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Endoscopy in Gastrointestinal Oncology - Slide 18 - T. Matsuda - Colorectal ESD
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Endoscopy in Gastrointestinal Oncology - Slide 18 - T. Matsuda - Colorectal ESD

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  • Thank you Mr. Chairman. Good afternoon ladies and gentleman. First of all, I would like to express my special thanks to the organizing committee especially Dr. Massimo for inviting me to this wonderful course. Today, I would like to talk about “Our perspective on endoscopic resection for colorectal neoplasms”.
  • Of course, EMR is … In contrast, surgical operation is …
  • So, EMR should be performed only for early CRC without risk of LNM or adenoma. According to the “Paris classification”, these 3 factors are considered as a risk of LNM. Of course, after EMR, we need to assess histopathologically. If it doesn’t meet this criteria, we need to recommend additional surgical operation.
  • Endoscopically, we can predict only the “depth of invasion”. It is impossible to predict lymphovascular invasion and poorly differentiated adenocarcinoma component in advance.
  • As I already mentioned, Non-polypoid CRNs are current topic. Among them,
  • This is the relationship between the lesion size and clinicopathological findings. During this period, we treated 1989 flat early stage colorectal neoplasms in our center. Based on the lesion size, we divided into three groups. Surprisingly, about 60% lesions located in the right-sided colon. Among the lesions judged as less than 5mm, almost all lesions were LGD. In contrast, the lesions diagnosed as so-called LSTs, 55% were high grade dysplasia or early invasive cancer.
  • As for the LST lesions, we usually classify into three groups. In short, LST-G uniform type, LST-G mixed type and LST-NG type.
  • As you can see, the incidence of SM cancer in this LST-G uniform type is very low less than 1%. In contrast, in these groups, about 13% cases are SM invasive cancer. Especially, large LST-NG type over 20mm has high incidence of SM invasion.
  • This is our treatment strategy for colorectal neoplasms. We usually decide the therapeutic plan based on the…
  • This slide shows the results of 250 colorectal ESD cases. The mean size of the lesion was about 4cm, and mean procedure time was 1hr and half. The rate of En-bloc resection was 84%, and complication’s rate was totally 7%. But, fortunately all cases except one case treated without emergent operation.
  • After introduction,

Endoscopy in Gastrointestinal Oncology - Slide 18 - T. Matsuda - Colorectal ESD Presentation Transcript

  • 1. Our Perspective on Endoscopic Resection for Colorectal Neoplasms 11-12 February, 2011, ROME Takahisa Matsuda, M.D, Ph.D National Cancer Center Hospital, Tokyo Endoscopy Division - Piecemeal EMR/ ESD - 3rd course on E NDOSCOPY IN GASTROINTESTINAL ONCOLOGY
  • 2.
    • Endoscopic mucosal resection (EMR) is a minimally invasive technique for effective treatment of early stage colorectal lesions with no invasive potential.
    Introduction
    • Endoscopic submucosal dissection (ESD) allows en-
    • bloc resection, irrespective of the lesion’s size.
    • The use of ESD for colorectal lesions has been studied
    • clinically, however, colorectal ESD is not yet established
    • generally as a standard therapeutic method.
  • 3. National Cancer Center Hospital, Tokyo During Screening Colonoscopy…
  • 4. How to Decide the “Therapeutic Plan”? - Endoscopic Treatment? Surgical Operation? EMR LN EMR Local resection without LN dissection Surgery Local resection with LN dissection Surgery LN
  • 5. EMR
    • should be performed only;
    • Early CRC without risk of LNM
    • Adenoma
    • SM deep invasion : ≥ 1000  m
    • Lymphovascular invasion (+)
    • Poorly differentiated component (+)
    Risk factors of lymph node metastasis (LNM)* - Endoscopic Treatment? Surgical Operation? * Paris Classification, Gastrointest Endosc 2003 How to Decide the “Therapeutic Plan”?
