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

2. ● ● ● ● ● ● ● ● ● ● ● ● New treatment strategy for early gastric cancer cancer Gastrectomy with lymph node dissection ● ● ● ● ● ● ● ● ● ● ● ● cancer Endoscopic mucosal resection (EMR)

3. Rational of endoscopic resection Primary gastric cancer Lymph nodes Peritoneum Blood circulation Local disease Systemic disease >Surgical treatment >Chemotherapy Local disease >Endoscopic resection

4. 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

5. 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

6. c Type 0 IIa+IIc T1 SM ? p Type 0 IIa+IIc T1 M, well differentiated, 30mm, UL(+)

7. 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%

8. 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

9. Endoscopic devices for conventional EMR Hard and soft hood for EMR-C EMR-L using pneumo-activated EVL device

10. Strip Biopsy method

11. Endoscopic resection by conventional EMR One piece resection Piecemeal resection

12. 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 (1988-1998) Strip Biopsy8.5% (53/620)

13. Local recurrence after piecemeal resection

14. Curability and local recurrence 1987-2003 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

15. LN metastasis after piecemeal resection 2 years later 3 years later

16. Histological assessment 1: assess the lateral margin 2: assess submucosal penetration 3: assess lymphatic vascular involvement cut every 2mm

17. The RENAISSANCE Endoscopic Submucosal Dissection (ESD)

18. 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

19. Endoscopic equipments for ESD IT knifeHook knife Flex knife Produced by Olympus Medical Systems Corp.

20. Curability and local recurrence 1987-2003 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

21. Video of ESD procedure

22. Bleeding

23. Endoscopic closure by metallic clips

24. Chronological trend of treatment strategy for 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

25. 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

26. ESD EMR Which way would you choose ?