Narrow-band imaging with magnification is a tool often used to predict the histology
of early depressed-type gastric cancer on the basis of the observation of the vascular
and surface structure [1]. However, it can be relatively difficult to characterize elevated-type lesions because
the alert signs, such as microvascular pattern or demarcation line, are sometimes
obscure [2]. New-generation endocytoscopy (single lens, continuous zoom) enables in vivo ultrahigh
magnification (× 520) for direct visualization at the cellular level and allows a
precise pathological prediction of gastrointestinal neoplasia [3]. Herein, we report two patients with gastric elevated lesions that were characterized
accurately by endocytoscopy ([Video 1]).
Video 1 Endocytoscopy with CM double staining (1 % methylene blue and 0.05 % crystal violet)
to characterize two elevated-type gastric lesions. The first case showed some enlarged,
disarranged, hyperchromatic nuclei, with complete distortion of the glandular structure,
consistent with gastric cancer. The second case revealed a regularly arranged glandular
structure with sparse small round nuclei, which was recognized as being a benign lesion.
Patient 1 An 80-year-old man was referred for endoscopic examination because of intermittent
epigastralgia. One 2-cm elevated lesion was found on the posterior wall of gastric
antrum using conventional white-light endoscopy ([Fig. 1 a]) and narrow-band imaging ([Fig. 1 b]). Prior to endocytoscopic observation, a mixture of 1 % methylene blue and 0.05 %
crystal violet (CM double staining) was sprayed over the lesion to stain the nuclei
and cytoplasm. Endocytoscopy showed some enlarged, disarranged, hyperchromatic nuclei
(“enlarged nuclear sign”), with complete distortion of the glandular structure, features
which are consistent with gastric cancer ([Fig. 1 c]) [4]. Endoscopic submucosal dissection (ESD) was performed, with histopathology revealing
a well-differentiated adenocarcinoma with invasion of the muscularis mucosa ([Fig. 1 d]).
Fig. 1 Images from patient 1 showing: a a 2-cm elevated lesion on the posterior wall of the gastric antrum on conventional
white-light endoscopy; b the same lesion on narrow-band imaging; c some enlarged, disarranged, hyperchromatic nuclei (enlarged nuclear sign), with complete
distortion of the glandular structure on endocytoscopy; d a well-differentiated adenocarcinoma with invasion of the muscularis mucosa on histopathology
of the endoscopic submucosal dissection specimen.
Patient 2 A 52-year-old man underwent endoscopic examination for longstanding acid regurgitation.
A 2-cm elevated lesion was found accidentally on the posterior wall of the prepyloric
antrum on endoscopy ([Fig. 2 a, b]). Endocytoscopy was performed after CM double staining and showed a regularly arranged
glandular structure, with sparse small round nuclei, which was recognized as being
a benign lesion ([Fig. 2 c]). ESD was performed, and the histopathology revealed a hyperplastic polyp ([Fig. 2 d]).
Fig. 2 Images from patient 2 showing: a a 2-cm elevated lesion on white-light endoscopy; b the same lesion on narrow-band imaging; c a regularly arranged glandular structure with sparse small round nuclei on endocytoscopy;
d a hyperplastic polyp on histopathology of the endoscopic resection specimen.
Endocytoscopy is therefore useful for real-time optical biopsy to distinguish early
gastric cancer from non-cancerous lesions.
Endoscopy_UCTN_Code_CCL_1AB_2AD_3AB
Endoscopy E-Videos is an open access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
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