QUANDO E QUALE TRATTAMENTO ENDOSCOPICO Takuji Gotoda, MD Endoscopy Division, National Cancer Center Hospital XXIV Congresso Nationale ACOI Montecatini Terme 26 Maggio 2005

● ● ● ● ● ● ● ● ● ● ● ● New treatment strategy for early gastric cancer cancer Gastrectomy with 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 adenocarcinoma Intramucosal cancer No lymph-vascular involvement Irrespective of ulcer findings Incidence95% C.I. Tumor less than 3cm Differentiated adenocarcinoma Intramucosal cancer No 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. yesno 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 adenocarcinoma Intramucosal cancer No lymph-vascular involvement Irrespective of ulcer findings Incidence95% 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 AuthorMethods Strip Biopsy, EAM3.5% (15/423) Recurrence rate Kawaguchi et al Strip Biopsy, EMR-C35.3% (97/266) Ida et al EMR+Laser6.7% (11/165) Chonan et al EMR10.9% (21/193) Hirao et al ERHSE2.3% (8/349) Mitsunaga et al Strip Biopsy18.2% (54/296) NCCH ( ) Strip Biopsy8.5% (53/620)

Local recurrence after piecemeal resection

Curability and local recurrence at NCCH One piece (1451) CurativeNon-curativeNot evaluable 1194 (82%)209 (14%)48 (4%) Piecemeal (331) 148 (45%)81 (24%)102 (31%) Local rec.0168 Local rec.7 (5%)2617

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 knifeHook knife Flex knife Produced by Olympus Medical Systems Corp.

Curability and local recurrence at NCCH One piece (1451) CurativeNon-curativeNot evaluable 1194 (82%) 209 (14%) 48 (4%) Piecemeal (331) 148 (45%) 81 (24%) 102 (31%) Local rec Local rec. 7 (5%) 2617

Video of ESD procedure

Bleeding

Endoscopic closure by metallic clips

Chronological trend of treatment strategy for patients with early gastric cancer at NCCH Cases ‘ ‘ ‘02‘ % ‘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 ?