Endoscopic management of early gastric cancer based on Japanese & ESGE Guidelines

1. Endoscopic Management
of Early Gastric Cancer
(EGC)
Dr. Mohamed El-Sherbiny, MD
Dr. Shaimaa Elkholy, MD
Lecturer of Gastroenterology
Faculty of Medicine, Cairo
University

2. Agenda
What is Early Gastric Cancer (EGC)?
How to detect EGC?
Why EGC?
How to manage EGC?
What are the complications?
How to follow up?

3. Case presentation
-58 years old male patient
-Complaining of dyspepsia
-During gastroscopy
this lesion was found
What do you think?

4. Case presentation
a. Adenoma
b. Metaplasia
c. Early cancer
d. Invasive carcinoma

5. What is EGC ?
• Tumor confined to mucosa or
submucosa (T1), regardless to
lymph node metastasis

6. Acute gastritis
Chronic gastritis
Atrophic gastritis
Intestinal metaplasia
Dysplasia
Carcinoma
(differentiated type)

8. What is the type of this lesion？
. I
. IIa
. IIb
. IIc
. III
In the combined superficial types, the type occupying the largest
area should be described first, followed by the next type

9. What is the next step?
• Biopsy
• Magnification Endoscopy
• EUS
• CT Scan

10. Magnification endoscopy (VS classification)
Vascular changes
(microvasculature)
Structural changes
(pit pattern)

11. Evaluation Before Endoscopic Resection
Information to assist the
determination of the
indication for endoscopic
treatment
Information to assist the
determination of horizontal
resection margins

12. Information to assist the determination of the
indication for endoscopic treatment
(1) Histopathological type
(2) Size
(3) Depth of invasion
(4) Whether ulceration is present
(evidence level VI, grade of recommendation C1)

13. Information to assist the determination of
horizontal resection margins
In general;
Conventional endoscopy + Dye spraying
(evidence level V, grade of recommendation C1)

14. ESGE recommends
High quality endoscopy;
(ideally with contrast or digital chromoendoscopy)
By an experienced endoscopist
(strong recommendation, moderate quality
evidence)

15. ESGE recommends
US, CT, or other procedures are not routinely
recommended for the assessment of gastric superficial
lesions prior to endoscopic resection
(strong recommendation, moderate quality
evidence)

17. How to manage?
• EMR
• ESD
• Surgery

18. Basic approach
Once EGC has been diagnosed, endoscopic or surgical treatment
is recommended
(evidence level IVa, grade of recommendation B)

19. Basic approach
In general;
Endoscopic resection should be carried out when the
likelihood of LNs metastasis is extremely low
&
The lesion size & site are amenable to enbloc resection
(evidence level V, grade of recommendation C1)

20. Depth of Invasion
(macroscopic)
Ulceration Differentiated Undifferentiated
CT1a (mucosa) (-) UL < 2 cm > 2 cm < 2 cm > 2 cm
(+) UL < 3 cm > 3 cm < 3 cm > 3 cm
CT1b (submucosa)
(<500um)
(-) UL < 3cm

22. EMR Vs ESD
Easier
Less complication
Less expensive
Better En bloc resection
Better R0
Less local recurrence

23. EMR
pEMR

25. Depth of Invasion
(macroscopic)
Ulceration Differentiated Undifferentiated
CT1a (mucosa) (-) UL < 2 cm > 2 cm < 2 cm > 2 cm
EMR/ESD ESD ESD
(+) UL < 3 cm > 3 cm < 3 cm > 3 cm
ESD
CT1b (submucosa)
(<500um)
(-) UL < 3cm
ESD

29. EMR ESD
En bloc resection rate 56–73% 88–95%
Curative resection rate 61% 74–95%
Complication rate;
Delayed bleeding 3.9% 1.8–16%
Perforation 0.5–3.2% 1.2–9.7%

31. Why EGC ?
- Good prognosis
- Can be cured by minimally invasive approaches
- 5-year survival rates of EGC:
–> 99% when limited to the mucosa
–> 96% when the submucosa is invaded
- If no resection was > 6 months --> cumulative 5-year risk 63%
(95% CI: 48–78%)

32. What are the complications?
• Perforation

33. Purse string suture

34. Bleeding
Hemoclips
Coagulation forceps

35. Curative resection
"Evaluation of curability is based on local factors and risk factors for
lymph node metastasis"
• For absolute indication:
En bloc resection, <2cm + differentiated, pT1a,UL(–),ly(–), v(–) & negative
surgical margins

36. Curative resection For Expanded criteria
When a lesion is resected en bloc and is:
(1) ≥2cm, differentiated, pT1a, UL(–)
(2) <3 cm, differentiated, pT1a, UL(+)
(3) <2 cm, undifferentiated, pT1a,UL(–)
(4) <3 cm, differentiated type, pT1b (SM1)
ly(–), v(–) with
negative surgical
margins

37. +ve horizontal margin or resection is piecemeal, but there is no
submucosal invasion and no other high risk criteria are met
=>> endoscopic surveillance (3, 9-12, annually) /re-treatment is
recommended rather than surgery
(strong recommendation, moderate quality evidence)

38. Surgery is recommended:
-Lymph-vascular invasion,
-Deeper infiltration more than sm1 (>500μm),
-Positive vertical margins
-Ulcerated features in tumors >30mm or with submucosal invasion
are diagnosed
(strong recommendation, moderate quality evidence)

40. ESGE suggests an endoscopy after 3–6 months and then
annually (strong recommendation, low quality evidence)
If the curative ESD was performed according to expanded
indications (ulcerated, submucosal, or undifferentiated tumors)
a staging abdominal CT can be considered
(weak recommendation, low quality evidence)

41. Thank you