- Email: [email protected]
Autofluorescence imaging of a diminutive, depressed-type early colon cancer invaded to the submucosal layer
At the Focal Point
Autofluorescence imaging of a diminutive, depressed-type early colon cancer invaded to the submucosal layer
A 61-year-old woman with a positive fecal occult blood study result underwent a colonoscopy that indicated an early cancer in her sigmoid colon. She was then referred to our hospital for further evaluation. Colonoscopic re-evaluation of the lesion was done using an autofluorescence imaging system consisting of an image processor (XCV-260HP; Olympus Medical Systems, Tokyo, Japan), a light source (XCLV-260HP, Olympus), and a colonoscope with 2 charged, coupled devices for white light imaging and autofluorescence imaging modes (XCF-Q240FZI, Olympus). Autofluorescence imaging revealed a 5-mm green area surrounded by magenta mucosa (A). White light imaging (B) and chromoendoscopy with 0.4% indigo carmine (C) revealed a depressed-type lesion colored similarly to the surrounding mucosa. EUS revealed a minute tumor that invaded down to the submucosa. The lesion was diagnosed as an early co-
lon cancer invading into the submucosa, and sigmoidectomy was performed. Histologic examination (D, H&E, orig. mag. 7.5) of the resected specimen revealed a moderately differentiated adenocarcinoma invading into the submucosa (submucosal invasion [SM] 150 mm). The cancer was more depressed than the surrounding mucosa, whereas the surrounding submucosal layer was relatively thick. Thus, a green image of a lesion surrounded by a magenta mucosa on autofluorescence imaging may be representative of the depressed-type colon cancer.
www.giejournal.org
Volume 71, No. 2 : 2010 GASTROINTESTINAL ENDOSCOPY 399
DISCLOSURE All authors disclosed no financial relationships relevant to this publication.
At the Focal Point
Yoji Takeuchi, MD, Noriya Uedo, MD, Koji Higashino, MD, Ryu Ishihara, MD, Masaharu Tatsuta, MD, Hiroyasu Iishi, MD, Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Dis-
eases, Makiko Matsumura, MD, Department of Internal Medicine, Nagano Chuo Hospital, Osaka, Japan doi:10.1016/j.gie.2009.09.008
Commentary The term fluorescence, coined by George Gabriel Stokes in 1852, refers to the emission of visible light by a substance that has absorbed light of a differing, usually invisible, wavelength. In biologic systems, autofluorescence refers to an intrinsic property of cells in which certain molecules act as fluorophores and become fluorescent when excited by light of certain wavelengths. Most cellular autofluorescence originates within mitochondria and lysosomes and involves a variety of substances including aromatic amino acids, lipid pigments, folate derivatives, and cytokeratins as well as various vitamins and coenzymes. In tissues, autofluorescence is not confined to cells, however, and the collagen and elastin in the extracellular matrix also are rich in fluorophores. It is known that cells in varying stages of progression toward malignancy differ in the qualitative and quantitative nature of these intrinsic cellular fluorophores and that certain aerodigestive mucosal neoplasias can be discriminated from normal mucosa by their autofluorescent profile. Endoscopic assessment of real-time tissue autofluorescence, without the need for invasive biopsies, may prove valuable not only for diagnosis but as part of any treatment protocol to measure tumor response. Louis D. Brandeis said that sunlight is . the best of disinfectants [and] electric light the most efficient policeman. It seems as if autofluorescent light is a better diagnostician than white light, but is it the best it can be? Stay tuned. Lawrence J. Brandt, MD Associate Editor for Focal Points
Fulminant amebic colitis mimicking pseudomembranous colitis
A 53-year-old man was referred with a 7-day history of diffuse abdominal pain and watery diarrhea. He had been diagnosed as having schizophrenia two years previously and had been treated in a long-term-care hospital. He had not traveled to the tropics in recent years. On examination, his abdomen was distended and had signs of peritonitis. A fecal occult blood test result was positive. Sigmoidoscopy demonstrated erythematous mucosa with numerous raised, whitish-yellow plaques throughout the rectosigmoid colon, an appearance that suggested pseudomembranous colitis (A). After sigmoidoscopy, a chest film
showed subdiaphragmatic intraperitoneal air. Exploratory laparotomy was performed urgently, and a cecal perforation with a gangrenous appendix was found. The appendix and cecum were resected and an ileostomy created. Histologic examination of the resected colon demonstrated trophozoites of Entamoeba histolytica in the appendiceal wall (B, H&E, orig. mag. 400). Stool examinations for Clostridium difficile toxin and culture were negative. The patient was treated with antibiotics including metronidazole for 14 days, and he recovered without further difficulty.
