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A case in which implantation of esophageal squamous cell carcinoma onto a post-dissection gastric ulcer was strongly suspected is presented. A 72-year-old man with alcoholic liver cirrhosis underwent esophagogastroduodenoscopy (EGD). Esophageal cancer (EC) (Mt, 20 mm, 0-Is) and gastric cancer (GC) (antrum, 15 mm, 0-IIc) were identified. Biopsy specimens revealed moderately differentiated squamous cell carcinoma (SCC) and differentiated adenocarcinoma, respectively. The GC was resected by endoscopic submucosal dissection (ESD) [14 mm × 9 mm, type 0-IIc, tub1, pT1a(M), ly0, v0, HM(-), VM(-)]. Two months after ESD, radiation therapy was started for the EC, and an almost complete response was obtained. Nine months after the ESD, a follow-up EGD showed a submucosal tumor-like lesion with ulceration, located immediately under the post-ESD scar, and biopsy specimens showed moderately differentiated SCC. There were no similar lesions suggesting hematogenous or lymphatic metastasis in the stomach.

Although the possible existence of micrometastasis in superficial esophageal cancer cases is the most important factor in deciding the therapeutic strategy, it is difficult. There are also limits to the diagnosis of the depth of tumor invasion by endoscopy and EUS. Therefore, the extension of the indication of EMR is planned. Then, the complement of diagnostic ability by EMR is being tried. Sentinel lymph node (s) identification and its biopsy also seem to be useful. In advanced esophageal cancer cases, diagnostic accuracy has been improving by speedup of CT and MRI scans and various image processing technology. More accurate diagnosis of metastasis using PET is much awaited. However, there is still insufficient ability to detect micrometastasis to date. Molecular bio-markers with comprehensiveness are not a valuable selection at this stage. Although advanced equipment has brought more diagnostic accuracy, ways to integrate or use these tools at the clinical level are sought. Some equipment developing and how to integrate them and how to select the appropriate examination in each patient are problems which are required in clinical practitioners.

Background and Study Aims: We have previously demonstrated that an ultrasonic tactile sensor (UTS) could be used to distinguish between mucosal and submucosal cancer in surgically resected specimens, by providing a measurement of tissue stiffness which could be less prone to subjective errors. In the current study, we evaluated the potential of a newly developed, thin UTS to differentiate in vivo between mucosal and submucosal invasion during clinical endoscopic examination., Patients and Methods: Between March and July 1997, 15 patients with esophageal cancer who were not receiving special treatment, underwent preoperative UTS examination during endoscopy. The thin UTS probe was inserted through the biopsy channel of the endoscope. A transparent cap was placed on the distal end of the endoscope in order to facilitate vertical placement of the probe on the tumor., Results: Although the probe used in this study was a prototype, the results of the current in vivo study were in agreement with our previous in vitro study on surgically resected specimens. The mean delta(f) value of the mucosal cancers, which means the magnitude of the frequency shift recorded by the UTS, was -5356.23 Hz, and the corresponding value for submucosal cancers was -4126.56 Hz; this difference was significant., Conclusion: The UTS is potentially an essential tool for preoperative evaluation of esophageal cancers. The ability to differentiate between mucosal and submucosal cancers is important because of the differences in surgical management of these tumors, i.e. endoscopic mucosal resection or conventional open esophagectomy.

Endoscopic mucosal resection (EMR) is one of several local treatments that provide a specimen for histopathological analysis. The authors developed a technique of EMR using a transparent plastic cap (EMRC) in 1992. By using the EMRC procedure, any part of the gastrointestinal tract mucosa can be easily accessed. The technical details of EMRC are described. The authors have performed EMR in 380 cases of gastrointestinal lesions. The most serious complication may be perforation. Two perforations (one in the esophagus and one in the colon) have occurred. By evaluating recorded videotapes, it was determined that the lack of submucosal saline injection was the major cause. Therefore, large volume injection, which creates a large bleb and potentially reduces the risk of perforation, is recommended. Furthermore, target mucosa should be strangulated at the middle part of the created bleb (never strangulated at the base). Particularly in the colon, injecting a sufficient volume of saline and controlling the power of suction are extremely important, because the cap on the colonoscope is relatively large in size.

