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Our Perspective on Endoscopic Resection for Colorectal Neoplasms 11-12 February, 2011, ROME Takahisa Matsuda, M.D, Ph.D Na...
<ul><li>Endoscopic mucosal resection  (EMR)  is a minimally invasive technique for effective treatment of early stage colo...
National Cancer Center Hospital, Tokyo During Screening Colonoscopy…
How to Decide the “Therapeutic Plan”? - Endoscopic Treatment? Surgical Operation? EMR LN EMR Local resection  without  LN ...
EMR <ul><li>should be performed only;  </li></ul><ul><li>Early CRC  without  risk of LNM  </li></ul><ul><li>Adenoma </li><...
Importance of Estimation of SM Invasion Risk factors for lymph node metastasis in patients with submucosal cancer O   We c...
Pre-operative Endoscopic  Depth Diagnosis Magnifying Colonoscopy  Pit Pattern (Kudo’s) Classification Matsuda T, Fujii T, ...
& Demarcated area Irregular, distorted crypts 0.05% Crystal violet staining There is a strong relationship between this pa...
Non-Invasive pattern Almost all the lesions of this pattern are intra-mucosal lesions (LGD or HGD)
LST-NG  LST-NG  IIa (< 5mm) LST-G  IIa (5-10mm) LST (> 10mm) * LST: laterally spreading tumor;  “Flat elevated lesion >10m...
Relationship Between Lesion Size and Clinicopathological Findings -  1989 Flat early stage colorectal neoplasms, NCCH, 199...
LST (Laterally spreading tumor) Saito Y, et al. Endoscopy 2001;33: 682-686.  - Subclassification of LSTs - LST-granular (L...
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...
16 (84%) 3 (16%) 19 Under the large nodule Under the depressed area 9  (27%) 23 (72%) 32 Multifocal Under the depressed ar...
EMR Strategy for LST LST-G En-bloc  Resection 1 st; As large as possible LST-NG Endoscopic piecemeal resection (EPMR) is f...
Treatment Strategy for Colorectal Neoplasms “ Based on the Lesion’s  SIZE ,  MACROSCOPIC TYPE  and  Estimated DEPTH of INV...
Rectum, 40mm, Is+IIa (LST-G: mixed type) Injected Solution:  Glycerol , Snare:  Snare master 25mm  (OYMPUS), Scope:  PCF24...
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-bl...
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: Fol...
Colorectal ESD Location: Ra, Size: 30mm, Macroscopic type: IIa+IIc
#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
800μm #5   SM Invasion Desmin
#4   SM Invasion
Final Histopathological Diagnosis <ul><li>Well differentiated adenocarcinoma, </li></ul><ul><li>Polypoid Growth (PG) Type ...
What’s the  Advantages  of ESD? <ul><li>High En-Bloc Resection Rate and Low Recurrence Rate </li></ul><ul><li>Precise Hist...
What’s the  Disadvantages  of ESD? <ul><li>High Complication Rate (e.g. perforation, bleeding etc.) </li></ul><ul><li>Tech...
Endoscopic Mucosal Resection  with Circumferential Incision
■   ESD Using Several Knives under CO 2  Insufflations              Ball tip B-knife IT knife CO2 insufflations COLORECTAL...
Dual Knife  (OLYMPUS) <ul><li>SETTING (ERBE, ICC200) </li></ul><ul><li>Endocut:  30W   </li></ul><ul><li>(for Marginal res...
CO 2  Insufflations System  (OLYMPUS, UCR) CO2 Air
Virtual Colonoscopy Location: lower rectum (Rb) Size : 60mm Macroscopic type : 0-IIa (LST-G)
Conventional Endoscopy
Magnifying Endoscopy-NBI Capillary pattern: Type II (Sano’s classification)
Magnifying Chromoendoscopy Type IV/III L  pit (Kudo’s classification) Non-invasive pattern
ESD Procedure
Pathological findings <ul><li>Well differentiated adenocarcinoma,  </li></ul><ul><li>low and high grade atypia, with adeno...
* All cases except one treated without surgery Saito Y,  Uraoka T, Matsuda T et al. Gastrointest Endosc, 2010 Results of 5...
National Cancer Center Hospital, Tokyo How often should we choose ESD? The Prevalence of Suitable Lesions for ESD
*  LSTs: LST-G and LST-NG ** Definite indication: LST-NG lesion ≥20 mm §  Relative indication: LST-G Mixed type [Is+IIa (L...
Endoscopic Depth Diagnosis is Important! All lesions are SM deep invasive cancer!
