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Novel endoscopic findings as visualized by non-magnification endoscopy with linked color imaging are indicative of gastric intestinal metaplasia.

Min M1, Dong TH1, Liu Y1, Bi YL1, Ma CY1.

Chin Med J (Engl). 2019 Apr 5;132(7):782-788.

Background: Gastric intestinal metaplasia (GIM) is generally considered to be the main mucosal background for the development of gastric adenocarcinomas. Using linked color imaging (LCI), we noticed that the color pattern in areas of GIM was purple mixed with white on the epithelium with signs of mist that were detected by the non-magnifying LCI observation. We have termed this endoscopic finding “Purple in Mist” (PIM). The aim of this study was to investigate whether PIM could be a useful optical sign for predicting GIM.

Methods: We prospectively evaluated consecutive patients undergoing endoscopy for various indications. The endoscopist used the LCI system to carefully observe the gastric antrum, body and angulus. When a PIM was identified in the surface layer, targeted biopsies were subsequently taken from this part. If the suspected area had no PIM on the surface, targeted biopsies were also taken.

Results: Sixty-three consecutive patients were included in this study. The prevalence of intestinal metaplasia (IM) was 29/63 (46%). In PIM-positive patients, the prevalence of IM was 23/26 (89%). Of these patients, 146 biopsy specimens were included in this study. For the diagnosis of IM, compared to histological assessment, the LCI finding had an accuracy of 91.1% (95%CI: 86.5%-95.7%), a sensitivity of 89.8% (95%CI: 81.3%-98.3%), a specificity of 91.8% (95%CI: 86.3%-97.2%), a positive predictive value of 84.6% (95%CI: 74.8%-94.4%), and a negative predictive value of 94.7% (95%CI: 90.1%-99.2%).

Conclusions: A positive PIM finding in a suspicious lesion on LCI would complement LCI diagnosis of possible IM because of the positive predictive value of PIM. PIM could be a novel endoscopic marker for IM.

1 Department of Gastroenterology and Hepatology, Affiliated Hospital of Academy of Military Medical Sciences, Beijing 100071, China


Usefulness of close observation with non-magnified blue laser imaging for determining cold polypectomy indications.

Suzuki T1, Kitagawa Y1, Nankinzan R1, Takashiro H2, Hara T3, Yamaguchi T2.

Scand J Gastroenterol. 2018 Jul 24:1-5. doi: 10.1080/00365521.2018.1488181

Purpose: To examine the usefulness of non-magnified close observation with blue laser imaging (BLI) using a colonoscope with close observation capability in determining indications for cold polypectomy.

Methods: We conducted an image evaluation study on 100 consecutive colorectal lesions of 10 mm or less which were observed endoscopically without magnification using BLI mode prior to treatment. Two experts and two non-experts reviewed the images using the Japan NBI expert team (JNET) classification and the diagnostic accuracy was analyzed.

Results: The final pathological diagnoses of the 100 lesions were hyperplastic/sessile serrated polyp (HP/SSP), low grade dysplasia (LGD), high grade dysplasia (HGD) and deep submucosal invasive cancer (dSM), respectively, in 12, 79, 9 and 0 lesions. When JNET classification type 1 corresponds to HP/SSP; 2A to LGD; 2B to HGD; and 3 to dSM; the overall diagnostic accuracy was 84.3%. Accuracy was 90.5% for experts and 78.0% for non-experts. High confidence rate was 67.5% for experts and 48.0% for non-experts. In diagnostic accuracy for HGD, the sensitivity, specificity, PPV and NPV were, respectively, 77.8%, 98.9%, 87.5% and 97.8% for experts; and 66.6%, 92.3%, 46.2% and 96.6% for non-experts.

Conclusions: The diagnostic accuracy of unmagnified close observation with BLI using a colonoscope with close observation capability is similar to that reported for magnifying endoscopy and is useful in predicting the histological diagnosis of colorectal polyps of 10 mm or less although the effectiveness may be limited for non-experts. This modality is a potentially useful tool in deciding indications for cold polectomy.

1 Department of Endoscopy, Chiba Cancer Center, Chiba, Japan
2 Department of Gastroenterology, Chiba Cancer Center, Chiba, Japan
3 Hara Clinic


Predictability of gastric intestinal metaplasia by patchy lavender color seen on linked color imaging endoscopy.

