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S1605: Novel Endoscopic Submucosal Incision Associated Direct Division Biopsy for Gastric Submucosal Tumor
Abstracts of cells and regularity of cellular arrangement similar to Papanicolaou classification. Endocytoscopic images were compared with histological images. We developed double staining method using methylene blue and crystal violet to achieve better and stable view.Result :One hundred three lesions (91.1%) of 113 lesions which were classified to ECA 1 to ECA 3 were corresponding to Japanese classification of gastric cancer category 1 to 3. Seventy nine (89.8%) of 88 lesions which were classified to ECA 4 or ECA 5 were corresponding to Japanese classification of gastric cancer category 4 or 5. Overall accuracy was 91.5%.Discussion :With endocytoscopy, we can take optical biopsy even in patients with anti-coagulant therapy. Endocytoscopy may allow providing images similar to conventional Hematoxyline and Eosin staining. Single-CCD endocytoscope was newly developed which helps precise magnifying observation of targeted tissue continuously. Using endocytoscopy, the information about the cellular structure of surface cells can be obtained. But if the cancer cells are not exposed to surface, for example, poorly differentiated adenocarcinoma which progresses beneath normal epithelium or the lesions covered with regenerative epithelium, to make a precise diagnosis may be difficult.Conclusion :Development of endocytoscopy accelerated in vivo tissue imaging with demonstrating living cancer cell. Endocytoscopy allows endoscopic diagnosis of tissue cytological atypia during regular endoscopic examination.
S1605 Novel Endoscopic Submucosal Incision Associated Direct Division Biopsy for Gastric Submucosal Tumor Keiko Kudo, Yoshirou Tamegai, Takashi Koike INTRODUCTION: As a predictor of malignant potential of Gastointestinal Stromal Tumor (GIST), the risk classification using index to measure cellular proliferative potential in combination with assessing the size of the lesion has been advocated, and an immunohistochemical diagnosis is essential when making a definite diagnose of gastric submucosal tumor and deciding on courses of treatment. Therefore, Endoscopic Ultrasound-guided Fine Needle Aspiration Biopsy (EUS-FNAB) procedures have been increasingly performed in recent years. However, these procedures are difficult to apply to some locations,including the gastric upper body, and it is often difficult to obtain a sufficient sample. This time, we investigated the usefulness of novel Endoscopic Submucosal Incision associated Direct Division Biopsy (ESI-ADDB) for gastricl submucosal tumor.AIMS & METHODS: We studied eight cases of gastric submucosal tumor with eight lesions which were diagnosed gastric submucosal tumor (male: three cases, female: five cases, average age: 66.3 years old). We performed Endoscopic Submucosal Incision Associated Direct Division Biopsy (ESI-ADDB) procedures in these cases and obtained a histopathological diagnosis. In conformity with Endoscopic Submucosal Dissection (ESD) procedures, we made a partial mucosal incision at first, exposed the lesion under mucosal layer and perfomed a biopsy with conventional biopsy forceps. We then sew up the lesion using endoscopy for the prevention of bleeding and avoidance of tumor exposure.RESULTS: In the histopathological diadnosis made after ESI-ADDB, two lesions were found as leiomyoma and six lesions as GIST. Excluding three lesions, we performed operation. Regarding the five lesions for which surgery was performed, the average size was 38mm (10-90mm). The affected areas were cardia (one lesion), gastric angle (one lesion), body (two lesions) and antrum (one lesion). Histopathological diagnosis obtained after ESI-ADDB procedures and treatment were follows: two lesions were found as leiomyoma and four lesions as GIST with the Ki-67 index standing at10% or less in all the five lesions. The immunohistochemical diagnosis made before treatment, including the degree of malignancy, corresponded to one made after treatment. Moreover, no cacses showed bleeding and any other sighs of complication. CONCLUSION: A reliable immunohistochemical diagnosis was obtained safely through the Novel Endoscopic Submucosal Incision associated Direct Division Biopsy (ESI-ADDB) for gastric submucosal tumor, which suggests the were clinical usefulness of the ESIADDB.
