EMR Can anyone do this?

Transcription

1 EMR Can anyone do this? Norio Fukami, MD University of Colorado Piecemeal resection? 1

2 Endoscopic mucosal resection (EMR) and Endoscopic submucosal dissection (ESD) Endoscopic removal of premalignant or malignant gastrointestinal epithelium = Minimally invasive endosurgical treatment of GI tumors = Diagnostic and Therapeutic procedure Can remove certain submucosal tumors e.g. Granular cell tumor, Carcinoid; GIST (?) History of EMR & ESD Simple snare removal (1968) Saline injection and snare resection (1983) Double channel - pinch and cut (1984) Movement to explore Endoscopic removal as an alternative to Surgery Band and resect (1993) EMR cap method (1993) Endoscopic submucosal dissection (mid-late 1990s) Soetikno et al. GIE. 2003(4) 2

3 EMR tools Snare injection Cap-EMR Band-EMR ESD knives KD 10Q-1 3

4 EMR/ESD for the cure of cancer Resection of premalignant or malignant lesion as an alternative to surgery Aimed for R0 resection Negative lateral and deep margin = local recurrence Cure = No or very low risk for lymph node metastasis or distant metastasis Preprocedural assessment is mandatory Know when to do it! - Exclude possible non-candidate Weigh risk and benefit Re-assessment after resection: Pathological evaluation Cancer T stage Depth of cancer invasion T1 T2 T3 4

5 Sub-classification of T1 tumor m1: limited within mucosa (HGD) m2: invades into lamina propria m3: invades into muscularis mucosae sm1-3: divide submucosal layer in three even thickness Soetikno et al. GIE. 2003(4) T1 T2 Esophageal cancer AJCC/UICC TNM, 7th edition 5

6 Colon cancer AJCC/UICC TNM, 7th edition Lymph node metastasis risk for T1 tumor varies EMR absolute indication Esophagus SCC m1 0% m2 3% Esophagus Adeno Ca 0% m3 9% 2-3% sm % sm2 sm3 Stomach 13~48% 35~50% ~20% Colon 0-0.4% 0% ~2.5% 10~% Important Factors: lymphovascular invasion, tumor differentiation, tumor budding 6

7 How far can we go? Expanded indications Esophageal cancer (mostly SCC) T1-m1-m2: LN mets 0-3% T1 m3-sm1: LN mets 10-20% But, LN mets 4% if differentiated type & no LV invasion & expansion growth *1 *1 Oyama et al

8 Esophageal cancer (Barrett cancer) sm1 invasion: 9.5% LN mets if LV(-) vs. 20% if LV (+) *1 sm1 invasion with LV(-), differentiated type, expansive growth: - No clinical evidence of metastasis, cancer death during the mean f/u 62 months *2 *1 Badreddine et al. CGH 2010 *2 Manner et al. AJG 2008 Gastric cancer Expanded indication less than 500 μm LN mets; 0-2.5% Gotoda et al. Gastric Cancer % Hirasawa et al. Gastric Cancer 2009 Soetikno et al. J Clin Oncol

9 Colon cancer SM invasion is not considered to be absolute surgical contraindication for endoscopic therapy - no LN mets in the absence of LV invasion less than 3000 μm invasion depth for polypoid less than 1000 μm invasion depth for nonpolypoid lesions *1 *1 Kitajima et al. J Gastroenterol 2004 SM indication for EMR/ESD: less than 1000 μm depth of invasion, differentiated type, no LVI, and no tumor budding. Master s guide for endoscopic diagnosis. Tajiri and Saito Lymph node metastasis risk for T1 tumor EMR absolute indication expanded d indication Esophagus SCC m1 0% m2 3% Esophagus Adeno Ca 0% m3 9% 2-3% sm % sm2 sm3 Stomach 13~48% 35~50% ~20% Colon 0-0.4% 0% 500 μm superficial ~2.5% 1000 μm sm invasion 10~% Important Factors: lymphovascular invasion, tumor differentiation, tumor budding 9

10 Diagnostic or Therapeutic? Basic technique for pathology specimen processing Specimen processing Evaluation of the margins (lateral/deep) requires perpendicular slices Pinnig specimens onto the board before formalin fixation Good! 10

11 Stage/depth assessment Endoscopic assessment of cancer to predict T stage Meticulous evaluation: 85-95% accurate (Tm1-2, 3 vs. sm superficial vs. deep invasion) - superficial type of esophageal SCC (0-IIa-c) and <2cm = m1-2 EUS with HF probe: 80-90% accuracy Paris workshop group. GIE

12 What to look for? Configuration Fold convergence (thickening, irregularity etc.) Depression Loss of surface patterns or abnormal vessels Stiffness of the wall What to look for as a sign of deep invasion? Master s guide for endoscopic diagnosis. Tajiri and Saito

13 Case study esophagus SCC moderately differentiated, 2.4cm, sm1 no LV invasion 13

14 well differentiated adenocarcinoma, T1a (m2) poorly differentiated adenocarcinoma, T3N1 14

15 Barrett s esophagus with LGD adecarcinoma in Barrett s, T1sm-T2 15

16 Barrett s esophagus with poorly differentiated adenocarcinoma T1sm, N1 at upper paratracheal LN stomach 16

17 well differentiated adenocarcinoma, T1a (m2) 6cm poorly differentiated adenocarcinoma, T1b positive deep margin total gastrectomy no tumor and negative LN 17

18 differentiated adenocarcinoma, T1a (m3), UL + Master s guide for endoscopic diagnosis. Tajiri and Saito poorly differentiated adenocarcinoma, T1a (m3) Master s guide for endoscopic diagnosis. Tajiri and Saito

19 colon Tubular adenoma 19

20 invasive adenocarcinoma, T2 High Grade Dysplasia 20

21 8mm moderately differentiated adenocarcinoma, T1sm, 3700 μm Master s guide for endoscopic diagnosis. Tajiri and Saito adenocarcinoma, T2 21

22 adenocarcinoma, Tis (invasive to lp) LST, granular type 5.5cm, Tis 22

23 Conclusions You can do it! - Learn the proper steps Understand the proper indication and the assessment for curative resection Pre-EMR/ESD evaluation is important to select the treatment modality - cut BIG as necessary! Process the specimen properly = prediction of the outcome and risk for recurrence 23