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Tu1589 Outcome of Endoscopic Submucosal Dissection for Barrett's Esophageal High Grade Dysplasia and Cancer
Abstracts
adenocarcinoma (EA) which has increased in incidence over the last decade. Grades of dysplasia can help predict risk of EA. Pathologists cannot distinguish regenerative changes from true dysplasia in up to 20% of patients (Indeterminate for dysplasia -IND). The rate of progression and clinical significance of IND are uncertain. Endoscopic surveillance and treatment patterns are also not standardized. Objectives: To understand the practice patterns and clinical outcomes for patients with BE IND. Methods: We conducted a retrospective study of patients with BE with IND from 2000-2010 at one university referral center. Statistical analysis was performed with SPSS (17.0). Results: 322 patients with BE were identified. 48 patients with IND on index EGD were identified. 24 patients were excluded since they had other degrees of dysplasia prior to or at the time of index EGD. All patients were non-Hispanic white (75% males, median age 53). 14 patients had a documented diagnosis of GERD (58%). 17 patients were on a PPI (71%). 14 patients (58%) had a recommendation for follow up after the first EGD (median 46 weeks, 6-104 weeks). The median actual follow up EGD was 40 weeks (range 12-108). Findings on repeat EGD included IND (23%), no dysplasia (46%), and low grade dysplasia (LGD) (31%). Of the patients who continued to have surveillance EGD, almost 50% had no dysplasia on subsequent biopsies. Endoscopic surveillance intervals ranged from every 2 months to every 16 months. Only 1 patient had high grade dysplasia (HGD) with an incidence of 14.3 patients per 1000 person-year. 11 patients had histologic evidence of esophagitis on the index EGD (46%). Patients without dysplasia on the 2nd EGD were more likely to have had histologic evidence of esophagitis on the 1st EGD. None of the patients with LGD on the 2nd EGD had histologic evidence of esophagitis on the 1st EGD. All patients with persistent IND or documented progression of dysplasia had a hiatal hernia. Patients who progressed to LGD or continued to have IND were more likely to be on a PPI. Immunohistochemical staining for biomarkers was performed on the initial biopsy of 12 out of 14 patients who had a second EGD. p53, ␣-methylacylcoenzyme A racemase (AMACR), and beta-catenin were positive in 9 (75%), 7 (58%), and 6 (50%) patients. All 3 markers were positive in the patient who progressed to HGD. Re-examination of H&E slides by 2 pathologists confirmed indefinite of dysplasia in 12 out of 13 patients. Conclusions: Patients with IND may be at low risk of progression to HGD. Significant variation in endoscopic surveillance patterns for IND was found. Biomarkers may help predict progression of dysplasia. More research is needed to better understand this population and guide resource utilization in patients with BE.
Tu1588 Usefulness of Japan Esophageal Society Classification of Magnified Endoscopy for the Diagnosis of Superficial Esophageal Squamous Cell Carcinoma Tsuneo Oyama*1, Ryu Ishihara2, Manabu Takeuchi3, Dai Hirasawa4, Miwako Arima5, Haruhiro Inoue6, Kenichi Goda7, Akihisa Tomori1, Kumiko Momma8 1 Gastroenterology, Saku Central Hospital, Saku, Japan; 2Osaka medical center, Osaka, Japan; 3Niigata University, NIigata, Japan; 4 Sendai open, Sendai, Japan; 5Saitama cancer center, Saitama, Japan; 6 Yokohama northern, Yokohama, Japan; 7Jikei University, Tokyo, Japan; 8Komagome, Tokyo, Japan The usefulness of magnified endoscopy for the diagnosis of invasion depth of esophageal squamous cell carcinoma (SCC) has been reported. There are two different classifications established by Inoue and Arima. However, both classifications are a little bit complicated for beginners. Therefore, Japan esophageal society decided to put the two classifications together and make a new classification. Aim: The aim of this study is to clarify the usefulness of this new classification for the diagnosis of invasion depth of esophageal SCC. Design: A prospective multicenter study. Patients and Methods: New classification; this new classification is composed of two major criteria. One is the shape and width of vessels and the other is the size of avascular area (AVA). The vessels observed by magnified endoscopy were classified into two groups, Type A and B. Type A is the vessels with mild or no atypia of intra papillary capillary loops (IPCL). And Type B is that with atypia including dilatation, meandering, caliber change and uneven form in each vessel. A lesion with Type A and B vessels strongly suggests intraepithelial neoplasia (IN) and SCC, respectively. Type B was subclassified into 3 groups, B1, B2 and B3. Type B1, B2 and B3 were composed by loop like, non-loop and large vessels 3 times or more than B2, respectively. And, the invasion depth of B1, B2 and B3 was diagnosed as T1aEP or LPM, T1aMM or T1bSM1 and T1bSM2, respectively. AVA was defined as an area without or poor in vessels. AVA was divided into three groups according to the size. AVA-small, AVA-middle and AVA-large were defined as 0.5mm or less, between 0.5 and 3mm and 3mm or larger. Each AVA suggested the invasion depth as T1aEP or LPM, T1aMM or T1bSM1 and T1bSM2, respectively. A prospective study on diagnosis of the invasion depth according to the new classification had been carried out by Saku central, Osaka, Sendai, Niigata University and Saitama cancer center hospital. 210 consecutive patients who had superficial esophageal SCC and treated by ESD were enrolled to this study. All of the cases were diagnosed using this new classification, and the endoscopic findings and pictures were recorded. The invasion depth was diagnosed as T1aEP or LPM, T1aMM or
T1bSM1 and T1bSM2. T1bSM1 was defined as submucosal invaded cancer 200 micrometer or less. Result159 of 172 lesions diagnosed as T1aEP-LPM were correct (92%). The remaining 7 and 6 lesions were T1aMM-SM1 and T1bSM2. 21 of 28 lesions diagnosed as T1aMM-T1bSM1 were correct (75%). And remaining 4 and 3 lesions was T1aEP-LPM and T1bSM2, respectively. 10 of 10 lesions diagnosed as T1bSM2 was correct (100%). The average of accuracy was 90% (190/210). Conclusion: The new classification of magnified endoscopy is simple and useful for diagnosis of invasion depth of esophageal SCC.
Tu1589 Outcome of Endoscopic Submucosal Dissection for Barrett’s Esophageal High Grade Dysplasia and Cancer Tsuneo Oyama*, Takaaki Kishino Gastroenterology, Saku Central Hospital, Saku, Japan Endoscopic Submucosal Dissection (ESD) is widely accepted as the first choice treatment for the superficial gastric cancer and esophageal Squamous cell carcinoma in Japan. However, the outcome of ESD for esophageal adenocarcinoma is unknown. Aim: The aim of this study is to clarify the feasibility and outcome of ESD for esophageal adenocarcinoma. Design: A single center, retrospective study. Patients and Method: thirty six lesions of BEA (Barrett’s esophageal adenocarcinoma) from thirty patients were treated by ESD from 2000 to 2010. The lateral extension of all cases was diagnosed by magnified endoscopy. Both of surface and vascular pattern were observed, and the lateral extension was diagnosed by the difference of such patterns. Biopsies were taken when the diagnosis of lateral extension was difficult. ESD procedure; marks were placed 3mm outside of lateral extension using magnified endoscopy. Glycerol was injected into submucosal layer to make space in submucosal layer. Mucosal incision and submucosal dissection was performed by Hook knife. A transparent hood was used in all cases to keep good visual field during ESD. Generator was ICC 200 or VIO 300D. Patients characteristics were ad follows; Male 26, Female 4, Age: 66 (32-88), Result: 1. En bloc resection rate was 100%. R0 resection rate was 95% (34/36). The reason why R0 wasn’t achieved was misdiagnosis of lateral extension under non-neoplastic squamous cell epithelium. Two cases of R1 resection were treated by re-ESD. There wasn’t local recurrence in one case, however the other case had a local recurrence, 2mm in size. 2. Complications: Perforation rate was 0%. Delayed perforation rate was 3% (1/36). The only perforated case could be treated by antibiotics and fast without operation. 