Usefulness of linked color imaging for the detection of obscure early gastric cancer: Multivariate analysis of 508 lesions

Abstract

Objectives Early gastric cancers (EGCs) of the elevated type or with submucosal invasion are easily found by routine endoscopy. However, most early cancers are challenging to detect because of subtle morphological or color differences from surrounding atrophic mucosa and intestinal metaplasia. Linked color imaging (LCI) enhances mucosal color difference, making it easier to detect EGCs. The aim of this study is to clarify the advantages and possible disadvantages of LCI for screening for obscure EGC. Methods A total of 665 malignant gastric lesions resected using endoscopic submucosal dissection between January 2015 and April 2018 were retrospectively reviewed. Obviously detectable lesions were not included in the main analysis when determining the target lesion. White light imaging (WLI)/LCI images of 508 endoscopically obscure malignant lesions were included in the final analysis and evaluated by three non‐expert and three expert endoscopists using visibility scores for detection and extent. Results The detection visibility scores using LCI were significantly higher than those using WLI regardless of lesion characteristics including location, size, histological type, depth of invasion, and Helicobacter pylori status. The detection score improved in 46.4% cases and deteriorated in 4.9% when the modality changed from WLI to LCI. A mixed‐effects multivariate logistic regression analysis showed that use of LCI (odds ratio [OR] 2.57), elevated type (OR 1.92), invasion to submucosa (OR 2.18) were significantly associated with improved visibility of EGC. Conclusions Linked color imaging significantly improves visibility of EGC regardless of differences in lesion morphology, histology, location, depth of invasion, and H. pylori status compared to conventional WLI.

Current status and future perspective of linked color imaging for gastric cancer screening: a literature review

“…Further investigations focusing on EGC are desired to determine whether LCI is more effective in a general population for gastric cancer screening. More recently, Khurelbaatar et al [ 67 ] showed that when compared with conventional WLI, LCI significantly improved the visibility of EGC regardless of differences in lesion morphology, histology, location, depth of invasion, and Hp status, which may explain the improved detection rates and reduced miss rates previously reported.…”

“…Non-experts placed the biopsy mark more accurately with LCI (82.3% vs. 87.2%, P < 0.001). Non-experts were indicated to prefer LCI over WLI Khurelbaatar et al [ 67 ] 2022 Retrospective/SC 508 EGCs from 456 patients Images of EGCs LCI significantly improved visibility of EGC regardless of differences in lesion morphology, histology, location, depth of invasion, and Hp status compared with conventional WLI Ishida et al [ 28 ] 2022 Retrospective/SC 99 EGC lesions from 88 patients Videos of EGCs and gastric mucosa captured using LED and laser endoscopy LED-WLI and LED-LCI can be used to visualize EGCs with non-inferiority to Laser-WLI and Laser-LCI Haruma et al [ 68 ] 2022 RCT/MC 1502 patients (patients with a history of gastrointestinal cancer) Real-time observation The detection rate of upper gastrointestinal neoplasms tended to be higher with LCI than with WLI among patients who underwent ultra-slim endoscopy Khurelbaatar et al [ 69 ] 2022 Retrospective/SC 52 EGCs and 29 nonmalignant lesions Video including cases of EGC or gastric atrophy alone using standard and ultra-thin endoscopies Ultra-thin LCI had a higher diagnostic sensitivity and significantly higher visibility scores and color difference than standard WLI SC single-center, MC multicenter, RCT randomized controlled trial, EGC early gastric cancer, IM intestinal metaplasia, LCI linked color imaging, WLI white-light imaging, BLI blue laser imaging, LED light-emitting diode, Hp Helicobacter pylori , M-Chromo-LCI magnifying linked color imaging with indigo carmine dye, M-BLI magnifying blue laser imaging, MR map-like redness, IC indigo carmine contrast method, CI confidence interval, AIM acetic acid indigo carmine mixture

Fig. 2 PRISMA 2009 flow diagram describing the selection of the studies included in our review

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“…In general, most early-stage gastric cancers are orange-red, orange, or orange-white on LCI [ 13 ]. In comparison with BLI, LCI is associated with improved visibility of EGC, regardless of the endoscopist’s experience [ 53 , 55 , 57 , 58 , 63 , 67 ], and several studies have reported its advantage of improving the visibility of malignant gastrointestinal lesions with higher scores than WLI. LED-based LCI endoscopy has also been reported to be effective in detecting EGC [ 28 , 29 ].…”

“…While LCI may improve visibility of EGC in most cases when compared with WLI, it may also reduce visibility in certain cases of EGC [ 67 ]. Fukuda et al [ 46 ] reported that malignant lesions exhibiting a redder color than the surrounding mucosa on WLI are observed as purple on LCI and may not be recognized as malignant lesions, even if the surface is irregular.…”

Diagnostic accuracy of linked colour imaging versus white light imaging for early gastric cancers: a prospective, multicentre, randomized controlled trial study

“…As IEE screening for gastrointestinal malignant lesions has progressed, LCI has been demonstrated to be a brighter IEE technique than WLI and thus more useful in screening for lesions because it provides improved visualization of changes in redness, allowing easy recognition and detection of EGCs ( 18–20 ). Recently, two clinical randomized studies have reported the efficacy of LCI in detecting EGC.…”