Management of early gastric cancer
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Management of Early Gastric Cancer. Charing Chong Division of Upper GI Surgery Department of Surgery Prince of Wales Hospital The Chinese University of Hong Kong. Early Gastric Cancer. Definition – tumour confined to the gastric mucosa or submucosa Convention management – Gastrectomy.

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Management of Early Gastric Cancer

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Management of Early Gastric Cancer

Charing Chong

Division of Upper GI Surgery

Department of Surgery

Prince of Wales Hospital

The Chinese University of Hong Kong


Early Gastric Cancer

  • Definition – tumour confined to the gastric mucosa or submucosa

  • Convention management – Gastrectomy


Conventional Open Gastrectomy vs Laparoscopic Assisted Gastrectomy


PWH experience - Laparoscopic assisted gastrectomy

  • 2003 - 2005

  • 25 patients

  • Laparoscopic D2 subtotal gastrectomy

  • Mean OT time: 330 mins

  • Hospital stay: 7 days

  • Complication

    • Minor anastomotic leak (1)

    • Anastomotic bleeding (1)

  • No conversion


Minimal Invasive Treatment Options of EGC

Local - regional Treatment

Local Treatment

Endoscopic Resection

(EMR/ESD)

Laparoscopic AssistedGastrectomy

(LAG)


How to choose

  • Major factors predicting the survival:

    • lymph node status

    • depth of wall invasion

  • Risk of LN metastasis in EGC is very low

    • Mucosa: 1 – 3%

    • Submucosal: 11 – 20%

  • Risk of gastrectomy and negative effect on patient’s quality of life


Endoscopic Mucosal Resection (EMR)


EMR - Classification- Pulling or suction methods

Injection and Cut Technique

Injection, Lift and Cut Technique

Cap Technique

Ligation Technique

Soetikno;J Clin Oncol; 2005


Survival:

99% 5-year and 10-year disease specific survival

Complications:

Perforation

0 - 1.5%

Bleeding

6 -15%

Local recurrence

EMR - Results

Tanabe et al; GIE; 2002

Hamanaka et al; Dig Endosc; 2005

Uedo et al; Gastric Cancer; 2006


EMR - Limitation- Local recurrence after conventional EMR

Author

Methods

Recurrence rate

Tanabe et al

Strip Biopsy, EAM

3.5% (15/423)

Kawaguchi et al

Strip Biopsy, EMR-C

35.3% (97/266)

Ida et al

EMR+Laser

6.7% (11/165)

Chonan et al

EMR

10.9% (21/193)

Hirao et al

ERHSE

2.3% (8/349)

Mitsunaga et al

Strip Biopsy

18.2% (54/296)

Strip Biopsy

8.5% (53/620)

NCCH (1988-1998)


EMR – Limitation- en-bloc resection

Piecemeal resection

One piece resection


EMR – Limitation- tumor size


Endoscopic Resection– changing criteria

Gotoda;

Gastric Cancer; 2000


Management Strategy for Early Gastric Cancer

Guidelines for the Treatment of Gastric Cancer; The Japanese Gastric Cancer Association; 2001


Endoscopic Submucosal Dissection (ESD)


ESD - Procedures

  • Marking of the periphery of the lesion with needle knife

  • Injection of diluted epinephrine to raise the submucosal layer

  • Circumferential mucosal cutting

  • Subumucoal dissection

  • Specimen resected in one -piece


ESD - Results


PWH experience - ESD

  • 2004 to 2006

    • 25 ESD performed for early gastric cancer

    • Mean duration: 84.3 mins

    • Hospital stay: 3 days

    • Mean size of the specimen: 8.5 cm2

    • Perforation - 0 (0%);

      Bleeding - 1 (4%);

      Margins involved - 1 (4%);

    • Mean follow-up: 12 months

    • No local recurrence


Early Gastric Cancer

Mucosal Tumour

Submucosal Tumour

Intestinal Type

Diffuse Type

Intestinal Type

> 30mm

No Ulceration

Ulceration

Sm 1,

< 30 mm

< 30 mm

> 30 mm

Endoscopic Resection

Endoscopic Resection

Laparoscopic Surgery

Conclusion


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