update on early gi-cancer · strategy for gi endoscopists: concerning advanced carcinomas, - there...
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Update on EARLY GI-cancer
T PonchonE.Herriot HospitalLyon, France
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Rationale
Epidemiology
Diagnosis
Treatment
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Rationale
Epidemiology
Diagnosis
Treatment
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Why do we need, as GI endoscopists, to be concerned by early GI cancer ?
1- Health care improvement
2- Strategy
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Health care improvement:
A carcinoma detected at early stage meansbetter prognosis for the patientless cost for the society
* It does mean that we need to screen the whole population
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Strategy for GI endoscopists:
Concerning advanced carcinomas,
- there is a increasing impact of chemotherapy (andradiotherapy) and less room for endoscopicpalliationExemples: eso SCC, colonic cancer
- there is an increasing impact of radiology for thediagnosisExemple: MRCP replaced ERCP
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Strategy for GI endoscopists:
Concerning advanced carcinomas,
There is a « competition » between oncologists andgastroenterologists for the management ofcases and for fundings
Gastroenterologists and endoscopists must focuson early GI-cancer and claim that the management of early GI-cancer is part of oncology and thefuture of GI oncology.
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Rationale
Epidemiology
Diagnosis
Treatment
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Are we effective, as GI endoscopists, to find early GI cancer ?
Exemple: gastric carcinoma
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Ratio T1/ total gastric carcinomas
Japan 40% Osaka Cancer Registry 98
France 7% Registre bourguignon 02
5y survival
Japan 47% Osaka Cancer Registry 98
Europe 22% IARC 99
USA 19% Bethesda 98
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Japan
5 y survival
1975-77 26%1987-89 45%
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Why are we late in Occident ?
1- Difference in incidence2- Decreasing incidence3- No limited high risk population4- No symptoms5- Low rate of polypoid lesions6- Difference in endoscopic practice
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1- Difference in incidence: nber/year
car colon car gastricJapan 48 000 115 000Europe 186 000 77 000
2- Decreasing incidence 1963 1989
Japan: less 36%, Europe: less 43%
Globocan
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France
60 millions inhabitants, 30 millions > 40y1 million upper GI endosc / y6000 new gastric car / y
We have to find 200 new asymptomatic cases/y
We are 2000 gastroenterologists
Each of us does 500 upper GI endoscopyEach of us has to find one superficial gastric car / 10 years orone per 5000 patientsSo 2.5 during our carreer
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3- Low role of etiological factors
Atrophic gastritis: 1,8-2,5 (Inoue IJC 90 Sipponen EJGH 94)
Intestinal metaplasia, Helicobacter pyloriGastrectomy, BiermerFamilial types ++++++
Except rare familial types, no high risk population to be screened
4- No specific symptom or no symptom
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5- Low ratio of polypoid lesions3223 lésions stade 0 (class. Vienne-JSGE)J Gastroenterol Mass Survey 2002
0-I 6%
0-II a17%
0-IIb
0-IIc 70%
0-III 7%
Adenoma= 10%of gastricneoplasms
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0-IIc , sm 1 (M.Sasako)
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6- Difference in endoscopic pratice
Japan: standard gastric endoscopy
Exploration and picture zone by zoneWithout (color abnormalities)
then with chromoscopy (pattern abnormalities)Zoom if abnormalityMinimum: 10 minutes
Sensitivity for dg of superf. neoplasm: 81%Hoskova Endoscopy 98
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6- Difference in endoscopic pratice
France: standard gastric endoscopy
Mean duration of gastric exploration: 130 sec
Sensitivity for dg of superficial neoplasms ??Certainly << 80%
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Japanese endoscopists are better educated and more motivated to find flat lesions than European who are mainly looking for polypoid lesions
Is it also true for colonic cancers or esophageal cancers ?
