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Duodenal sessile serrated adenoma/polyp with characteristic endoscopic and pathologic features

Takashi Ueno1, Yoshimasa Miura1, Hiroyuki Osawa1, Kenichi Tabata2, Alan Kawarai Lefor3, Hironori Yamamoto1

Clin J Gastroenterol. 2021 Mar 1. doi: 10.1007/s12328-021-01358-x. Online ahead of print.

Sessile serrated adenomas/polyps (SSA/Ps), recently called sessile serrated lesions, have a neoplastic pathway in the large intestine and are treated as lesions with malignant potential. There are a few reports of traditional serrated adenomas in the duodenum but no reports of duodenal SSA/Ps. A 66-year-old man underwent screening upper gastrointestinal endoscopy and was found to have a white elevated lesion in the second portion of the duodenum. Magnifying blue laser imaging showed various sized villous-like structures with dilated crypt openings in the white surface mucosa, similar to a SSA/P. Based on these images, a duodenal adenoma was suspected at the time of endoscopic resection. Pathological findings of the resected specimen showed a saw-tooth structure corresponding to basal crypt dilatation and branching with mucus and positive immunostaining for MUC6 and MUC2, similar to a colonic SSA/P. MUC5AC did not stain the glandular crypt cells. KRAS mutation was detected. Immunohistochemical expression of Annexin A10 was clearly identified in the lesion. Although not all of molecular biological features were satisfied, these findings were similar to a colonic SSA/P which has malignant potential. This is the first report of a duodenal SSA/P which should be considered when evaluating elevated duodenal lesions.

1 Division of Gastroenterology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan
2 Department of Diagnostic Pathology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan
3 Department of Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan

Evaluation of blue laser endoscopy for detecting colorectal non-pedunculated adenoma

Ying Zhu1, Wei Hu1, Fang Wang1, Yan Zhou3, Guili Xia1, Jianguo Xu2, Wei Gong1

Arab J Gastroenterol. 2021 Mar 15;S1687-1979(20)30135-0. doi: 10.1016/j.ajg.2020.12.002. Online ahead of print.

Background and study aims: Non-pedunculated lesions are easily missed on endoscopy, and histopathological examination shows that some of these lesions are adenomas. Adenoma is a precursor of colorectal cancer, a common tumor of the digestive tract. This study was conducted to compare the detection efficacy of non-pedunculated lesions in the same patient under different modes of blue laser endoscopy and to determine whether the surface pattern of the sample was consistent with its histopathological results.

Patients and methods: A total of 91 patients with non-pedunculated lesions diagnosed at our hospital between April 2018 and March 2019 were included in this study. White light imaging (WLI), linked color imaging (LCI), and blue laser imaging (BLI) modes were used to record the location, number, and Hiroshima classification of the surface patterns of the non-pedunculated lesions. The lesions were removed by different endoscopic excision methods for histopathological examination; the histopathological results were compared with the surface patterns.

Results: A total of 105, 198, and 223 lesions were detected using the WLI, BLI, and LCI modes, respectively. The Wilcoxon signed rank test revealed a significant difference in the number of lesions detected using each observation mode (p < 0.01). The non-pedunculated lesions were primarily located in the rectum and transverse colon, followed by the sigmoid, descending, and ascending colon. The efficacy of LCI and BLI modes was better than that of WLI mode for detecting the non-pedunculated lesions measuring < 5 mm in size (p < 0.05). The surface pattern was not detected by the WLI mode. The surface patterns detected using the LCI and BLI modes were primarily types A and B. Histopathological results of the non-pedunculated lesions included inflammatory polyp, hyperplastic polyp, tubular adenoma, and adenoma. Surface patterns could not be detected using the WLI mode. The McNemar’s test revealed a significant difference between the WLI mode findings and the histopathological results (p < 0.01). No significant difference was observed between the histopathological results and the surface patterns detected using the LCI mode (kappa = 0.57); the agreement was poor. There was also no significant difference between the histopathological results and the surface patterns detected using the BLI mode (kappa test, p < 0.01; kappa = 0.88); hence, there was good agreement between the surface patterns detected using the BLI mode and the histopathological results.

