteria are significantly more accurate for pretreatment biopsy diagnosis of GC. The Western criteria could lead to underdiagnosis of a lesion as high-grade dysplasia, even if submucosal invasive cancer is present.

Esophageal squamous cell carcinoma with special reference to its early stage

The term 'early squamous cell carcinoma of the oesophagus', which was previously restricted to superficial carcinoma with no lymph node metastasis, now encompasses intramucosal carcinoma regardless of the nodal status. Such lesions are rare in Western countries, where the experience is limited. In recent years, the development and greater use of chromoendoscopy and narrow band imaging (NBI), both of which facilitate the evaluation of mucosal morphology, have played an important role in the detection of early esophageal squamous cell carcinoma. In addition, the techniques and indications of endoscopic resection (mucosal resection [EMR] and mucosal dissection [ESD]) are still being refined. In the present article, we will discuss the clinical and pathologic features of esophageal early squamous cell carcinoma, as well as the epidemiology and aetiology of esophageal cancer in general. In addition, we will provide a therapeutic decision tree taking into account endoscopic and surgical modalities as they apply to early esophageal squamous cell carcinoma.

Chromoendoscopy to detect early synchronous second primary esophageal carcinoma in patients with squamous cell carcinomas of the head and neck?

Objective. To evaluate the use of flexible esophagoscopy and chromoendoscopy with Lugol's solution in the detection of early esophageal carcinomas (second primary carcinomas) in patients with squamous cell carcinoma of the head and neck (HNSCC). Methods. All patients with newly diagnosed HNSCC underwent office-based Lugol's chromoendoscopy. After flexible esophagoscopy with white light, 3.0% Lugol's iodine solution was sprayed over the entire esophageal mucosa. Areas with less-intense staining (LVLs) were evaluated and biopsies taken. Results. 132 patients with HNSCC were enrolled in this study. The most frequent primary tumors were oropharyngeal (49/132), tumors of the oral cavity (36/132), and larynx (35/132). The majority of subjects (107/132 patients, 81.1%) had advanced HNSCC carcinomas (stages III and IV). Multiple LVLs were discovered in 24 subjects (18.2%) and no LVLs in 108 (81.8%) subjects. Fifty-five LVL biopsy specimens were obtained and assessed. Squamous cell carcinomas were detected in two patients, peptic esophagitis in 11 patients, gastric heterotopic mucosa in two patients, hyperplasia in two patients, and low- and high-grade dysplasia in three patients. Conclusion. Although only two patients with synchronous primary carcinomas were found among the patients, esophagoscopy should be recommended after detection of HNSCC to exclude secondary esophageal carcinoma or dysplasia.

Parameters predicting lymph node metastasis in patients with superficial esophageal squamous cell carcinoma

Endoscopic resection is a less invasive treatment than esophagectomy for superficial esophageal squamous cell carcinoma, but patients with lymph node metastasis need additional treatment after endoscopic resection. The purpose of this study was to establish a set of indicators to identify superficial esophageal squamous cell carcinoma patients at a high risk of metastasis. In all, 271 superficial esophageal squamous cell carcinoma esophagectomy cases were reviewed retrospectively. The relationships between clinicopathological parameters and immunohistochemical findings (p53, cyclin D1, EGFR and VEGF) on tissue microarrays, on the one hand, and lymph node metastasis were assessed by univariate and multivariate logistic regression analyses. Patients with intraluminal masses and ulcerated masses had a high risk of lymph node metastasis. Patients with superficial esophageal squamous cell carcinoma (1) thinner than 1200 μm; (2) confined to the mucosa; (3) with submucosal invasion <250 μm; (4) with submucosal invasion ≥250 μm but with negative VEGF expression and well/moderately differentiated or basaloid histology; or (5) with submucosal invasion ≥250 μm but with weak VEGF expression and well-differentiated histology had almost no risk of lymph node metastasis. We recommend endoscopic resection for all erosive, papillary and plaque-like superficial esophageal squamous cell carcinomas where endoscopic resection is clinically feasible, and esophagectomy for all other erosive, papillary and plaque-like cases and all intraluminal masses and ulcerated tumors. No additional treatment is needed for endoscopic resection cases with superficial esophageal squamous cell carcinoma (1) thinner than 1200 μm; (2) confined to the mucosa; (3) with submucosal invasion <250 μm; (4) with submucosal invasion ≥250 μm but with negative VEGF expression and well/moderately differentiated or basaloid histology; or (5) with submucosal invasion ≥250 μm but with weak VEGF expression and well-differentiated histology. These clinical and pathological criteria should enable more accurate selection of patients for these procedures.

