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There is a well-known discrepancy between East and West classifications of colorectal neoplasm, especially "intramucosal carcinoma," categorized as subgroup 4.4 in the Vienna classification, usually recognized as high-grade dysplasia in the United States and as carcinoma in situ in Japan. Focusing on management, in the current National Comprehensive Cancer Network algorithm, high-grade dysplasia, carcinoma in situ, and intramucosal carcinoma are managed similarly, whereas submucosal invasion by carcinoma requires en bloc resection. To bridge the differences with regard to these conceptual problems in the definition and management of carcinoma in situ and intramucosal carcinoma, endoscopists and pathologists from Japan and the United States gathered and discussed from their perspectives how to accurately assess specimens of en bloc/piecemeal resection and to effectively predict lymph node metastasis risk.

Background Argon plasma coagulation (APC) is a noncontact technique for tissue coagulation. APC has been used to treat early gastric cancer in patients who cannot undergo EMR or open surgery, but a standard procedure for APC is lacking. Objective Our objectives were to assess the clinical usefulness of APC in patients with early gastric cancer. Design This was a small, retrospective pilot study. Setting All patients were treated at the Department of Gastroenterology, Kitasato University East Hospital, Sagamihara, Japan. Methods We studied 40 patients with early gastric cancer in whom both EMR and open surgery were contraindicated. The macroscopic tumor type was superficial elevated in 11 patients, superficial depressed in 27, and superficial elevated plus superficial depressed in two. The histologic classification was intestinal type in 37 patients and diffuse type in 3. Intervention From January 1998 through March 1999, all patients received one session of APC. From April 1999 through August 2001, all patients received two sessions of APC. From September 2001 through March 2002, an additional session of APC was given only to patients who had large protruding lesions, depressed lesions 2 cm or greater in diameter, or submucosal invasion. Main Outcome Measurements The main outcome measurements were residual tumor or recurrence of early gastric cancer. Results Intestinal-type intramucosal carcinoma disappeared after one or two sessions of APC. Submucosal and diffuse-type tumors had a high risk of residual tumor cells because of inadequate treatment after one session of APC. However, such lesions were locally controlled by follow-up APC. Limitations This was a small, retrospective pilot study. Confirmation of long-term outcome is required. Conclusions Small early gastric carcinomas can be successfully treated by a single session of APC. Larger protruding-type lesions and submucosal tumors are likely to require two sessions of APC.

Background We assessed the usefulness of acetic acid–enhanced magnifying endoscopy in the diagnosis of gastric neoplasia. Methods Forty-five patients (27 men, 18 women; median age 61.6 years) with gastric carcinoma or adenoma were enrolled in a prospective trial of enhanced magnifying endoscopy after instillation of 1.5% acetic acid. Acetic acid–enhanced magnified views of carcinoma or adenoma and the surrounding non-neoplastic mucosa were observed, and the duration of whitening time of each lesion was recorded. Observations Magnified views of carcinoma showed a minute, grain-like pattern that differed from the surrounding noncancerous mucosa. The histopathologic diagnostic criteria were based on the Vienna classification of GI epithelial neoplasia. The mean duration of whitening differed with each histologic type: low-grade adenoma, 94 seconds; high-grade adenoma, 24.3 seconds; noninvasive carcinoma, 20.1 seconds; invasive intramucosal carcinoma, 3.5 seconds; and submucosal carcinoma or beyond, 2.5 seconds. The duration in the non-neoplastic surrounding mucosa was 90 seconds. After the disappearance of whitening in the carcinoma, the irregular pattern of the carcinoma reappeared, and the contrast between carcinomatous microvessels and the whitened non-neoplastic tissue became very clear on magnifying endoscopy. In accordance with the duration of whitening, more than 1 minute was termed "continuous whitening," from 31 to 60 seconds was "delayed disappearance of whitening," from 30 to 6 seconds was "early disappearance of whitening," and 0 to 5 seconds was "no response." Conclusions Acetic acid–enhanced magnifying endoscopy was useful for the diagnosis of gastric adenocarcinoma. The duration of whitening differed among grades of neoplasia, and it was possible to observe changes in the whitening with time. Acetic acid–enhanced magnifying endoscopy, therefore, can be termed "dynamic chemical magnifying endoscopy."