  • 6. Importance of Estimation of SM Invasion Risk factors for lymph node metastasis in patients with submucosal cancer O We can predict only the “Depth of Invasion” X Lymphovascular invasion X P/D adenocarcinoma Vascular involvement (+) Submucosal deep invasion (+)
  • 7. Pre-operative Endoscopic Depth Diagnosis Magnifying Colonoscopy Pit Pattern (Kudo’s) Classification Matsuda T, Fujii T, Saito Y, et al : Am J Gastroenterol, 2008 Endoscopic Treatment (EMR) Operation (OPE) No Treatment
  • 8. & Demarcated area Irregular, distorted crypts 0.05% Crystal violet staining There is a strong relationship between this pattern and invasive cancer Demarcated area Irregular, distorted    crypts Invasive pattern
  • 9. Non-Invasive pattern Almost all the lesions of this pattern are intra-mucosal lesions (LGD or HGD)
  • 10. LST-NG LST-NG IIa (< 5mm) LST-G IIa (5-10mm) LST (> 10mm) * LST: laterally spreading tumor; “Flat elevated lesion >10mm” Non-polypoid (Flat & Depressed) CRNs are Current Topic Clinically, it is very important “How to manage these LST lesions”. Flat Lesions
  • 11. Relationship Between Lesion Size and Clinicopathological Findings - 1989 Flat early stage colorectal neoplasms, NCCH, 1998-2003 - Adenoma (LGD) M-SM Ca Size Pathology (HGD- Early Invasive ca) Location (C/A/T: D/S: R) 508:288:34 387:276:43 260:111:82 ( 61% :35%:4%) ( 55% :39%:6%) ( 57% :25%:18%) Total 1155:675:159 ( 58% :34%:8%) Matsuda T, Saito Y, et al : Dig Endoscopy, 2010 Flat Lesions < 5mm (830) 5-10mm (706) ≥ 10mm (453: 23% ) 828 (99.8%) 657 (93.1%) 203 (44.8%) 1688 (84.9%) 2 (0.2%) 49 (6.9%) 250 (55.2%) 301 (15.1%)
  • 12. LST (Laterally spreading tumor) Saito Y, et al. Endoscopy 2001;33: 682-686. - Subclassification of LSTs - LST-granular (LST-G) uniform type LST-granular (LST-G) mixed type LST-nongranular (LST-NG) LST-G LST-NG
  • 13. LST-NG 10mm - 20mm - 30mm - 12/246 (4.9%) 24/106 (22.6%) 11/33 (33.3%) Total 55/402 (13.7%) 0/115 (0%) 0/70 (0%) 1/31 (3.2%) 1/227 LST-G (uniform) LST-G (mixed) 4/72 (5.6%) 6/70 (8.6%) 9/65 (13.8%) 44/321 (0.4%) (13.7%) 40mm - 8/17 (47.0%) 0/13 (0%) 25/114 (21.9%) Relationship Between the Size of LSTs & the Rate of SM Invasion NCCH 1998-2006 Matsuda T, Saito Y, Conio M, et al : Gastroenterol Clin Biol, 2010
  • 14. 16 (84%) 3 (16%) 19 Under the large nodule Under the depressed area 9 (27%) 23 (72%) 32 Multifocal Under the depressed area LST-G LST-NG The Area of SM Penetration Uraoka T, Saito Y, Matsuda T, et al. Gut. 2006. The extent of SM penetration of LST-G is easy to diagnose endoscopically. In contrast, the prediction of SM penetration of LST-NG is difficult.
  • 15. EMR Strategy for LST LST-G En-bloc Resection 1 st; As large as possible LST-NG Endoscopic piecemeal resection (EPMR) is feasible for LST-granular type. In contrast, we should perform En-bloc resection for LST-non-granular type.
  • 16. Treatment Strategy for Colorectal Neoplasms “ Based on the Lesion’s SIZE , MACROSCOPIC TYPE and Estimated DEPTH of INVASION ” SIZE DEPTH of Invasion 2cm 4cm SM ca 1000 µ m LAC (Laparoscopic Surgery) Open Surgery Conventional EMR Hot biopsy/ Polypectomy ESD EPMR M ca/ Adenoma Adv.ca (<5mm) (>5mm)
  • 17. Rectum, 40mm, Is+IIa (LST-G: mixed type) Injected Solution: Glycerol , Snare: Snare master 25mm (OYMPUS), Scope: PCF240ZI (OLYMPUS) Procedure Time: 15 min EPMR (piecemeal EMR)
  • 18. Hotta K, Saito Y, Matsuda T, et al. Int J Colorectal Dis. 2008 Local Recurrence Rate Size (mm) 10-19 20-29 30+ Total En-bloc Piecemeal Total 0.8% 0% 0% 0.7% (3/366) (0/65) (0/9) (3/440) 14.7% 21.7% 34.2% 23.5% (5/34) (13/60) (13/38) (31/132) 2.0% 10.4 % 27.7% 5.9% (8/400) (13/125) (13/47) (34/572)
  • 19. A B C D E F G Recurrent Case: Rs, 50mm, Is+IIa (LST-G: mixed) A-C: Piecemeal EMR , W/D adenocarcinoma, pM (HGD) D-F: Follow-up CF (after 6M) -> Additional hot biopsy G: Follow-up CF (after 12M) -> No re-recurrence
  • 20. Colorectal ESD Location: Ra, Size: 30mm, Macroscopic type: IIa+IIc
  • 21. #10 -> O A ← Mapping and Panoramic View #2 #3 #4 #5 #6 #7 #8 #9 #10 #11 #2 #3 #4 #5 #6 #7 #8 #9 #10 #11 #12 #1
  • 22. 800μm #5   SM Invasion Desmin
  • 23. #4   SM Invasion
  • 24. Final Histopathological Diagnosis
    • Well differentiated adenocarcinoma,
    • Polypoid Growth (PG) Type
    • Size: 29×16 mm
    • Depth: pSM superficial (800μm)
    • < Multifocal SM invasion (+) >
    • ly0, v0, HM(-), VM (-)  
  • 25. What’s the Advantages of ESD?
