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Staging and Less Invasive Tx of Esophageal Cancer

Staging and Less Invasive Tx of Esophageal Cancer. Jun Haeng Lee Sungkyunkwan University School of Medicine Samsung Medical Center, Seoul, Korea,. Diagnosis and staging of esophageal cancer. Siersema. Gastroenterol Clin N Am 2008:37:943-964. Different modalities have different roles.

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Staging and Less Invasive Tx of Esophageal Cancer

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  1. Staging and Less Invasive Tx of Esophageal Cancer Jun Haeng Lee Sungkyunkwan University School of Medicine Samsung Medical Center, Seoul, Korea,

  2. Diagnosis and staging of esophageal cancer Siersema. Gastroenterol Clin N Am 2008:37:943-964

  3. Different modalities have different roles • For the evaluation of distant metastases, FDG-PET may have a higher sensitivity than CT. • For the detection of regional and celiac lymph node metastases, EUS is most sensitive, whereas CT and FDG-PET are more specific tests. • The combined use of FDG-PET and CT, which is increasingly being applied, could be of clinical value, with FDG-PET detecting possible metastases and CT confirming or excluding their presence and precisely determining their location. Siersema. Gastroenterol Clin N Am 2008:37:943-964

  4. Why accurate staging is important? • Accurate staging is essential to select patients who will benefit from aggressive therapy and to avoid aggressive therapy in patients with distant metastases. • Despite these efforts, metastatic spread is encountered during operation in up to 60% of patients. • No one technology can completely stage all aspects of esophageal carcinoma with high accuracy. Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 8th ed. Ch 44

  5. Comparative study will not be coming. • The current enthusiasm for neoadjuvant therapy makes it unlikely that definitive studies comparing accuracy of specific or combination staging modalities will be forthcoming. • Staging of newly diagnosed esophageal cancer may incorporate crosssectional imaging, EUS, positron emission tomography (PET) scanning, transcutaneous ultrasound scanning of the neck, laparoscopy, and video-assisted thoracoscopy (VATS) staging. Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 8th ed. Ch 44

  6. Role of Endoscopy Jun Haeng Lee Sungkyunkwan University School of Medicine Samsung Medical Center, Seoul, Korea,

  7. Role of endoscopy • Location of the lesion (with respect to distance from the incisors) • Nature of the lesion (friable, firm, polypoid) • Proximal and distal extent of the lesion • Relationship of the lesion to the cricopharyngeus muscle, the GEJ, and the gastric cardia • Distensibility of the stomach

  8. Early esophageal cancer- carcinoma in-situ. 1.2x0.4 cm. confined to the basement membrane in ESD

  9. Esophageal cancer- usefulness of Lugol chromoendoscopy

  10. Early esophageal cancer type I- 1.3 x 0.8 cmm, endolymphatic tumor emboli (+), LN 2/40

  11. Advanced esophageal cancer- extension to perimuscular adventitia, LN 3/62

  12. Esophageal cancer + EGC (M/60)

  13. Esophageal cancer after lye stricture (F/48) Invasive SCC (M/D), 2x1.8 cm, PM, 0/24

  14. CT, MRI, EUS Jun Haeng Lee Sungkyunkwan University School of Medicine Samsung Medical Center, Seoul, Korea,

  15. CT and MRI • CT is much less accurate in detecting lymph node metastases and is more accurate for subdiaphragmatic lymph nodes than for mediastinal ones. • MRI can assess mediastinal invasion and liver metastasis as well as CT can but has not demonstrated any significant advantages. Because of accessibility and its lower cost, CT is preferred. • The main limitations of CT are its insensitivity to the identification of irresectability (T4) and its inability to identify metastatic disease in normal-sized lymph nodes. Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 8th ed. Ch 44

  16. Features of malignant lymph on EUS • Size greater than 1cm • Hypoechogenicity • Distinct margins • Round shape • No single feature independently predicted malignant status. • When all four features were present, the accuracy in predicting malignancy was 80%. • However, these combined features were present in only 25% of the malignant lymph nodes observed.