Chen H1, Wang H2, Wu X3, Liu Y3, Wu Q3, Lu Y3, Lin X3, Fan D3, Li C3.

Lasers Med Sci. 2019 Mar 22. doi: 10.1007/s10103-019-02775-8. [Epub ahead of print]

Abstract:We aimed to investigate the ability of linked color imaging (LCI) versus white light endoscopy (WLE) to detect gastric intestinal metaplasia (GIM). One hundred and seven participants who underwent upper gastrointestinal endoscopy were included. Under WLE endoscopy, biopsies were performed on any suspected abnormal mucosal changes. Under LCI endoscopy, we tested whether the specific color feature of patchy lavender color (PLC) pathologically indicated GIM. Biopsies were randomly performed in participants who had neither PLC nor suspected lesions. The detection abilities of LCI and WLE were assessed by comparison of histological and endoscopic findings. A total of 41 participants had histological GIM. The total diagnostic accuracy rate for GIM by LCI was 79.44%, higher than that of WLE (40.19%) (P < 0.001). Moreover, LCI with targeted biopsies showed a significantly increased ability to detect GIM (P < 0.001). PLC observed in the gastric mucosa on LCI can guide endoscopic biopsies and increase the detection rate of GIM. Thus, LCI could be a good tool for detecting GIM. ClinicalTrials.gov Identifier: ChiCTR-DDD-17011326).

1 Department of Gastrointestinal Endoscopy, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, Guangdong, People’s Republic of China
2 Department of Gastrointestinal Surgery, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, Guangdong, People’s Republic of China
3 Department of Gastrointestinal Surgery, the Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen 518033, Guangdong, People’s Republic of China


Utility of linked color imaging for endoscopic diagnosis of early gastric cancer.

Fujiyoshi T1, Miyahara R1, Funasaka K1, Furukawa K1, Sawada T2, Maeda K2, Yamamura T2, Ishikawa T1, Ohno E1, Nakamura M1, Kawashima H1, Nakaguro M3, Nakatochi M4, Hirooka Y2.

World J Gastroenterol. 2019 Mar 14;25(10):1248-1258. doi: 10.3748/wjg.v25.i10.1248.

Background: Linked color imaging (LCI) is a method of endoscopic imaging that emphasizes slight differences in red mucosal color.

Aim: To evaluate LCI in diagnostic endoscopy of early gastric cancer and to compare LCI and pathological findings.

Methods: Endoscopic images were obtained for 39 patients (43 lesions) with early gastric cancer. Three endoscopists evaluated lesion recognition with white light imaging (WLI) and LCI. Color values in Commission Internationale de l’Eclairage (CIE) 1976 Lab* color space were used to calculate the color difference (ΔE) between cancer lesions and non-cancer areas. After endoscopic submucosal dissection, blood vessel density in the surface layer of the gastric epithelium was evaluated pathologically. The identical region of interest was selected for analyses of endoscopic images (WLI and LCI) and pathological analyses.

Results: LCI was superior for lesion recognition (P < 0.0001), and ΔE between cancer and non-cancer areas was significantly greater with LCI than WLI (29.4 vs 18.6, P < 0.0001). Blood vessel density was significantly higher in cancer lesions (5.96% vs 4.15%, P = 0.0004). An a* cut-off of ≥ 24 in CIE 1976 Lab* color space identified a cancer lesion using LCI with sensitivity of 76.7%, specificity of 93.0%, and accuracy of 84.9%.

Conclusion: LCI is more effective for recognition of early gastric cancer compared to WLI as a result of improved visualization of changes in redness. Surface blood vessel density was significantly higher in cancer lesions, and this result is consistent with LCI image analysis.

1 Department of Gastroenterology Hepatology, Nagoya University Graduate School of Medicine, Nagoya 4668550, Japan
2 Department of Endoscopy, Nagoya University Hospital, Nagoya 4668560, Japan
3 Department of Pathology and Laboratory Medicine, Nagoya University Hospital, Nagoya 4668560, Japan
4 Division of Data Science, Data Coordinating Center, Department of Advanced Medicine, Nagoya University Hospital, Nagoya 4668560, Japan


Bronchoscopic observation with linked colour imaging.

