- Email: [email protected]
Endoscopic Mucosal Resection of Neoplasia in the Esophagus and Gastroesophageal Junction: Impact On Histological Diagnosis and Further Management
Abstracts
S1319 Factors Predicting a Better Outcome After Pneumatic Dilatation for the Treatment of Achalasia Yuriko Tanaka, Katsuhiko Iwakiri, Noriyuki Kawami, Hirohito Sano, Yoshinori Hayashi, Makoto Kotoyori, Choitsu Sakamoto Background: Pneumatic dilatation (PD) is an effective and safe treatment for achalasia but the factors predicting a better outcome after PD are poorly understood. Methods: Between January, 2002 and October, 2006, 42 consecutive patients (22 male, 20 females, median age of 57.0 years) with achalasia (diagnosed by esophageal manometry, barium esophagogram, and/or esophagoscopy) were treated by PD (1-2 dilatations with a progressively larger balloon). Patients were evaluated clinically (frequency of symptoms, weight loss, age, gender, duration of achalasia), radiologically (the esophageal diameter of the middle esophagus), and manometrically (basal LES pressure and nadir LES pressure after a swallowing) before PD. The definition of remission after PD is the reduction of more than 75% of the symptoms of achalasia. The success of PD is defined as remission of more than 6 months. Results: There were no serious side effects (no perforation) after PD. The success rate of PD was 28 of the 42 patients (66.7%). A single dilatation was successful in 26 patients and 2 dilatations were performed in 2 patients. Age, in the successful group of PD (60.5 years (50.0-66.0), median (interquartile range)) was significantly (p ! 0.05) higher than that of the failure group (37.5 (27.5-58.0)). There were no differences in other factors between the groups. In the group over 40 years old, the success rate of PD was 85.7%, but it was 33.3% in the group of less than 40. In addition, no patient with achalasia of less than 30 years was treated by PD. Conclusions: PD is an effective and safe treatment for achalasia. The major factor predicting a better outcome is old age. Young patients of less than 30 years should be offered alternative therapy.
S1320 Comparison of Endoscopic Submucosal Dissection (ESD) Using Sodium Hyaluronate and Needle-Knife Versus Endoscopic Aspiration Mucosectomy (EAM) for Esophageal Squamous Cell Neoplasm Makoto Nishimura, Masafumi Sakaguchi, Michio Hifumi, Hironori Yamamoto, Kentaro Sugano Background and Aims: En-bloc resection by endoscopic submucosal dissection (ESD) is desirable to facilitate accurate histopathological assessment of tissue specimens, and is indispensable in treating the superficially-spreading type of esophageal cancer. An ESD method using sodium hyaluronate and needle-knife had been developed at Jichi Medical University for endoscopic en-bloc resection of large superficial gastric and colonic lesions. We developed and improved this method for application to large superficial esophageal cancer. This study compared recent data at our institution between ESD and endoscopic aspiration mucosectomy (EAM) for esophageal squamous cell neoplasm. Methods: Between March 2003 and November 2006, a total of 35 patients (35 males; median age 63.4 years, range 53-79 years) with esophageal squamous cell neoplasm were treated at Japanese Red Cross Kumamoto Hospital. ESD were performed in 20 patients, and EAM was performed in 15 patients. The size of the resected specimen, en-bloc rate, and histopathological findings were compared. Results: The mean size of the resected specimen was 35.3 mm (range 22-50 mm in diameter) with ESD and 22.1 mm (range 12-40 mmin diameter) with EAM (p ! 0.05). The en-bloc rate was 100% with ESD and 60% with EAM (p ! 0.02). Histopathologically, there were 18 squamous cell carcinomas (SCC) and 2 dysplasias in the ESD group, and 9 SCC and 6 dysplasias in the EAM group. Rate of negative horizontal margin was 90.0% with ESD and 44.4% with EAM (p ! 0.01). There were 2 minor air leaks to mediastinum with ESD, which ware successfully managed conservatively, and no complications with EAM. Conclusions: In our data, ESD using sodium hyaluronate and needleknife could accomplish en-bloc resection without severe complications, and achieved a high cure rate. Therefore, we conclude that our method of ESD is a more reliable treatment for esophageal squamous cell neoplasm than conventional EMR.