Early cancer (high-grade dysplasia [HGD] and intramucosal carcinoma [ImCa]) associated with Barrett's esophagus (BE) may have a circumferential spatial predilection.To describe the esophageal circumferential location of early cancer in BE.Retrospective study, single tertiary referral center.One hundred nineteen patients were referred for endoscopic eradication therapy for early cancer associated with BE. Endoscopic images and reports and pathology were reviewed.Circumferential location designation of early cancer in BE by using a clock-face orientation.One hundred nineteen of 131 patients referred for endoscopic eradication therapy had a location designation for their advanced histology (91.9%). There were a total of 57 patients (47.9%) with HGD and 62 patients (52.1%) with ImCa. There was a significantly higher rate of early cancer (HGD or ImCa) in the right hemisphere (12 to 6 o'clock location) compared with the left hemisphere (84.9% vs 15.1%, P.0001). The highest percentage of early cancer was found in the 12 to 3 o'clock quadrant (64.7%); 71.9% of HGD and 58.1% of ImCa lesions were located in the 12 to 3 o'clock quadrant.Retrospective design, single center.Early cancer associated with BE is far more commonly found in the right hemisphere of the esophagus (12 to 6 o'clock) with the highest rate in the 12 to 3 o'clock quadrant. These findings support enhanced scrutiny of the right hemisphere of the esophagus during surveillance and endoscopic treatment of patients with BE.

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elevated flat lesion with wide pit spreading on the margin of LST and we named it “Skirt”. However, not much is known regarding the differences between rectal LST and colonic LST, and the characteristics of Skirt have not been clarified. Aim: To evaluate retrospectively the clinicopathological characteristics of rectal LST and Skirt. Methods: From February 2006 to April 2012, a total of 663 LST in 612 patients undergoing endoscopic or surgical resection in our hospital were enrolled. LST were classified into the following three groups: granularhomogeneous type (LST-GH), granular-nodular mixed type (LST-GM) and nongranular type (LST-NG). The location was divided into two regions: rectum (from upper rectum to lower rectum) and colon (from cecum to recto-sigmoid colon). The “Skirt” was defined as having three findings: 1) spreading on the margin of LST, 2) hardly elevated lesion and 3) presenting the wide shape pit. We assessed the clinicopathological characteristics of the patient such as age, gender, location, size, tumor type and histological type. Results: A total of 114 LST were located in the rectum (LST-GH: 8 lesions (7%), LST-GM: 87 (76%), LST-NG: 19 (17%)) and 549 LST were located in the colon (LST-GH: 128 lesions (23%), LSTGM: 113 (21%), LST-NG: 308 (56%)). The mean sizes of rectal LST and colonic LST were 40.2 19.7mm and 25.5 13.9mm. The histological types of rectal LST were 21 adenoma (18%), 61 intramucosal carcinoma (54%) and 32 submucosal carcinoma (28%). As for colonic LST, those were 310 (57%), 169 (31%) and 70 (13%). Significant difference was seen in the frequency of LST-GM (p 0.001), large size of tumor (p 0.05), the frequency of carcinoma (p 0.001) between rectal and colonic LST. In contrast, no significant differences in age and gender were seen between rectal and colonic LST. All 21 LST with Skirt were attaching LST-GM lesions. Of the 21 LST, 19 LST were located in the rectum and 2 LST were located in the colon. Rectal LST with Skirt had significantly more female (12/19, p 0.05) and larger tumor size (47.1 17.9mm, p 0.05) than those without Skirt (35/95, 38.9 19.7mm). Conclusions: Rectal LST had significantly more LST-GM, larger tumor size and more cancers in comparison to colonic LST. As for Skirt, rectal LST with Skirt group was characterized with more female and larger tumor size. In the future, further studies need to involve not only clinical pathology but also molecular biology to clarify the significance of Skirt.