Yamamoto S1, Shibano T1, Sogabe M1, Negishi H1, Mitsuda S1, Endo S1

Respirol Case Rep. 2019 Feb 14;7(3):

Abstract:We report two cases of the comparison of diagnosis made with linked color imaging (LCI) and conventional white-light imaging (WLI) on the same patients. In case 1, a 75-year-old man in whom right upper lobectomy with mediastinal lymph node dissection was performed due to lung cancer had signs of bronchitis on postoperative day 8. The LCI demonstrated slight inflammatory changes that were not detectable with the conventional WLI on the tracheal wall. In case 2, in a 61-year-old woman who was diagnosed with adenoid cystic carcinoma, the bronchial wall was checked to confirm the extent of the tumour. The submucosal vascularity and tumour margin on the bronchial mucosa were better visible on LCI than on WLI. We could easily detect the mucosal inflammatory lesion and the malignant lesion with LCI in comparison with conventional WLI. Both mucosal inflammatory and malignant lesions were better visible with LCI in comparison to WLI.

1 Department of General Thoracic Surgery, Jichi Medical University, Shimotsuke, Japan.


The Characteristics of Blue Laser Imaging and the Application in Diagnosis of Early Digestive Tract Cancer.

Bi Y1, Min M2, Zhang F1, Li X3.

Technol Cancer Res Treat. 2019 Jan 1;

Background: The blue laser imaging is a kind of new endoscopic system, sending 2 different wavelengths of laser.

Result: It can observed that the gastrointestinal mucosa shallow capillaries and mucosal surface microstructure are shown in bright and high resolution images, thus being helpful to the diagnosis of early digestive tract cancer. It has unique advantages compared with the existing technique. This article reviewed the application of blue laser imaging in diagnosis of early gastrointestinal carcinoma.

1 Department of Gastroenterology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
2 Department of Head surgrey, Linyi Tumor Hospital of Shandong, Linyi, China
3 Department of Oncology, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China


Computer-aided diagnosis of colorectal polyps using linked color imaging colonoscopy to predict histology.

Min M1, Su S1, He W2, Bi Y1, Ma Z2, Liu Y2.

Sci Rep. 2019 Feb 27;9(1):2881. doi: 10.1038/s41598-019-39416-7.

We developed a computer-aided diagnosis (CAD) system based on linked color imaging (LCI) images to predict the histological results of polyps by analyzing the colors of the lesions. A total of 139 images of adenomatous polyps and 69 images of non-adenomatous polyps obtained from our hospital were collected and used to train the CAD system. A test set of LCI images, including both adenomatous and non-adenomatous polyps, was prospectively collected from patients who underwent colonoscopies between Oct and Dec 2017; this test set was used to assess the diagnostic abilities of the CAD system compared to those of human endoscopists (two experts and two novices). The accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of this novel CAD system for the training set were 87.0%, 87.1%, 87.0%, 93.1%, and 76.9%, respectively. The test set included 115 adenomatous polyps and 66 non-adenomatous polyps that were prospectively collected. The CAD system identified adenomatous or non-adenomatous polyps in the test set with an accuracy of 78.4%, a sensitivity of 83.3%, a specificity of 70.1%, a PPV of 82.6%, and an NPV of 71.2%. The accuracy of the CAD system was comparable to that of the expert endoscopists (78.4% vs 79.6%; p = 0.517). In addition, the diagnostic accuracy of the novices was significantly lower to the performance of the experts (70.7% vs 79.6%; p = 0.018). A novel CAD system based on LCI could be a rapid and powerful decision-making tool for endoscopists.

1 Department of Gastroenterology and Hepatology, Affiliated Hospital of Academy of Military Medical Sciences Beijing, 100071, China
2 Pattern Recognition and Intelligent System Laboratory, School of Information and Communication Engineering, Beijing University of Posts and Telecommunications, Beijing, 100876, China. Min Min and Song Su contributed equally.


Linked color imaging improves the endoscopic visibility of gastric mucosal cancers.

Kitagawa Y1, Suzuki T1, Hara T2, Nankinzan R1, Takashiro H1, Sugita O1, Imazeki H3, Yamaguchi T3.

Endosc Int Open. 2019 Feb;7(2):E164-E170. doi: 10.1055/a-0733-7086. Epub 2019 Jan 18.