www.giejournal.org
S1321 Endoscopic Mucosal Resection of Neoplasia in the Esophagus and Gastroesophageal Junction: Impact On Histological Diagnosis and Further Management Heiko Pohl, Mario Anders, Katja Scheiner, Bertram H. Wiedenmann, Thomas Roesch Background: Endoscopic mucosal resection (EMR) is increasingly used to remove early esophageal carcinomas. Endosonography less accurately defines depth of infiltration and node invasion for early cancers compared to more advanced disease. It is unclear how often endoscopic mucosal resection of suspected early cancers without prior endosonography will help in decision for further management. Method: We evaluated all patients who presented to our endoscopy unit for EMR of HGIN or early esophageal carcinoma between 12/2004 and 11/2006; EMR was performed in the cap technique with submucosal injection, mostly piecemeal. Primary outcome was the change of histological diagnosis in the resected specimen compared to histology prior to EMR. We further evaluated the proportion of patients who underwent surgery after initial EMR. We considered infiltration into the submucosa for adenocarcinomas or deep mucosal layer (m3) for squamous cell cancers an indication for surgery. Results: We enrolled 39 patients: 77% (n Z 30) had Barrett associated neoplasia, 13% (n Z 5) squamous cell neoplasia, and 10% (n Z 4) primary cardia neoplasia. The mean age was 63.2 (9.6) and 97% were men. Initial histology from biopsies was carcinoma in 67% (n Z 26) and high grade intraepithlial neoplasia (HGIN) in 33% (n Z 13). EMR confirmed the precise initial histological diagnosis in 69% (n Z 27). Of all patients with initial diagnosis of HGIN, cancer was detected in 31% (n Z 4); initial cancer diagnosis was downstaged in 23% (n Z 6). In two patients with esophageal adenocarcinoma deep infiltration was noted during EMR by an inability to sufficiently lift the mucosa by submucosal injection and to completely remove the lesion. Of the remaining cancers, 86% were confined to the mucosa (n Z 13) or superficial submucosa (!500 mm, sm1) (n Z 6). Considering comorbidities and increased operative risk, only 15% (n Z 6) of all patients underwent surgery, while according to established criteria (sm1 for adenocarcinoma and m3 for squamous cell cancers), 33% (n Z 13) would have been surgical candidates. Conclusion: EMR changes the initial histological diagnosis in almost a third of patients. Only a minority with initial diagnosis of HGIN or suspected early esophageal or gastroesophageal junction cancers will undergo surgery after EMR.