S1606 -VOIS, A Novel Three-Dimensional Microstructure Imaging System Based on Optical Coherence Tomography Kazuhiro Kaneko, Hiroaki Ikematsu, Tomonori Yano, Keiko Minashi, Takashi Kojima, Yasuhiro Oono, Atsushi Ohtsu, Atsushi Ochiai, Hiroyasu Esumi
Background: Micrometer-Volumetric Optical Imaging System (-VOIS, FUJIFILM) is a novel imaging system which is based on Fourier Domain Optical Coherence Tomography (FD-OCT) using laser beams. The in vivo resolution is approximately 10 m and depth of penetration is limited to 1.5-2 mm. The VOIS can visualize a three-dimensional (3D) cross sectional image at any region. Segmentation of tissue microstructure, such as muscularis mucosa (MM), and 3D imaging is useful for greater understanding of tissue structure. Aim: To examine the usefulness of -VOIS for diagnosing depth of invasion and visualization of the mucosal glandular structure.Methods: Colorectal flat lesions treated by endoscopic submucosal dissection before formalin fixation were scanned using -VOIS. Two-dimensional laser beam scan of the tissue is achieved using a linear scanning mirror and a moving stage. We can then produce a 3D
AB206 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
volumetric image from a series of cross sectional images. The -VOIS images of normal mucosa, adenoma, mucosal carcinoma, and carcinoma infiltrating into the submucosal layer were compared to both pathologic and colonoscopic findings.Results: Comparing histopathologic findings, the mucosal layer, submucosal layer, and MM could be distinguished into -VOIS images in vertical cross sectional views. The 3D images of the MM in both normal mucosa and intramucosal neoplastic lesions exhibited a uniform structure with no defects of the MM. In contrast, small defects, 1 mm in diameter, were identified in the 3D images of the MM from a slightly invasive submucosal carcinoma case. The 3D MM images in a massively invasive submucosal carcinoma exhibited large defects. The size and portion of MM defects in the 3D structure corresponded to histologic findings. However, the small defects could not be correctly diagnosed in colonoscopic findings for pit patterns. In horizontal cross sectional images, the 3D structure of the mucosal layer was observed in 200 m depth sections. The -VOIS images of glandular structure revealed fine and straight glands in normal mucosa, contrasting with circular and irregular shapes in neoplastic lesions. Furthermore, it was possible to identify the grade of irregularity of the glandular structure in carcinoma from these images.Conclusions: The -VOIS is a novel imaging system which allows visualization of 3D images of intramucosal microstructure and MM. Therefore, this system will be useful for diagnosing areas infiltrating into the submucosal layer in colorectal flat lesions. Furthermore, we also suggest the possibility that the 3D features of glandular structure in normal and neoplastic regions can be differentiated using these images.
S1607 The Usefulness of Tumor Margin Marking Using Autofluorescence Endoscopy in Endoscopic Submucosal Dissection Jin Su Kim, Kwan Woo Nam, Yu Kyung Cho, Jae Myung Park, Sang Woo Kim, Myung-Gyu Choi, Kyu-Yong Choi, In-Sik Chung Background: With the spread of endoscopic submucosal resection (ESD) for gastric neoplasia, the importance of complete resection has increased. In order to achieve this, it is important to accurately determine the lateral spread of the gastric neoplasia. Recently, a new endoscopic technique, autofluorescence imaging (AFI), has been developed in order to differentiate benign from malignant lesions in vivo and may useful for defining the resection margins for ESD. Aim: To investigate if the determination of resection margin for ESD using AFI is as useful as chromoendoscopy using indigocarmine. Method: Patients with gastric neoplasia who were referred for ESD were eligible for this study. A total of 48 patients (21 cases of EGC, 27 cases of adenoma) were enrolled in this study, half of them allocated as AFI-group and the rest of them as Chromoendoscopy group. In the AFI group, after white light endoscopy, AFI was performed (GIF-FQ260Z, Olympus, Japan) to determine the real extension of the neoplasia (area or lesion that was different from the surrounding mucosa in the color of AFI and had a defined circumferential margin). Marking of resection