Background and study aims: As a newly developed endoscopy technique, linked color imaging (LCI) provides very bright images with enhanced color tones. With the objective of improving the detection rate of gastric mucosal cancers, which are often difficult to detect, we examined the utility of LCI from the viewpoint of visibility.

Patients and methods: The current study used 100 consecutive gastric mucosal cancers ≤ 20 mm in diameter. For each lesion, we selected one endoscopic image acquired by white-light imaging (WLI), blue-laser imaging (BLI) -bright, and LCI modes. Four endoscopists interpreted the images; using a previously reported scale, we scored the visibility level on a scale of 1 - 4.

Results: The mean (± SD) visibility scores were 2.54 ± 1.10 for WLI, 3.02 ± 1.07 for BLI-bright, and 3.28 ± 0.97 for LCI. The score was significantly higher for BLI-bright compared with WLI ( P  < .001) and again higher for LCI compared with BLI-bright ( P  < .001). For the experts, the scores for BLI-bright and LCI were similar, but both were significantly higher than the score for WLI. For the trainees, there was no significant difference between the WLI and BLI-bright scores, but LCI score was significantly higher than those for WLI and BLI-bright scores. With regard to clinical characteristics, LCI particularly enhanced visibility of normochromic, flat and depressed lesions, which had the lowest visibility scores of all three modalities compared with those of the other lesions.

Conclusion: LCI increased visibility and may contribute to early detection of gastric mucosal cancers.

1 Endoscopy Division, Chiba Cancer Center, Chiba, Japan
2 Hara Clinic, Chiba, Japan
3 Department of Gastroenterology, Chiba Cancer Center, Chiba, Japan


Advanced Treatment and Imaging in Colonoscopy: The Pocket-Creation Method for Complete Resection and Linked Color Imaging for Better Detection of Early Neoplastic Lesions by Colonoscopy.

Yamamoto H1, Shinozaki S2, Hayashi Y1, Miura Y1, Khurelbaatar T1, Osawa H1, Lefor AK3.

Clin Endosc. 2019 Jan 10. doi: 10.5946/ce.2018.189. [Epub ahead of print]

Early detection and resection of neoplastic lesions are key objectives to diminish colorectal cancer mortality. Resection of superficial colorectal neoplasms, cold snare polypectomy, endoscopic mucosal resection, and endoscopic submucosal dissection have all been developed and used worldwide. The pocket-creation method facilitates the resection of tumors in difficult and routine locations. Early detection is the most important first step to maximize the benefits of recent advancements in endoscopic techniques. However, the detection of small, flat-shaped, or faded color lesions remains difficult. Linked color imaging, a novel multi-light technology, facilitates the recognition of minor differences in tissue by enhancing the color contrast between early colorectal neoplasms and surrounding normal mucosa in a bright field of view. The most striking feature of linked color imaging is its ability to display the color of early neoplastic lesions as distinct from inflammatory changes, both of which have similar “redness” when viewed using white light imaging. To increase the detection rate of neoplasms, linked color imaging should be used from the outset for endoscopic observation. Early detection of superficial colorectal tumors can result in decreased mortality from colorectal cancer and maintain a good quality of life for patients.

1 Division of Gastroenterology, Department of Medicine, Jichi Medical University, Shimotsuke
2 Shinozaki Medical Clinic, Utsunomiya,
3 Department of Surgery, Jichi Medical University, Shimotsuke, Japan


Spraying l-menthol enhances gastric intestinal metaplasia in linked color imaging.

Ono S1, Ono Y2, Sakamoto N3.

Dig Endosc. 2019 Jan 28. doi: 10.1111/den.13362. [Epub ahead of print]

Recently, there have been some reports that image-enhanced endoscopy (IEE) may be useful for detection of gastric intestinal metaplasia (GIM) (1, 2). Linked color imaging (LCI) enables noninvasive detection of GIM as a lavender color, which is called lavender color sign (LCS) (3). Spraying l-menthol directly onto the gastric antral mucosa is useful for anti-peristalsis. As a secondary effect of spraying l-menthol, Mori et al. reported annular-reticular-like mucosal changes that were mucosal morphologic changes. This article is protected by copyright. All rights reserved.

1 Department of Gastroenterology, Hokkaido University Hospital, Sapporo
2 Department of Gastroenterology, Sapporo City Hospital, Sapporo
3 Department of Gastroenterology and Hepatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.