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

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

  1. 1. Esophageal ESDNational Cancer Center Hospital, Tokyo Endoscopy Division Ichiro Oda, MD
  2. 2. Agenda Introduction Indication of Endoscopic resection for esophageal SCC ESD for esophageal SCC
  3. 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. 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. 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. 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. 7. Agenda Introduction Indication of Endoscopic resection for esophageal SCCESD for esophageal SCC
  8. 8. Indications for endosopic resection  Depth of tumor invasion  Mucosal defect (luminal circumference)
  9. 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. 10. M2
  11. 11. SM2
  12. 12. Mucosal defect >3/4 luminal circumference Require balloon dilatationMucosal defect>3/4 luminalcircumference develop stenosis
  13. 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. 14. Agenda Introduction Indication of Endoscopic resection for esophageal SCCESD for esophageal SCC
  15. 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. 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. 17. EMRCSCC, m1, , 1cm, ly0, v0, cut end(-)
  18. 18. Piecemeal resection of EMRC• Difficult to en-bloc resect for large lesions
  19. 19. Disadvantage of piecemeal resectionPiecemeal resection  is difficult to evaluate the histological curability.  has a risk of local recurrence tumor.
  20. 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. 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. 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. 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. 24. ESD for early gastric cancer
  25. 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. 26. ESD in the esophagus
  27. 27. ESD procedures Marking Injection Initial incision Mucosal incision Submucosal dissection
  28. 28. Marking Needle knife or Dual knife anal lesion FORCED COAG; 20W onal
  29. 29. Initial incision Needle knife or Dual knife anal lesion onal ENDO CUT; 80W, Effect 3
  30. 30. Mucosal incision IT knife 2 or Dual knife anal lesion onal ENDO CUT; 80W, Effect 3
  31. 31. Submucosal dissection IT knife 2 or Dual knife anal lesion onal ENDO CUT; 80W, Effect 3
  32. 32. Mucosal inicision IT knife 2 or Dual knife anal lesion onal ENDO CUT; 80W, Effect 3
  33. 33. Submucosal dissection IT knife 2 or Dual knife anal lesion onal ENDO CUT; 80W, Effect 3
  34. 34. ESD (Video)
  35. 35. Results of esophageal ESD Ono S, et al. Gastroint Endosc 2009
  36. 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. 37. Perforation during Esophageal ESD
  38. 38. Subcutaneous & Mediastinal EmphysemaInduced by Perforation during Esophageal ESD Air insufflation CO2 insufflation Nonaka S, Oda I, et al, Surg Endosc 2010
  39. 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.

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