Barrett's esophagus. Practical issues for daily routine diagnosis

Most clinicians and researchers agree that Barrett's esophagus (BE) is a precancerous condition which, however, is not easily defined. Whether goblet cells must be present or not is a matter of debate and definitions vary worldwide. Although the use of the term "columnar metaplasia" tends to circumvent these issues, it can also be subdivided into those with and without goblet cells. There is some evidence that Barrett's esophagus results from a multistep process in which goblet cells are a secondary event. Hence, Barrett's adenocarcinoma has recently been shown to originate from areas lacking goblet cells. The histological diagnosis of neoplasia is often hampered by marked interobserver variation. New endoscopic techniques allow for local resections of neoplasia with curative intent. Pathologists should know which pieces of information gastroenterologists need for management options: surveillance versus therapy such as endoscopic resection with or endoscopic ablation without histological specimen. The most important information for gastroenterologists is whether there is neoplasia or not; if any, they need to know the grade (low grade, high grade, carcinoma) and risk factors (vessel permeation, poor differentiation, resection complete in case of endoscopic resection, depth of infiltration).

Endoscopic submucosal dissection for early esophageal neoplasia: a single center experience in South Taiwan

BACKGROUND/PURPOSE

Endoscopic submucosal dissection (ESD) is an advanced endoscopic procedure to resect early gastrointestinal neoplasm. It is technically more difficult and risky when used to treat early esophageal tumors. We report our experiences related to performing ESD for early esophageal neoplasia. The efficacy, complications, and outcome were also analyzed.

METHODS

From December 2007 to April 2010, 22 patients with documented early esophageal neoplasm underwent ESD. All patients completed a meticulous endoscopic examination using conventional endoscopy followed by narrow-band imaging. Lugol's staining was performed to identify the margin of the suspicious lesion. Insulation-tipped diathermic knife 2 was used for ESD.

RESULTS

A total of 26 neoplastic lesions (including 13 tumors with high-grade dysplasia, 12 tumors with squamous cell carcinoma, and one tumor with adenocarcinoma) in 22 patients were enrolled. All patients were men. The mean age was 47.6 ± 8.6 years (range, 30-68 years). The mean size of tumors was 33.7 ± 21.7 mm (range, 8-80 mm). ESD was performed for 24 lesions in 20 patients. The mean size of resected specimens was 43.1 ± 19.2 mm (range, 15-90 mm). The mean operation time was 92.7 ± 69 minutes (range, 30-310 minutes). There were three ESD-related complications, including one with delayed bleeding, one with subcutaneous emphysema, and one with perforation. Two patients received additional operations after ESD due to deep submucosal invasion by cancer. Three lesions in two patients (12.5%) developed post-ESD esophageal stricture that needed repeated endoscopic bougination. There was no procedure-related mortality. No local recurrence was found during the follow-up period.

CONCLUSION

ESD is a promising local curative treatment option for early esophageal neoplasia in Taiwan. However, this procedure may result in complications that are worth noting, especially post-ESD esophageal stricture. Education regarding this procedure and more hands-on training will facilitate endoscopists to improve the outcomes of patients undergoing this procedure.

Development of squamous neoplasia in esophageal iodine-unstained lesions and the alcohol and aldehyde dehydrogenase genotypes of Japanese alcoholic men

We investigated the development of esophageal neoplasia in biopsy specimens of the distinct iodine-unstained lesions (DIULs) ≥ 5 mm detected in 280 of 2,115 Japanese alcoholic men who underwent screening by esophageal iodine staining. Low-grade intraepithelial neoplasia (LGIN) was diagnosed in 155 of them, high-grade intraepithelial neoplasia (HGIN) in 57, and invasive SCC in 35. The size of the DIULs increased with the degree of neoplasia. Most LGINs were flat and were missed before iodine staining. Some DIULs became a light pink color (PC) about 2 min after staining, and 2.6, 56.1 and 96.0% of the LGIN, HGIN and invasive SCC lesions, respectively, were PC-sign-positive. Multiple DIULs of any size markedly increased the risk of LGIN [adjusted OR (95%CI) = 10.1 (7.12-14.5)], HGIN [27.9 (14.6-53.4)] and invasive SCC [21.6 (10.1-46.4)], and were strongly associated with the presence vs. absence of DIULs ≥ 5 mm [13.3 (9.21-19.1)], inactive heterozygous aldehyde dehydrogenase-2 (ALDH2*1/*2) vs. ALDH2*1/*1 [2.60 (1.79-3.78)], and less-active alcohol dehydrogenase-1B (ADH1B*1/*1) vs. ADH1B*2 allele [2.61 (1.87-3.64)]. The combination of ALDH2*1/*2 and ADH1B*1/*1 synergistically increased the risk of LGIN [4.53 (2.17-9.47)], HGIN [10.4 (4.34-24.7)] and invasive SCC [21.7 (7.96-59.3)]. Esophageal neoplasia developed at earlier ages in those with ALDH2*1/*2. Biopsy-proven HGIN was diagnosed as invasive SCC in 15 (39.5%) of 38 patients after endoscopic mucosectomy or surgery. In conclusion, large size, non-flat appearance, positive PC sign and multiplicity of DIULs and ALDH2*1/*2 and ADH1B*1/*1 were associated with development of esophageal neoplasia in Japanese alcoholics. Biopsy-proven HGIN should be totally resected for both diagnostic and therapeutic purposes.