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EsophagealEsophageal carcinomascarcinomas
T1/totalT1/total TmuqTmuq/total/total
J Nat Ca J Nat Ca CenterCenter 42%42% 18%18%JapaneseJapanese enquiriesenquiries 25%25% 6%6%BurgundyBurgundy enquiryenquiry 4%4% 0.8%0.8%
DespiteDespiteprevalenceprevalence ofof esoeso car car BurgundyBurgundy > > JapanJapan
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Colonic carcinomas
KUDO S 2003
10357 superficial lesions: adenomas or adenocarcinomas
Adenocar & severe dysplasia: 961 (9.3%)
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POURCENTAGE OF CANCERS
Polypoïds5863 (57%)
Flats4218 (41%)
Depressed276 (2.6%)
<5 mm
0%
0,1%
8.1%
6-10
1.3%
0.6%
29.2%
11-15
9.4%
1.1%
68.8%
16-20
17.4%
9.8%
83.3%
>20mm
30.7%
23%
100%
Depressed lesions = « cancer de novo »
diameter
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Ca II c Ca II c
Ca II aCa II a
Earlacarcinoma
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Japanese endoscopist experience in Europe
Watanabe, Stockholm232 pts with superficial neoplasms
KcFlat lesions 95 (41%) 9 (10%)
Depressed lesions 14 (6%) 6 (43%)
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Fujii, Leeds722 consecutive pts, 166 superf neo.
Carpolypoïds 100 (60%) 9 (19%)flats 61 (6%) 7 (11%)depressed 5 (3%) 4 (80%) (1/200 pts)
« If we miss - the flat adenomas, we miss 35% of car- the depressed lesions, we miss 20% of car »
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Saitoh 99Japanese observer in an endoscopy unit in Texas
Number of neoplastic lesions: + 125%
Teixeira 2000Brasilian endoscopist, education in Japan
13 depressed lesions found on 3.5y =1 for 100 pts
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Why japanese endosc see more lesions than european endosc ?
Education of vision:Small abnormalities of reliefSmall abnormalities of colour +++:
erythroplastic (flat, depressed)or whitish (elevated)
Less lumen inflationAnalysis during peristaltic waveMore accurate analysis of the pattern
Motivation to find small lesions
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Rationale
Epidemiology
Diagnosis
Treatment
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Diagnosis: How to improve ?
MUCOSA (Patient)
ENDOSCOPEOPERATOR
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Diagnosis: How to improve ?
MUCOSA (Patient)
ENDOSCOPEOPERATOR
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How to improve ? MUCOSA
1- to select mucosa at risk
2- to make analysis of the mucosa easier
= Screening
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Mass Mass screeningscreening ofof colorectal colorectal carcinomacarcinomaexemple: exemple: HemoccultHemoccult II, if positive II, if positive colonoscopycolonoscopy
((mortalitymortality/cancer /cancer decreasesdecreases))
2002
2007:National
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IlleIlle--etet--VilaineVilaine
NumberNumber ofof tests: 90877tests: 90877
ComplianceCompliance to test: 54%to test: 54%
ComplianceCompliance to to colonoscopycolonoscopy if test positive: if test positive: 82%82%
NumberNumber ofof detecteddetected cancers: cancers: 207 (61% T1)207 (61% T1)
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EsophagealEsophageal squamoussquamous cellcell carcinomacarcinomaSystematicSystematic lugollugol stainingstaining in in highhigh riskrisk ptsptsFrench French studystudy (SFED)(SFED)1098 1098 ptspts, 45 , 45 centerscenters, , systematicsystematic LugolLugol
RATERATE
HistoryHistory ofof ENT cancer: ENT cancer: 393 393 ptspts 6.8% 37% T16.8% 37% T1ChronicChronic pancreatitispancreatitis: : 76 76 ptspts 0%0%AlcoholicAlcoholic cirrhosiscirrhosis: : 220 220 ptspts 3.2%3.2%AlcoholAlcohol--tobaccotobacco abuse: 408 abuse: 408 ptspts 2.4%2.4%
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How to improve ? MUCOSA
1- to select mucosa at risk
Only screening of colonic carcinoma and ofesophageal SC carcinoma in ENT patients could be cost effective and should beorganized
= Screening
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How to improve ? MUCOSA
1- to select mucosa at risk
2- to make analysis of the mucosa easier
= Screening
= To improve patient tolerance
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To improve patient tolerance =- to organize sedation- but also to reduce the need for sedation
in order to reduce cost and constraints
transnasal endoscopy upper GI
capsule
new colonoscopes lower GI
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If we also suppress the need for endoscope reprocessing …..
and colonic prep……..