Conclusion <ul><li>EMR techniques, new devices and injected solution have been developed that enable us to treat larger an...
Thank you for your kind attention! Takahisa Matsuda M.D., Ph.D. National Cancer Center Hospital, Tokyo Endoscopy Division ...
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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

  1. 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. 2. <ul><li>Endoscopic mucosal resection (EMR) is a minimally invasive technique for effective treatment of early stage colorectal lesions with no invasive potential. </li></ul>Introduction <ul><li>Endoscopic submucosal dissection (ESD) allows en- </li></ul><ul><li>bloc resection, irrespective of the lesion’s size. </li></ul><ul><li>The use of ESD for colorectal lesions has been studied </li></ul><ul><li>clinically, however, colorectal ESD is not yet established </li></ul><ul><li>generally as a standard therapeutic method. </li></ul>
  3. 3. National Cancer Center Hospital, Tokyo During Screening Colonoscopy…
  4. 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. 5. EMR <ul><li>should be performed only; </li></ul><ul><li>Early CRC without risk of LNM </li></ul><ul><li>Adenoma </li></ul><ul><li>SM deep invasion : ≥ 1000  m </li></ul><ul><li>Lymphovascular invasion (+) </li></ul><ul><li>Poorly differentiated component (+) </li></ul>Risk factors of lymph node metastasis (LNM)* - Endoscopic Treatment? Surgical Operation? * Paris Classification, Gastrointest Endosc 2003 How to Decide the “Therapeutic Plan”?
  6. 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. 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. 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. 9. Non-Invasive pattern Almost all the lesions of this pattern are intra-mucosal lesions (LGD or HGD)
  10. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 20. Colorectal ESD Location: Ra, Size: 30mm, Macroscopic type: IIa+IIc
  21. 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. 22. 800μm #5   SM Invasion Desmin
  23. 23. #4   SM Invasion
  24. 24. Final Histopathological Diagnosis <ul><li>Well differentiated adenocarcinoma, </li></ul><ul><li>Polypoid Growth (PG) Type </li></ul><ul><li>Size: 29×16 mm </li></ul><ul><li>Depth: pSM superficial (800μm) </li></ul><ul><li>< Multifocal SM invasion (+) > </li></ul><ul><li>ly0, v0, HM(-), VM (-)   </li></ul>
  25. 25. What’s the Advantages of ESD? <ul><li>High En-Bloc Resection Rate and Low Recurrence Rate </li></ul><ul><li>Precise Histopathological Assessment </li></ul>
  26. 26. What’s the Disadvantages of ESD? <ul><li>High Complication Rate (e.g. perforation, bleeding etc.) </li></ul><ul><li>Technical Difficulty </li></ul><ul><li>Long Operation Time </li></ul>
  27. 27. Endoscopic Mucosal Resection with Circumferential Incision
  28. 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. 29. Dual Knife (OLYMPUS) <ul><li>SETTING (ERBE, ICC200) </li></ul><ul><li>Endocut: 30W </li></ul><ul><li>(for Marginal resection) </li></ul><ul><li>Forced Coag: 30W </li></ul><ul><li>(for Submucosal Dissection) </li></ul>1.5mm
  30. 30. CO 2 Insufflations System (OLYMPUS, UCR) CO2 Air
  31. 31. Virtual Colonoscopy Location: lower rectum (Rb) Size : 60mm Macroscopic type : 0-IIa (LST-G)
  32. 32. Conventional Endoscopy
  33. 33. Magnifying Endoscopy-NBI Capillary pattern: Type II (Sano’s classification)
  34. 34. Magnifying Chromoendoscopy Type IV/III L pit (Kudo’s classification) Non-invasive pattern
  35. 35. ESD Procedure
  36. 36. Pathological findings <ul><li>Well differentiated adenocarcinoma, </li></ul><ul><li>low and high grade atypia, with adenoma </li></ul><ul><li>Category 4.2 Vienna classification </li></ul>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. 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. 38. National Cancer Center Hospital, Tokyo How often should we choose ESD? The Prevalence of Suitable Lesions for ESD
  39. 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. 40. Endoscopic Depth Diagnosis is Important! All lesions are SM deep invasive cancer!
  41. 41. Conclusion <ul><li>EMR techniques, new devices and injected solution have been developed that enable us to treat larger and difficult colorectal lesions endoscopically. </li></ul><ul><li>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. </li></ul><ul><li>Preoperative endoscopic diagnosis and decision making is very important. </li></ul>
  42. 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

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