Multi-susceptibility genes associated with the risk of the development stages of esophageal squamous cell cancer in Feicheng County

BACKGROUND

The purpose of this study was to evaluate the association of multi-genotype polymorphisms with the stepwise progression of esophageal squamous cell cancer (ESCC) and the possibility of predicting those at higher risk.

METHODS

A total of 1,004 subjects were recruited from Feicheng County, China, between Jan. 2004 and Dec. 2007 and examined by endoscopy for esophageal lesions. These subjects included 270 patients with basal cell hyperplasia (BCH), 262 patients with esophageal squamous cell dysplasia (ESCD), 226 patients with ESCC, and 246 controls with Lugol-voiding area but diagnosed as having normal esophageal squamous epithelial cells by histopathology. The genotypes for CYP2E1 G1259C, hOGG1 C326G, MTHFR C677T, MPO G463A, and ALDH2 allele genes were identified in blood samples collected from all participants.

RESULTS

The alleles ALDH2 and MTHFR C677T were critical for determining individual susceptibility to esophageal cancer. Compared to the ALDH 1*1 genotype, the ALDH 2*2 genotype was significantly associated with increased risks of BCH, ESCD, and ESCC. However, the TT genotype of MTHFR C677T only increased the risk of ESCC. Further analysis revealed that the combination of the high-risk genotypes 2*2/1*2 of ALDH 2 and TT/TC of MTHFR C677T increased the risk of BCH by 4.0 fold, of ESCD by 3.7 fold, and ESSC by 8.72 fold. The generalized odds ratio (ORG) of the two combined genotypes was 1.83 (95%CI: 1.55-2.16), indicating a strong genetic association with the risk of carcinogenic progression in the esophagus.

CONCLUSIONS

The study demonstrated that the genotypes ALDH2*2 and MTHFR 677TT conferred elevated risk for developing esophageal carcinoma and that the two susceptibility genotypes combined to synergistically increase the risk.

Multi-susceptibility genes associated with the risk of the development stages of esophageal squamous cell cancer in Feicheng County

Background

The purpose of this study was to evaluate the association of multi-genotype polymorphisms with the stepwise progression of esophageal squamous cell cancer (ESCC) and the possibility of predicting those at higher risk.

Methods

A total of 1,004 subjects were recruited from Feicheng County, China, between Jan. 2004 and Dec. 2007 and examined by endoscopy for esophageal lesions. These subjects included 270 patients with basal cell hyperplasia (BCH), 262 patients with esophageal squamous cell dysplasia (ESCD), 226 patients with ESCC, and 246 controls with Lugol-voiding area but diagnosed as having normal esophageal squamous epithelial cells by histopathology. The genotypes for CYP2E1 G1259C, hOGG1 C326G, MTHFR C677T, MPO G463A, and ALDH2 allele genes were identified in blood samples collected from all participants.

Results

The alleles ALDH2 and MTHFR C677T were critical for determining individual susceptibility to esophageal cancer. Compared to the ALDH 1*1 genotype, the ALDH 2*2 genotype was significantly associated with increased risks of BCH, ESCD, and ESCC. However, the TT genotype of MTHFR C677T only increased the risk of ESCC. Further analysis revealed that the combination of the high-risk genotypes 2*2/1*2 of ALDH 2 and TT/TC of MTHFR C677T increased the risk of BCH by 4.0 fold, of ESCD by 3.7 fold, and ESSC by 8.72 fold. The generalized odds ratio (OR_G) of the two combined genotypes was 1.83 (95%CI: 1.55-2.16), indicating a strong genetic association with the risk of carcinogenic progression in the esophagus.

Conclusions

The study demonstrated that the genotypes ALDH2*2 and MTHFR 677TT conferred elevated risk for developing esophageal carcinoma and that the two susceptibility genotypes combined to synergistically increase the risk.