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ExampleExample 1:1:nasogastroscopenasogastroscope
VideoVideo 5 mm5 mmoneone plan plan bendingbending
SingleSingle--useuse sheathsheathVision sciencesVision sciences65 cm65 cmoperatingoperating channelchanneldiameterdiameter: 5.1mm : 5.1mm
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500 500 ptspts, 10 , 10 centerscenters, , randomizedrandomizedstudystudy oral standard vs oral standard vs nasonaso
0 1 2 3 4
SCORE
Gagging
Bloating
Discomfort
Retching
Sensation asphyxia ORAL
NASAL
P<0.0001P<0.0001
P<0.0001P<0.0001
P<0.0001P<0.0001
P<0.001P<0.001
P<0.0001P<0.0001
P<0.0001P<0.0001
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NumberNumber ofof ptspts refusingrefusing anotheranother procedureprocedurein in thethe samesame conditions:conditions:
Oral Oral gastroscopygastroscopy:: 25.2%25.2%
NasogastroscopyNasogastroscopy:: 10.3%10.3%p<0.001p<0.001
500 500 ptspts, 10 , 10 centerscenters, , randomizedrandomizedstudystudy oral standard vs oral standard vs nasonaso
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NasogastroscopyNasogastroscopy isis veryvery popularpopular andand consideredconsidered to to bebeveryvery helpfulhelpful in Francein FranceFirstFirst procedureprocedure in Lyon, E.Herriot in Lyon, E.Herriot HospitalHospitalThenThen rapidrapid expansion to Rhôneexpansion to Rhône--Alpes Alpes regionregionandand thenthen to Franceto France
In Lyon,In Lyon,83% 83% ofof upperupper GI diagnostic endoscopiesGI diagnostic endoscopies6 6 nasogastroscopesnasogastroscopes in in E.HerriotE.Herriot HospitalHospital3 3 nasogastroscopesnasogastroscopes in a large in a large privateprivate hospitalhospital
In France, In France, 139 139 nasogastroscopesnasogastroscopes soldsold in 2004in 2004
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EliakimEliakim endosc06endosc06«« pillcampillcam »»
Exemple 2: Exemple 2: EsophagealEsophageal videocapsulevideocapsule
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Esophageal CapsuleEliakim
Still under evaluation
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ExampleExample 33
SelfSelf--propellingpropelling singlesingle--useuse colonoscopecolonoscope
-- AerAer--OO--scopescope-- InvendoInvendo-- ColonosightColonosight-- CathcamCathcam-- ……………………..
Still under evaluation
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SOME EXEMPLES SOME EXEMPLES ……..
2 technologies2 technologies
11-- single use single use sheathsheath22-- pneumaticpneumatic advanceadvance
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Still under evaluation
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Still under evaluation
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Diagnosis: How to improve ?
MUCOSA (Patient)
ENDOSCOPEOPERATOR
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CHROMOSCOPYCHROMOSCOPYHIGH DEFINITION VIDEOHIGH DEFINITION VIDEOSTRUCTURE ENHANCEMENTSTRUCTURE ENHANCEMENTMAGNIFICATIONMAGNIFICATIONNARROW BAND IMAGING, NARROW BAND IMAGING, IHb color enhancFLUORESCENCEFLUORESCENCEINTERFEROMETRY:INTERFEROMETRY: 10 10 micrommicrom
CONFOCAL MICROSCOPY:CONFOCAL MICROSCOPY: 1 1 micrommicromENDOCYSTOSCOPYENDOCYSTOSCOPYELASTIC SCATTERING:ELASTIC SCATTERING: subcellsubcell
RAMAN SPECTROSCOPY:RAMAN SPECTROSCOPY: molecmolec
????
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DIAGNOSIS = 3 DIAGNOSIS = 3 stepssteps
I I trytry to to detectdetect DetectionDetectiononeone lesionlesion
ThereThere isis a a lesionlesion CharacterizationCharacterizationWhatWhat isis itit ??
ItIt isis a a neoplasmneoplasm StagingStagingWhichWhich isis itsits extension ?extension ?
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DIAGNOSISDIAGNOSIS
TheThe main main targettarget == improvementimprovement in in detectiondetection
WhyWhy ??firstfirst stepstep, , needneed ++++: ++++: nono alternativealternative
caracterisationcaracterisation = = biopsybiopsy«« opticoptic biopsybiopsy »» isis a a secondarysecondary targettargetstagingstaging = EUS, = EUS, ……. . surgerysurgery
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HighHigh grade grade dysplasiadysplasia
Dysplasia
Improvement in detection
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WhichWhich are are thethe bestbest candidates ?candidates ?