S1322 Endoscopic Mucosal Resection (EMR) and Photodynamaic Therapy (PDT) As Curative Salvage Treatments for Local Failure After Definitive Chemoradiotherapy (CRT) for Esophageal Cancer (EC) Tomonori Yano, Manabu Muto, Keiko Minashi, Santa Hattori, Atsushi Ohtsu, Shigeaki Yoshida Background: Although definitive CRT for EC shows a high response rate, local failure without distant metastasis is up to 40% or more. Salvage esophagectomy is considered to be only curative treatment option, however, it is relevant to high morbidity and mortality rate. We have previously published short-term results of salvage EMR and PDT. (Hattori S, et al. GIE 2003,58, Yano T, et al. GIE 2005, 62). Aim: The aim of this retrospective analysis is to up date these results with further follow up periods and evaluate the efficacy and safety. Patients and Methods: CRT consists of more than 50.4 Gy of external beam irradiation and concurrent with chemotherapy (cisplatin þ 5-fluorouracil (5FU) or nedapratin þ 5FU). The indication of salvage EMR or PDT were as follows; 1) clinically defined N0M0 by computed tomography and endoscopic ultrasound (EUS) after CRT, 2) patients’ refusal of salvage esophagectomy 3) written informed consent. EMR or PDT was performed up to the following findings: 1) If the cancerous lesion was limited within mucosal layer without ulceration, we select salvage EMR, 2) if the lesion had ulceration or invaded into the submucosal layer or estimated as uT2 by EUS, we select salvage PDT. EMR was performed with strip-biopsy methods. PDT proceeded with injection of Photofrin and irradiation with excimer dye laser. Results: From Feb. 1998 to Feb. 2005, a total of 67 patients with EC were underwent endoscopic salvage treatment for local failure definitive CRT. (EMR 30 / PDT 37) [Salvage EMR]Median age was 63 y-o (range, 47-70) Baseline clinical stage before CRTwas as follows: T1/2/3/4 in 15/2/12/1, N0/1 in 18/12 and stage I/II/III in 13/9/8 patients. 21 patients could achieve complete resection. Major complication was perforation with one patient. There was no treatment-related death (TRD) with EMR. With a median follow up period of 39 months after salvage EMR, 3 year overall survival (OS) rate was 64.4%. [Salvage PDT]Median age was 64.5 y-o (range, 50-75) Baseline clinical stage before CRT was as follows: T1/2/3/4 in 3/4/21/2, N0/1 in 13/24 and clinical stage I/II/III/IV in 2/11/21/2 patients. Before PDT, 20 patients were assessed having uT1 lesion and remaining were uT2. 22 patients were achieved complete response (CR rate; 59.5%, uT1: 15/20; 75%, uT2:7/17; 41.2%). Major complication was 4 perforations and 20 esophageal stenosis. A patient was died with perforation 2 months after PDT. With a median follow up period of 28 months after salvage PDT, 2 year OS rate was 53.1%. Conclusion: Salvage EMR and PDT could be promising curative intent treatment option for local failure after definitive CRT for EC with low rate of morbidity and mortality.
Volume 65, No. 5 : 2007 GASTROINTESTINAL ENDOSCOPY AB143
S1319 Factors Predicting a Better Outcome After Pneumatic Dilatation for the Treatment of Achalasia Yuriko Tanaka, Katsuhiko Iwakiri, Noriyuki Kawami, Hirohito Sano, Yoshinori Hayashi, Makoto Kotoyori, Choitsu Sakamoto Background: Pneumatic dilatation (PD) is an effective and safe treatment for achalasia but the factors predicting a better outcome after PD are poorly understood. Methods: Between January, 2002 and October, 2006, 42 consecutive patients (22 male, 20 females, median age of 57.0 years) with achalasia (diagnosed by esophageal manometry, barium esophagogram, and/or esophagoscopy) were treated by PD (1-2 dilatations with a progressively larger balloon). Patients were evaluated clinically (frequency of symptoms, weight loss, age, gender, duration of achalasia), radiologically (the esophageal diameter of the middle esophagus), and manometrically (basal LES pressure and nadir LES pressure after a swallowing) before PD. The definition of remission after PD is the reduction of more than 75% of the symptoms of achalasia. The success of PD is defined as remission of more than 6 months. Results: There were no serious side effects (no perforation) after PD. The success rate of PD was 28 of the 42 patients (66.7%). A single dilatation was successful in 26 patients and 2 dilatations were performed in 2 patients. Age, in the successful group of PD (60.5 years (50.0-66.0), median (interquartile range)) was significantly (p ! 0.05) higher than that of the failure group (37.5 (27.5-58.0)). There were no differences in other factors between the groups. In the group over 40 years old, the success rate of PD was 85.7%, but it was 33.3% in the group of less than 40. In addition, no patient with achalasia of less than 30 years was treated by PD. Conclusions: PD is an effective and safe treatment for achalasia. The major factor predicting a better outcome is old age. Young patients of less than 30 years should be offered alternative therapy.