Clinical impact of narrow-band imaging magnifying endoscopy for 'basal layer type squamous cell carcinoma' in the esophagus

A 61-year-old man had received endoscopic submucosal dissection (ESD) for early gastric cancer twice. Then he had undergone annual control esophagogastroduodenoscopy using narrow-band imaging (NBI) magnifying endoscope. At the esophagogastroduodenoscopy, we were not able to detect any significant finding in the esophagus by conventional endoscopy. Switching to NBI mode, a brownish area was showed in the middle esophagus. The lesion showing the brownish area was predicted to be mucosal squamous cell carcinoma (SCC) as a result of assessment of morphologic change of intraepithelial papillary capillary loop under magnifying NBI observation. Lugol chromoendoscopy displayed the lesion as unstained area corresponding to the brownish area visualized by NBI. The ESD was performed for the lesion. Histology from ESD specimen showed SCC with minimal invasion to lamina propria at multifocal sites. The SCC was surrounded by low-grade intraepithelial neoplasia. Most of the SCC showed a high degree of cytological and architectural atypia confined to the lower half of the epithelium. The type of SCC was called as 'basal layer type SCC' mainly by Japanese pathologists. We suggest that magnifying NBI endoscopy can be useful for detecting and diagnosing 'basal layer type SCC'.

A study of indefinite for dysplasia in Barrett's oesophagus: reproducibility of diagnosis, clinical outcomes and predicting progression with AMACR (alpha-methylacyl-CoA-racemase)

AIMS

To assess interobserver variation in the diagnosis of dysplasia in Barrett's oesophagus, especially indefinite dysplasia (IND) using the revised Vienna classification. A secondary aim was to study clinical outcome of IND cases and to evaluate expression of alpha-methyl-CoA racemase (AMACR) as a marker predictive of progression.

METHODS AND RESULTS

Cases of Barrett's oesophagus and dysplasia over a 20 year period were assessed. Three experienced histopathologists reviewed 101 cases on set criteria in a blinded fashion. Slides were immunostained for AMACR and evaluated for the presence, extent and location of AMACR expression. Clinical and progression data were collected. Overall agreement for the diagnosis of dysplasia was fair (k = 0.35) but that for IND was poor (k = 0.18). 6 IND cases progressed after a median follow-up of 31.4 months to a higher grade. The sensitivity of AMACR for the detection of abnormality was 22% for IND and specificity 100%. The positive predictive value of AMACR for progression was 0.44 and the negative predictive value was 0.92.

CONCLUSION

Fair agreement was achieved for the diagnosis of dysplasia but poor agreement for IND. A proportion of IND cases progress. Re-diagnosis or consensus diagnosis did not predict progression. AMACR shows promise as a marker to indicate IND patients in need of more intensive surveillance.

Neoplasia without dysplasia: lessons from Barrett esophagus and other tubal gut neoplasms

CONTEXT

Classic pathology teaching emphasizes that neoplastic lesions of the gastrointestinal tract are characterized by architectural and cytologic abnormalities that distinguish it from normal tissue. Recent studies suggest that many important-and in some cases clonal-molecular abnormalities that lead to dysregulation of cell proliferation and differentiation (neoplasia) occur before morphologic expression of dysplasia.

OBJECTIVE

To summarize the biologic and pathologic features of preneoplastic conditions of the tubal gut that reveal evidence of neoplastic alteration, but without the traditional morphologic features of dysplasia, in order to provide guidance on how to identify these lesions. Particular attention is given to Barrett esophagus, a chronic inflammatory condition in which early molecular and morphologic events that drive carcinogenesis are best understood.

DATA SOURCES

Selected references and abstracts were obtained by a PubMed (US National Library of Medicine) search by using the search headings neoplasia, preneoplasia, dysplasia, adenoma, serrated polyps, and Barrett's esophagus between the years 1980 and 2009.

CONCLUSIONS

Many types of lesions throughout the tubal gut fulfill the most basic and classic principles of a neoplastic precursor lesion but lack conventional morphologic evidence of dysplasia and/or maintain the capacity for cell differentiation and maturation. All of these lesions, such as squamous dysplasia of the esophagus, dysplasia in Barrett esophagus, and hyperplastic/serrated polyps of the colon, represent early neoplastic precursor lesions but without conventional histologic features of dysplasia. It is important for pathologists to be aware of these lesions, both for diagnostic and prognostic purposes, but also so that future studies can be performed with regard to risk stratification of patients.

