QUANDO E QUALE TRATTAMENTO ENDOSCOPICO

Takuji Gotoda, MDEndoscopy Division, National Cancer Center Hospital

XXIV Congresso Nationale ACOI Montecatini Terme 26 Maggio 2005

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New treatment strategy for early gastric cancer

cancer

Gastrectomywith lymph node dissection

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cancer

Endoscopic mucosal resection (EMR)

Rational of endoscopic resection

Primary gastric cancer

Lymph nodes

Peritoneum Blood circulation

Local disease

Systemic disease

>Surgical treatment

>Chemotherapy

Local disease>Endoscopic resection

Indication : EGC with no risk of LN metastasis

Conditions

Differentiated adenocarcinomaIntramucosal cancerNo lymph-vascular involvement

Irrespective of ulcer findings

Incidence 95% C.I.

Tumor less than 3cm

Differentiated adenocarcinomaIntramucosal cancerNo lymph-vascular involvement

Without ulcer findings

Irrespective of tumor size

Differentiated adenocarcinoma

Minute submucosal penetration (SM1)No lymph-vascular involvement

Tumor less than 3cm

0/1230 (0%)

0/929 (0%)

0/145 (0%)

0-0.3%

0-0.4%

0-2.5%

Gotoda et al, Gastric Cancer, 2000

Clinical management for patients with EGC

Finding EGC

Pretreatment evaluation using endoscopy, biopsy, EUS, etc.

Histological assessment

Endoscopic resection

Surgery (gastrectomy+D2)Recently, LADG, SNS, etc.

yes no

curative

non-curative

Annual surveillance

c Type 0 IIa+IIc T1 SM ?

p Type 0 IIa+IIc T1 M, well differentiated, 30mm, UL(+)

No risk of LN metastasis

Conditions

Differentiated adenocarcinomaIntramucosal cancer

No lymph-vascular involvementIrrespective of ulcer findings

Incidence

95% C.I.

Tumor less than 3cm

0/1230 (0%)

0-0.3%

Standard EMR procedure

Soetikno et al, Gastrointest Endosc, 2003

Polypectomy; Deyhle et al., Endoscopy, 1973

Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984

EMR-C; Inoue et al., Gastrointest Endosc, 1993

EMR-L; Akiyama et al., Gastrointest Endosc, 1997

Endoscopic devices for conventional EMR

Hard and soft hood for EMR-C

EMR-L using pneumo-activated EVL device

Strip Biopsy method

Endoscopic resection by conventional EMR

One piece resection Piecemeal resection

Local recurrent gastric cancer after previous EMR

Tanabe et al

Author Methods

Strip Biopsy, EAM 3.5% (15/423)

Recurrence rate

Kawaguchi et al Strip Biopsy, EMR-C35.3% (97/266)

Ida et al EMR+Laser 6.7% (11/165)

Chonan et al EMR 10.9% (21/193)

Hirao et al ERHSE 2.3% (8/349)

Mitsunaga et al Strip Biopsy 18.2% (54/296)

NCCH (1988-1998)Strip Biopsy 8.5% (53/620)

Local recurrence after piecemeal resection

Curability and local recurrence

1987-2003 at NCCH

One piece (1451)

Curative Non-curative Not evaluable

1194 (82%) 209 (14%) 48 (4%)

Piecemeal (331) 148 (45%) 81 (24%) 102 (31%)

Local rec. 0 16 8

Local rec. 7 (5%) 26 17

LN metastasis after piecemeal resection

2 years later

3 years later

Histological assessment

1: assess the lateral margin

2: assess submucosal penetration

3: assess lymphatic vascular involvement

cut every 2mm

The RENAISSANCE Endoscopic Submucosal Dissection (ESD)

Large one piece resection - by Endoscopic Submucosal Dissection

(ESD) -

well diff. adenoca.,Type 0-IIc, 8x7mm, M, ly0, v0, ul(-)

20x20mm

50x40mm

65x45mm

well diff. adenoca.,Type 0-IIc, 30x25mm, M, ly0, v0, ul-IIs

well diff. adenoca.,Type 0-IIc, 21x17mm, M, ly0, v0, ul-IIs

Endoscopic equipments for ESD

IT knife Hook knife

Flex knife

Produced by Olympus Medical Systems Corp.

Curability and local recurrence

1987-2003 at NCCH

One piece (1451)

Curative Non-curative Not evaluable

1194 (82%)209 (14%) 48 (4%)

Piecemeal (331) 148 (45%) 81 (24%) 102 (31%)

Local rec. 0 16 8

Local rec. 7 (5%) 26 17

Video of ESD procedure

Bleeding

Endoscopic closure by metallic clips

Chronological trend of treatment strategyfor patients with early gastric cancer at

NCCH

Cases

200

150

100

50

1988

1990

1996

‘00

300

250

‘01

350

‘02 ‘03

50

100%

‘99

Guideline EMR

Surgery

Expanded EMR

EMR for patients with major complications

Conclusion

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●Curability is confirmed only through histological assessment

ESD is possible to remove a large en bloc resection

EMR provides histological staging

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● En bloc makes accurate histological assessment possible,and reduces local recurrences

ESD EMR

Which way would you choose ?