Endoscopy in Gastrointestinal Oncology - Slide 4 - I. Oda - Esophageal ESD

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  • 1. Esophageal ESDNational Cancer Center Hospital, Tokyo Endoscopy Division Ichiro Oda, MD
  • 2. Agenda Introduction Indication of Endoscopic resection for esophageal SCC ESD for esophageal SCC
  • 3. Incidence and MortalityEsophageal cancer  It is the eighth most common cancer worldwide, accounting for 462,000 new cases in 2002.  It is the sixth most common cause of cancer related death (386,000 deaths).  Squamous cell carcinoma (SCC) is the most common histological type worldwide. Japan Adenocarcinoma 1-2% SCC 92-93% Others 5-6% Muto M, et al. J Clin Oncol 2010;28:1566-72.
  • 4. Risk Factors for SCC in Esophagus Alcohol Smoking Male over 50ys History of Esophageal Cancer History of Head and Neck Cancer Family history AchalasiaCastellsague X, et al , Cancer 82:657-664,1999Aggestrup S, et al. Chest 102:1013‐ 1016,1992T. Yoshida , et al. The GI Forefront (Japanese Journal) vol3 (2) 118-122,2007
  • 5. Risk Factors for SCC in Esophagus Prevalence of drinkers and smokers in Japanese men is so high.  35.7% of men drink every day  43.3% are current smokers in 2004 Aldehyde dehydrogenase-2 (ALDH2) genotype determines an individual’s blood acetaldehyde concentration. Acetaldehyde has been established as a carcinogen in experimental animals and is also suspected of playing a critical role in cancer development in humans. Yokoyama T, et al. Cancer Epidemiol Biomarkers Prev 2008;17:2846-54.
  • 6. Risk Factors for SCC in Esophagus Recent study shows that inactive ALDH2 is a very strong risk factor for esophageal SCC in alcohol drinkers. Alcohol flushing is a marker of inactive ALDH2. Yokoyama T, et al. Cancer Epidemiol Biomarkers Prev 2008;17:2846-54.
  • 7. Agenda Introduction Indication of Endoscopic resection for esophageal SCCESD for esophageal SCC
  • 8. Indications for endosopic resection  Depth of tumor invasion  Mucosal defect (luminal circumference)
  • 9. Relationship Between Depth of Invasion and Lymph Node Metastasis in Superficial Esophageal Cancer m1 m2 m3 sm1 sm2 sm3 EP LPM MM SM Frequency of Lymph Node Metastasis 0% 0% 10〜15% 40〜50% Definite Indication Relative Indication Definite Non-indication
  • 10. M2
  • 11. SM2
  • 12. Mucosal defect >3/4 luminal circumference Require balloon dilatationMucosal defect>3/4 luminalcircumference develop stenosis
  • 13. Stenosis Stenosis +ve Stenosis -ve n=11 n=54 < 1/2 2 40Circumferental > 1/2 4 13extention > 3/4 5 1 < 0.0001Longitudinal diameter (mm) 45.0±15.9 31.5±13.6 0.0062Circumferental diameter (mm) 37.2±8.6 26.8±9.7 0.0020 Ono S, Fujishiro M, et al. Gastroint Endosc 2009
  • 14. Agenda Introduction Indication of Endoscopic resection for esophageal SCCESD for esophageal SCC
  • 15. Endoscopic resection modalities Endoscopic mucosal resection (EMR)  Strip biopsy  EMR with cap  EMR with ligating device  EEMR tube  etc  Endoscopic submucosal dissection (ESD)
  • 16. EMRStrip Biopsy EMR with a cap-fitted scope (EMRC) Tada M, et al. Endoscopy 1993 Inoue H et al. Gastrointest Endosc. 1993• Technically simple• Low en-bloc resection rate• Difficult to resect large lesions
  • 17. EMRCSCC, m1, , 1cm, ly0, v0, cut end(-)
  • 18. Piecemeal resection of EMRC• Difficult to en-bloc resect for large lesions
  • 19. Disadvantage of piecemeal resectionPiecemeal resection  is difficult to evaluate the histological curability.  has a risk of local recurrence tumor.