400 GASTROINTESTINAL ENDOSCOPY Volume 71, No. 2 : 2010
www.giejournal.org
Autofluorescence imaging of a diminutive, depressed-type early colon cancer invaded to the submucosal layer
A 61-year-old woman with a positive fecal occult blood study result underwent a colonoscopy that indicated an early cancer in her sigmoid colon. She was then referred to our hospital for further evaluation. Colonoscopic re-evaluation of the lesion was done using an autofluorescence imaging system consisting of an image processor (XCV-260HP; Olympus Medical Systems, Tokyo, Japan), a light source (XCLV-260HP, Olympus), and a colonoscope with 2 charged, coupled devices for white light imaging and autofluorescence imaging modes (XCF-Q240FZI, Olympus). Autofluorescence imaging revealed a 5-mm green area surrounded by magenta mucosa (A). White light imaging (B) and chromoendoscopy with 0.4% indigo carmine (C) revealed a depressed-type lesion colored similarly to the surrounding mucosa. EUS revealed a minute tumor that invaded down to the submucosa. The lesion was diagnosed as an early co-
lon cancer invading into the submucosa, and sigmoidectomy was performed. Histologic examination (D, H&E, orig. mag. 7.5) of the resected specimen revealed a moderately differentiated adenocarcinoma invading into the submucosa (submucosal invasion [SM] 150 mm). The cancer was more depressed than the surrounding mucosa, whereas the surrounding submucosal layer was relatively thick. Thus, a green image of a lesion surrounded by a magenta mucosa on autofluorescence imaging may be representative of the depressed-type colon cancer.
www.giejournal.org
Volume 71, No. 2 : 2010 GASTROINTESTINAL ENDOSCOPY 399
DISCLOSURE All authors disclosed no financial relationships relevant to this publication.
At the Focal Point
Yoji Takeuchi, MD, Noriya Uedo, MD, Koji Higashino, MD, Ryu Ishihara, MD, Masaharu Tatsuta, MD, Hiroyasu Iishi, MD, Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Dis-
eases, Makiko Matsumura, MD, Department of Internal Medicine, Nagano Chuo Hospital, Osaka, Japan doi:10.1016/j.gie.2009.09.008
Commentary The term fluorescence, coined by George Gabriel Stokes in 1852, refers to the emission of visible light by a substance that has absorbed light of a differing, usually invisible, wavelength. In biologic systems, autofluorescence refers to an intrinsic property of cells in which certain molecules act as fluorophores and become fluorescent when excited by light of certain wavelengths. Most cellular autofluorescence originates within mitochondria and lysosomes and involves a variety of substances including aromatic amino acids, lipid pigments, folate derivatives, and cytokeratins as well as various vitamins and coenzymes. In tissues, autofluorescence is not confined to cells, however, and the collagen and elastin in the extracellular matrix also are rich in fluorophores. It is known that cells in varying stages of progression toward malignancy differ in the qualitative and quantitative nature of these intrinsic cellular fluorophores and that certain aerodigestive mucosal neoplasias can be discriminated from normal mucosa by their autofluorescent profile. Endoscopic assessment of real-time tissue autofluorescence, without the need for invasive biopsies, may prove valuable not only for diagnosis but as part of any treatment protocol to measure tumor response. Louis D. Brandeis said that sunlight is . the best of disinfectants [and] electric light the most efficient policeman. It seems as if autofluorescent light is a better diagnostician than white light, but is it the best it can be? Stay tuned. Lawrence J. Brandt, MD Associate Editor for Focal Points
Fulminant amebic colitis mimicking pseudomembranous colitis
A 53-year-old man was referred with a 7-day history of diffuse abdominal pain and watery diarrhea. He had been diagnosed as having schizophrenia two years previously and had been treated in a long-term-care hospital. He had not traveled to the tropics in recent years. On examination, his abdomen was distended and had signs of peritonitis. A fecal occult blood test result was positive. Sigmoidoscopy demonstrated erythematous mucosa with numerous raised, whitish-yellow plaques throughout the rectosigmoid colon, an appearance that suggested pseudomembranous colitis (A). After sigmoidoscopy, a chest film
showed subdiaphragmatic intraperitoneal air. Exploratory laparotomy was performed urgently, and a cecal perforation with a gangrenous appendix was found. The appendix and cecum were resected and an ileostomy created. Histologic examination of the resected colon demonstrated trophozoites of Entamoeba histolytica in the appendiceal wall (B, H&E, orig. mag. 400). Stool examinations for Clostridium difficile toxin and culture were negative. The patient was treated with antibiotics including metronidazole for 14 days, and he recovered without further difficulty.
400 GASTROINTESTINAL ENDOSCOPY Volume 71, No. 2 : 2010
www.giejournal.org