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Gastric intestinal metaplasia assessment between linked color imaging based on endoscopy and pathology

Guanpo Zhang1,2, Jin Zheng2,3, Linfu Zheng1,2, Shentong Yu4, Chuanshen Jiang1,2, Wulian Lin1,2, Dazhou Li1,2, Lijuan Qu4, Wen Wang1,2

Scand J Gastroenterol. 2021 Jan;56(1):103-110. doi: 10.1080/00365521.2020.1849385. Epub 2020 Nov 24.

Objective: Cumulative evidence suggests that linked color imaging (LCI) can be used to identify gastric intestinal metaplasia (GIM). We aimed to develop endoscopic grading for GIM (EGGIM) with LCI.

Methods: Two hundred and seventy-seven patients who underwent high-resolution white-light gastroscopy followed by LCI for EGGIM estimation were included. LCI was performed for the entire mucosa, and images of five areas each were recorded from the lesser and greater curvatures of the antrum and corpus, and for the incisura. For each area, scores of 0 (no GIM), 1 (focal GIM, ≤30% of the area), and 2 (extensive GIM, >30% of the area) were attributed for 10 points. If GIM was suspected based on endoscopy findings, targeted biopsies were performed; if GIM was not evident, random biopsies were performed according to the Sydney system to estimate the operative link on GIM (OLGIM).

Results: GIM was staged as OLGIM 0, I, II, III, and IV in 136, 70, 37, 28, and 6 patients, respectively. For OLGIM III/IV diagnosis, the area under the receiver operating curve was 0.949 (95% CI 0.916-0.972). EGGIM of 4, with sensitivity and specificity of 94.12% (95% CI 80.3%-99.3%) and 86.42% (95% CI 81.5%-90.5%), respectively, was determined the best cut-off value for identifying OLGIM III/IV patients.

Conclusions: Our findings demonstrated the ability of EGGIM for diagnosing the extent of intestinal metaplasia and showed that EGGIM is related to OLGIM staging. EGGIM of 4 was the best cut-off value for identifying OLGIM III/IV patients.

1 Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, Fujian Medical University, Fuzhou, China
2 Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, People’s Liberation Army, Fuzhou, China
3 Department of Gastroenterology, Oriental Hospital Affiliated to Xiamen University, Fuzhou, China
4 Department of Pathology, 900th Hospital of Joint Logistics Support Force, People’s Liberation Army, Fuzhou, China

Linked color imaging can improve the visibility of superficial non-ampullary duodenal epithelial tumors

Kenichiro Okimoto1, Daisuke Maruoka1, Tomoaki Matsumura1, Mamoru Tokunaga1, Tatsuya Kaneko1, Hirotaka Oura1, Naoki Akizue1, Yuki Ohta1, Keiko Saito1, Makoto Arai1, Jun Kato1, Naoya Kato1

Scientific Reports volume 10, Article number: 20667 (2020)

The current study aimed to evaluate the efficacy of linked color imaging (LCI) in improving the visibility of superficial non-ampullary duodenal epithelial tumors (SNADETs). We prospectively evaluated 44 consecutive patients diagnosed with SNADETs. Three trainees and three experts assessed the visibility scores of white light imaging (WLI), LCI, and blue laser imaging-bright (BLI-b) for SNADETs, which ranged from 1 (not detectable without repeated cautious examination) to 4 (excellent visibility). In addition, the L* a* b* color values and color differences (ΔE) were evaluated using the CIELAB color space system. For SNADETs, the visibility scores of LCI (3.53 ± 0.59) were significantly higher than those of WLI and BLI-b (2.66 ± 0.79 and 3.41 ± 0.64, respectively). The color differences (ΔE) between SNADETs and the adjacent normal duodenal mucosa in LCI mode (19.09 ± 8.33) were significantly higher than those in WLI and BLI-b modes (8.67 ± 4.81 and 12.92 ± 7.95, respectively). In addition, the visibility score of SNADETs and the color differences in LCI mode were significantly higher than those in WLI and BLI-b modes regardless of the presence of milk white mucosa (MWM). LCI has potential benefits, and it is considered a promising clinical modality that can increase the visibility of SNADETs regardless of the presence of MWM.

1 Department of Gastroenterology, Graduate School of Medicine, Chiba University, Inohana 1‐8‐1, Chiba City 260‐8670, Japan

Prevalence of Barrett’s Epithelium Shown by Endoscopic Observations with Linked color Imaging in Subjects with Different H. pylori Infection Statuses

Kyoichi Adachi1, Norihisa Ishimura2, Kanako Kishi1, Takumi Notsu1, Tomoko Mishiro1, Kazunari Sota1, Shunji Ishihara2

Intern Med. 2020 Sep 30. doi: 10.2169/internalmedicine.5676-20. Online ahead of print.