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CHROMOSCOPYCHROMOSCOPYHIGH DEFINITION VIDEOHIGH DEFINITION VIDEOSTRUCTURE ENHANCEMENTSTRUCTURE ENHANCEMENTMAGNIFICATIONMAGNIFICATIONNARROW BAND IMAGINGNARROW BAND IMAGING, , IHb color enhancFLUORESCENCEFLUORESCENCEINTERFEROMETRY:INTERFEROMETRY: 10 10 micrommicrom
CONFOCAL MICROSCOPY:CONFOCAL MICROSCOPY: 1 1 micrommicromENDOCYSTOSCOPYENDOCYSTOSCOPYELASTIC SCATTERING:ELASTIC SCATTERING: subcellsubcell
RAMAN SPECTROSCOPY:RAMAN SPECTROSCOPY: molecmolec
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Conventional
NBI
Spectrum
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NBI
Indigo carmine
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CHROMOSCOPYCHROMOSCOPYHIGH DEFINITION VIDEOHIGH DEFINITION VIDEOSTRUCTURE ENHANCEMENTSTRUCTURE ENHANCEMENTMAGNIFICATIONMAGNIFICATIONNARROW BAND IMAGINGNARROW BAND IMAGING, , IHb color enhancFLUORESCENCEFLUORESCENCEINTERFEROMETRY:INTERFEROMETRY: 10 10 micrommicrom
CONFOCAL MICROSCOPY:CONFOCAL MICROSCOPY: 1 1 micrommicromENDOCYSTOSCOPYENDOCYSTOSCOPYELASTIC SCATTERING:ELASTIC SCATTERING: subcellsubcell
RAMAN SPECTROSCOPY:RAMAN SPECTROSCOPY: molecmolec
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Juntendo University
AutofluorescenceAutofluorescenceOlympusOlympus AFI ColonAFI Colon
AFI
AFI
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AutofluorescenceAutofluorescenceOlympusOlympus AFI AFI BarrettBarrettKara GIE 05Kara GIE 05
©© AMC AmsterdamAMC Amsterdam
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Kara AMC
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CHROMOSCOPYCHROMOSCOPYHIGH DEFINITION VIDEOHIGH DEFINITION VIDEOSTRUCTURE ENHANCEMENTSTRUCTURE ENHANCEMENTMAGNIFICATIONMAGNIFICATIONNARROW BAND IMAGINGNARROW BAND IMAGING, , IHb color enhancFLUORESCENCEFLUORESCENCEINTERFEROMETRY:INTERFEROMETRY: 10 10 micrommicrom
CONFOCAL MICROSCOPY:CONFOCAL MICROSCOPY: 1 1 micrommicromENDOCYSTOSCOPYENDOCYSTOSCOPYELASTIC SCATTERING:ELASTIC SCATTERING: subcellsubcell
RAMAN SPECTROSCOPY:RAMAN SPECTROSCOPY: molecmolec
Toopunctual
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DIAGNOSIS = 3 DIAGNOSIS = 3 stepssteps
I I trytry to to detectdetect DetectionDetectiononeone lesionlesion
ThereThere isis a a lesionlesion CharacterizationCharacterizationWhatWhat isis itit ??
ItIt isis a a neoplasmneoplasm StagingStagingWhichWhich isis itsits extension ?extension ?
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CHROMOSCOPYCHROMOSCOPYHIGH DEFINITION VIDEOHIGH DEFINITION VIDEOSTRUCTURE ENHANCEMENTSTRUCTURE ENHANCEMENTMAGNIFICATIONMAGNIFICATIONNARROW BAND IMAGING, NARROW BAND IMAGING, FLUORESCENCEFLUORESCENCE
INTERFEROMETRYINTERFEROMETRY
CONFOCAL MICROSCOPYCONFOCAL MICROSCOPYENDOCYSTOSCOPYENDOCYSTOSCOPYELASTIC SCATTERINGELASTIC SCATTERING
RAMAN SPECTROSCOPYRAMAN SPECTROSCOPY
Detection
Characterization
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CHROMOSCOPYCHROMOSCOPYHIGH DEFINITION VIDEOHIGH DEFINITION VIDEOSTRUCTURE ENHANCEMENTSTRUCTURE ENHANCEMENTMAGNIFICATIONMAGNIFICATIONNARROW BAND IMAGING, NARROW BAND IMAGING, FLUORESCENCEFLUORESCENCE
INTERFEROMETRYINTERFEROMETRY
CONFOCAL MICROSCOPYCONFOCAL MICROSCOPYENDOCYSTOSCOPYENDOCYSTOSCOPYELASTIC SCATTERINGELASTIC SCATTERING
RAMAN SPECTROSCOPYRAMAN SPECTROSCOPY
Détection
Characterization
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Adenoma
Kiesslich
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Colonic cancer
Kiesslich
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DetectionDetection CharacterizationCharacterization
StagingStaging
Finally…….
