Transcript PowerPoint プレゼンテーション

XXIV Congresso Nationale ACOI Montecatini Terme 26 Maggio 2005
QUANDO E QUALE TRATTAMENTO ENDOSCOPICO
Takuji Gotoda, MD
Endoscopy Division, National Cancer Center Hospital
New treatment strategy for early gastric cancer
Endoscopic mucosal resection (EMR)
Gastrectomy
with lymph node dissection
●
●
●
●
●
●
●
●
●
●
●
●
●
●
cancer
●
●
● ● ●
●
●
●
●
cancer
●
●
●
Rational of endoscopic resection
Primary gastric cancer
Local disease
>Endoscopic resection
Local disease
Lymph nodes
>Surgical treatment
Systemic disease
>Chemotherapy
Peritoneum
Blood circulation
Indication : EGC with no risk of LN metastasis
Conditions
Differentiated adenocarcinoma
Intramucosal cancer
Incidence
95% C.I.
0/1230 (0%)
0-0.3%
0/929 (0%)
0-0.4%
0/145 (0%)
0-2.5%
No lymph-vascular involvement
Irrespective of ulcer findings
Tumor less than 3cm
Differentiated adenocarcinoma
Intramucosal cancer
No lymph-vascular involvement
Without ulcer findings
Irrespective of tumor size
Differentiated adenocarcinoma
Minute submucosal penetration (SM1)
No lymph-vascular involvement
Tumor less than 3cm
Gotoda et al, Gastric Cancer, 2000
Clinical management for patients with EGC
Finding EGC
Pretreatment evaluation using endoscopy, biopsy, EUS, etc.
yes
no
Endoscopic resection
Histological assessment
curative
Annual surveillance
non-curative
Surgery (gastrectomy+D2)
Recently, LADG, SNS, etc.
c Type 0 IIa+IIc T1 SM ?
p Type 0 IIa+IIc T1 M, well differentiated, 30mm, UL(+)
No risk of LN metastasis
Conditions
Differentiated adenocarcinoma
Intramucosal cancer
No lymph-vascular involvement
Irrespective of ulcer findings
Tumor less than 3cm
Incidence
95% C.I.
0/1230 (0%)
0-0.3%
Standard EMR procedure
Polypectomy; Deyhle et al., Endoscopy, 1973
Strip Biopsy; Tada et al., Gastroenterol Endosc, 1984
EMR-C; Inoue et al., Gastrointest Endosc, 1993
EMR-L; Akiyama et al., Gastrointest Endosc, 1997
Soetikno et al, Gastrointest Endosc, 2003
Endoscopic devices for conventional EMR
EMR-L using pneumo-activated
EVL device
Hard and soft hood for
EMR-C
Strip Biopsy method
Endoscopic resection by conventional EMR
One piece resection
Piecemeal resection
Local recurrent gastric cancer after
previous EMR
Author
Methods
Recurrence rate
Tanabe et al
Strip Biopsy, EAM
3.5% (15/423)
Kawaguchi et al
Strip Biopsy, EMR-C
Ida et al
EMR+Laser
Chonan et al
EMR
Hirao et al
ERHSE
Mitsunaga et al
Strip Biopsy
18.2% (54/296)
NCCH (1988-1998)
Strip Biopsy
8.5% (53/620)
35.3% (97/266)
6.7% (11/165)
10.9% (21/193)
2.3% (8/349)
Local recurrence after piecemeal resection
Curability and local recurrence
1987-2003 at NCCH
Curative
One piece (1451)
Local rec.
Piecemeal (331)
Local rec.
1194 (82%)
0
148 (45%)
7 (5%)
Non-curative
209 (14%)
16
81 (24%)
26
Not evaluable
48 (4%)
8
102 (31%)
17
LN metastasis after piecemeal resection
2 years later
3 years later
Histological assessment
1: assess the lateral margin
2: assess submucosal
penetration
3: assess lymphatic
vascular involvement
cut every 2mm
The RENAISSANCE
Endoscopic Submucosal Dissection (ESD)
Large one piece resection
- by Endoscopic Submucosal Dissection (ESD) -
well diff. adenoca.,
Type 0-IIc, 30x25mm,
M, ly0, v0, ul-IIs
20x20mm
well diff. adenoca.,
Type 0-IIc, 8x7mm,
M, ly0, v0, ul(-)
50x40mm
well diff. adenoca.,
Type 0-IIc, 21x17mm,
M, ly0, v0, ul-IIs
65x45mm
Endoscopic equipments for ESD
IT knife
Hook knife
Flex knife
Produced by Olympus Medical Systems Corp.
Curability and local recurrence
1987-2003 at NCCH
Curative
One piece (1451)
Local rec.
Piecemeal (331)
Local rec.
1194
(82%)
0
148
Non-curative
209
(14%)
16
(45%)
7 (5%)
81
(24%)
26
Not evaluable
48
(4%)
8
102
17
(31%)
Video of ESD procedure
Bleeding
Endoscopic closure by metallic clips
Chronological trend of treatment strategy
for patients with early gastric cancer at NCCH
100%
Cases
350
Guideline EMR
300
Expanded EMR
EMR for patients with major complications
Surgery
250
200
50
150
100
50
1988
1990
1996
‘99
‘00
‘01
‘02
‘03
Conclusion
●
EMR provides histological staging
●
Curability is confirmed only through histological assessment
●
ESD is possible to remove a large en bloc resection
●
En bloc makes accurate histological assessment possible,
and reduces local recurrences
Which way would you choose ?
EMR
ESD