Objective: This study was conducted to clarify the prevalence of short segment Barrett’s esophagus (SSBE) using endoscopic observations with linked color imaging (LCI). In addition, the relationship between the presence of Barrett’s epithelium (BE) and the status of H. pylori infection was investigated.

Methods: The study subjects were 3,353 individuals (2,186 men, 1,167 women; mean age 55.2±9.4 years old) whose status of H. pylori infection had been determined. An endoscopic observation using LCI was performed to examine the distal margin of palisade vessels and confirm the area of BE. The prevalence of BE ≥5 mm in length was investigated.

Results: BE was diagnosed in 1,884 (56.2%) subjects, with lengths of <10, 10-19, 20-29, and ≥30 mm found in 1,005, 851, 27, and 1, respectively. Its prevalence in H. pylori-negative, H. pylori-positive, and post-eradicated subjects was 41.7%, 64.4%, and 69.9%, respectively (p<0.001). The duration since successful eradication of H. pylori did not affect the prevalence of BE. The degree of gastric mucosal atrophy was higher in cases with BE (p<0.001), although negativity for H. pylori infection and mild gastric mucosal atrophy were significant factors for the development of longer BE.

Conclusion: A high prevalence of SSBE was noted when LCI was used to determine the area of BE, as the distal end of the palisade vessels was easily visualized. Negativity for H. pylori infection and mild gastric mucosal atrophy were not correlated with SSBE prevalence.

1 Health Center, Shimane Environment and Health Public Corporation, Japan
2 Second Department of Internal Medicine, Shimane University, Faculty of Medicine, Japan

Magnification linked color imaging characterization of the irregular vessel network of diffuse mucosal rectal metastatic spread from high-grade serous ovarian cancer

Vincent Zimmer1,2, Elke Eltze3

Dig Liver Dis. 2020 Oct 17;S1590-8658(20)30931-2. doi: 10.1016/j.dld.2020.10.002. Online ahead of print.

A 62-year-old female patient presented with lower abdominal pain in combination with a 2-kg weight loss and stool retention. Medical history was significant for ovarian cancer that was treated by curative-intent surgery and adjuvant chemotherapy two years before. Imaging studies were consistent with peritoneal carcinomatosis and suggested incipient large bowel obstruction, for which the patient underwent lower GI endoscopy. While a high-grade stricture at the rectosigmoidal junction due to external compression precluded scope advancement, apart from mild unspecific erythema multiple nodular aphthoid-like lesions were identified throughout the rectum (Fig. 1A). Further endoscopic assessment including magnification image-enhanced endoscopy was performed. On blue laser imaging (BLI) no pit pattern was discernible (Fig. 1B). Linked color imaging (LCI) in escalating magnification levels, however, clearly depicted an irregular vessel network within the lesion with avascular areas, marked caliber changes, curtailed interruptions, tortuosity up to irregular loop formation (Fig. 1C,D). Overall, these findings were highly suggestive of diffuse multi-nodular metastases as an exceedingly uncommon type of gastrointestinal metastatic spread in ovarian cancer [1]. This was confirmed by final pathology indicating mucosal infiltration by atypical solid, in part, papillary epithelial complexes (Fig. 2A,B) with CK-7 and WT-1 positivity (Fig. 2C,D) and lymphovascular invasion, consistent with recurrent high-grade serous ovarian cancer.

1 Department of Medicine, Marienhausklinik St. Josef Kohlhof, Neunkirchen, Germany
2 Department of Medicine II, Saarland University Medical Center, Saarland University, Homburg, Germany
3 Institute of Pathology Saarbrücken-Rastpfuhl, Saarbrücken, Germany

The Efficacy of Linked Color Imaging in the Endoscopic Diagnosis of Barrett’s Esophagus and Esophageal Adenocarcinoma

Mamoru Tokunaga1, Tomoaki Matsumura1, Kentaro Ishikawa1, Tatsuya Kaneko1, Hirotaka Oura1, Tsubasa Ishikawa1, Ariki Nagashima1, Wataru Shiratori1, Kenichiro Okimoto1, Naoki Akizue1, Daisuke Maruoka1, Yuki Ohta1, Keiko Saito1, Tomoo Nakagawa1, Tetsuhiro Chiba1, Makoto Arai1,2, Jun Kato1, Naoya Kato1

Gastroenterol Res Pract. 2020 Sep 29;2020:9604345. doi: 10.1155/2020/9604345. eCollection 2020.

Background: The present study aimed to evaluate the efficacy of linked color imaging (LCI) in diagnosing Barrett’s esophagus (BE) and esophageal adenocarcinoma (EAC).