Background: We have performed endoscopic mucosal resection of the esophagus (172 cases), stomach (102 cases), and colon (28 cases) using a transparent plastic cap. Because the lesion-bearing mucosa is suctioned up inside the cap under endoscopic suction, the mucosa should be dissected sufficiently from the proper muscle layer to prevent perforation., Methods: To avert the risk of perforation, we introduced endosonographic assessment of submucosal dissection (47 cases). In all cases, just keeping the ultrasonic probe on the surface of the mucosa allowed us to evaluate whether the mucosal lesion was lifted up sufficiently from the proper muscle layer after local saline injection., Results: It was possible to confirm that the muscle layer was kept outside the strangulating snare by the same procedure (32 of 37 cases, 86.5%)., Conclusions: We experienced five muscular resections in cases without the ultrasonic probe and no muscular resection with the ultrasonic probe. Thus we recommend endosonographic assessment during endoscopic mucosal resection to enhance its safety.

Endoscopic mucosal resection (EMR) has gained increasing popularity in the treatment of esophageal and gastric mucosal cancers in Japan, for complete local resection of the cancer-bearing mucosa. In Western countries, the concept of mucosal cancer and the necessity of treating it are gradually but steadily coming to be accepted. As a treatment for inoperable cases of advanced cancer, on the other hand, intubation with self-expanding metal stents has been widely accepted as a less invasive form of palliation for malignant obstruction of the upper gastrointestinal tract. Tumor ingrowth into the stent can be mechanically avoided by adding a membrane coating to it. In the last two years, applications for therapeutic endoscopy in the treatment of esophageal and gastric tumors have continued to widen.

The endoscopic diagnosis of early esophageal and gastric cancers located within 2 cm above and below the esophagogastric junction (EGJ) is discussed. We reviewed 25 cases (10 mucosal cancers and 15 submucosal cancers). Histologically, early cancers frequently appeared as type IIc lesions (16/25: 64%). There was no relationship between tumor size and the depth of invasion of cancer lesions, and most of the lesions were well or moderately differentiated carcinomas. Endoscopically, homogenous redness with a thin white coating, some granular appearance, and easy bleeding were very important factors for the diagnosis of early gastric cancer. For superficial esophageal cancer, differential diagnosis from reflux esophagitis is correctly performed with the endoscopic dye (lugol)-staining method and biopsy. In order not to overlook early cancer at the EGJ, this area should be observed with sufficient air inflation by the U-turn or J-turn method using a frontal-view panendoscope.

Background and Study Aims: In ultrasonic probe studies for early-stage esophageal cancer the original soft-balloon method utilizing a condom had succeeded in obtaining a clear and reproducible picture by keeping deaerated water in a condom; however, the condom, which covered the endoscope lens, eliminated the usual endoscopic sight. Therefore, the authors endeavored to develop a modified method which enables both normal endoscopic observation and ultrasonic probe study with only a single insertion of the endoscope., Patients and Methods: Thirty-one patients with superficial esophageal cancer were included in this pilot study. As modifications of the soft-balloon technique, two novel methods of 'wrapping' and 'invagination' were developed., Results: These modifications are considered to have solved the above-mentioned problem and enable one to acquire both normal endoscopic photos and ultrasonic probe images during the same insertion of the endoscope., Conclusion: In a pilot study novel modifications improved the method of ultrasonic probe study for superficial esophageal cancer.

Background and Aims: Endoscopic treatment has become increasingly popular in recent years as an alternative to surgical treatment with the hope of offering superior quality of life (QOL) for the patient. The results of endoscopic treatment of mucosal lesions of mostly early oesophageal or gastric cancer performed in 145 patients (155 lesions) over the past eight years were reviewed from the standpoint of QOL., Results: In 56 patients who underwent radical resection of the oesophageal mucosa, no serious complications and symptoms occurred, with epithelialisation completed within about a month. Patients also showed good results regarding dietary intake and performance status (PS), and all are currently alive without any sign of recurrence. One time fractionated endoscopic resection was carried out in about 40% of the 57 patients who underwent gastric mucosal resection. In these 57 patients, an artificial ulcer measuring 3 cm or more was formed, resulting in a favourable outcome after healing. An overwhelming proportion of these subjects had no symptoms and good PS after the treatment., Conclusions: The introduction of this method, endoscopic mucosal resection using a cap fitted panendoscope, is expected to permit additional indications for endoscopic treatment. Endoscopic Nd-YAG laser irradiation was applied mainly to early gastric cancer lesions (32 patients), usually for relative indications for endoscopic treatment. This procedure is safe and advantageous in that it requires no hospitalisation, permits fractionated irradiation, and secures good QOL.

Thoracoscopic enucleation of leiomyoma of the esophagus was successfully performed in two cases. This paper mainly describes a 53-year-old man who experienced with a slight dysphagia and retrosternal discomfort when moving. Esophagoscopy showed a mass beneath normal mucosa located at 26 cm from the incisor of the left anterior esophagus. Endoscopic ultrasonography showed a sharply delineated low echoic mass with regular echo-pattern, measuring 4 cm along the axis. The lesion was diagnosed as leiomyoma. The operation was performed under general anesthesia, keeping the patient on the left postero-lateral position. A double-lumen endotracheal tube was utilized and the right lung was collapsed. Six trocars were inserted through right intercostal spaces for operation. The azygos vein first of all was dissected and divided by an EndoGIA. The esophagus was then mobilized lengthwise enough to rotate the left side to the right with two slings traction for better visualization of the lesion site. Intraluminal balloon-mounted esophagoscope was useful enough to expose the tumor inner side out of the esophageal wall and the tumor was easily enucleated. After resection, intact esophageal mucosa was confirmed by endoscopy and the proper muscle layer of the esophagus was closed with 2-0 Vicryl. In the 2nd case, leiomyoma located at 32 cm from the incisor of the right esophageal wall, 4 x 1.5 x 1 cm in size, was removed by the same technique using five trocars, where neither the azygos vein divided nor the esophagus mobilized. Both patients showed uneventful recovery and the symptoms disappeared after operation. Intraluminal balloon-mounted esophagoscope was useful to do this kind of thoracoscopic procedure.

Limited surgery, esophagectomy without thoracotomy or endoscopic mucosal resection (EMR), is indicated for mucosal cancer of the esophagus without lymph node metastasis. Mucosal cancer less than 2 cm in size or less than a third of the circumference of the esophagus, is suitable for EMR. However, mucosal cancer invasive to the muscularis mucosa is excluded. As for postoperative complications, a small fissure, two cases of stenosis and 3 cases of oozing bleeding, were experienced. Conservative treatment was performed for all patients except one. The 5-year survival rate of EMR was 95%-100% in several institutions in Japan. Recurrence was observed in 3%-7%, however, it was cured by means of local treatment of esophageal cancer.

A total of 211 patients with gastric cancer in the upper third of the stomach were clinicopathologically evaluated. Of the 211 patients, 82 had esophageal infiltration and 129 did not. These two groups were compared. The study on patients who had undergone resection and radioisotope (99mTc-phytate) uptake testing revealed that it was important to dissect the lymph nodes (predominantly nodes 7, 9, 11, and 16) during surgery in the patients with gastric cancer plus esophageal infiltration. When cancer infiltration of the esophagus exceeds 1 cm, the preferred surgical procedure is lower esophagectomy and total gastrectomy with abdominal and intrathoracic lymphadenectomy via the left thoracoabdominal approach. When residual cancer is suggested in the more proximal esophageal stump due to intramural metastasis from vascular invasion, rapid pathologic diagnosis should be made by frozen sections during surgery and then subtotal esophagectomy by blunt removal of the esophagus proximally from the aortic arch using a left thoracotomy considered.

Endoscopic and histopathological findings were compared in 74 patients with gastric cancer infiltrating the lower esophagus who had undergone gastrectomy to evaluate mode of esophageal infiltration. There were no early cancers. Cancer infiltration modes were histopathologically broken down into three types: superficial, whole layer, and deep layer. Endoscopic findings were broken down into five types for proximal infiltration. Endoscopy used for histological evaluation frequently revealed the protruded type to be whole layer and had a highly accurate diagnosis rate (94%); it revealed the histology of the other four types to be primarily superficial. Extent of cancer invasion was underestimated in giant-rugae tumors (40%), as endoscopy could barely detect the small nest of esophageal infiltrations. Lugol staining was useful in preventing underestimation. For flat cancer, which is poorly demarcated and is often accompanied by vascular invasion, preoperative evaluation is very difficult, requiring preoperative examination of a frozen section taken from the proximal edge of resected specimen.

Early-stage esophageal cancerous lesions in four clinical cases were endoscopically resected via a newly developed procedure, endoscopic esophageal mucosal resection using a transparent tube (EMRT). In the complete resection of cancer-bearing mucosa, more than half of the circumferential mucosal resections did not involve major complications such as perforation or massive bleeding. Large ulcers artificially induced by this procedure disappeared within 3 weeks, exhibiting no stenotic changes. Resected specimens contributed well to microscopic examination for histological classification and determination of the depth of cancer invasion and possible vascular involvement. No signs of recurrence were observed during the 15-month follow-up period. We conclude that EMRT is a safe and minimally invasive local treatment for early-stage esophageal cancer that also provides specimens that are suitable for accurate histopathological diagnosis.

A case of carcinoma in situ of the esophagus accompanied by esophageal varices was treated by endoscopic mucosal resection using a transparent tube (EMRT) following eradication of the varices via injection sclerotherapy (EIS). Intravariceal injection sclerotherapy was performed for esophageal varices, and after eradication of the varices had been achieved, half of the circumferential esophageal mucosal resection of the cancer lesion was carried out. No serious complication such as perforation or mass bleeding was observed. Cancer-involved mucosa was completely resected and all specimens contributed well to accurate histopathological study, being diagnosed as intraepithelial squamous-cell carcinoma. The artificial ulcer recovered completely, showing no stenotic changes. Our conclusion from this experience is that EIS + EMRT is a valuable and minimally invasive treatment for patients exhibiting this disease, providing an accurate histological diagnosis.

144 cases of the superficial esophageal cancer, of which invasion was limited to the submucosa, have been resected for the last 23 years. 94 cases (65%) were early cancer, and 50 cases (35%) were superficial cancer with metastasis. The 5-year survival rate of early cancer cases was 65%, otherwise, that of superficial cancer cases with metastasis was 24%. There was a significant difference between these two groups. As for the depth of cancerous invasion, the 5-year survival rate of mucosal cancer cases was 100%. That of submucosal cancer cases was 70% even in cases without nodal involvement. Analyzing the cancerous depth of the superficial cancer and its nodal involvement and its vascular invasion, the lymph node metastasis and the vascular invasion were not observed in 90% of mucosal cancer cases, otherwise these were negative only in 30% of submucosal cancer cases. So to obtain the remarkable improvement of the long term results of esophageal cancer, the diagnosis and the treatment of mucosal cancer of the esophagus are essential. The endoscopic examination have come to play a large role for the diagnosis of mucosal cancer of the esophagus. Moreover, the endoscopic dyeing with Lugol's solution is important in the diagnosis of flat type of esophageal lesions, that is mucosal cancer and epithelial cancer. At present time, the treatment of early esophageal cancer is in principle surgery. And the operative mortality was low, 1.4%. However, the non-invasive treatments; endoscopic LASER therapy, radiation, endoscopic strip-biopsy etc., will be performed more frequently in minute mucosal cancer.

In order to obtain a reliable experimental model simulating human esophageal cancer, endoscopic and histopathological studies were undertaken in the esophageal cancer produced in the beagle dog. Thirty-seven dogs had been given a solution of N-Ethyl-N'-nitro-N-nitrosoguanidine (ENNG) at a concentration of 150 micrograms/ml for 3-9 months. Follow-up studies included serial endoscopy and biopsy, and almost all animals were eventually sacrificed for histological examination. The results were as follows: Squamous cell carcinoma was observed in 5 out of 22 female dogs, while none in male dogs at all. For the induction of squamous cell carcinoma in the esophagus, administration in the condition of 150 micrograms/ml (75mg/day) for 6-9 months was most suitable. Almost all of esophageal lesions were protruding and well-differentiated squamous cell carcinoma with invasion of the submucosa. The stages of hyperplasia, dysplasia and squamous cell carcinoma in the esophagus were chronologically followed. Carcinoma had been observed in the stomach about 4 months prior to the appearance of esophageal carcinoma. This experimental model was proved to be useful for studies on histogenesis of human esophageal cancer both light and electron microscopically.

The endoscopic findings and the surgical results of 131 resected cases of superficial oesophageal cancer are described. Of these 131 cases 24 (18%) had mucosal cancer. Twenty-one (88%) of 24 cases of mucosal cancer of the oesophagus had neither nodal involvement nor vascular invasion, and therefore excellent long-term results can be anticipated. In order to obtain good results in the treatment of mucosal cancer of the oesophagus, the role of oesophagoscopy is extremely important in the early diagnosis of this cancer.

A rare case of solitary neurofibroma located in the esophagus is reported. A large (4.2 X 4.0 X 3.0 cm) submucosal tumor was surgically removed from the midportion of the esophagus of a 64-year-old woman. Light and electron microscopic examination, and immunohistochemistry of S-100 protein in the tumor tissue confirmed neurofibroma. The patient had no evidence of von Recklinghausen's neurofibromatosis. A review of literature failed to find other reports of solitary neurofibroma of the esophagus with reliable histological diagnosis.