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Sa1625 Endoscopic and Oncologic Outcomes After Endoscopic Resection for Early Gastric Cancer: Comparison of Absolute and Extended Indications
Abstracts
Sa1624 Heterotopic Pancreas: Five-Year Experience At Single Academic Institution Hiral Shah1, Mandeep Singh2, Stephen J. Heller1, Jeffrey L. Tokar1, Oleh Haluszka1 1 Gastroenterology, Fox Chase Cancer Center, Philadelphia, PA; 2 Internal Medicine, Temple Univeristy, Philadelphia, PA Introduction: Heterotopic pancreas (HP) is the presence of pancreatic tissue outside of its normal location and lacking anatomic or vascular connections with the pancreas. The incidence is 0.11%-0.21% at autopsy. Usually found in the upper gastrointestinal tract, ⬎ 90% of the cases involve the stomach, duodenum or jejunum. HP is typically an asymptomatic and incidental finding with the classic appearance of a submucosal gastric antral lesion with central umbilication. However, in rare cases, HP may cause bleeding, obstruction or undergo malignant transformation. Methods: A retrospective review of our electronic medical record was performed. The pathology and endoscopy reports were searched for cases of histologically confirmed or endosonographically suspected HP diagnosed between Jan 2005-Sept 2010. Patient demographics, location of HPs, and surgical or endoscopic interventions were recorded. Results: A total of 513 patients meeting our search criteria were identified. Of these, a diagnosis of HP was made in 30 patients (17 with histologic confirmation, 13 with the typical endosonographic appearance of a heterogeneous hypoechoic lesion in the 3rd echogenic wall layer). In the 17 patients with HP histology, diagnostic tissue was obtained by endoscopic mucosal resection (9/17), forceps biopsy (3/17), or surgery (5/17). Median age was 53 (19 female). The majority of HPs (25/30) were found in the gastric antrum. Four patients with HP were symptomatic and required surgery: one with recurrent abdominal pain and elevated serum lipase was found to have a 7 cm solid and cystic antral lesion on EUS (cystic dystrophy of heterotopic pancreas on histology), one with a submucosal mass in the 4th portion of the duodenum who presented with nausea and vomiting, an actively bleeding ileal HP identified by double balloon enteroscopy, and a patient with a mesenteric mass and recurrent abdominal pain (HP with inflammation and necrosis on histology). Another case of HP with features of intraductal papillary mucinous neoplasm (IPMN) was found on the serosal surface of the duodenum in a post-operative specimen after Whipple resection for pancreatic adenocarcinoma. Discussion: To our knowledge, this is the largest reported series of HP, the first report of a bleeding HP of the ileum discovered by double balloon enteroscopy (DBE), and the first description of an HP with features of IPMN arising from the serosa of the duodenum. Our series confirms that most HPs appear as described above, but in atypical cases the diagnosis may be made by EMR. HPs can be located at sites other than the stomach (as in our patients with duodenal, ileal, and mesenteric masses), and may produce symptoms and require surgical resection for diagnosis.
Sa1625 Endoscopic and Oncologic Outcomes After Endoscopic Resection for Early Gastric Cancer: Comparison of Absolute and Extended Indications Ji Yong Ahn, Hwoon-Yong Jung, Ji Young Choi, Mi-Young Kim, Jeong Hoon Lee, Kwi-Sook Choi, Do Hoon Kim, Kee Don Choi, Ho June Song, Gin Hyug Lee, Jin-Ho Kim Department of gastroenterology, Asan Medical Center, Seoul, Republic of Korea Introduction: Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are novel techniques that can remove early gastric cancer (EGC) en bloc. However, there is no consensus about the criteria for their use. We aimed to assesss the clinical outcomes of endoscopic treatment based on indication criteria and endoscopic method. Methods: EMR or ESD was performed on 1340 cases of EGC of 1187 patients from July 1994 to January 2009 in Asan Medical Center. Of the 1340 EGCs, 856 were placed in the absolute indication group for EMR or ESD (differentiated mucosal cancer; elevated lesions ⱕ20 mm in diameter and depressed lesions ⱕ10 mm without ulceration), and 484 were placed in the extended indication group (differentiated cancer; mucosal cancer without ulceration, regardless of tumor size, mucosal cancer with ulceration ⱕ30 mm and located ⬍500 m from the muscularis mucosae; and submucosal invasive cancer ⱕ20 mm in size). Each group was sub-divided according to whether EMR or ESD had been performed. Results: Although the complete resection rate was significantly higher (96.0% vs 86.8%, p⬍0.001) and the risks of complication and operation were lower (6.8% vs 10.0%, p⫽0.049 and 2.7% vs 11.8%, p⬍0.001) in the absolute indication group, but there was no betweengroup difference in local recurrence rate (1.3% vs 0.8%, p⫽0.498). In the extended indication group, ESD resulted in a significantly higher complete resection rate and a significantly lower operation rate than EMR. Of ESD group, even though the risks of complication and operation were higher in the extended indication, but local recurrence rate was similar in the absolute and extended indication groups. Conclusion: Endoscopic treatment may be useful with acceptable clinical outcomes in extended criteria for EGC. Especially, ESD showed superior outcomes compared with EMR in the extended indication group.