border which is demarcated by AFI mode was done with argon plasma coagulation. Submucosal injection was performed to lift the lesion. Circular incision and en bloc resection of the lesion was followed. For ESD of the chromoendoscopy group, indigocarmine was sprayed around the lesion. After the lesion was confirmed, the entire border between the tumor and normal mucosa was marked and ESD was performed as described previously. After pathologic mapping, the diameters of the resection samples, diameters of the tumors and lateral safety margins were compared. Results: In 20 patients (83.4%) of the AFI group, tumor margins were clearly visualized by AFI. There were no statistical differences between the two groups in diameters of the resection samples, tumors and tumor free lateral safety margins. Incomplete resection (resection margin positive) was observed in one patient of the chromoendoscopy group (Table 1). Conclusion: Tumor margin marking using AFI can be a promising simple method without using dye for ESD and can avoid underestimation of the true extension of the tumor Table1. Results of endoscopic submucosal dissection using AFI and Chromoendoscopy
Long diameter of resection sample (cm, mean⫾SD) Short diameter of resection sample Long diameter of tumor Short diameter of tumor Resection margin positive (%) Lateral safety margin (mm, mean⫾SD)
AFI group
Chromoendoscopy Group
P-value
4.36 ⫾ 0.99
4.02 ⫾ 1.00
0.255
3.59 ⫾ 1.15
3.15 ⫾ 0.89
0.145
1.71 ⫾ 1.19 1.41 ⫾ 1.08 0%
1.36 ⫾ 0.87 0.92 ⫾ 0.42 3.5%
0.248 0.071 1.0
6.3 ⫾ 2.9
6.5 ⫾ 3.4
0.83
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S1605 Novel Endoscopic Submucosal Incision Associated Direct Division Biopsy for Gastric Submucosal Tumor Keiko Kudo, Yoshirou Tamegai, Takashi Koike INTRODUCTION: As a predictor of malignant potential of Gastointestinal Stromal Tumor (GIST), the risk classification using index to measure cellular proliferative potential in combination with assessing the size of the lesion has been advocated, and an immunohistochemical diagnosis is essential when making a definite diagnose of gastric submucosal tumor and deciding on courses of treatment. Therefore, Endoscopic Ultrasound-guided Fine Needle Aspiration Biopsy (EUS-FNAB) procedures have been increasingly performed in recent years. However, these procedures are difficult to apply to some locations,including the gastric upper body, and it is often difficult to obtain a sufficient sample. This time, we investigated the usefulness of novel Endoscopic Submucosal Incision associated Direct Division Biopsy (ESI-ADDB) for gastricl submucosal tumor.AIMS & METHODS: We studied eight cases of gastric submucosal tumor with eight lesions which were diagnosed gastric submucosal tumor (male: three cases, female: five cases, average age: 66.3 years old). We performed Endoscopic Submucosal Incision Associated Direct Division Biopsy (ESI-ADDB) procedures in these cases and obtained a histopathological diagnosis. In conformity with Endoscopic Submucosal Dissection (ESD) procedures, we made a partial mucosal incision at first, exposed the lesion under mucosal layer and perfomed a biopsy with conventional biopsy forceps. We then sew up the lesion using endoscopy for the prevention of bleeding and avoidance of tumor exposure.RESULTS: In the histopathological diadnosis made after ESI-ADDB, two lesions were found as leiomyoma and six lesions as GIST. Excluding three lesions, we performed operation. Regarding the five lesions for which surgery was performed, the average size was 38mm (10-90mm). The affected areas were cardia (one lesion), gastric angle (one lesion), body (two lesions) and antrum (one lesion). Histopathological diagnosis obtained after ESI-ADDB procedures and treatment were follows: two lesions were found as leiomyoma and four lesions as GIST with the Ki-67 index standing at10% or less in all the five lesions. The immunohistochemical diagnosis made before treatment, including the degree of malignancy, corresponded to one made after treatment. Moreover, no cacses showed bleeding and any other sighs of complication. CONCLUSION: A reliable immunohistochemical diagnosis was obtained safely through the Novel Endoscopic Submucosal Incision associated Direct Division Biopsy (ESI-ADDB) for gastric submucosal tumor, which suggests the were clinical usefulness of the ESIADDB.