S1320 Comparison of Endoscopic Submucosal Dissection (ESD) Using Sodium Hyaluronate and Needle-Knife Versus Endoscopic Aspiration Mucosectomy (EAM) for Esophageal Squamous Cell Neoplasm Makoto Nishimura, Masafumi Sakaguchi, Michio Hifumi, Hironori Yamamoto, Kentaro Sugano Background and Aims: En-bloc resection by endoscopic submucosal dissection (ESD) is desirable to facilitate accurate histopathological assessment of tissue specimens, and is indispensable in treating the superficially-spreading type of esophageal cancer. An ESD method using sodium hyaluronate and needle-knife had been developed at Jichi Medical University for endoscopic en-bloc resection of large superficial gastric and colonic lesions. We developed and improved this method for application to large superficial esophageal cancer. This study compared recent data at our institution between ESD and endoscopic aspiration mucosectomy (EAM) for esophageal squamous cell neoplasm. Methods: Between March 2003 and November 2006, a total of 35 patients (35 males; median age 63.4 years, range 53-79 years) with esophageal squamous cell neoplasm were treated at Japanese Red Cross Kumamoto Hospital. ESD were performed in 20 patients, and EAM was performed in 15 patients. The size of the resected specimen, en-bloc rate, and histopathological findings were compared. Results: The mean size of the resected specimen was 35.3 mm (range 22-50 mm in diameter) with ESD and 22.1 mm (range 12-40 mmin diameter) with EAM (p ! 0.05). The en-bloc rate was 100% with ESD and 60% with EAM (p ! 0.02). Histopathologically, there were 18 squamous cell carcinomas (SCC) and 2 dysplasias in the ESD group, and 9 SCC and 6 dysplasias in the EAM group. Rate of negative horizontal margin was 90.0% with ESD and 44.4% with EAM (p ! 0.01). There were 2 minor air leaks to mediastinum with ESD, which ware successfully managed conservatively, and no complications with EAM. Conclusions: In our data, ESD using sodium hyaluronate and needleknife could accomplish en-bloc resection without severe complications, and achieved a high cure rate. Therefore, we conclude that our method of ESD is a more reliable treatment for esophageal squamous cell neoplasm than conventional EMR.
www.giejournal.org
S1321 Endoscopic Mucosal Resection of Neoplasia in the Esophagus and Gastroesophageal Junction: Impact On Histological Diagnosis and Further Management Heiko Pohl, Mario Anders, Katja Scheiner, Bertram H. Wiedenmann, Thomas Roesch Background: Endoscopic mucosal resection (EMR) is increasingly used to remove early esophageal carcinomas. Endosonography less accurately defines depth of infiltration and node invasion for early cancers compared to more advanced disease. It is unclear how often endoscopic mucosal resection of suspected early cancers without prior endosonography will help in decision for further management. Method: We evaluated all patients who presented to our endoscopy unit for EMR of HGIN or early esophageal carcinoma between 12/2004 and 11/2006; EMR was performed in the cap technique with submucosal injection, mostly piecemeal. Primary outcome was the change of histological diagnosis in the resected specimen compared to histology prior to EMR. We further evaluated the proportion of patients who underwent surgery after initial EMR. We considered infiltration into the submucosa for adenocarcinomas or deep mucosal layer (m3) for squamous cell cancers an indication for surgery. Results: We enrolled 39 patients: 77% (n Z 30) had Barrett associated neoplasia, 13% (n Z 5) squamous cell neoplasia, and 10% (n Z 4) primary cardia neoplasia. The mean age was 63.2 (9.6) and 97% were men. Initial histology from biopsies was carcinoma in 67% (n Z 26) and high grade intraepithlial neoplasia (HGIN) in 33% (n Z 13). EMR confirmed the precise initial histological diagnosis in 69% (n Z 27). Of all patients with initial diagnosis of HGIN, cancer was detected in 31% (n Z 4); initial cancer diagnosis was downstaged in 23% (n Z 6). In two patients with esophageal adenocarcinoma deep infiltration was noted during EMR by an inability to sufficiently lift the mucosa by submucosal injection and to completely remove the lesion. Of the remaining cancers, 86% were confined to the mucosa (n Z 13) or superficial submucosa (!500 mm, sm1) (n Z 6). Considering comorbidities and increased operative risk, only 15% (n Z 6) of all patients underwent surgery, while according to established criteria (sm1 for adenocarcinoma and m3 for squamous cell cancers), 33% (n Z 13) would have been surgical candidates. Conclusion: EMR changes the initial histological diagnosis in almost a third of patients. Only a minority with initial diagnosis of HGIN or suspected early esophageal or gastroesophageal junction cancers will undergo surgery after EMR.