www.giejournal.org
Sa1626 Is It Necessary to Perform Endoscopic Resection for Gastric Adenomas? An Analysis on Gastric Neoplasms Whose Biopsy Finding Was Adenoma Yosuke Tsuji1, Ken Ohata1, Masau Sekiguchi1, Takafumi Ito1, Hideyuki Chiba1, Toshiaki Gunji2, Nobuyuki Matsuhashi1 1 Gastroenterology, NTT Medical Center, Tokyo, Shinagawa-ku, Japan; 2 Center for Preventive Medicine, NTT Medical Center, Tokyo, Shinagawa-ku, Japan Background: Endoscopic resection(ER) is now a standard treatment for early gastric cancers and adenomas. All gastric cancers need treatment including ER, but there is no consensus on the indication of resection for gastric adenomas. Small adenomas might be followed up closely without therapy, while we sometimes encounter cases with early gastric cancers whose pre-ER biopsy finding was adenoma. Aim: We aimed to identify predictive factors for gastric carcinoma in lesions with biopsy finding of adenoma. Methods: We evaluated 162 consecutive cases of gastric neoplasms that were resected endoscopically with a diagnosis of gastric adenoma in a pre-procedural biopsy between July 2007 and July 2010. We retrospectively reviewed endoscopic findings of those lesions; size, location, ulceration, depressed area, color. We compared these factors in addition to the patients’ age and sex between two groups; group A, those diagnosed as adenoma (80 cases) and group B, those diagnosed as cancer (82 cases) in post-ER histological examination. In addition, we also reviewed magnified endoscopic findings combined with narrow band imaging (ME-NBI). 111 of the 162 cases were also examined with ME-NBI. We also evaluated predictive factors for carcinoma as to these 111 cases (group A, 61 cases vs. group B, 50 cases). Results: In the 162 cases, en block resection rate was 100%. The mean age of group A and group B patients were 67.4⫾10.1 and 69.8⫾10.3 y, respectively (p⫽0.15). 57 patients were men in group A and 66 were men in group B (p⫽0.17). In all cases in group B, histological finding was intestinal type of adenocarcinoma. Among them, most cancers were confined to the mucosal layer, but in three cases, the cancer had already invaded into the submucosal layer. Multivariate logistic regression analysis confirmed that the following were independent predictive factors for carcinoma: size (OR, 1.09; 95% CI: 1.03-1.15, P ⫽ 0.003), red color (OR, 6.93; 95% CI: 2.83-16.96, P ⬍ 0.001). We analyzed the 111 cases with ME-NBI examination in the same way. Size, color (which were significant predictors in the previous analysis) and ME-NBI were included in multiple logistic regression model. The result was that only irregular microvascular pattern (IMVP) in ME-NBI (OR, 13.02; 95% CI: 3.8344.24, P ⬍ 0.001) was an independent predictor. Lesion size and red color were not predictive of cancer in this analysis. Conclusions: This study revealed that a large gastric neoplasm with red color was suggestive of cancer. If these factors are recognized in lesions with a diagnosis of gastric adenoma on biopsy, ER may well be considered. However, our study also suggested that IMVP in ME-NBI was a much stronger predictor than size and red color.