The pattern of invasion of early carcinomas in Barrett's esophagus is dependent on the depth of infiltration

The differential diagnosis "high-grade intraepithelial neoplasia" or "well-differentiated Barrett's adenocarcinoma limited to the mucosa" is controversial. We investigated 277 endoscopically resected specimens of early Barrett's carcinoma. Depth of infiltration was classified as follows: m 1=carcinoma limited to Barrett's mucosa; m 2=carcinoma infiltrating the neo-muscularis mucosae; m 3=infiltration of the original lamina propria of the esophageal mucosa; m 4=infiltration of the original muscularis mucosae; sm 1, sm 2, and sm 3=infiltration into the upper third, middle third, and lower third of the submucosa. The pattern of invasion was classified and graded as follows: tubular (D 0)=only neoplastic tubuli showing cytologic criteria of malignancy - no tumor cell dissociation; dissociation grade 1 (D 1)=few dissociated tumor cells; D 2=moderate amount of dissociated tumor cells; D 3=pronounced tumor cell dissociation. 74-96% of m 1-m 4 Barrett's carcinomas limited to the mucosa have a D 0-pattern. Tubular invasion decreases only when the submucosa has been infiltrated (sm 1: 70.4%, sm 2: 30.0%, sm 3: 24.0%). Our study shows that the pattern of invasion in early cancer in Barrett's esophagus statistically significantly depends on depth of infiltration.

Early detection of superficial squamous cell carcinoma in the head and neck region and esophagus by narrow band imaging: a multicenter randomized controlled trial

PURPOSE

Most of the esophageal squamous cell carcinomas (ESCCs) and cancers of the head and neck (H&N) region are diagnosed at later stages. To achieve better survival, early detection is necessary. We compared the real-time diagnostic yield of superficial cancer in these regions between conventional white light imaging (WLI) and narrow band imaging (NBI) in high-risk patients.

PATIENTS AND METHODS

In a multicenter, prospective, randomized controlled trial, 320 patients with ESCC were randomly assigned to primary WLI followed by NBI (n = 162) or primary NBI followed by WLI (n = 158) in a back-to-back fashion. The primary aim was to compare the real-time detection rates of superficial cancer in the H&N region and the esophagus between WLI and NBI. The secondary aim was to evaluate the diagnostic accuracy of these techniques.

RESULTS

NBI detected superficial cancer more frequently than did WLI in both the H&N region and the esophagus (100% v 8%, P < .001; 97% v 55%, P < .001, respectively). The sensitivity of NBI for diagnosis of superficial cancer was 100% and 97.2% in the H&N region and the esophagus, respectively. The accuracy of NBI for diagnosis of superficial cancer was 86.7% and 88.9% in these regions, respectively. The sensitivity and accuracy were significantly higher using NBI than WLI in both regions (P < .001 and P = .02 for the H&N region; P < .001 for both measures for the esophagus, respectively).

CONCLUSION

NBI could be the standard examination for the early detection of superficial cancer in the H&N region and the esophagus.

Pathology and pathobiology of the oesophageal carcinoma

Carcinoma of the oesophagus including carcinoma of gastro-oesophageal junction are rapidly increasing in incidence. During recent years there have been changes in the knowledge surrounding biology of the disease progression. Identification of dysplasia in mucosal biopsies is the most reliable pathologic indicator of an increased risk of development of squamous cell carcinoma and passes through the sequence of chronic esophagitis, low-grade and high-grade dysplasia and invasive carcinoma. Although Barrett's esophagus is a precursor to esophageal adenocarcinoma and have a well described sequence of carcinogenesis: the Barrett's metaplasia-dysplasia-adenocarcinoma sequence, not all patients with this disorder require intensive surveillance. The natural history of dysplasia is poorly understood, particularly in low-risk regions, and prospective follow-up studies are needed. Adjunctive methods to improve reproducibility, such as immunostaining for alpha-methylacyl-coenzyme A racemase (AMACR), show promise, but require confirmation in larger studies. In addition, several controversial methods such as detection of p16, p53, and DNA content abnormalities may help identify patients at particularly high risk for progression to cancer, but these techniques are not yet widely available for routine clinical application. More studies are needed to define other early nonmorphologic biomarkers for risk of squamous cell carcinoma. Recent evidence regarding the importance of several histopathologically derived prognostic factors, such as circumferential resection margin status and lymph node metastases are evaluated, including lymph node micrometastases and the sentinel node concept. With the rising use of multimodal treatments for oesophageal cancer it is important that the response of the tumour to this therapy can be carefully documented by histopathology.

Squamous intraepithelial neoplasia of the esophagus: past, present, and future

With regard to the esophagus, the term "squamous dysplasia" has been used in European countries, the United States, and China, while its use is controversial in Japan. Recently, "low-grade intraepithelial neoplasia" and "high-grade intraepithelial neoplasia" have been used as inclusive terms for dysplasia and carcinoma in situ in the World Health Organization classification. Endoscopically, it is often difficult to identify squamous intraepithelial neoplasia by conventional endoscopy, but application of iodine is useful for the diagnosis of such a lesion. In addition, new types of endoscopic techniques, including magnifying endoscopy, narrow-band imaging (NBI), and endocytoscopy are helpful to detect squamous intraepithelial neoplasia. NBI is very useful for identifying the intrapapillary capillary loop pattern. Regarding the pathological criteria of squamous dysplasia and squamous cell carcinoma, the views of Japanese and Western pathologists have differed significantly. Before the term "intraepithelial neoplasia" was introduced, severe dysplasia as diagnosed by Western pathologists was in fact the same as squamous cell carcinoma in situ or noninvasive carcinoma as diagnosed by Japanese pathologists. This problem has been solved by the introduction of the Vienna classification; however, there are still some issues that need to be resolved. One of them is the presence of basal layer type squamous cell carcinoma in situ, which is often underdiagnosed as lowgrade intraepithelial neoplasia by Western pathologists. Endoscopic treatments such as endoscopic mucosal resection and endoscopic submucosal dissection have recently become possible choices for squamous intraepithelial neoplasia; however, these techniques are not in widespread use in the West. We believe that a consensus meeting between Japanese and Western pathologists as well as endoscopists should be held promptly to reach a common ground for the nomenclature.

[Dysplasia in glandular digestive tissues: new concepts, new classifications]

The term of dysplasia is currently used to designate morphological alterations, identifiable at microscopic examination, revealing the existence of an unequivocally neoplastic process, at an early, non-invasive, stage of its natural history. The pathologist bears the full responsibility for the diagnosis of dysplasia, based on a broad spectrum of cytological and architectural abnormalities. It is important to grade the severity of the dysplastic lesions, in order to help guide clinical management and choose the therapeutic strategy. The Vienna classification, proposed in 2000 as a compromise between the Western and Japanese concepts, is now used for classification and grading of digestive epithelial dysplasia. The major advantages of the Vienna classification are the use of uniform terminology worldwide, achievement of good diagnostic reproducibility between pathologists and clear and consensual clinical consequences. Its use is strongly supported by the recent international recommendations.

Risk factors of lymph node metastasis in T1 esophageal squamous cell carcinoma

BACKGROUND AND AIM

To perform endoscopic mucosal resection (EMR) for T1 esophageal cancer, it is essential to estimate the lymph node status exactly. In order to evaluate the feasibility of EMR for esophageal cancers, we evaluated the clinicopathological features of T1 esophageal squamous carcinomas with an emphasis on the risk factors and distribution patterns of lymph node metastasis.

METHODS

From 1994 to 2006, a total of 200 patients with T1 esophageal carcinoma were treated surgically in our institution. Among them, clinicopathological features were evaluated for 197 consecutive patients with T1 squamous cell carcinoma.

RESULTS

The frequency of lymph node involvement was 6.25% (4/64) in mucosal cancers and 29.3% (39/133) in submucosal cancers (P < 0.001). In patients with M1 (n = 32) and M2 (n = 14) cancers, no lymph node metastasis was found. In multivariate analysis, size larger than 20 mm, endoscopically non-flat type, and endo-lymphatic invasion were significant independent risk factors for lymph node metastasis. The differentiation of tumor cell was not a risk factor for lymph node metastasis.

CONCLUSIONS

We suggest that EMR may be attempted for flat superficial squamous esophageal cancers smaller than 20 mm. After EMR, careful histological examination is mandatory.

Squamous dysplasia and other precursor lesions related to esophageal squamous cell carcinoma

Squamous cell carcinoma is the most common tumor of the esophagus worldwide, and it is believed to develop through a sequence of dysplastic precursor lesions, which can be detected both endoscopically and microscopically. There are no published guidelines regarding treatment for dysplasia; however, most authorities recommend increased endoscopic surveillance, with biopsies, for patients with flat low-grade dysplasia and endoscopic mucosal resection, endoscopic submucosal dissection, or esophagectomy for patients with high-grade dysplasia. Future studies are needed to define appropriate endoscopic surveillance frequencies for patients with premalignant lesions of the esophagus. This article discusses squamous dysplasia in detail, which is the most important and well-described risk factor for squamous cell carcinoma of the esophagus.

