Date post: | 14-Jan-2016 |
Category: |
Documents |
Upload: | adrian-skains |
View: | 217 times |
Download: | 0 times |
QUANDO E QUALE TRATTAMENTO ENDOSCOPICO
Takuji Gotoda, MDEndoscopy Division, National Cancer Center Hospital
XXIV Congresso Nationale ACOI Montecatini Terme 26 Maggio 2005
●●●
●
●●
●
●●
● ●
●●
New treatment strategy for early gastric cancer
cancer
Gastrectomywith lymph node dissection
●●●
●
●●
●
●●
● ●
●●
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
●
●Curability is confirmed only through histological assessment
ESD is possible to remove a large en bloc resection
EMR provides histological staging
●
● En bloc makes accurate histological assessment possible,and reduces local recurrences
ESD EMR
Which way would you choose ?