    • High En-Bloc Resection Rate and Low Recurrence Rate
    • Precise Histopathological Assessment
  • 26. What’s the Disadvantages of ESD?
    • High Complication Rate (e.g. perforation, bleeding etc.)
    • Technical Difficulty
    • Long Operation Time
  • 27. Endoscopic Mucosal Resection with Circumferential Incision
  • 28. ■ ESD Using Several Knives under CO 2 Insufflations            Ball tip B-knife IT knife CO2 insufflations COLORECTAL ESD PROCEDURE Zeon Medical Co. Olympus Co. Olympus Co. Colorectal ESD Olympus Co. Dual knife Water jet Scope Olympus Co.
  • 29. Dual Knife (OLYMPUS)
    • SETTING (ERBE, ICC200)
    • Endocut: 30W
    • (for Marginal resection)
    • Forced Coag: 30W
    • (for Submucosal Dissection)
    1.5mm
  • 30. CO 2 Insufflations System (OLYMPUS, UCR) CO2 Air
  • 31. Virtual Colonoscopy Location: lower rectum (Rb) Size : 60mm Macroscopic type : 0-IIa (LST-G)
  • 32. Conventional Endoscopy
  • 33. Magnifying Endoscopy-NBI Capillary pattern: Type II (Sano’s classification)
  • 34. Magnifying Chromoendoscopy Type IV/III L pit (Kudo’s classification) Non-invasive pattern
  • 35. ESD Procedure
  • 36. Pathological findings
    • Well differentiated adenocarcinoma,
    • low and high grade atypia, with adenoma
    • Category 4.2 Vienna classification
    cf. The revised Vienna classification Category Diagnosis Clinically equivalent terms 3 Mucosal low-grade neoplasia LGIN, low grade adenoma/ dysplasia 4 Mucosal high-grade neoplasia 4. 1 HGIN, high-grade adenoma/ dysplasia 4. 2 HGIN, non-invasive carcinoma (CIS) 4. 3 Suspicious for invasive Ca. 4. 4 Intramucosal Ca 5 Submucosal or deeper invasion by carcinoma
  • 37. * All cases except one treated without surgery Saito Y, Uraoka T, Matsuda T et al. Gastrointest Endosc, 2010 Results of 500 Colorectal ESDs Macroscopic Type   Is, IIa+IIc, IIc, SMT LST-G LST-NG Recurrent lesions 52 220 200 28 Location C: 35, Rt: 195, Lt: 130, R: 140 Size of Lesion (mean) 40  20mm (20-150mm) Procedure Time 90  73 (15-390) min. En-bloc Resection 88% Curative Resection 86% Complications   Perforation   Delayed Bleeding    13* (2.6%) 5 (1%) Histopathology Adenoma: 127, M-SM1: 315, SM2-: 55
  • 38. National Cancer Center Hospital, Tokyo How often should we choose ESD? The Prevalence of Suitable Lesions for ESD
  • 39. * LSTs: LST-G and LST-NG ** Definite indication: LST-NG lesion ≥20 mm § Relative indication: LST-G Mixed type [Is+IIa (LST-G)] ≥40 mm Matsuda T, Saito Y, Conio M, et al. Gastroenterol Clin Biol 2010 National Cancer Center Hospital, Tokyo, 1998-2006 The Prevalence of Suitable Lesions for ESD All Neoplastic Lesions ( n = 11,488) Early Colorectal Cancers ( n = 1,691) LSTs * 5.9% ( n = 674) 22.6% ( n = 382) Indication for ESD 2.3% ( n = 267) 12.1% ( n = 205) Definite indication ** for ESD 1.0% ( n = 115) 5.0% ( n = 85) Relative indication § for ESD 1.3% ( n = 152) 7.1% ( n = 120)
  • 40. Endoscopic Depth Diagnosis is Important! All lesions are SM deep invasive cancer!
  • 41. Conclusion
    • EMR techniques, new devices and injected solution have been developed that enable us to treat larger and difficult colorectal lesions endoscopically.
    • The ESD procedure is undoubtedly an ideal method to achieve en-bloc resection, however, the prevalence of “definite indication for ESD” is not so high.
    • Preoperative endoscopic diagnosis and decision making is very important.
  • 42. Thank you for your kind attention! Takahisa Matsuda M.D., Ph.D. National Cancer Center Hospital, Tokyo Endoscopy Division E-mail: tamatsud@ncc.go.jp