Sa1627 Usefulness and Problems of Endoscopic Ultrasonography in Prediction of the Depth of Tumor Invasion in Early Gastric Cancer Takao Tsuzuki1, Hiroyuki Okada1, Yoshiro Kawahara1, Junichiro Nasu1, Ryuta Takenaka2, Masahumi Inoue1, Seiji Kawano1, Masahide Kita1, Keisuke Hori1, Kazuhide Yamamoto1 1 Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; 2Tsuyama Central Hospital, Tsuyama, Japan Aims: The objectives of this study were to evaluate the accuracy of endoscopic ultrasonography (EUS) in local and regional staging of early gastric cancer, to analyze the factors influencing the accuracy of EUS, and to reveal the usefulness and problems of EUS in pre-treatment staging of gastric cancer. Methods: Between September 2003 and October 2009, 105 lesions in 104 patients (75 men and 29 women) with gastric cancer diagnosed by conventional endoscopic examination and confirmed with biopsy specimen, underwent EUS examination to determine the depth of tumor invasion prior to endoscopic resection or surgery at our institution. Of these 105 lesions investigated in the present study, 78 underwent ESD and 27 underwent surgery. Results: The median age of the patients was 70 years (range: 52-91 years), and the male: female ratio was 2.59:1 (75:29). Thirty lesions (29%) were located in the upper third of the stomach, 36 (34%) in the middle third, and 39 (37%) in the lower third. The median tumor diameter was 20 mm (range: 5-60 mm).The overall diagnostic accuracy of EUS for the depth of cancer invasion was 86%. There were 8 lesions (8%) with type 0-I tumor, 33 (31%) with type 0-IIa or IIa⫹IIc (mainly superficial elevated type), and 64 (61%) with type 0-IIc or 0-IIc⫹IIa (mainly superficial depressed type). The histological examination showed that 96 lesions (91.4%) were differentiated adenocarcinoma and the others were undifferentiated adenocarcinoma The overall accuracy, sensitivity, and specificity were 86%, 60%, and 96%,
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB227
Sa1624 Heterotopic Pancreas: Five-Year Experience At Single Academic Institution Hiral Shah1, Mandeep Singh2, Stephen J. Heller1, Jeffrey L. Tokar1, Oleh Haluszka1 1 Gastroenterology, Fox Chase Cancer Center, Philadelphia, PA; 2 Internal Medicine, Temple Univeristy, Philadelphia, PA Introduction: Heterotopic pancreas (HP) is the presence of pancreatic tissue outside of its normal location and lacking anatomic or vascular connections with the pancreas. The incidence is 0.11%-0.21% at autopsy. Usually found in the upper gastrointestinal tract, ⬎ 90% of the cases involve the stomach, duodenum or jejunum. HP is typically an asymptomatic and incidental finding with the classic appearance of a submucosal gastric antral lesion with central umbilication. However, in rare cases, HP may cause bleeding, obstruction or undergo malignant transformation. Methods: A retrospective review of our electronic medical record was performed. The pathology and endoscopy reports were searched for cases of histologically confirmed or endosonographically suspected HP diagnosed between Jan 2005-Sept 2010. Patient demographics, location of HPs, and surgical or endoscopic interventions were recorded. Results: A total of 513 patients meeting our search criteria were identified. Of these, a diagnosis of HP was made in 30 patients (17 with histologic confirmation, 13 with the typical endosonographic appearance of a heterogeneous hypoechoic lesion in the 3rd echogenic wall layer). In the 17 patients with HP histology, diagnostic tissue was obtained by endoscopic mucosal resection (9/17), forceps biopsy (3/17), or surgery (5/17). Median age was 53 (19 female). The majority of HPs (25/30) were found in the gastric antrum. Four patients with HP were symptomatic and required surgery: one with recurrent abdominal pain and elevated serum lipase was found to have a 7 cm solid and cystic antral lesion on EUS (cystic dystrophy of heterotopic pancreas on histology), one with a submucosal mass in the 4th portion of the duodenum who presented with nausea and vomiting, an actively bleeding ileal HP identified by double balloon enteroscopy, and a patient with a mesenteric mass and recurrent abdominal pain (HP with inflammation and necrosis on histology). Another case of HP with features of intraductal papillary mucinous neoplasm (IPMN) was found on the serosal surface of the duodenum in a post-operative specimen after Whipple resection for pancreatic adenocarcinoma. Discussion: To our knowledge, this is the largest reported series of HP, the first report of a bleeding HP of the ileum discovered by double balloon enteroscopy (DBE), and the first description of an HP with features of IPMN arising from the serosa of the duodenum. Our series confirms that most HPs appear as described above, but in atypical cases the diagnosis may be made by EMR. HPs can be located at sites other than the stomach (as in our patients with duodenal, ileal, and mesenteric masses), and may produce symptoms and require surgical resection for diagnosis.
