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Mo1034 Analysis of Endoscopic Resection for Superficial Non-Ampullary Duodenal Tumor
Abstracts
Mo1033 Natural History of Superficial Head and Neck Squamous Cell Carcinoma Under Follow-Up Endoscopic Observation With Narrow Band Imaging Hiroshi Nakamura*3, Tomonori Yano3, Satoshi Fujii1, Tomohiro Kadota3, Toshifumi Tomioka2, Takeshi Shinozaki2, Ryuichi Hayashi2, Kazuhiro Kaneko3 1 Pathology Division, Research Center for Innovative Oncology, National Cancer Center Hospital East, Kashiwa, Japan; 2Head and Neck Surgery, National Cancer Center Hospital East, Kashiwa, Japan; 3Dept. of Gastroenterology, Endoscopy Division, National Cancer Center Hospital East, Kashiwa, Japan Background and Study Aim: The incidence rate of superficial head and neck squamous cell carcinoma (HNSCC) has been increasing through surveillance endoscopy using narrow band imaging (NBI), of which a procedure mainly used for highrisk patients with esophageal squamous cell carcinoma (ESCC). While almost all of superficial HNSCCs are treatable with endoscopic resection (ER), it can be occasionally observed without any intervention because of patients’ intolerable physical condition or concomitant further advanced ESCC and HNSCC at another site. However, there are few reports on the natural history of superficial HNSCC. The aim of this retrospective study is to investigate the natural history of superficial HNSCC. Patients and Methods: From January 2007 to December 2012, consecutive histologically-confirmed superficial HNSCCs at the oropharynx, hypopharynx, or larynx were detected by oral endoscopic examination using NBI in high-risk patients who had prior or present HNSCC and ESCC. Of those, untreated and observed lesions fulfilled the eligibility criteria were analyzed in this retrospective study. The major eligibility criteria: 1) the lesion was clinically the primary superficial mucosal cancer, 2) the size was 20mm or less in diameter, 3) follow-up period after detection was longer than 1 year, 4) no systemic chemotherapy for any cancer, and 5) absence of prior radiotherapy that involved the head and neck region. The study protocol was approved by the institutional review board of our institution. Results: Of the 535 consecutive lesions in 319 patients, 15 lesions (2.8%) in 12 patients were enrolled and analyzed. All patients were men, and the median age was 69 years, ranging from 59 to 86 years. All lesions were endoscopically diagnosed as squamous cell carcinoma in situ. The median tumor size was 10mm in diameter (range, 5-20 mm). The median endoscopic follow-up period was 29 months (range, 12–71); 12 lesions progressed in size, and remaining 3 did not progress and instead maintained their size during the follow-up period. In the progression lesions, the median period from diagnosis to appearance of lesion enlargement was 11.5 months (range, 3-29). The size of 1 lesion doubled at the earliest 3 months after diagnosis. Endoscopic findings revealed submucosal invasion in 6 lesions during follow-up and the median time to appearance was 20 months (range, 14-58). In this study, 2 patients died; 1 patient died of synchronous ESCC and another died of unknown causes. No patients died from progression of superficial HNSCC. Conclusions: Most superficial HNSCC had a high potential to change progressively. Therefore, superficial HNSCC should be detected at an early stage and be treated less invasively such as with endoscopic resection or surgically partial resection.
Mo1034 Analysis of Endoscopic Resection for Superficial Non-Ampullary Duodenal Tumor Yasutoshi Ochiai*1, Teppei Akimoto1, Seiji Sagara1, Tadateru Maehata1, Ai Fujimoto1, Rieko Nakamura1, Toshihiro Nishizawa1, Osamu Goto1, Toshio Uraoka1,2, Naohisa Yahagi1 1 Keio University, School of Medicine, Tokyo, Japan; 2National Hospital Organization Tokyo Medical Center, Tokyo, Japan
bloc resection rate was 82% (61/74). Regarding complications, delayed bleeding and perforation occurred in 5 (7%) and 11 (15%), respectively. All delayed bleeding cases were conservatively treated by endoscopic hemostasis. Perforation required surgical treatment in 2 (3%). This study clarified that the cancer-bearing rate of duodenal tumors rises with an increase in the diameter. For small lesions, EMR with a simple procedure causing fewer complications may be sufficient, but reliable resection is needed for the treatment of large tumors. Although duodenal ESD is very difficult with a high risk, when it is performed by a skilled operator, it may be minimally invasive treatment for which marked efficacy while retaining safety can be expected.