  • 20. Local recurrence after EMR National cancer center East, Japan Katada et al. GIE 2005;61:219-25116 consecutive patients with a total of 165 squamous-cell carcinomRetrospective studyLocal recurrence: cancer was detected at the site of the EMR scarMedian follow-up: 35 months (12-110 months)Method of EMR: 157 strip biopsy, 8 EEMR tubeLocal recurrence rate: 20% (33/165 lesions)
  • 21. Predictors of local recurrence after EMR ~Univariate analysis~ No. Local rec (%) p ValueTumor size <20 88 13 (14.8)(mm) 0.07 ≧20 77 20 (26.0)Tumor location Upper 22 1 (4.5) 0.03 Middle+lower 143 32 (22.4)Depth of invasion m1+m2 128 23 (18.0) 0.2 m3 37 10 (27.0)No.resection en-bloc 38 1 (2.6) <0.001 Piece meal 127 32 (25.2)Multiple LVLs Without 78 13 (16.7) <0.01 With 38 15 (39.5)LVL: Lugol-voiding lesion Katada et al. GIE 2005;61:219-25
  • 22. Predictors of local recurrence after EMR ~Multivariate logistic regression analysis~Variables Odds ratio (95% CI) p ValueTumor size (≧20mm vs. <20mm) 1.2 (0.5-2.8) 0.7Tumor location (Middle+lower vs. Upper) 3.1 (0.4-26.2) 0.2Depth of invasion (m3 vs. m1+m2) 1.5 (0.6-3.8) 0.3No. resection (piecemeal vs. en-bloc) 8.4 (1.0-69.7) 0.01Multiple LVLs (with vs. without) 3.1 (1.1-8.5) 0.03 Katada et al. GIE 2005;61:219-25
  • 23. For reducing the local recurrence En-bloc resection seems to be the ideal forreducing the local recurrence rate. However en-bloc resection is technicallydifficult for larger lesions by conventional EMR. ESD (Endoscopic Submucosal Dissection)
  • 24. ESD for early gastric cancer
  • 25. ESD One-Piece Resection Rate NCCH, 2000-2003 Upper (n=176) 97% (170) Location Middle (n=431) 97% (418) Lower (n=426) 98% (419) ≦ 20 (n=719) 98% (706) Size, mm 21-30 (n=176) 97% (171) >30 (n=138) 95% (131) Ulcer + (n=243) 97% (236) - (n=790) 98% (772) Total (n=1,033) 98% (1,008) Oda I, et al. Digestive Endoscopy 2005
  • 26. ESD in the esophagus
  • 27. ESD procedures Marking Injection Initial incision Mucosal incision Submucosal dissection
  • 28. Marking Needle knife or Dual knife anal lesion FORCED COAG; 20W onal
  • 29. Initial incision Needle knife or Dual knife anal lesion onal ENDO CUT; 80W, Effect 3
  • 30. Mucosal incision IT knife 2 or Dual knife anal lesion onal ENDO CUT; 80W, Effect 3
  • 31. Submucosal dissection IT knife 2 or Dual knife anal lesion onal ENDO CUT; 80W, Effect 3
  • 32. Mucosal inicision IT knife 2 or Dual knife anal lesion onal ENDO CUT; 80W, Effect 3
  • 33. Submucosal dissection IT knife 2 or Dual knife anal lesion onal ENDO CUT; 80W, Effect 3
  • 34. ESD (Video)
  • 35. Results of esophageal ESD Ono S, et al. Gastroint Endosc 2009
  • 36. Our series: EMR vs ESD for Lesions >2cm EMR (88) ESD (44) POne-piece resection 22 (25) 41 (93) 0.0001Curative resection(EP-LPM/ly-/v-/ce-) 13 (15) 15 (34) 0.01Local recurrence 2 (2) 0 (0) NS (); % NS; not significant
  • 37. Perforation during Esophageal ESD
  • 38. Subcutaneous & Mediastinal EmphysemaInduced by Perforation during Esophageal ESD Air insufflation CO2 insufflation Nonaka S, Oda I, et al, Surg Endosc 2010
  • 39. Conclusions Noninvasive SCCs (m1) and intramucosal invasive SCCs limited to the lamina propria mucosae (m2) are definite indications for endoscopic resection with curative intent. ESD has an advantage for archiving en-bloc resection of large superficial esophageal SCC.