S1322 Endoscopic Mucosal Resection (EMR) and Photodynamaic Therapy (PDT) As Curative Salvage Treatments for Local Failure After Definitive Chemoradiotherapy (CRT) for Esophageal Cancer (EC) Tomonori Yano, Manabu Muto, Keiko Minashi, Santa Hattori, Atsushi Ohtsu, Shigeaki Yoshida Background: Although definitive CRT for EC shows a high response rate, local failure without distant metastasis is up to 40% or more. Salvage esophagectomy is considered to be only curative treatment option, however, it is relevant to high morbidity and mortality rate. We have previously published short-term results of salvage EMR and PDT. (Hattori S, et al. GIE 2003,58, Yano T, et al. GIE 2005, 62). Aim: The aim of this retrospective analysis is to up date these results with further follow up periods and evaluate the efficacy and safety. Patients and Methods: CRT consists of more than 50.4 Gy of external beam irradiation and concurrent with chemotherapy (cisplatin þ 5-fluorouracil (5FU) or nedapratin þ 5FU). The indication of salvage EMR or PDT were as follows; 1) clinically defined N0M0 by computed tomography and endoscopic ultrasound (EUS) after CRT, 2) patients’ refusal of salvage esophagectomy 3) written informed consent. EMR or PDT was performed up to the following findings: 1) If the cancerous lesion was limited within mucosal layer without ulceration, we select salvage EMR, 2) if the lesion had ulceration or invaded into the submucosal layer or estimated as uT2 by EUS, we select salvage PDT. EMR was performed with strip-biopsy methods. PDT proceeded with injection of Photofrin and irradiation with excimer dye laser. Results: From Feb. 1998 to Feb. 2005, a total of 67 patients with EC were underwent endoscopic salvage treatment for local failure definitive CRT. (EMR 30 / PDT 37) [Salvage EMR]Median age was 63 y-o (range, 47-70) Baseline clinical stage before CRTwas as follows: T1/2/3/4 in 15/2/12/1, N0/1 in 18/12 and stage I/II/III in 13/9/8 patients. 21 patients could achieve complete resection. Major complication was perforation with one patient. There was no treatment-related death (TRD) with EMR. With a median follow up period of 39 months after salvage EMR, 3 year overall survival (OS) rate was 64.4%. [Salvage PDT]Median age was 64.5 y-o (range, 50-75) Baseline clinical stage before CRT was as follows: T1/2/3/4 in 3/4/21/2, N0/1 in 13/24 and clinical stage I/II/III/IV in 2/11/21/2 patients. Before PDT, 20 patients were assessed having uT1 lesion and remaining were uT2. 22 patients were achieved complete response (CR rate; 59.5%, uT1: 15/20; 75%, uT2:7/17; 41.2%). Major complication was 4 perforations and 20 esophageal stenosis. A patient was died with perforation 2 months after PDT. With a median follow up period of 28 months after salvage PDT, 2 year OS rate was 53.1%. Conclusion: Salvage EMR and PDT could be promising curative intent treatment option for local failure after definitive CRT for EC with low rate of morbidity and mortality.
Volume 65, No. 5 : 2007 GASTROINTESTINAL ENDOSCOPY AB143