Methods: A total of 112 and 12 consecutive patients with BE and EAC were analyzed. The visibility scores of BE and EAC ranging from 4 (excellent visibility) to 0 (not detectable) were evaluated by three trainees and three experts using white light imaging (WLI), LCI mode, and blue laser imaging bright (BLI-b) mode. In addition, L∗a∗b∗ color values and color differences (ΔE∗) were evaluated using the CIELAB color space system.

Results: The visibility score of the BE in LCI mode (2.94 ± 1.32) was significantly higher than those in WLI (2.46 ± 1.48) and BLI-b mode (2.35 ± 1.46) (p < 0.01). The color difference (ΔE∗) from the adjacent gastric mucosa in LCI mode (17.11 ± 8.53) was significantly higher than those in other modes (12.52 ± 9.37 in WLI and 11.96 ± 6.59 in BLI-b mode, p < 0.01). The visibility scores of EAC in LCI mode (2.56 ± 1.47) and BLI-b mode (2.51 ± 1.28) were significantly higher than that in WLI (1.64 ± 1.46) (p < 0.01). The color difference (ΔE∗) from the adjacent normal Barrett’s mucosa in LCI mode (19.96 ± 7.97) was significantly higher than that in WLI (12.95 ± 11.86) (p = 0.03).

Conclusion: The present findings suggest that LCI increases the visibility of BE and EAC and contributes to the improvement of the detection of these lesions.

1 Department of Gastroenterology, Graduate School of Medicine, Chiba University Chiba, Japan
2 Department of Medical Oncology, Chiba University Chiba, Japan

Linked color imaging improves visibility of reflux esophagitis

Tsutomu Takeda1, Daisuke Asaoka2, Daiki Abe1, Maiko Suzuki2, Yuta Nakagawa2, Hitoshi Sasaki2, Yoshihiro Inami2, Muneo Ikemura1, Hisanori Utsunomiya1, Shotaro Oki1, Nobuyuki Suzuki1, Atsushi Ikeda1, Noboru Yatagai1, Hiroyuki Komori1, Yoichi Akazawa1, Kohei Matsumoto1, Kumiko Ueda1, Hiroya Ueyama1, Yuji Shimada1, Kenshi Matsumoto1, Mariko Hojo1, Taro Osada1, Shuko Nojiri3, Akihito Nagahara1

BMC Gastroenterol. 2020 Oct 27;20(1):356. doi: 10.1186/s12876-020-01511-9.

Background: With more prevalent gastroesophageal reflux disease comes increased cases of Barrett’s esophagus and esophageal adenocarcinoma. Image-enhanced endoscopy using linked-color imaging (LCI) differentiates between mucosal colors. We compared LCI, white light imaging (WLI), and blue LASER imaging (BLI) in diagnosing reflux esophagitis (RE).

Methods: Consecutive RE patients (modified Los Angeles [LA] classification system) who underwent esophagogastroduodenoscopy using WLI, LCI, and BLI between April 2017 and March 2019 were selected retrospectively. Ten endoscopists compared WLI with LCI or BLI using 142 images from 142 patients. Visibility changes were scored by endoscopists as follows: 5, improved; 4, somewhat improved; 3, equivalent; 2, somewhat decreased; and 1, decreased. For total scores, 40 points was considered improved visibility, 21-39 points was comparable to white light, and < 20 points equaled decreased visibility. Inter- and intra-rater reliabilities (Intra-class Correlation Coefficient [ICC]) were also evaluated. Images showing color differences (ΔE) and L a* b* color values in RE and adjacent esophageal mucosae were assessed using CIELAB, a color space system.

Results: The mean age of patients was 67.1 years (range: 27-89; 63 males, 79 females). RE LA grades observed included 52 M, 52 A, 24 B, 11 C, and 3 D. Compared with WLI, all RE cases showed improved visibility: 28.2% (40/142), LA grade M: 19.2% (10/52), LA grade A: 34.6% (18/52), LA grade B: 37.5% (9/24), LA grade C: 27.3% (3/11), and LA grade D: 0% (0/3) in LCI, and for all RE cases: 0% in BLI. LCI was not associated with decreased visibility. The LCI inter-rater reliability was “moderate” for LA grade M and “substantial” for erosive RE. The LCI intra-rater reliability was “moderate-substantial” for trainees and experts. Color differences were WLI: 12.3, LCI: 22.7 in LA grade M; and WLI: 18.2, LCI: 31.9 in erosive RE (P < 0.001 for WLI vs. LCI).

Conclusion: LCI versus WLI and BLI led to improved visibility for RE after subjective and objective evaluations. Visibility and the ICC for minimal change esophagitis were lower than for erosive RE for LCI. With LCI, RE images contrasting better with the surrounding esophageal mucosa were more clearly viewed.

1 Department of Gastroenterology, Juntendo University School of Medicine,2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan.
2 Department of Gastroenterology, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan.
3 Department of Medical Technology Innovation Center, Juntendo University School of Medicine, Tokyo, Japan.