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. 2019 Mar 14;25(10):1248-1258.
doi: 10.3748/wjg.v25.i10.1248.

Utility of linked color imaging for endoscopic diagnosis of early gastric cancer

Toshihisa Fujiyoshi  1 , Ryoji Miyahara  2 , Kohei Funasaka  1 , Kazuhiro Furukawa  1 , Tsunaki Sawada  3 , Keiko Maeda  3 , Takeshi Yamamura  3 , Takuya Ishikawa  1 , Eizaburo Ohno  1 , Masanao Nakamura  1 , Hiroki Kawashima  1 , Masato Nakaguro  4 , Masahiro Nakatochi  5 , Yoshiki Hirooka  3
Affiliations

Utility of linked color imaging for endoscopic diagnosis of early gastric cancer

Toshihisa Fujiyoshi et al. World J Gastroenterol. .

Abstract

Background: Linked color imaging (LCI) is a method of endoscopic imaging that emphasizes slight differences in red mucosal color.

Aim: To evaluate LCI in diagnostic endoscopy of early gastric cancer and to compare LCI and pathological findings.

Methods: Endoscopic images were obtained for 39 patients (43 lesions) with early gastric cancer. Three endoscopists evaluated lesion recognition with white light imaging (WLI) and LCI. Color values in Commission Internationale de l'Eclairage (CIE) 1976 L*a*b* color space were used to calculate the color difference (ΔE) between cancer lesions and non-cancer areas. After endoscopic submucosal dissection, blood vessel density in the surface layer of the gastric epithelium was evaluated pathologically. The identical region of interest was selected for analyses of endoscopic images (WLI and LCI) and pathological analyses.

Results: LCI was superior for lesion recognition (P < 0.0001), and ΔE between cancer and non-cancer areas was significantly greater with LCI than WLI (29.4 vs 18.6, P < 0.0001). Blood vessel density was significantly higher in cancer lesions (5.96% vs 4.15%, P = 0.0004). An a* cut-off of ≥ 24 in CIE 1976 L*a*b* color space identified a cancer lesion using LCI with sensitivity of 76.7%, specificity of 93.0%, and accuracy of 84.9%.

Conclusion: LCI is more effective for recognition of early gastric cancer compared to WLI as a result of improved visualization of changes in redness. Surface blood vessel density was significantly higher in cancer lesions, and this result is consistent with LCI image analysis.

Keywords: Color difference; Early gastric cancer; Endoscopic submucosal dissection; Linked color imaging; Vessel density.

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Conflict of interest statement

Conflict-of-interest statement: All authors declare no conflicts-of-interest related to this article.

Figures

Figure 1
Figure 1
Color values and color differences between cancer and non- cancer areas. A region of interest (diameter: 24 pixels) was established in each lesion. Color values (L*, a*, b*) were measured using Adobe Photoshop CS4 to estimate color differences (ΔE) between cancer and non-cancer areas. The results are shown in Table 2. WLI: White light imaging; LCI: Linked color imaging.
Figure 2
Figure 2
An example of blood vessel density calculation by imaging analysis software. A: Hematoxylin and eosin staining of a cancer lesion (case 43, original magnification × 100, scale bar 100 μm). B: CD31 immunohistochemistry highlights blood vessels. C: A depth of 350 μm was trimmed manually. Automatically recognized blood vessels are colored in the cancer lesion (D) and non-cancer area (E). The calculated blood vessel area and ratio in this case are shown in the table.
Figure 3
Figure 3
Recognition of early gastric cancer lesions using a Likert scale. Linked color imaging was superior to white light imaging for recognition of early gastric cancer lesions based on evaluations by three endoscopists (P < 0.0001). This effect was stronger for flat/depressed lesions than for protruding lesions.
Figure 4
Figure 4
Blood vessel densities from the surface layer to a depth of 350 μm in cancer and non-cancer areas. The blood vessel density was significantly higher in cancer than in non-cancer areas [median (range): 5.96% (2.17-17.08) vs 4.15% (1.71-8.22), P = 0.0004].
Figure 5
Figure 5
Relationship of a* in Commission Internationale de l'Eclairage 1976 L*a*b* color space (X axis) with blood vessel density from the surface layer to 350 μm (Y axis) using (A) white light imaging (WLI) and (B) linked color imaging (LCI). Cancer and non-cancer areas were better differentiated with LCI compared to WLI. The blood vessel density was ≥ 9% in all cancer lesions. Using a cut-off value of ≥ 24 for cancer lesions, the diagnostic performance with LCI had sensitivity of 76.7%, specificity of 93.0%, positive predictive value of 91.7%, negative predictive value of 80.0%, and accuracy of 84.9%. WLI: White light imaging; LCI: Linked color imaging.
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