Mo1035 Complex Colorectal Polyps: A Tertiary Centre Experience; Tailoring the EMR Technique to the Polyp Zacharias P. Tsiamoulos*, Timothy Elliott, Noriko Suzuki, Leonidas A. Bourikas, Paul Bassett, Brian P. Saunders Wolfson Unit for Endoscopy, St Mark, London, United Kingdom Introduction: Features that characterise polyp complexity should be clearly defined and recognised to avert suboptimal piecemeal endoscopic mucosal resection (pEMR) strategies and need for salvage surgery. Methods: A prospective database of all colorectal polyps excised at our tertiary referral centre between Jan 2010 and August 2012 was collected. Standard p-EMR with a semi-stiiff standard snares (10mm and 15mm) was performed but for polyps where this strategy was considered inadequate, p-EMR using a 20mm spiral snare (sp-EMR), or hybrid p-EMR (hp-EMR; p-EMR plus endoscopic mucosal ablation or endoscopic submucosal dissection) were performed. Multinomial logistic regression was performed and categorical variables summarised including polyp characteristics and p-EMR techniques applied. The primary outcomes were to define characteristic features of complex polyps and factors associated with the chosen resection technique. Results: Of 330 patients with 341 polyps (mean size 3.7cm), 81% (261/323, p<.001) were tertiary and 19% were local referrals. 94/261 (36%, p<.001) tertiary referrals mentioned one or more previous endoscopic resection attempts. Endoscopic polyp access was described as difficult in 174/341 (51%, pZ.001), incomplete polyp lift in 179/341 (52%, pZ.002) cases and polyp size 4cm (median size 5cm) in 123/341 (36%, p<.001) cases. Polyps 4cm were more frequently in a difficult position (4cm; 63% vs <4cm; 37%, p < .001). Polyps <4cm were more likely to be in the caecum or ascending colon (<4cm; 35% vs 4cm; 16%, p < .001). Endoscopically complete polypectomy was achieved in one session in 336/341 (98%, p<.001) polyps. Procedural and delayed bleeding were significantly higher in the 4cm group where 2 of the 3 micro-perforations also occurred (3/341, 0.9%, p<.001) that were all treated successfully with endoscopic clipping. The overall long-term recurrence at 24 months was 17% (28% for 4cm/pZ.02). Only eleven patients (4 benign recurrence/7 cancer at histology, 3%) in this cohort underwent surgery. Using multivariable analysis, factors associated with need for sp-EMR or hp-EMR were; i) tertiary referrals (sp-EMR, OR 3.41, p <.001), ii) incomplete polyp lift (hp-EMR, OR 8.3 > sp-EMR, OR 1.19 p<.001), iii) previous polypectomy attempt (hp-EMR, OR 2.77, pZ.02), iv) larger polyp size (for an increase of 1cm - hp-EMR (OR 1.37)/sp-EMR (OR 1.66,) p<.001, v) polyps in the rectosigmoid location (sp-EMR and hp-EMR, p<.001) and vi) Paris IIa+IIb polyps (sp-EMR, OR 5.01 and hp-EMR, OR 2.9, p-.007). Conclusion: Complex colorectal polyps referred to this tertiary centre were characterised by polyp size 4cm, caecal location, previous unsuccessful polypectomy, difficult endoscopic access, or incomplete polyp lift. Advanced techniques such as hybrid-pEMR and spiral p-EMR were required in 33% of tertiary referrals.