  17. Accuracy of EUS in early studies Rosch. Gastrointest Endosc Clin N Am 1995;5:537

  18. Limitation of EUS (1): safety concerns Eloubeidi. Am J Gastroenterol 2009;104:53-56

  19. Limitation of EUS (2): publication bias- positive results만 보고되는 경향이 있다. Harewood GC. Am J Gastroenterol 2005:100;808-816

  20. Limitation of EUS (3): publication bias- 직장암에서 EUS의 성적이 점점 나쁘게 보고되고 있다 Harewood GC. Am J Gastroenterol 2005:100;808-816

  21. Limitation of EUS (4): too subjective- T-staging by EUS is strongly influenced by the endoscopic impression Yanai. Intern J Gastointest Cancer 2003;34:1-8

  22. Limitation of EUS (5): lack of experience • 식도암 병기 결정에 있어서 EUS의 정확도 (국립암센터, 2008 대한 Hp 학회 추계학술대회) • Overall T 병기 정확도: 73.9% • 분화암보다 미분화암에서 유의하게 낮은 결과 • 표재성 식도암에서 점막암 및 점막하층암 진단 정확도: 53.8% (miniprobe 67.3%, radial 38.8%) • Overall N 병기 정확도: 72.7% Korean J Helicobacter and Upper GI Gastrointest Res 2008;8(Suppl 2): 68

  23. Twine. Surg Endosc 2009 May 14. [Epub ahead of print]

  24. Twine. Surg Endosc 2009 May 14. [Epub ahead of print]

  25. Role of PET Jun Haeng Lee Sungkyunkwan University School of Medicine Samsung Medical Center, Seoul, Korea,

  26. NORMAL TUMOR • Overexpression of Glucose transporters • Higher levels of Hexokinase • Down-regulation of Glucose-6-phosphatase • Anaerobic glycolysis, less ATP per glucose molecule, • more glucose molecules needed for ATP production • General increase in metabolism from high growth rates

  27. SMC experience Yoon YC. Radiology 2003;227:764-770

  28. PET is very useful for distant mets van Westreenen HL. J Clin Oncol 2004;22:3805-3812

  29. Esophageal cancer with LN mets

  30. BUT, less useful for locoregional mets ♠ In the included studies, change in patient management ranged from 3% to 20% due to the addition of PET to preoperative workup. van Westreenen HL. J Clin Oncol 2004;22:3805-3812

  31. EMR/ESD for early esophageal cancer Jun Haeng Lee Sungkyunkwan University School of Medicine Samsung Medical Center, Seoul, Korea,

  32. Surgery for mucosal cancer: 7 (2.9%) F/U after ESD for EGC at SMC ESD (n=243) submucosal invasion or undifferentiated cancer (n=47) Surgery (n=34) Follow up (n=13) Intramucosal differentiated cancer (n=196) Complete resection (n=182) Not assessable (n=10) Incomplete resection (n=4) Less than two EGD follow up (n=7) Follow up (n=5) ESD (n=2) Surgery (n=3) Follow up (n=2) Surgery (n=2) Metachronous recurrence (n=9) Local recurrence (n=1) Surgery (n=1) ESD (n=8) Surgery (n=1) No recurrence Median follow-up: 17 months (range: 4-37 months) Min. Dig Liver Dis. 2009 Mar;41(3):201-9

  33. EMR was not considered as a Tx option- NCCN treatment guideline 2008 http://www.nccn.org/

  34. Risk of lymph node metastasis in EEC- a single center experience at Samsung Medical Center (n=197) Kim. J Gastroenterol Hepatol 2008;23(4):619-625

  35. Risk of lymph node metastasis in EEC- a multicenter study in Japan (n=1740) Kodama. Surgery 1998;123:432-439

  36. Risk of lymph node metastasis depends on the gross type of EEC Endo. Endoscopy 1993;25:672-674

  37. Indications for EMR for SCC Gotoda. GIE 2008;67:805-807

  38. Methods of endoscopic treatments - tissue retrieval techniques • Techniques without suction • Conventional snare polypectomy without injection • Inject and cut • Inject, lift and cut • Inject, precut and cut: EMR-P • ESD: needle knife, IT kinfe, hook knife, Flex knife • Techniques with suction • Suction and cut: EMR-C • Suction and ligate: EMR-L Modified from Endoscopy 2001;33:271-275

  39. 한시적 인정 비급여 ESD에 대한 용어의 정리- ESD를 EMR에서 분리하여 새로운 시술로 봄 • ER = EMR + ESD

  40. Recurrence after EMR for EEC Ishihara. GIE 2008;67:799-804

  41. Esophageal ESD- M/D squamous cell carcinoma (M2)

  42. Early esophageal cancer 0.7 cm

  43. ESD for EEC with perforation

  44. Endoscopic resection for early squamous cell carcinoma Pech. Gut 2007;56:1625-1634

  45. Take home message • 식도암의 치료 전 병기판정의 방법은 어떠한 치료를 염두에 두는가에 따라 달라질 수 있다. • 각 검사법이 서로 다른 역할을 가지고 있으므로 경쟁적이기보다는 보완적인 관계로 이해할 필요가 있다. • 조기식도암의 내시경치료는 아직 개발단계의 시술로 향후 많은 발전이 예상된다. 현재로서는 합병증을 줄이기 위한 다양한 노력이 필요하다.

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