Endoscopic Therapy for Early Esophageal Cancer: EMR and ESD AATS Toronto April 26, 2014 Lorenzo Ferri MD PhD David S. Mulder Chair in Surgery Associate Professor of Surgery and Oncology
Disclosures Olympus Speaking Honoraria (ESD) Cook Medical Speaking Honoraria (Blue Rhino) Roche Speaking Honoraria (Chemotherapy for Esoph CA)
Surgical Resection is Effective Treatment for Esophageal Cancer
High Rate of Complications with Esophagectomy Pneumonia Anastomotic leak Finks and Birkmeyer 2011
MIE and ERP can reduce some of these complications Minimally Invasive Esophagectomy Enhanced Recovery Program POD #2 - Esophagectomy Sudarshan and Ferri 2012 Li and Ferri 2011
Endoscopic Resection of Early Esophageal Cancer 1000 299 Pts 116 EMR All EMR / 183 ESD Western Sapporo, Germany Japan ESD of ct1n0 SCC Intramucosal Squamous Cell Adenocarcinoma Carcinoma Takahashi Pech 2014 2009
Criteria for Endoscopic Resection of Early Cancer Curative Intent #1 Negligible Rate of Lymph Node Metastasis #2 Amenable to Complete en bloc Resection 72y.o F ct1n0 ADC
Esophageal CA Early Access to Lymphatics Lymphatic channels in Lamina Propria Rate of LN Mets in Resected T1a ADC Rice 1998 3% Gockel DDW 2009 7% Pennathur 2009 7% Altorki 2008 7% Barbour 2010 0% Sepesi 2010 0% Moss 2011 0% Tom Rice, Clev Clinic
DETERMINE Presence of CLINICAL Lymph Node Metastasis ut1an0 ct1n0
PREDICT Presence of OCCULT Lymph Node Metastasis Size and Depth Lymphovascular Invasion Tumour Grade Gastric Cancer Gotoda and Sasako 2004 Esophageal AdenoCa- Lee et al 2013
258 pts with pt1 ADC McGill/Ottawa/Toronto/ Scoring Nomogram Variable Points Size +1 per cm Depth T1a +0 T1b +2 Differentiation Well +0 Moderate +2 Poor +2 Lymphovascular invasion +4 Risk Risk of Points Category LNM Low 1% - 4% 0-1 Moderate 7 10% 2-3 High >17% 4+ Mannheim/MD Anderson JACS June 2013
Application of the Scoring Normogram Good PS pt1b, 1 cm Well Diff, LVI-, R0 Risk of Occult LN Metastasis Score = 3 Risk = 7-10% Poor PS Surveillance
Endoscopic Mucosal Resection 1 cm Cap or Ligation Up to 1 cm Department 56 y.o. of Surgery M C3M5 Barretts Multifocal HGD
Tumour > 1 cm?
Where is the Margin? Diagnostic EMR Local Recurrence 35-40% Curative EMR? Kawaguchi, Manner and Ell, Yahagi
Endoscopic Submucosal Dissection Hook knife 3 cm IT knife Needle knife Dual knife
Short Cap Irrigating Catheter
En Bloc Resection Circumferential Margin Deep Margin
ESD Complications Bleeding Post Procedure Bleeding = (3%) ESD During Procedure Bleeding = 100%!!! Use clips, epi injection, APC, Coag Grasper, Hemospray Cools-Lartigue and Ferri, DDW 2013
ESD Complications Perforation ut1n0 SCC mid esophagus Perforation = 3/33 (10%) ESD all repaired endoscopically Cools-Lartigue and Ferri, DDW 2013
What About Barrett s Esophagus? HYBRID APPROACH Resect Early Cancer Ablate Barrett s Esophagus 67 y.o M, C0M5 (>50% circumference) Multifocal HGD + foci of invasive carcinoma
pt1a (M3), 1 cm, well diff, no LVI, R0 (for cancer) Risk of LN metastasis = 1%
3months 9 months
Endoscopic Resection Diagnostic vs Curative Summary Criteria for Curative Endoscopic Resection En Bloc resection Low (acceptable) Risk of LN metastasis Predictive Score EMR ESD technically facile but piecemeal for lesions>1 cm Technically complex en bloc Hybrid Approaches for Barrett s with ADC McGill Combined University Endoscopic Resection with Ablation