Duodenal ESD has not been standardized because of difficulty and a very high risk of complications. However, the surgical treatment loads a large burden and functional disorder may remain depending on the location. Thus, minimally invasive treatment is needed. In this study, the outcomes of 128 duodenal tumors treated at our hospital between July 2010 and June 2015 were investigated, and the safety and efficacy of EMR and ESD were evaluated. The subjects were patients at a mean age of 62.3 years old (29-84), and the sex ratio (male/female) was 92/36. The location of the lesion was bulb in 18, SDA in 14, descending part in 83, LDA in 8, and horizontal part in 5, circumferentiality was <1/2 in 111 and >1/2 in 14, and the macroscopic type was elevated in 97 and depressed in 31. The treatment method employed was EMR in 46, ESD in 74, circumferential EMR in 5, EMRL in 1, and resection by forceps in 3. The mean tumor diameter was 19.1 mm (2-75), and the lesion was adenoma in 85, cancer in 37, carcinoid in 4, and others in 2. The cancer-bearing rates exceed with the tumor size. By the procedure, in 44 lesions treated with EMR (excluding large Brunner gland adenoma in the bulb treated with planned piecemeal resection), the mean tumor diameter was 9.3 mm (3-21), and the lesion was adenoma in 38, adenocarcinoma in 3, carcinoid in 1, and another in 1. The en bloc resection rate was 93% (41/44), and the complete en bloc resection rate was 73% (32/44). No complication occurred (delayed bleeding: 0, perforation: 0). In the 74 lesions treated with ESD, the mean tumor diameter was 25.5 mm (2-75) and mean procedure time was 86.1 minutes (10-360). The lesion was adenoma in 39, adenocarcinoma in 33, and carcinoid in 1. The en bloc resection rate was 97% (72/74), and the complete en
AB436 GASTROINTESTINAL ENDOSCOPY Volume 83, No. 5S : 2016
www.giejournal.org
Mo1033 Natural History of Superficial Head and Neck Squamous Cell Carcinoma Under Follow-Up Endoscopic Observation With Narrow Band Imaging Hiroshi Nakamura*3, Tomonori Yano3, Satoshi Fujii1, Tomohiro Kadota3, Toshifumi Tomioka2, Takeshi Shinozaki2, Ryuichi Hayashi2, Kazuhiro Kaneko3 1 Pathology Division, Research Center for Innovative Oncology, National Cancer Center Hospital East, Kashiwa, Japan; 2Head and Neck Surgery, National Cancer Center Hospital East, Kashiwa, Japan; 3Dept. of Gastroenterology, Endoscopy Division, National Cancer Center Hospital East, Kashiwa, Japan Background and Study Aim: The incidence rate of superficial head and neck squamous cell carcinoma (HNSCC) has been increasing through surveillance endoscopy using narrow band imaging (NBI), of which a procedure mainly used for highrisk patients with esophageal squamous cell carcinoma (ESCC). While almost all of superficial HNSCCs are treatable with endoscopic resection (ER), it can be occasionally observed without any intervention because of patients’ intolerable physical condition or concomitant further advanced ESCC and HNSCC at another site. However, there are few reports on the natural history of superficial HNSCC. The aim of this retrospective study is to investigate the natural history of superficial HNSCC. Patients and Methods: From January 2007 to December 2012, consecutive histologically-confirmed superficial HNSCCs at the oropharynx, hypopharynx, or larynx were detected by oral endoscopic examination using NBI in high-risk patients who had prior or present HNSCC and ESCC. Of those, untreated and observed lesions fulfilled the eligibility criteria were analyzed in this retrospective study. The major eligibility criteria: 1) the lesion was clinically the primary superficial mucosal cancer, 2) the size was 20mm or less in diameter, 3) follow-up period after detection was longer than 1 year, 4) no systemic chemotherapy