Sa1625 Endoscopic and Oncologic Outcomes After Endoscopic Resection for Early Gastric Cancer: Comparison of Absolute and Extended Indications Ji Yong Ahn, Hwoon-Yong Jung, Ji Young Choi, Mi-Young Kim, Jeong Hoon Lee, Kwi-Sook Choi, Do Hoon Kim, Kee Don Choi, Ho June Song, Gin Hyug Lee, Jin-Ho Kim Department of gastroenterology, Asan Medical Center, Seoul, Republic of Korea Introduction: Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are novel techniques that can remove early gastric cancer (EGC) en bloc. However, there is no consensus about the criteria for their use. We aimed to assesss the clinical outcomes of endoscopic treatment based on indication criteria and endoscopic method. Methods: EMR or ESD was performed on 1340 cases of EGC of 1187 patients from July 1994 to January 2009 in Asan Medical Center. Of the 1340 EGCs, 856 were placed in the absolute indication group for EMR or ESD (differentiated mucosal cancer; elevated lesions ⱕ20 mm in diameter and depressed lesions ⱕ10 mm without ulceration), and 484 were placed in the extended indication group (differentiated cancer; mucosal cancer without ulceration, regardless of tumor size, mucosal cancer with ulceration ⱕ30 mm and located ⬍500 m from the muscularis mucosae; and submucosal invasive cancer ⱕ20 mm in size). Each group was sub-divided according to whether EMR or ESD had been performed. Results: Although the complete resection rate was significantly higher (96.0% vs 86.8%, p⬍0.001) and the risks of complication and operation were lower (6.8% vs 10.0%, p⫽0.049 and 2.7% vs 11.8%, p⬍0.001) in the absolute indication group, but there was no betweengroup difference in local recurrence rate (1.3% vs 0.8%, p⫽0.498). In the extended indication group, ESD resulted in a significantly higher complete resection rate and a significantly lower operation rate than EMR. Of ESD group, even though the risks of complication and operation were higher in the extended indication, but local recurrence rate was similar in the absolute and extended indication groups. Conclusion: Endoscopic treatment may be useful with acceptable clinical outcomes in extended criteria for EGC. Especially, ESD showed superior outcomes compared with EMR in the extended indication group.