S1606 -VOIS, A Novel Three-Dimensional Microstructure Imaging System Based on Optical Coherence Tomography Kazuhiro Kaneko, Hiroaki Ikematsu, Tomonori Yano, Keiko Minashi, Takashi Kojima, Yasuhiro Oono, Atsushi Ohtsu, Atsushi Ochiai, Hiroyasu Esumi
Background: Micrometer-Volumetric Optical Imaging System (-VOIS, FUJIFILM) is a novel imaging system which is based on Fourier Domain Optical Coherence Tomography (FD-OCT) using laser beams. The in vivo resolution is approximately 10 m and depth of penetration is limited to 1.5-2 mm. The VOIS can visualize a three-dimensional (3D) cross sectional image at any region. Segmentation of tissue microstructure, such as muscularis mucosa (MM), and 3D imaging is useful for greater understanding of tissue structure. Aim: To examine the usefulness of -VOIS for diagnosing depth of invasion and visualization of the mucosal glandular structure.Methods: Colorectal flat lesions treated by endoscopic submucosal dissection before formalin fixation were scanned using -VOIS. Two-dimensional laser beam scan of the tissue is achieved using a linear scanning mirror and a moving stage. We can then produce a 3D
AB206 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
volumetric image from a series of cross sectional images. The -VOIS images of normal mucosa, adenoma, mucosal carcinoma, and carcinoma infiltrating into the submucosal layer were compared to both pathologic and colonoscopic findings.Results: Comparing histopathologic findings, the mucosal layer, submucosal layer, and MM could be distinguished into -VOIS images in vertical cross sectional views. The 3D images of the MM in both normal mucosa and intramucosal neoplastic lesions exhibited a uniform structure with no defects of the MM. In contrast, small defects, 1 mm in diameter, were identified in the 3D images of the MM from a slightly invasive submucosal carcinoma case. The 3D MM images in a massively invasive submucosal carcinoma exhibited large defects. The size and portion of MM defects in the 3D structure corresponded to histologic findings. However, the small defects could not be correctly diagnosed in colonoscopic findings for pit patterns. In horizontal cross sectional images, the 3D structure of the mucosal layer was observed in 200 m depth sections. The -VOIS images of glandular structure revealed fine and straight glands in normal mucosa, contrasting with circular and irregular shapes in neoplastic lesions. Furthermore, it was possible to identify the grade of irregularity of the glandular structure in carcinoma from these images.Conclusions: The -VOIS is a novel imaging system which allows visualization of 3D images of intramucosal microstructure and MM. Therefore, this system will be useful for diagnosing areas infiltrating into the submucosal layer in colorectal flat lesions. Furthermore, we also suggest the possibility that the 3D features of glandular structure in normal and neoplastic regions can be differentiated using these images.
S1607 The Usefulness of Tumor Margin Marking Using Autofluorescence Endoscopy in Endoscopic Submucosal Dissection Jin Su Kim, Kwan Woo Nam, Yu Kyung Cho, Jae Myung Park, Sang Woo Kim, Myung-Gyu Choi, Kyu-Yong Choi, In-Sik Chung Background: With the spread of endoscopic submucosal resection (ESD) for gastric neoplasia, the importance of complete resection has increased. In order to achieve this, it is important to accurately determine the lateral spread of the gastric neoplasia. Recently, a new endoscopic technique, autofluorescence imaging (AFI), has been developed in order to differentiate benign from malignant lesions in vivo and may useful for defining the resection margins for ESD. Aim: To investigate if the determination of resection margin for ESD using AFI is as useful as chromoendoscopy using indigocarmine. Method: Patients with gastric neoplasia who were referred for ESD were eligible for this study. A total of 48 patients (21 cases of EGC, 27 cases of adenoma) were enrolled in this study, half of them allocated as AFI-group and the rest of them as Chromoendoscopy group. In the AFI group, after white light endoscopy, AFI was performed (GIF-FQ260Z, Olympus, Japan) to determine the real extension of the neoplasia (area or lesion that was different from the surrounding mucosa in the color of AFI and had a defined circumferential margin). Marking of resection border which is demarcated by AFI mode was done with argon plasma coagulation. Submucosal injection was performed to lift the lesion. Circular incision and en bloc resection of the lesion was followed. For ESD of the chromoendoscopy group, indigocarmine was sprayed around the lesion. After the lesion was confirmed, the entire border between the tumor and normal mucosa was marked and ESD was performed as described previously. After pathologic mapping, the diameters of the resection samples, diameters of the tumors and lateral safety margins were compared. Results: In 20 patients (83.4%) of the AFI group, tumor margins were clearly visualized by AFI. There were no statistical differences between the two groups in diameters of the resection samples, tumors and tumor free lateral safety margins. Incomplete resection (resection margin positive) was observed in one patient of the chromoendoscopy group (Table 1). Conclusion: Tumor margin marking using AFI can be a promising simple method without using dye for ESD and can avoid underestimation of the true extension of the tumor Table1. Results of endoscopic submucosal dissection using AFI and Chromoendoscopy
Long diameter of resection sample (cm, mean⫾SD) Short diameter of resection sample Long diameter of tumor Short diameter of tumor Resection margin positive (%) Lateral safety margin (mm, mean⫾SD)
AFI group
Chromoendoscopy Group
P-value
4.36 ⫾ 0.99
4.02 ⫾ 1.00
0.255
3.59 ⫾ 1.15
3.15 ⫾ 0.89
0.145
1.71 ⫾ 1.19 1.41 ⫾ 1.08 0%
1.36 ⫾ 0.87 0.92 ⫾ 0.42 3.5%
0.248 0.071 1.0
6.3 ⫾ 2.9
6.5 ⫾ 3.4
0.83
www.giejournal.org