for any cancer, and 5) absence of prior radiotherapy that involved the head and neck region. The study protocol was approved by the institutional review board of our institution. Results: Of the 535 consecutive lesions in 319 patients, 15 lesions (2.8%) in 12 patients were enrolled and analyzed. All patients were men, and the median age was 69 years, ranging from 59 to 86 years. All lesions were endoscopically diagnosed as squamous cell carcinoma in situ. The median tumor size was 10mm in diameter (range, 5-20 mm). The median endoscopic follow-up period was 29 months (range, 12–71); 12 lesions progressed in size, and remaining 3 did not progress and instead maintained their size during the follow-up period. In the progression lesions, the median period from diagnosis to appearance of lesion enlargement was 11.5 months (range, 3-29). The size of 1 lesion doubled at the earliest 3 months after diagnosis. Endoscopic findings revealed submucosal invasion in 6 lesions during follow-up and the median time to appearance was 20 months (range, 14-58). In this study, 2 patients died; 1 patient died of synchronous ESCC and another died of unknown causes. No patients died from progression of superficial HNSCC. Conclusions: Most superficial HNSCC had a high potential to change progressively. Therefore, superficial HNSCC should be detected at an early stage and be treated less invasively such as with endoscopic resection or surgically partial resection.
Mo1034 Analysis of Endoscopic Resection for Superficial Non-Ampullary Duodenal Tumor Yasutoshi Ochiai*1, Teppei Akimoto1, Seiji Sagara1, Tadateru Maehata1, Ai Fujimoto1, Rieko Nakamura1, Toshihiro Nishizawa1, Osamu Goto1, Toshio Uraoka1,2, Naohisa Yahagi1 1 Keio University, School of Medicine, Tokyo, Japan; 2National Hospital Organization Tokyo Medical Center, Tokyo, Japan
bloc resection rate was 82% (61/74). Regarding complications, delayed bleeding and perforation occurred in 5 (7%) and 11 (15%), respectively. All delayed bleeding cases were conservatively treated by endoscopic hemostasis. Perforation required surgical treatment in 2 (3%). This study clarified that the cancer-bearing rate of duodenal tumors rises with an increase in the diameter. For small lesions, EMR with a simple procedure causing fewer complications may be sufficient, but reliable resection is needed for the treatment of large tumors. Although duodenal ESD is very difficult with a high risk, when it is performed by a skilled operator, it may be minimally invasive treatment for which marked efficacy while retaining safety can be expected.
Mo1035 Complex Colorectal Polyps: A Tertiary Centre Experience; Tailoring the EMR Technique to the Polyp Zacharias P. Tsiamoulos*, Timothy Elliott, Noriko Suzuki, Leonidas A. Bourikas, Paul Bassett, Brian P. Saunders Wolfson Unit for Endoscopy, St Mark, London, United Kingdom Introduction: Features that characterise polyp complexity should be clearly defined and recognised to avert suboptimal piecemeal endoscopic mucosal resection (pEMR) strategies and need for salvage surgery. Methods: A prospective database of all colorectal polyps excised at our tertiary referral centre between Jan 2010 and August 2012 was collected. Standard p-EMR with a semi-stiiff standard snares (10mm and 15mm) was performed but for polyps where this strategy was considered inadequate, p-EMR using a 20mm spiral snare (sp-EMR), or hybrid p-EMR (hp-EMR; p-EMR plus endoscopic mucosal ablation or endoscopic submucosal dissection) were performed. Multinomial logistic regression was performed and categorical variables summarised including polyp characteristics and p-EMR techniques applied. The primary outcomes were to define characteristic features of complex polyps and factors associated with the chosen resection technique. Results: Of 330 patients with 341 polyps (mean size 3.7cm), 81% (261/323, p<.001) were tertiary and 19% were local referrals. 94/261 (36%, p<.001) tertiary referrals mentioned one or more previous endoscopic resection attempts. Endoscopic polyp access was described as difficult in 174/341 (51%, pZ.001), incomplete polyp lift in 179/341 (52%, pZ.002) cases and polyp size 4cm (median size 5cm) in 123/341 (36%, p<.001) cases. Polyps 4cm were more frequently in a difficult position (4cm; 63% vs <4cm; 37%, p < .001). Polyps <4cm were more likely to be in the caecum or ascending colon (<4cm; 35% vs 4cm; 16%, p < .001). Endoscopically complete polypectomy was achieved in one session in 336/341 (98%, p<.001) polyps. Procedural and delayed bleeding were significantly higher in the 4cm group where 2 of the 3 micro-perforations also occurred (3/341, 0.9%, p<.001) that were all treated successfully with endoscopic clipping. The overall long-term recurrence at 24 months was 17% (28% for 4cm/pZ.02). Only eleven patients (4 benign recurrence/7 cancer at histology, 3%) in this cohort underwent surgery. Using multivariable analysis, factors associated with need for sp-EMR or hp-EMR were; i) tertiary referrals (sp-EMR, OR 3.41, p <.001), ii) incomplete polyp lift (hp-EMR, OR 8.3 > sp-EMR, OR 1.19 p<.001), iii) previous polypectomy attempt (hp-EMR, OR 2.77, pZ.02), iv) larger polyp size (for an increase of 1cm - hp-EMR (OR 1.37)/sp-EMR (OR 1.66,) p<.001, v) polyps in the rectosigmoid location (sp-EMR and hp-EMR, p<.001) and vi) Paris IIa+IIb polyps (sp-EMR, OR 5.01 and hp-EMR, OR 2.9, p-.007). Conclusion: Complex colorectal polyps referred to this tertiary centre were characterised by polyp size 4cm, caecal location, previous unsuccessful polypectomy, difficult endoscopic access, or incomplete polyp lift. Advanced techniques such as hybrid-pEMR and spiral p-EMR were required in 33% of tertiary referrals.
Duodenal ESD has not been standardized because of difficulty and a very high risk of complications. However, the surgical treatment loads a large burden and functional disorder may remain depending on the location. Thus, minimally invasive treatment is needed. In this study, the outcomes of 128 duodenal tumors treated at our hospital between July 2010 and June 2015 were investigated, and the safety and efficacy of EMR and ESD were evaluated. The subjects were patients at a mean age of 62.3 years old (29-84), and the sex ratio (male/female) was 92/36. The location of the lesion was bulb in 18, SDA in 14, descending part in 83, LDA in 8, and horizontal part in 5, circumferentiality was <1/2 in 111 and >1/2 in 14, and the macroscopic type was elevated in 97 and depressed in 31. The treatment method employed was EMR in 46, ESD in 74, circumferential EMR in 5, EMRL in 1, and resection by forceps in 3. The mean tumor diameter was 19.1 mm (2-75), and the lesion was adenoma in 85, cancer in 37, carcinoid in 4, and others in 2. The cancer-bearing rates exceed with the tumor size. By the procedure, in 44 lesions treated with EMR (excluding large Brunner gland adenoma in the bulb treated with planned piecemeal resection), the mean tumor diameter was 9.3 mm (3-21), and the lesion was adenoma in 38, adenocarcinoma in 3, carcinoid in 1, and another in 1. The en bloc resection rate was 93% (41/44), and the complete en bloc resection rate was 73% (32/44). No complication occurred (delayed bleeding: 0, perforation: 0). In the 74 lesions treated with ESD, the mean tumor diameter was 25.5 mm (2-75) and mean procedure time was 86.1 minutes (10-360). The lesion was adenoma in 39, adenocarcinoma in 33, and carcinoid in 1. The en bloc resection rate was 97% (72/74), and the complete en
AB436 GASTROINTESTINAL ENDOSCOPY Volume 83, No. 5S : 2016
www.giejournal.org