www.giejournal.org
Sa1626 Is It Necessary to Perform Endoscopic Resection for Gastric Adenomas? An Analysis on Gastric Neoplasms Whose Biopsy Finding Was Adenoma Yosuke Tsuji1, Ken Ohata1, Masau Sekiguchi1, Takafumi Ito1, Hideyuki Chiba1, Toshiaki Gunji2, Nobuyuki Matsuhashi1 1 Gastroenterology, NTT Medical Center, Tokyo, Shinagawa-ku, Japan; 2 Center for Preventive Medicine, NTT Medical Center, Tokyo, Shinagawa-ku, Japan Background: Endoscopic resection(ER) is now a standard treatment for early gastric cancers and adenomas. All gastric cancers need treatment including ER, but there is no consensus on the indication of resection for gastric adenomas. Small adenomas might be followed up closely without therapy, while we sometimes encounter cases with early gastric cancers whose pre-ER biopsy finding was adenoma. Aim: We aimed to identify predictive factors for gastric carcinoma in lesions with biopsy finding of adenoma. Methods: We evaluated 162 consecutive cases of gastric neoplasms that were resected endoscopically with a diagnosis of gastric adenoma in a pre-procedural biopsy between July 2007 and July 2010. We retrospectively reviewed endoscopic findings of those lesions; size, location, ulceration, depressed area, color. We compared these factors in addition to the patients’ age and sex between two groups; group A, those diagnosed as adenoma (80 cases) and group B, those diagnosed as cancer (82 cases) in post-ER histological examination. In addition, we also reviewed magnified endoscopic findings combined with narrow band imaging (ME-NBI). 111 of the 162 cases were also examined with ME-NBI. We also evaluated predictive factors for carcinoma as to these 111 cases (group A, 61 cases vs. group B, 50 cases). Results: In the 162 cases, en block resection rate was 100%. The mean age of group A and group B patients were 67.4⫾10.1 and 69.8⫾10.3 y, respectively (p⫽0.15). 57 patients were men in group A and 66 were men in group B (p⫽0.17). In all cases in group B, histological finding was intestinal type of adenocarcinoma. Among them, most cancers were confined to the mucosal layer, but in three cases, the cancer had already invaded into the submucosal layer. Multivariate logistic regression analysis confirmed that the following were independent predictive factors for carcinoma: size (OR, 1.09; 95% CI: 1.03-1.15, P ⫽ 0.003), red color (OR, 6.93; 95% CI: 2.83-16.96, P ⬍ 0.001). We analyzed the 111 cases with ME-NBI examination in the same way. Size, color (which were significant predictors in the previous analysis) and ME-NBI were included in multiple logistic regression model. The result was that only irregular microvascular pattern (IMVP) in ME-NBI (OR, 13.02; 95% CI: 3.8344.24, P ⬍ 0.001) was an independent predictor. Lesion size and red color were not predictive of cancer in this analysis. Conclusions: This study revealed that a large gastric neoplasm with red color was suggestive of cancer. If these factors are recognized in lesions with a diagnosis of gastric adenoma on biopsy, ER may well be considered. However, our study also suggested that IMVP in ME-NBI was a much stronger predictor than size and red color.
Sa1627 Usefulness and Problems of Endoscopic Ultrasonography in Prediction of the Depth of Tumor Invasion in Early Gastric Cancer Takao Tsuzuki1, Hiroyuki Okada1, Yoshiro Kawahara1, Junichiro Nasu1, Ryuta Takenaka2, Masahumi Inoue1, Seiji Kawano1, Masahide Kita1, Keisuke Hori1, Kazuhide Yamamoto1 1 Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; 2Tsuyama Central Hospital, Tsuyama, Japan Aims: The objectives of this study were to evaluate the accuracy of endoscopic ultrasonography (EUS) in local and regional staging of early gastric cancer, to analyze the factors influencing the accuracy of EUS, and to reveal the usefulness and problems of EUS in pre-treatment staging of gastric cancer. Methods: Between September 2003 and October 2009, 105 lesions in 104 patients (75 men and 29 women) with gastric cancer diagnosed by conventional endoscopic examination and confirmed with biopsy specimen, underwent EUS examination to determine the depth of tumor invasion prior to endoscopic resection or surgery at our institution. Of these 105 lesions investigated in the present study, 78 underwent ESD and 27 underwent surgery. Results: The median age of the patients was 70 years (range: 52-91 years), and the male: female ratio was 2.59:1 (75:29). Thirty lesions (29%) were located in the upper third of the stomach, 36 (34%) in the middle third, and 39 (37%) in the lower third. The median tumor diameter was 20 mm (range: 5-60 mm).The overall diagnostic accuracy of EUS for the depth of cancer invasion was 86%. There were 8 lesions (8%) with type 0-I tumor, 33 (31%) with type 0-IIa or IIa⫹IIc (mainly superficial elevated type), and 64 (61%) with type 0-IIc or 0-IIc⫹IIa (mainly superficial depressed type). The histological examination showed that 96 lesions (91.4%) were differentiated adenocarcinoma and the others were undifferentiated adenocarcinoma The overall accuracy, sensitivity, and specificity were 86%, 60%, and 96%,
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB227