Diagnostic performance of routine esophagogastroduodenoscopy using magnifying endoscope with narrow-band imaging for gastric cancer

Magnifying image-enhanced endoscopy-only mode boosted early cancer diagnostic efficiency: a multicenter randomized controlled trial

BACKGROUND AND AIMS

Magnifying image-enhanced endoscopy (MIEE) is an advanced endoscopy with image enhancement and magnification used in preoperative examination. However, its impact on the detection rate is unknown.

METHODS

We conducted an open-label, randomized, parallel (1:1:1), controlled trial in 6 hospitals in China. Patients were recruited between February 14, 2022 and July 30, 2022. Eligible patients were aged ≥18 years and undergoing gastroscopy in outpatient departments. Participants were randomly assigned to the MIEE-only mode (o-MIEE) group, white-light endoscopy-only mode (o-WLE) group, and MIEE when necessary mode (n-MIEE) group (initial WLE followed by switching to another endoscope with MIEE if necessary). Biopsy sampling of suspicious lesions of the lesser curvature of the gastric antrum was performed. Primary and secondary aims were to compare detection rates and positive predictive value (PPV) of early cancer and precancerous lesions in these 3 modes, respectively.

RESULTS

A total of 5100 recruited patients were randomly assigned to the o-MIEE (n = 1700), o-WLE (n = 1700), and n-MIEE (n = 1700) groups. In the o-MIEE, o-WLE, and n-MIEE groups, 29 (1.51%; 95% confidence interval [CI], 1.05-2.16), 4 (.21%; 95% CI, .08-.54), and 8 (.43%; 95% CI, .22-.85) early cancers were found, respectively (P < .001). The PPV for early cancer was higher in the o-MIEE group compared with the o-WLE and n-MIEE groups (63.04%, 33.33%, and 38.1%, respectively; P = .062). The same trend was seen for precancerous lesions (36.67%, 10.00%, and 21.74%, respectively).

CONCLUSIONS

The o-MIEE mode resulted in a significant improvement in diagnosing early upper GI cancer and precancerous lesions; thus, it could be used for opportunistic screening. (Clinical trial registration number: ChiCTR2200064174.).

Magnifying endoscopy is superior at detecting easy-missed neoplastic lesions on the upper gastrointestinal tract

Magnifying endoscopy is advantageous in detecting precancerous lesions. Our study aimed to clarify its ability to detect easily missed neoplastic lesions on the upper gastrointestinal tract. A retrospective analysis of clinical, endoscopic, and pathological data of cases undergoing gastroscopy was performed using magnifying and routine endoscopy. The detection rates of overall lesions, the ability to identify flat-type neoplastic lesions, and the easily missed neoplastic lesions were compared between the two groups. Endoscopic data from 32,367 patients was analyzed in this study. The use of magnifying endoscopy was an independent factor in identifying flat lesions (OR 2.236, 95% CI 1.969-2.540, p < 0.001), particularly type IIb lesions (OR 3.117, 95% CI 2.333-4.165, p < 0.001). For neoplastic lesions, magnifying endoscopy was also identified as having better sensitivity than routine endoscopy (sensitivity, 90.4% vs. 78.9%, p < 0.001). Similarly, magnifying endoscopy was an independent factor for identifying flat lesions (OR 2.927, 95% CI 2.365-3.621, p < 0.001), especially type IIc lesions (OR 4.415, 95% CI 3.076-6.339, p < 0.001). Magnifying endoscopy was also identified as having superior sensitivity (44.7% vs. 13.3%, p = 0.034) for early cancerous lesions. Compared to routine endoscopy, magnification endoscopy is advantageous in detecting and identifying neoplastic lesions in the upper gastrointestinal tract, especially flat neoplastic lesions and early cancers.

Value of serum pepsinogen, gastrin, and cadherin-17 detection combined with narrowband imaging magnifying endoscopy in distinguishing early gastric cancer and precancerous lesions

BACKGROUND

The early screening of cancer has always been the focus of cancer research. As a common cancer in the world, gastric cancer has had a high incidence rate and mortality for many years, and canceration is difficult to detect. Current detection methods are not ideal for early detection of gastric cancer and precancerous lesions.

AIM

To assess the value of detection of serum pepsinogen (PG), gastrin (G-17), and hepato-intestinal cadherin-17 (CDH-17) combined with narrowband imaging magnifying endoscopy in the identification of early gastric cancer and precancerous lesions.

METHODS

The clinical data of patients with early gastric cancer (106 cases) and precancerous lesions (134 cases) at our hospital from January 2018 to January 2021 were retrospectively analyzed. All patients underwent narrow-band imaging magnifying endoscopy and detection of serum PG (including PGⅠ and PGⅡ), G-17, and CDH-17 levels. The sensitivity, specificity, and accuracy of PG, G-17, CDH-17, and narrow-band imaging magnifying endoscopy, alone and in combination, in the diagnosis of early gastric cancer and precancerous lesions were calculated.

RESULTS

In the early gastric cancer group, the incidence of lesions with border limits, mucosal microvascular irregularities, irregular surface ducts, and increased glandular spacing as detected by narrow-band imaging magnifying endoscopy was higher than that in the precancerous lesion group (P < 0.05). The diagnostic coincidence rates of magnifying endoscopy for early gastric cancer and precancerous lesions were 83.02% and 85.07%, respectively, and the difference was not statistically significant (P > 0.05). Serum PGⅠ level in the early gastric cancer group was lower than that of the precancerous lesion group, but there was no significant difference in serum PGⅡ between the two groups (P > 0.05); serum G-17 and CDH-17 levels were higher than those of the precancerous lesion group (P < 0.05). There was no statistically significant difference in the diagnostic coincidence rates of serum PGI, G-17, and CDH-17 alone (P > 0.05). The sensitivity, specificity and accuracy of serum PGⅠ, G-17, and CDH-17 combined with narrow-band imaging magnifying endoscopy in the diagnosis of early gastric cancer and precancerous lesions were higher than those of any serum index alone (PGⅠ/G-17/CDH-17) or narrowband imaging magnifying endoscopy alone (P < 0.05).

CONCLUSION

The detection of serum PG, G-17, and CDH-17 combined with narrow-band imaging magnifying endoscopy has high sensitivity, specificity, and accuracy in the differential diagnosis of early gastric cancer and precancerous lesions.

Preoperative evaluation of endoscopic submucosal dissection for early gastric cancer

OBJECTIVE

To retrospectively analyze the preoperative endoscopic evaluation of the size, nature, and depth of lesions in endoscopic submucosal dissection (ESD) for early gastric cancer and precancerous lesions, determine whether the lesions can be completely resected, and reduce the risk of additional surgery after ESD.

METHODS

A total of 114 patients with high-grade intraepithelial neoplasia(HGIN) and early gastric cancer treated with ESD in Hebei General Hospital from January 2016 to April 2021 were enrolled in this study. The lesions were evaluated preoperatively according to the endoscopic findings of white light, magnifying endoscopy, endoscopic features of narrow band imaging, and preoperative pathology. Lesion size, positive resection margin, lesion depth, and vascular invasion of postoperative pathology were used as criteria.

RESULTS

There were 121lesions in 114 patients. The coincidence rates of preoperative and postoperative pathology were 87.21% (75/86) for HGIN and 92.1% (35/38) for adenocarcinoma. There was no significant difference in the coincidence rate between preoperative pathological evaluation and postoperative pathology among the 3 lesions (χ2 = 10.614, P = .005). The type and malignancy of the lesion were not related to its location or size. Magnifying endoscopy combined with narrow-band imaging showed that HGIN and early gastric cancer had clear borders, irregular microvessels, and irregular surface microarchitecture on endoscopic features. Lesions > 3 cm, surface ulcers and spontaneous bleeding may be risk factors for deeper lesions.

CONCLUSION

ESD is not only a method for the treatment of early gastric cancer and precancerous lesions, but is also an important method for definite pathological diagnosis. Accurate preoperative assessment of lesion type, lesion extent and depth of invasion is helpful to improve the complete resection rate of ESD and reduce the risk of additional surgery.

Gastric Cancer: Emerging Trends in Prevention, Diagnosis, and Treatment

Gastric adenocarcinoma (GC) is the fourth leading cause of global cancer mortality, and the leading infection-associated cancer. Helicobacter pylori is the dominant risk factor for GC and classified as an IARC class I carcinogen. Surveillance of gastric premalignant conditions is now indicated in high-risk patients. Upper endoscopy is the gold standard for GC diagnosis, and image-enhanced endoscopy increases the detection of gastric premalignant conditions and early gastric cancer (EGC). Clinical staging is crucial for treatment approach, defining early gastric cancer, operable locoregional disease, and advanced GC. Endoscopic submucosal dissection is the treatment of choice for most EGC. Targeted therapies are rapidly evolving, based on biomarkers including MSI/dMMR, HER2, and PD-L1. These advancements in surveillance, diagnostic and therapeutic strategies are expected to improve GC survival rates in the near term.

Diagnostic ability of magnification endoscope with narrow-band imaging in screening esophagogastroduodenoscopy

OBJECTIVES

Magnifying endoscopy with narrow-band imaging (M-NBI) is useful for the optical diagnosis of gastrointestinal neoplasms. However, the utility of M-NBI in screening esophagogastroduodenoscopy (EGD) is unclear. We aimed to evaluate the diagnostic ability of the magnification endoscope (ME) in screening EGD for a population with a low prevalence of upper gastrointestinal cancers.

METHODS

Overall, 4887 asymptomatic examinees without a history of laryngopharyngeal and/or upper gastrointestinal neoplasms who underwent opportunistic screening EGD between April 2011 and December 2017 were enrolled in this retrospective study. The examinees were categorized into two groups depending on whether screening EGD was performed using ME (ME group) or not (non-ME group). Using a propensity score-matched analysis, the diagnostic ability of EGD was compared between the two groups.

RESULTS

In total, 1482 examinees (30%) were allocated to the ME group and 3405 (70%) to the non-ME group. Thirty-five epithelial neoplasms were detected in 30 examinees (0.6%). The groups were matched for baseline characteristics (1481 pairs). Both groups showed no significant difference in the epithelial neoplasm detection rate (0.8% vs. 0.3%; P = 0.14). The biopsy rate was significantly lower in the ME group than in the non-ME group (12% vs. 15%; P = 0.003). The positive predictive value (PPV) for biopsy was significantly higher in the ME group than in the non-ME group (6.6% vs. 2.8%; P = 0.048).

CONCLUSIONS

Using an ME for screening EGD in an apparently healthy, asymptomatic population could reduce unnecessary biopsies by improving PPV for biopsy without decreasing the epithelial neoplasm detection rate.

Proposal of minimum elements for screening and diagnosis of gastric cancer by an international Delphi consensus

The World Endoscopy Organization Stomach and Duodenal Diseases Committee extracted minimum elements for screening and diagnosis of gastric cancer (GC) in aim to support countries that do not have national guidelines on screening and diagnosis of GC. Current national or international guidelines were collected worldwide and recommendations were classified according to the quality of evidence and were finalized through a modified Delphi method. The minimum elements consist of seven categories: [1] Extraction of high-risk patients of GC before esophagogastroduodenoscopy (EGD), [2] Patients who need surveillance of GC, [3] Method to ensure quality of EGD for detection of GC, [4] Individual GC risk assessment by EGD, [5] Extraction of high-risk patients of GC after EGD [6] Qualitative or differential diagnosis of GC by EGD, and [7] Endoscopic assessment to choose the therapeutic strategy for GC. These minimum elements will be a guide to promote the elimination of GC among countries with a high incidence of GC who lack national guidelines or screening programs.

Comparison of the diagnostic efficacy of blue laser imaging with narrow band imaging for gastric cancer and precancerous lesions: a meta-analysis

BACKGROUND AND AIMS

novel endoscopic techniques including narrowband imaging (NBI) and blue laser imaging (BLI) have led to the improved detection of early stage gastric cancer and precancerous lesions. However, these techniques are not generally thought to be equivalent at present and BLI is generally considered as superior to NBI. Therefore, this comprehensive meta-analysis aimed to definitively compare the diagnostic efficacy of NBI and BLI for the diagnosis of gastric cancer and precancerous lesions.

METHODS

relevant articles were identified via searches of the PubMed, Web of Science, Embase and Cochrane Library databases from their inception until October 2019. In total, 28 relevant studies were identified and incorporated into the meta-analysis. RevMan5.3 was used to assess the relative diagnostic efficacy of these two imaging modalities in these studies. The threshold was assessed using Meta-DiSc 1.4 and STATA 14.0 for bivariate regression modeling of pooled studies.

RESULTS

the pooled sensitivity of BLI for gastric cancer was 0.89 (0.80, 0.95) and the specificity was 0.92 (0.76, 0.98). The pooled sensitivity of NBI for gastric cancer was 0.83 (0.75, 0.89) and the specificity was 0.95 (0.91, 0.97). The pooled sensitivity of BLI for precancerous lesions was 0.81 (0.71, 0.87) and the specificity was 0.90 (0.80, 0.96). The pooled sensitivity of NBI for precancerous lesions was 0.80 (0.75, 0.85) and the specificity was 0.88 (0.77, 0.94).

CONCLUSIONS

this study showed that both BLI and NBI have a very high diagnostic efficacy for the detection of gastric cancer and precancerous lesions, the sensitivity and specificity of these two approaches were similar.

Influence of Sedation on the Detection Rate of Early Cancer and Precancerous Lesions During Diagnostic Upper Gastrointestinal Endoscopies: A Multicenter Retrospective Study

INTRODUCTION

The influence of sedation on the endoscopic detection rate of upper gastrointestinal (UGI) early cancer (EC) and precancerous lesions, including high-grade intraepithelial neoplasia (HGIN) and low-grade intraepithelial neoplasia, has not been assessed. The aim of this research is to assess whether the use of sedation can help improve the detection rate of UGI EC and precancerous lesions. The second objective is to evaluate its potential influencing factors.

METHODS

The study includes 432,202 patients from a multicenter database from January 2012 to July 2019. Information on endoscopic findings and histology biopsies was obtained from endoscopy quality-control system. Associations of sedation with the detection rate of EC and precancerous lesions were assessed.

RESULTS

The sedation group has a higher detection rate of UGI EC and HGIN compared with the no-sedation group, whereas the detection rate of low-grade intraepithelial neoplasia was similar between the 2 groups. There were more cases examined by using staining, image enhancement, or magnifying techniques in the sedation group (P < 0.001). And, the mean observation time was also longer in the sedation group (P < 0.001). The type 0-IIb esophageal HGIN and EC cases were significantly increased in the sedation group. No significant difference was detected on lesion subtypes for gastric HGIN and EC according to the Paris classification. More gastric HGIN and EC were detected at gastric body in the sedation group (P = 0.001).

DISCUSSION

Sedation may improve the endoscopic detection rate of EC and HGIN in the UGI tract probably through enhancing the use of accessary endoscopic techniques, prolonging observation time, and taking more biopsies in different locations (see Visual Abstract, Supplementary Digital Content 2, http://links.lww.com/AJG/B926).

Diagnosis of early gastric cancer using image enhanced endoscopy: a systematic approach

This paper provides an overview of the principles of a vessel plus surface (VS) classification system to explain the diagnostic system of early gastric cancer using image-enhanced magnifying endoscopy. Furthermore, this paper introduces the magnifying endoscopy simple diagnostic algorithm for gastric cancer (MEADA-G) developed according to the VS classification system, with a description of the procedures performed for diagnosis. In addition to the diagnostic system, white opaque substance (WOS), light blue crest (LBC), white globe appearance (WGA), and vessels within epithelial circle (VEC) patterns, which are representative findings that can be observed in the gastric mucosa by image-enhanced magnifying endoscopy, are also described. Image-enhanced magnifying endoscopy is particularly useful in the diagnosis of differentiated-type early gastric cancer. It is important to use the appropriate clinical strategies based on a comprehensive understanding of the usefulness and limitations of the diagnostic system described in this paper.

Diagnostic limitations of magnifying endoscopy with narrow-band imaging in early gastric cancer

Background and study aims  Magnifying endoscopy with narrow band imaging (M-NBI) has made a huge contribution to endoscopic diagnosis of early gastric cancer (EGC). However, we sometimes encountered false-negative cases with M-NBI diagnosis (i. e., M-NBI diagnostic limitation lesion: M-NBI-DLL). However, clinicopathological features of M-NBI-DLLs have not been well elucidated. We aimed to clarify the clinicopathological features and histological reasons of M-NBI-DLLs. Patients and methods  In this single-center retrospective study, M-NBI-DLLs were extracted from 456 EGCs resected endoscopically at our hospital. We defined histological types of M-NBI-DLLs and analyzed clinicopathologically to clarify histological reasons of M-NBI-DLLs. Results  Of 456 EGCs, 48 lesions (10.5 %) of M-NBI-DLLs were enrolled. M-NBI-DLLs was classified into four histological types as follows: gastric adenocarcinoma of fundic-gland type (GA-FG, n = 25), gastric adenocarcinoma of fundic-gland mucosal type (GA-FGM, n = 1), differentiated adenocarcinoma (n = 14), and undifferentiated adenocarcinoma (n = 8). Thirty-nine lesions of M-NBI-DLLs were H. pylori -negative gastric cancers (39/47, 82.9 %). Histological reasons for M-NBI-DLLs were as follows: 1) completely covered with non-neoplastic mucosa (25/25 GA-FG, 8/8 undifferentiated adenocarcinoma); 2) well-differentiated adenocarcinoma with low-grade atypia (1/1 GA-FGM, 14/14 differentiated adenocarcinoma); 3) similarity of surface structure (10/14 differentiated adenocarcinoma); and 4) partially covered and/or mixed with a non-neoplastic mucosa (1/1 GA-FGM, 6/14 differentiated adenocarcinoma). Conclusions  Diagnostic limitations of M-NBI depend on four distinct histological characteristics. For accurate diagnosis of M-NBI-DLLs, it may be necessary to fully understand endoscopic features of these lesions using white light imaging and M-NBI based on these histological characteristics and to take a precise biopsy.

Guidelines for endoscopic diagnosis of early gastric cancer

The Japan Gastroenterological Endoscopy Society developed the Guideline for Endoscopic Diagnosis of Early Gastric Cancer based on scientific methods. Endoscopy for the diagnosis of early gastric cancer has been acknowledged as a useful and highly precise examination, and its use has become increasingly more common in recent years. However, the level of evidence in this field is low, and it is often necessary to determine recommendations based on expert consensus only. This clinical practice guideline consists of the following sections to provide the current guideline: [I] Risk stratification of gastric cancer before endoscopic examination, [II] Detection of early gastric cancer, [III] Qualitative diagnosis of early gastric cancer, [IV] Diagnosis to choose the therapeutic strategy for gastric cancer, [V] Risk stratification after endoscopic examination, and [VI] Surveillance of early gastric cancer.

Hemorrhage control during gastric endoscopic submucosal dissection: Techniques using uncovered knives

Since the last decade, endoscopic submucosal dissection (ESD) has been used as the standard treatment for superficial gastrointestinal neoplasms. Trainees learning ESD frequently encounter difficulties such as vascularity, peristalsis, and fibrosis during the procedure. Because individual vascularity differs, it generally cannot be consistently avoided. Given that massive hemorrhages can prolong the procedure time and diminish treatment efficacy and that insufficient vessel handling may also increase postoperative bleeding, hemorrhage control during ESD becomes important to ensure procedure safety. This article discusses methods for controlling hemorrhage during gastric ESD. Endoscopists should have a basic understanding of the vascular architecture and the high‐density areas in blood vessels, which are susceptible to intraoperative hemorrhage. Efficient preventative coagulation should be performed in addition to mastering the techniques for hemorrhage control using hemostatic forceps. Techniques useful for preventing intraoperative hemorrhage at every step (e.g. submucosal injection, mucosal incision, and dissection) should be learned. Gaining procedural competence and learning hemorrhage control techniques not only during ESD but also in daily work would help provide safe and effective treatment.

A Rare Case of Local Recurrence Following Curative Endoscopic Submucosal Dissection of Intramucosal Differentiated-Type Gastric Cancer

A 78-year-old man underwent endoscopic submucosal dissection (ESD) of early gastric cancer (EGC) (type 0-IIa) in the anterior wall of the antrum. En bloc resection was achieved. The histopathological examination revealed very well-differentiated tubular adenocarcinoma (tub1) of 30 × 22 mm in size, confined to the mucosa. No lymphovascular invasion or ulceration was observed, and there was no undifferentiated-type component and the margins were tumor-free. Therefore, this lesion fulfilled the eCuraA criteria. Two years after ESD, esophagogastroduodenoscopy revealed an irregular, slightly-depressed lesion within the post-ESD scar. Tubular adenocarcinoma was suspected based on histopathological examination of a biopsy specimen. The tumor was resected by ESD. A histopathological examination revealed well-differentiated tubular adenocarcinoma (tub1) of 6 × 4 mm in size, confined to the mucosa. No lymphovascular invasion was detected and the margins were tumor-free. These findings indicated a curative resection. Recurrence following a curative ESD of an intramucosal differentiated-type EGC which fulfilled the eCuraA criteria is rare. Careful endoscopic observation using magnifying narrow band imaging (NBI) is needed after ESD, even when curative resection is achieved.

Presence of blood in gastric juice: A sensitive marker for gastric cancer screening in a poor resource setting

BACKGROUND

Gastric cancer survival rates in Africa are low as many cases are diagnosed late. Currently, there are no inexpensive, non-invasive and simple techniques that can be employed in poor resource settings for early case detection. In this study, we explored the possibility using blood in gastric juice as a screening tool to identify patients requiring referral for endoscopy.

METHODS

The study was conducted at the University Teaching Hospital endoscopy unit in Lusaka, Zambia. During esophagogastroduodenoscopy, gastric juice was aspirated and the pH determined using pH paper test strips. The presence of blood was tested using urinalysis reagent strips.

RESULTS

We enrolled 276 patients; 147(53%) were female and median age was 49 years (IQR 40-64 years). The presence of blood was associated with mucosal lesions, [OR 2.1; 95% CI 1.2-3.7, P = 0.004]. It was also associated with gastric cancer, [OR 6.7; 95% CI 2-35, P = 0.0005], even at 1:10 and 1:100 dilutions, [OR 5.4; 95% CI 2.3-13.8, P<0.0001] and [OR 9.1; 95% CI 3.5-23, P<0.0001] respectively. The sensitivity for gastric cancer detection using blood in gastric juice was 91% and the specificity was 41%. Analysis using the intensity of blood in gastric juice yielded an area under the receiver operating characteristic curve of 0.78; 95% CI 0.71-0.86 with a sensitivity of 79% and a specificity of 77%.

CONCLUSIONS

The presence of blood in gastric juice is associated with gastric mucosal lesions. It has a high sensitivity but low specificity for gastric cancer detection.

Application of artificial intelligence using a convolutional neural network for detecting gastric cancer in endoscopic images

BACKGROUND

Image recognition using artificial intelligence with deep learning through convolutional neural networks (CNNs) has dramatically improved and been increasingly applied to medical fields for diagnostic imaging. We developed a CNN that can automatically detect gastric cancer in endoscopic images.

METHODS

A CNN-based diagnostic system was constructed based on Single Shot MultiBox Detector architecture and trained using 13,584 endoscopic images of gastric cancer. To evaluate the diagnostic accuracy, an independent test set of 2296 stomach images collected from 69 consecutive patients with 77 gastric cancer lesions was applied to the constructed CNN.

RESULTS

The CNN required 47 s to analyze 2296 test images. The CNN correctly diagnosed 71 of 77 gastric cancer lesions with an overall sensitivity of 92.2%, and 161 non-cancerous lesions were detected as gastric cancer, resulting in a positive predictive value of 30.6%. Seventy of the 71 lesions (98.6%) with a diameter of 6 mm or more as well as all invasive cancers were correctly detected. All missed lesions were superficially depressed and differentiated-type intramucosal cancers that were difficult to distinguish from gastritis even for experienced endoscopists. Nearly half of the false-positive lesions were gastritis with changes in color tone or an irregular mucosal surface.

CONCLUSION

The constructed CNN system for detecting gastric cancer could process numerous stored endoscopic images in a very short time with a clinically relevant diagnostic ability. It may be well applicable to daily clinical practice to reduce the burden of endoscopists.