emr can anyone do this? - american college of...

Norio Fukami, MD

EMRCan anyone do this?

Norio Fukami, MD

University of Colorado

Piecemeal resection?Piecemeal resection?

ACG Regional Postgraduate Course - Los Angeles, CA Copyright 2013 American College of Gastroenterology

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Norio Fukami, MD

Endoscopic mucosal resection (EMR) and

Endoscopic submucosal dissection (ESD)

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 & ESDHistory of EMR & ESDSimple snare removal (1968)

Saline injection and snare resection (1983)(1983)

Double channel - pinch and cut (1984)

Band and resect (1993)

Movement to explore Endoscopic removal as an alternative to Surgery

EMR cap method (1993)

Endoscopic submucosal dissection (mid-late 1990s) Soetikno et al. GIE. 2003(4)


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Norio Fukami, MD

EMR toolsEMR tools

• Snare

• injection

• Cap-EMR

• Band-EMR

ESD knivesESD knives

KD 10Q-1


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Norio Fukami, MD

EMR/ESD for the cure of cancer

EMR/ESD for the cure of cancer

Resection of premalignant or malignant lesion as an alternative to surgeryas 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 mandatoryPreprocedural assessment is mandatory

Know when to do it! - Exclude possible non-candidate

Weigh risk and benefit

Re-assessment after resection: Pathological evaluation

Cancer T stageCancer T stage

• Depth of cancer invasion

T3T1 T2


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Norio Fukami, MD

Sub-classification of T1 tumorSub-classification of T1 tumor

• m1: limited within mucosa (HGD)

• m2: invades into lamina propria

• m3: invades into muscularis mucosae

T1

T2• sm1 - 3:

• divide submucosal layer in three even thickness

Soetikno et al. GIE. 2003(4)

T2

Esophageal cancerEsophageal cancer

AJCC/UICC TNM, 7th edition


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Norio Fukami, MD

Colon cancerColon cancer

AJCC/UICC TNM, 7th edition

Lymph node metastasis risk for T1 tumor varies

Lymph node metastasis risk for T1 tumor varies

EMR b l t i di ti• EMR absolute indication

Esophagus SCC

Esophagus Adeno Ca

Stomach Colon

m1 0%0%

0-0.4% 0%m2 3%

m3 9% 2 3%

Important Factors: lymphovascular invasion, tumor differentiation, tumor budding

m3 9% 2-3%

sm1 15-20%

13~48%

~2.5%

10~%sm235~50% ~20%

sm3


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Norio Fukami, MD

How far can we go?

Expanded indications

How far can we go?

Expanded indicationspp

Esophageal cancer (mostly SCC)

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. 2002

&


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Norio Fukami, MD

Esophageal cancer (Barrett cancer)

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 cancerGastric cancer

Expanded indication

less than 500 μm

Soetikno et al. J Clin Oncol. 2005LN mets; 0-2.5% Gotoda et al. Gastric Cancer 2000

0-0.96% Hirasawa et al. Gastric Cancer 2009


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Norio Fukami, MD

Colon cancerColon 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 non-polypoid lesions*1

*1 Kitajima et al. J Gastroenterol 2004p yp

SM indication for EMR/ESD: less than 1000 μm depth of invasion, differentiated type, no LVI, and no tumor budding.

j

Master’s guide for endoscopic diagnosis. Tajiri and Saito. 2011

Lymph node metastasis risk for T1 tumor

Lymph node metastasis risk for T1 tumor

EMR b l t i di ti d d i di ti• EMR absolute indication expanded indication

Esophagus SCC

Esophagus Adeno Ca

Stomach Colon

m1 0%0%

0-0.4% 0%m2 3%

m3 9% 2 3%

Important Factors: lymphovascular invasion, tumor differentiation, tumor budding

m3 9% 2-3%

sm1 15-20%

13~48%

~2.5%

10~%sm235~50% ~20%

sm3

1000 μm500 μm superficial sm invasion


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Norio Fukami, MD

Diagnostic or Therapeutic?p

Basic techniquefor

pathology specimen processing

Specimen processingSpecimen processingEvaluation of the margins (lateral/deep) requires perpendicular slices

Pinnig specimens onto the boardonto the board before formalin fixation

Good!


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Norio Fukami, MD

Stage/depth assessmentStage/depth assessment

Meticulous evaluation:

Endoscopic assessment of cancer to predict T stage

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 p yp p g(0-IIa-c) and <2cm = m1-2

EUS with HF probe: 80-90% accuracy

Paris workshop group. GIE 2003


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Norio Fukami, MD

What to look for?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?



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Norio Fukami, MD

Case studyesophagusCase studyesophagus

SCC moderately differentiated, 2.4cm, sm1 no LV invasion


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Norio Fukami, MD

well differentiated adenocarcinoma, T1a (m2)

poorly differentiated adenocarcinoma, T3N1


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Norio Fukami, MD

Barrett’s esophagus with LGD

adecarcinoma in Barrett’s, T1sm-T2


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Norio Fukami, MD

Barrett’s esophagus with poorly differentiated adenocarcinomaT1sm, N1 at upper paratracheal LN

stomachstomach


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Norio Fukami, MD

well differentiated adenocarcinoma, T1a (m2)

6cm poorly differentiated adenocarcinoma, T1bpositive deep margin total gastrectomy no tumor and negative LN


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Norio Fukami, MD

differentiated adenocarcinoma, T1a (m3), UL +



poorly differentiated adenocarcinoma, T1a (m3)


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Norio Fukami, MD

coloncolon

Tubular adenoma


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Norio Fukami, MD

invasive adenocarcinoma, T2

High Grade Dysplasia


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Norio Fukami, MD


8mm moderately differentiated adenocarcinoma, T1sm, 3700 μm

adenocarcinoma, T2


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Norio Fukami, MD

adenocarcinoma, Tis (invasive to lp)

LST, granular type 5.5cm, Tis


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Norio Fukami, MD

ConclusionsConclusions

• 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


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emr can anyone do this? - american college of...

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