Conclusion: The detection rate of colorectal non-pedunculated lesions may be improved using blue laser endoscopy. Non-pedunculated colorectal adenomas could be identified more accurately using the BLI mode, which might improve the adenoma detection rate, thus indicating that BLI is a feasible option in the practical settings.

1 Department of Gastroenterology, Shenzhen Hospital of Southern Medical University, Shenzhen, Guangdong 518100, China
2 Department of Liver Disease Center, Shenzhen Hospital of Southern Medical University, Shenzhen, Guangdong 518100, China
3 Information Management Section, Bethune International Peace Hospital, Shijiazhuang City, Hebei Province 050000, China

The efficacy of linked color imaging for the endoscopic diagnosis of mucosal healing in quiescent ulcerative colitis

Tomohisa Takagi1,2, Kazuhiko Uchiyama1, Mariko Kajiwara-Kubota1, Saori Kashiwagi1, Yuki Toyokawa1, Yuma Hotta1, Makoto Tanaka1, Ken Inoue1, Osamu Dohi1, Naohisa Yoshida1, Kazuhiro Kamada1, Takeshi Ishikawa1, Hideyuki Konishi1, Mitsuo Kishimoto 3, Nobuaki Yagi4, Yuji Naito1, Yoshito Itoh1

J Gastroenterol Hepatol. 2021 Mar 12. doi: 10.1111/jgh.15489. Online ahead of print.

Background and aim: The Mayo Endoscopic Subscore (MES) and the Ulcerative Colitis Endoscopic Index of Severity (UCEIS) are used to assess endoscopic mucosal healing in patients suffering from ulcerative colitis. Although mucosal healing is defined by MES 0, relapse of ulcerative colitis is often observed. Over a 48-month period, this study investigated the efficacy of linked color imaging (LCI) in predicting the long-term prognosis of ulcerative colitis patients diagnosed with MES 0.

Methods: Overall, 26 patients in ulcerative colitis remission, diagnosed with MES 0, were enrolled. Using a LASEREO endoscopic system (Fujifilm Co., Tokyo, Japan), endoscopic colonic images were assessed with linked color imaging and the colitis endoscopic index of severity. Endoscopic LCI images were separated into three subgroups (A, no redness; B, redness with visible vessels; and C, redness without visible vessels). The Geboes score was used to evaluate histology; active mucosa was defined as GS > 2B.1.

Results: Linked color imaging classification subdivided colonic mucosa, which had been diagnosed with MES 0, into two classes. The LCI-A group did not relapse, and the non-relapse rate was significantly higher (P = 0.018) than that in the LCI-B group. No difference in relapse rates was observed between patients with a colitis endoscopic index of severity of 0 and 1 (P = 0.655). There was no statistical difference between the composition of LCI-A group and the relapse rate between active and inactive mucosa diagnosed by Geboes score.

Conclusions: This methodology can be used to evaluate mucosal healing and predict long-term outcomes in ulcerative colitis patients.

1 Molecular Gastroenterology and Hepatology, Graduate School of Medical Science
2 Department for Medical Innovation and Translational Medical Science, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
3 Department of Surgical Pathology, Kyoto City Hospital, Kyoto
4 Department of Gastroenterology, Asahi University Hospital, Gifu, Japan

Linked colour imaging versus white-light colonoscopy for the detection of flat colorectal lesions: A randomized controlled trial

Takahiro Kudo1,2, Akira Horiuchi1, Reiko Kyodo1,2, Ichitaro Horiuchi1, Nobuyasu Arai1,2, Masashi Kajiyama1, Naoki Tanaka1,3

Colorectal Dis. 2021 Mar 1. doi: 10.1111/codi.15605. Online ahead of print.

Aim: Linked colour imaging is an image-enhanced endoscopy system that emphasizes the red portion of the mucosa’s colour. Our aim was to compare the effectiveness of linked colour imaging with white-light colonoscopy for the detection of flat-type colorectal polyps.