Early squamous cell carcinoma of the oesophagus: the Japanese viewpoint

In Japan, more than 90% of oesophageal malignancies are squamous cell carcinomas, and superficial and early carcinomas now account for about 40% and 20%, respectively, of all oesophageal carcinomas. Definition of early carcinoma has changed on the basis of new data. As of 2007, early carcinoma is defined as intramucosal carcinoma with or without metastasis. In the subclassification based on depth of cancer invasion, m1 and m2 carcinomas have no metastasis and are considered curable by endoscopic mucosal resection alone, whereas < 10% of m3 carcinomas and about 20% of sm1 carcinomas have lymph node metastasis. The relationship between various pathological findings and the incidence of lymph node metastasis has been reviewed. High-grade squamous dysplasia (squamous cell carcinoma in situ in Japan) requires surgical or endoscopic removal. Very minute carcinomas have recently been detected by magnifying endoscopy and/or narrowband imaging. Endocytoscopy could replace biopsy histopathological examination for diagnosis of oesophageal squamous cell carcinoma, and endocytoscopic diagnosis and endoscopic therapy may be performed simultaneously. As a result of advances in the development of endoscopes, pathologists are now expected to diagnose very minute lesions, < 1 mm in size, in the oesophagus.

Pathology of early upper GI cancers

Local endoscopic resection techniques for early neoplasms of the gastro-intestinal tract require exact description of the depth of infiltration for the decision of endoscopic versus surgical therapy. Subdivision of mucosal neoplasms is used only in the oesophagus. Mucosal oesophageal carcinoma (squamous cell carcinoma and adenocarcinoma) can be subdivided into m1-m3 and m1-m4. Distinction of high-grade intraepithelial neoplasia and mucosal carcinoma is without clinical relevance since the diagnosis of high-grade intraepithelial neoplasia should always first lead to a (diagnostic) endoscopic resection. The final histological diagnosis could then be made on the resection specimen. Diagnosis of low-grade intraepithelial neoplasia is often confused with regenerative changes. Histological diagnoses of early neoplasms are not the same worldwide and consensus should be improved further.

Endoscopic therapy of early gastric cancer

Endoscopic therapy of early gastric cancer is applicable for differentiated-type mucosal carcinomas that have an extremely low potency of lymph-node metastasis. Among various kinds of endoscopic therapy, endoscopic mucosal resection is the most recommended procedure, because pathological evaluation of affected tissues is available using this method. Recently, endoscopic submucosal dissection, a novel method of endoscopic mucosal resection, has gained interest as a more reliable therapeutic procedure. In the present chapter several issues will be presented on endoscopic therapy for early gastric cancer, including endoscopic diagnosis of early gastric cancer, currently accepted indications of endoscopic therapy, and the possibility of extending the indication and techniques used for mucosal resection.

Novel endoscopic therapies for gastrointestinal malignancies: endoscopic mucosal resection and endoscopic ablation

Gastrointestinal malignancies are often detected at advanced stages when the prognosis is poor. Screening guidelines that vary accord-ing to the regional disease prevalence are needed. High-resolution endoscopy, magnification endoscopy, chromoendoscopy, light autofluorescence endoscopy, and optical coherence tomography are new technologies designed to improve endoscopic detection. Once detected, lesions must be accurately staged, including depth of mucosal penetration and lymph node involvement, to determine endoscopic resectability. Widely applicable, relatively safe, and minimally invasive alternatives to surgery are needed. Endoscopic mucosal resection and endoscopic ablation are potentially curative for malignancies limited to the mucosa, obviating the need for surgery in these patients.

Prognostic value and interobserver agreement of endoscopic ultrasonography for superficial squamous cell carcinoma of the esophagus: a prospective study

BACKGROUND AND AIMS

Submucosal invasion of superficial esophageal cancer (SEC) is related to the prognosis. We prospectively analyzed outcomes of SEC in patients staged by endoscopic ultrasonography (EUS).

PATIENTS AND METHODS

We staged 31 endoscopically diagnosed SEC cases using a 20/15-MHz thin probe. The EUS tumor stage was classified as EUSM (limited within mucosa), EUS-SM (with submucosal invasion), or EUS-MP over (invading the muscularis propria or deeper). Lymph node metastasis and 2-yr survival were analyzed according to the EUS tumor stage in 29 squamous cell carcinoma cases. Interobserver agreement of the EUS stage was tested between the examiner and a blind reviewer.

RESULTS

Lymph node metastasis was significantly frequent in the EUS-SM group (8 of 18 cases [44.4%]) compared with the EUS-M group (1 of 10 cases [10%]) (p = 0.03). Patient survival at 2 yr after initial therapy was 72.2% in the EUS-SM group and 90% in the EUS-M group. Death from cancer was noted only in the EUS-SM group (three cases). The accuracy rates of EUS tumor staging were 74.1% by the examiner and 66.7% by the blind reviewer, with moderate interobserver agreement (kappa = 0.46).

CONCLUSIONS

Thin-probe EUS can classify SEC into two groups: the EUS-M group with excellent outcome and the EUS-SM group with a significant risk of lymph node metastasis.

