Catálogo de publicaciones - libros

The following 12 gastric, 7 colorectal, and 5 esophageal cases are part of the material used in previous studies []–[]. In total, 76 histological specimens of mostly early neoplastic lesions were circulated to and individually reviewed by 31 well-known pathologists from 12 countries a few months before the “Vienna meeting,” which was held on 5 and 6 September, 1998, and led to the Vienna classification of gastrointestinal epithelial neoplasia []. In Tables 1–24, the results of the assessments by these 31 pathologists are shown for 41 of the 76 specimens.These 41 specimens were taken from lesions in 23 Japanese patients, of which the endoscopic gross appearances are indicated by I, IIa, IIb, IIc, IIa+IIc or IIc+IIa according to the macroscopic classification of early neoplasia of the digestive tract [].

A man, aged 73 years, complaining of anorexia, cough, and rhinorrhea for a week, underwent a barium meal examination, which was followed up by an upper gastrointestinal (GI) endoscopic examination to rule out abnormalities. A lesion of about 5 mm in diameter was found in the corpus and was biopsied.Two months later he underwent endoscopic ultrasonographic examination and shortly thereafter endoscopic resection was performed. The resection margins were free of tumor. On follow-up endoscopic examinations, no local recurrence was found.

A woman, aged 54 years, with a history of gastric ulcer and endometriosis, had no recent abdominal symptoms, but because a fecal occult blood test had turned out to be positive she underwent a barium enema examination, which was followed up by colonoscopy.A lesion of about 13 mm in diameter was found in the descending colon. Endoscopic resection was performed. The resection margins were free of tumor. On follow-up endoscopic examinations no local recurrence was found.

A man, aged 59 years, complaining of occasional epigastric pain, underwent an upper GI endoscopic examination. At 33 cm from the teeth a lesion was found and biopsied. Three weeks thereafter endoscopic resection was performed. Histological examination of the two resected pieces revealed that not all resection margins were free of neoplastic change. However, on follow-up endoscopy 2 weeks later, no unstained area could be seen around the postresection ulcer; also, no neoplastic changes could be observed in 16 biopsies taken from the ulcer margin.

At first glance, the variability in the histological differential diagnosis of early epithelial neoplasia of the stomach, first reported by Schlemper et al. [] and subsequently confirmed in further reports []–[], is alarming. This variability then gave rise to critical comments []. One gastroenterologist was even moved to give his comments the title “Japanese Fairy Tales,” [] and concluded “The high prevalence of early gastric carcinoma in Japan and the successes in combating carcinoma of the stomach are possibly nothing but an artefact.” This commentator, however, overlooked the fact that one of the Western pathologists established exactly the same diagnoses, as did the four Japanese pathologists. He also failed to note that, in contrast to this group of four Japanese and one Western pathologist, the diagnoses made by the three other Western pathologists in forceps biopsy material differed considerably from their own diagnoses in the mucosectomy specimens from the same patients. Similar variable results in identical specimens were also revealed by the slide seminar that led to the compromise Vienna classification of gastrointestinal epithelial neoplasia [], so that we might be justified in claiming that, in this area the term “Western deficiency” might be a more accurate comment than “Japanese fairy tales.”[]

It is generally assumed that the distinction between cancer and noncancer is relatively straightforward and not subject to wide interobserver disagreement. A number of workshops involving the assessment of gastrointestinal lesions by Japanese and Western pathologists have highlighted major discrepancies []–[]. In general, Japanese pathologists have a lower threshold for the diagnosis of malignancy than Western pathologists. In view of the poor levels of diagnostic agreement, international dialogue and collaboration is impeded, and progress in both clinical and basic research suffers accordingly. The Vienna classification (Table 1) was developed in order to remedy this situation []. When the proposed terminology is adopted by Japanese and Western pathologists, the reporting differences are reduced but not eliminated.

Over the last 10–20 years, the incidence of adenocarcinomas in Barrett’s esophagus has increased enormously in many Western countries []–[]. The increase in these countries is greater than that of all other malignant epithelial tumors, so that the term “new epidemic” has even been applied [].

When early gastric cancer (EGC) was diagnosed for the first time a little more than 40 years ago, abnormal regions were detected by fluoroscopic barium examination and by photographs from a gastrocamera. With regard to the use of endoscopes for diagnosis, the gastrocamera was replaced by the fiberscope in the 1970s. The latter was then replaced with the electronic endoscope in the 1980s. Since the latter half of the 1990s, capsule endoscopes have come into use. In addition to conventional endoscopy, the following endoscopic examinations are now available: chromoscopy, endoscopic ultrasonography (EUS), magnifying endoscopy, and narrow band imaging etc. It is also worth noting that a definite diagnosis of EGC is impossible without biopsy.

Early colorectal cancers show diversity in configuration. The Japanese Research Society for Cancer of the Colon and Rectum divides the shapes of early cancers into type I (pedunculated, semipedunculated, and sessile), type II (superficial), and special type. Superficial lesions are subdivided into superficially elevated, flat, and superficially depressed types. This classification is also applied to the description of the shape of adenomas. Of these, the superficially depressed-type lesions are very important because they are often malignant and tend to invade the submucosa despite their small size [].

In 2517 cases of superficial esophageal cancer analyzed in Japan, 287 (11.4%) were intraepithelial cancer, 439 (17.4%) were cancer invading the lamina propria or cancer invading the muscularis mucosae, and 1791 (71.2%) were cancer invading the submucosa. Lymph node metastasis comprised 0% for epithelial cancer, 8.7% for cancer invading the lamina propria or the muscularis mucosae, and 36.5% for cancer invading the submucosa []. Following these results, in 1999 the definition of early esophageal cancer changed from cancer invading the submucosa to mucosal cancer without lymph node metastasis according to the Japanese Society of Esophageal Disease []. Cancer limited to the submucosa was redefined as superficial cancer []. This definition appeared practical, because patients with mucosal cancer had a better survival rate, 96.9% for Tis and 91.9% for cancer invading the lamina propria, compared with 66.9% for patients who had cancer invading the submucosa []. Therefore, the early stage of esophageal cancer should be defined as cancer limited to the mucosa.