Method: This was a single-centre, randomized controlled trial. Enrolled patients were those aged ≥50 years undergoing cap-assisted colonoscopy for colorectal cancer screening. They were randomized in a 1:1 ratio for observation using linked colour imaging or white-light colonoscopy. All colorectal polyps detected were removed or biopsied. The primary outcome was the number of flat-type polyps per patient in patients in whom flat polyps were detected. Secondary outcomes included adenoma and polyp detection rates.

Results: There were 302 subjects randomized: 152 to linked colour imaging and 150 to white-light colonoscopy. There were no differences in the clinical features between the two arms. The number of flat polyps detected per patient using linked colour imaging was approximately twice that with white light (2.9 ± 3.0 vs 1.2 ± 1.6, p = 0.045). Linked colour imaging also proved superior to white-light colonoscopy in terms of adenoma and polyp detection rates [adenomas 66% (101/152) vs 49% (73/150), p = 0.0024; polyps 69% (105/152) vs 55% (82/150), p = 0.013]. The ratio of polyps detected in the right colon compared with those detected in the left colon was significantly greater using linked colour than white-light imaging (168/64 vs 93/84; p < 0.001).

Conclusion: Compared with white-light colonoscopy, linked colour imaging improved adenoma and polyp detection rates, including detection of flat-type colorectal polyps.

1 Digestive Disease Center, Showa Inan General Hospital, Komagane, Japan
2 Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
3 Department of Metabolic Regulation, Shinshu University School of Medicine, Matsumoto, Japan

Clinical usefulness of linked color imaging for evaluation of endoscopic activity and prediction of relapse in ulcerative colitis

Kenta Matsumoto1, Shiro Oka 1, Shinji Tanaka2, Katsuaki Inagaki1, Yuki Okamoto1, Hidenori Tanaka1, Toshikatsu Naito1, Masaki Wakai1, Ken Yamashita2, Yuki Ninomiya2, Ryohei Hayashi2, Yasuhiko Kitadai3, Fumio Shimamoto 4, Kazuaki Chayama1

Int J Colorectal Dis. 2021 Jan 7. doi: 10.1007/s00384-020-03810-9. Online ahead of print.

Purpose: In the treatment of ulcerative colitis (UC), accurate evaluation of UC activity is important to achieve mucosal healing. We sought to investigate the clinical utility of linked color imaging (LCI) for the evaluation of endoscopic activity and prediction of relapse in UC patients.

Methods: We enrolled 72 consecutive UC patients in remission who underwent colonoscopy at our institution between September 2016 and October 2018. The relationship between the presence of redness in white light imaging (WLI) and LCI and histopathological inflammation (Geboes score: GS) at 238 biopsy sites was examined. We also assessed the presence or absence of planar redness in the entire rectum as ± and classified the patients into three groups according to the combination of WLI/LCI: A: WLI-/LCI-, B: WLI-/LCI+, and C: WLI+/LCI+. The relationship between WLI/LCI classification and relapse in 64 patients followed up for more than 12 months from initial colonoscopy was assessed and compared to the Mayo endoscopic subscore (MES).

Results: A GS of 0 or 1 accounted for 89% of WLI/LCI non-redness sites, while a GS of 2 or 3 accounted for 42% of WLI non-redness/LCI redness sites. LCI findings were significantly correlated with GS. During follow-up, 10 patients in group C and four patients in group B relapsed, but none in group A. Non-relapse rates were significantly correlated with WLI/LCI classification, but not with MES.

Conclusion: LCI is a useful modality for accurate assessment of endoscopic activity and prediction of relapse in UC by detecting mild inflammation unrecognizable by WLI.

1 Department of Gastroenterology and Metabolism, Hiroshima University Hospital, 1-2-3, Kasumi, Minami-ku, Hiroshima 734-8551, Japan
2 Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
3 Department of Health Sciences, Prefectural University of Hiroshima, Hiroshima, Japan
4 Faculty of Health Sciences, Hiroshima Shudo University, Hiroshima, Japan

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