Local endoscopic therapy for intraepithelial high-grade neoplasia and early adenocarcinoma in Barrett's oesophagus: acute-phase and intermediate results of a new treatment approach

BACKGROUND

Radical oesophageal resection has until now been regarded as the gold standard for treatment in intraepithelial high-grade neoplasia or early adenocarcinoma of the oesophagus. However, the mortality and morbidity rates are substantial.

DESIGN

A new therapeutic approach involving low-risk endoscopic therapy modalities was examined in the framework of a prospective study.

PATIENTS

A total of 115 patients with intraepithelial high-grade neoplasia (19) and early adenocarcinoma (96) in Barrett's oesophagus.

METHODS

Endoscopic mucosal resection (EMR) was used in 70 patients, and photodynamic therapy (PDT) was used in 32 patients. The two procedures were combined in ten patients. Three patients underwent primary treatment with argon plasma coagulation (APC). The average follow-up was 34 +/- 10 months (range 24-60 months).

RESULTS

Complete local remission was achieved in 98%. The overall complication rate was 9.5%. Major complications, such as perforation and severe bleeding, did not occur. Minor complications included not haemoglobin relevant bleeding (drop of haemoglobin less than 2 g/dl) (5) and stenosis (3) after EMR, and long-lasting odynophagia (1) and sunburn (2) after PDT. In all, 13 patients have died so far, but in only one case due to the underlying disease. The calculated overall 3-year survival rate is 88%. During the follow-up period, a 30% rate of metachronous lesions was observed; endoscopic therapy was performed successfully in all but one of these patients.

CONCLUSIONS

These good acute-phase and intermediate results, along with low morbidity rates and no mortality, suggest that the organ-preserving local endoscopic procedure including EMR and PDT is an attractive alternative to oesophageal resection. Therefore, endoscopic therapy might replace radical oesophageal resection in future in cases of intraepithelial high-grade neoplasia and early mucosal adenocarcinoma in Barrett's oesophagus.

Screening for oesophageal neoplasia in patients with head and neck cancer

Due to advanced disease at the time of diagnosis the prognosis of oesophageal cancer is generally poor. As mass screening for oesophageal cancer is neither feasible nor reasonable, high-risk groups should be identified and surveilled. The aim of this study was to define the risk of oesophageal cancer in patients with (previous) head and neck cancer. A total of 148 patients with (previous) head and neck cancer were prospectively screened for oesophageal cancer by video-oesophagoscopy and random oesophageal biopsies. Even in a macroscopically normal looking oesophagus, four biopsy specimens were taken every 3 cm throughout the entire length of the squamous oesophagus. Low- or high-grade squamous cell dysplasia was detected histologically in 10 of the 148 patients (6.8%). All but one dysplasias were diagnosed synchronously with the head and neck cancers. In addition, oesophageal squamous cell carcinoma was diagnosed in 11 of the 148 patients (7.4%). Most invasive cancers (63.6%) occurred metachronously. The risk of squamous cell neoplasia of the oesophagus is high in patients with (previous) head and neck cancer. Surveillance is recommended in this high-risk group.

Interobserver variability associated with the MIB-1 labeling index: high levels suggest limited prognostic usefulness for patients with primary brain tumors

BACKGROUND

The use of the MIB-1 labeling index (LI) as a potential prognostic marker for patients with primary brain tumors is controversial. Many studies advocating its prognostic usefulness have suggested discrete MIB-1 LI cut-off values, above which patients have significantly worse outcomes. However, interobserver variability associated previously with MIB-1 LI calculation has not been reported despite the fact that the degree of interobserver variability impacts the clinical usefulness of such cut-off values.

METHODS

MIB-1 LIs were calculated independently using a standardized protocol by six pathologist observers for 50 astrocytic gliomas of varying grades. The level of interobserver agreement was determined by calculating kappa statistics for pairwise pathologist comparisons using MIB-1 LI cut-off values of 2.5%, 5.0%, 8.0%, 11.0%, and 15.0%. Spearman rank correlation coefficients were used to assess the pairwise associations between observer MIB-1 LIs.

RESULTS

Although there was general agreement among pathologists regarding whether an MIB-1 LI for a given astroglial tumor was low, moderate, or high based on the analysis of correlation, a high level of interobserver variability was associated with the determination of specific MIB-1 LIs. The highest level of agreement occurred using a cut-off value of 5.0%, with pairwise kappa statistics for this value ranging from 0.52 to 0.80.

CONCLUSIONS

The high level of interobserver variability suggests that proposed discrete MIB-1 LI prognostic cut-off values most likely are not useful clinically for predicting outcome for individual patients with primary brain tumors. Further prospective studies are needed investigating the prognostic usefulness of MIB-1 LI ranges that optimize interobserver agreement.