Digestive Endoscopy 2015; 27 (Suppl. 1): 24

doi: 10.1111/den.12452

Letters, Techniques and Images Future potential of EUS in the upper gastrointestinal tract Submucosal fibrosis detected by endoscopic ultrasonography may predict incomplete endoscopic submucosal dissection Endoscopic ultrasonography (EUS) can visualize the layer structure of the gastric wall1–5 and it can detect changes resulting from ulcer scarring.1–3 EUS evaluation of ulcer scarring can predict the difficulty of endoscopic submucosal dissection (ESD) preoperatively.1 Figure 1a is a chromoendoscopic image of a local recurrence lesion of cancer after ESD. Preoperative EUS revealed interruption of the third layer and thickening of the fourth layer (UL-IIIs) (Fig. 1b). ESD was done and fibrotic changes in the submucosal layer were so severe that the resected specimen suffered a tear (Fig. 1c). This lesion was diagnosed as mucosal cancer histologically. However, the lateral/vertical margins at the tear could not be ascertained. Two years after ESD, a flat elevated lesion recurred at the scar (Fig. 2). This case shows that local recurrence resulting from imprecise pathological assessment because of a lack of sufficient tumor tissue or a burn artifact can occur when the specimen has been damaged, even if en bloc resection is achieved. In our center, 794 cases of early gastric cancer (EGC) underwent ESD from 2005 to 2009. Among them, 26 lesions were

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Figure 2 (a) Local re-recurrence was detected 2 years after endoscopic submucosal dissection (white arrows). (b) Endoscopic ultrasonography shows wide interruption of the third layer and thickening of the fourth layer as a result of ulcer scarring (yellow arrows). In contrast, the third layer was not interrupted at the area of normal mucosa (green arrow).

incompletely resected because of severe ulcer scarring. Interruption of the third layer in almost all cases (24 lesions) was shown by preoperative EUS, possibly suggesting imprecise histological assessment of ESD specimens such as damage to the specimens or piecemeal resection. We consider that surgery is more preferable than ESD for EGC with an interruption of >5 mm of the third layer. However, this result does not mean that lesions with interruption of the third layer should not be treated by ESD because there are no data on EUS findings of completely resected lesions. In the future, EUS findings of cases of complete resection should also be evaluated in order to validate the usefulness of EUS in preoperative evaluation for EGC with ulcer scarring.

CONFLICT OF INTERESTS

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UTHORS DECLARE no conflicts of interest for this article.

Dai Hirasawa and Yuki Maeda Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan

REFERENCES

Figure 1 (a) Chromoendoscopic image of cancer recurring at the site where endoscopic submucosal dissection had been carried out 2 years previously. (b) Endoscopic ultrasonography shows a 10-mm interruption of the third layer (white arrows) and thickening of the fourth layer, which was diagnosed as UL-III. (c) The area of carcinoma on the specimen is mapped with red lines. In some sections, the lateral margin was difficult to evaluate pathologically because the specimen had been damaged at the tear (yellow arrows).

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1 Maeda Y, Hirasawa D, Fujita N. Endoscopic submucosal dissection for early gastric cancer with ulcerous change and evaluation with endoscopic ultrasonography. Endoscopy 2011; 43: A38. 2 Chonan A. Clinical evaluation of endoscopic ultrasonography (EUS) in the diagnosis of depressed type early gastric cancers. Gastroenterol. Endosc. 1993; 35: 1269–81. (Japanese with English abstract.) 3 Sabet EA, Okai T, Minamimoto T, Mai M, Sawabu N. Threedimensional endoscopic ultrasonography for the assessment of early gastric carcinoma invasion: Could it provide diagnostic innovations? Dig. Endosc. 2002; 14: 53–60. 4 Hirasawa D, Fujita N, Yuki T et al. Diagnosis of gastric mucinous carcinoma by endoscopic ultrasonography. Dig. Endosc. 2004; 16: 315–21. 5 Chonan A, Fujita N, Mochizuki F et al. Diagnosis of advanced gastric cancer invasion by endoscopic ultrasonography – effectiveness of the balloon-compression method. Dig. Endosc. 1995; 7: 220–5.

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Submucosal fibrosis detected by endoscopic ultrasonography may predict incomplete endoscopic submucosal dissection.

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