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Rationale
Epidemiology
Diagnosis
Treatment
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Treatment of early GI cancer
We have to manage the risk of recurrence, ofmetachronous lesion, of lymph node, …
We need to apply the same principles as used in surgery
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Treatment of early GI cancer
First principleRESECTION >>> TUMOR DESTRUCTION
(PDT, APC, ……)
Specimen for histopathology
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ANALYZIS of the SPECIMEN
TO RECONSIDER SURGERYmain advantage on methodsbased on tumor destruction
STRETCHING ON A BOARD WITH PINS
1- Complete resection ?laterally and in depth
2- Invasiveness of carcinoma ?
Tumor
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Generator of radiofrequency
Electrodes
OneOne exception to exception to thisthis rulerule ??BARRxBARRx
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After tt
Swine, Ganz, 10 J/cm2
Prior tt
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BARRxBARRx: : GanzGanz, , SharmaSharma DDW 05DDW 05
32 32 ptspts: : BarrettBarrett, , nono dysplasiadysplasia1 sec ablation, 10 J/cm21 sec ablation, 10 J/cm2nono residualresidual intestinal intestinal metaplasiametaplasia (357 biopsies)(357 biopsies)nono stenosisstenosis
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Second principle
Complete resectionOne pieceSecurity margin
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CompleteComplete resectionresection, , securitysecurity marginmargin
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In situ carIn situ car
Invasive carInvasive car
PiecePiece--mealmeal to to bebe avoidedavoided
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MucosalMucosal resectionresection+/+/-- piecepiece mealmeal
MucosalMucosal dissectiondissection
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IT knife Needle knife
Flex knife Hook knife
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Third principle
To treat our complications
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Coag >> clips
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NB:In case of perforation,even following clippingwe still need surgical advice andF-U with surgeons…..
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Fourth principle
To prevent metachronous lesion= to treat the mucosa at risk
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CircumferentialCircumferential esophagealesophageal mucmuc. . resectionresection
Lyon, E.Herriot Lyon, E.Herriot hospitalhospital:: 32 cases, 32 cases, meanmean FF--UU: 19 : 19 momo12 12 stenosesstenoses
GiovanniniGiovannini endoscendosc 04:04: 21 cases, 21 cases, meanmean FF--UU: 18 : 18 momo3 3 recurrencesrecurrences9% 9% bleedingbleeding, , nono stenosisstenosis
SoehendraSoehendra EndoscEndosc 04:04: 12 cases, 12 cases, medianmedian FF--U: 9 U: 9 momonono recurrencerecurrence2 2 stenosesstenoses
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Fifth principle
To know the limits of endoscopy
= to evaluate the risk of lymph nodemetastases
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EUS is not enough effective to detectmetastatic lymph node
N status is dependent of T status
Evaluation of N status related to T status has been conducted by japanese authors on surgical specimen
Definition of frontiersbased on T status
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mm
sm
mp
colon
muc
stomachm1
1000 µµmm
eso
500 µµmm
Well differentiatedNo vasc or lymph invasion
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How to assesssubmucosal invasion ?
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II a + II c
II c + II a
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EUS miniprobe 20-30 MHz
m
smpm1pm2
Musc. mucosae
9 layers
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sm2
1000 μm
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Case 41800 μm
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sm2
7200 μm
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CONCLUSIONS
1- Health care and strategy2- Japan > Occident3- Dg: not only a question of technology but ofmotivation and organization (screening)4- Technology concerns images but alsoeasiness (cost, compliance). To improvedetection is the first target.5- Treatment: same principles as surgery
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Thank you