3. The macroscopic type of BEA was as follows; 0-I : 7 , 0-IIa :17 , 0-IIb : 4 , 0-IIc : 8, and 44% (16/36) BEA had IIb spreading. Only 4 cases of the 16 IIb spreading were diagnosed by conventional endoscopy, and 14 of 16 were diagnosed by magnified endoscopy. Therefore, magnified endoscopy was useful for the diagnosis of IIb spreading. 4. Resected size was 40(19-134) mm,Tumor size was 13 (1-94) mm. Invasion depth: Mucosal and submucosal adenocarcinoma was 29 and 7, respectively. 5. Synchronous cancer rate was 20%(6/30), Metachronous cancer rate was 3% (1/30), one case had synchronous and metachronous BEA. Surveillance EGD was performed one to twice a year, and the mean observation duration was 47 (2 - 129) months. Conclusion: There were no severe complications in ESD for BEA, and the R0 resection rate was 95% (34/36). Therefore, ESD is one of a good selection for the endoscopic treatment of Barrett’s high grade dysplasia and mucosal adenocarcinoma.
Tu1590 Usefulness of Oral Prednisolone in Treatment of Esophageal Stricture Following Endoscopic Submucosal Dissection for Superficial Esophageal Epithelial Neoplasms Naoyuki Yamaguchi* Department of Endoscopy and **Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan Objective: Endoscopic submucosal dissection (ESD) permits removal of esophageal epithelial neoplasms en bloc, but postprocedural stricture was commonly occurred following ESD for superficially extendsive tumors. Endoscopic balloon dilatation (EBD) has been a treatment choice for the stricture management, but certain cases are refractory requiring multiple EBD sessions. We sought to disclose the effectiveness of oral prednisolone in controlling the postprocedural esophageal stricture. Design: This was an observation study of a single centre cohort. Patients Consecutive patients who underwent complete circular or semicircular ESD for esophageal squamous cell carcinoma involving more than three quarter of the lumen and with nominal risks of nodal metastasis were enrolled in this study. The eligible patients were treated by either the preemptive EBD or oral prednisolone. Results: Preemptive EBD was applied in 26 patients, which was started on the third post-ESD day and was performed twice a week for 48 weeks until post ESD ulcer healed up. Twenty-five patients was safely given prednisolone orally; the initial dose was 30 mg daily on the third post-ESD day, tapered gradually, and then discontinued 616 weeks later. EBD was applied on demand whenever dysphagia was appeared. En bloc ESD with tumor-free margins was safely achieved in each case. In the preemptive EBD group, median EBD sessions required for dysphagia relief were 12.0 and
AB456 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012
www.giejournal.org
adenocarcinoma (EA) which has increased in incidence over the last decade. Grades of dysplasia can help predict risk of EA. Pathologists cannot distinguish regenerative changes from true dysplasia in up to 20% of patients (Indeterminate for dysplasia -IND). The rate of progression and clinical significance of IND are uncertain. Endoscopic surveillance and treatment patterns are also not standardized. Objectives: To understand the practice patterns and clinical outcomes for patients with BE IND. Methods: We conducted a retrospective study of patients with BE with IND from 2000-2010 at one university referral center. Statistical analysis was performed with SPSS (17.0). Results: 322 patients with BE were identified. 48 patients with IND on index EGD were identified. 24 patients were excluded since they had other degrees of dysplasia prior to or at the time of index EGD. All patients were non-Hispanic white (75% males, median age 53). 14 patients had a documented diagnosis of GERD (58%). 17 patients were on a PPI (71%). 14 patients (58%) had a recommendation for follow up after the first EGD (median 46 weeks, 6-104 weeks). The median actual follow up EGD was 40 weeks (range 12-108). Findings on repeat EGD included IND (23%), no dysplasia (46%), and low grade dysplasia (LGD) (31%). Of the patients who continued to have surveillance EGD, almost 50% had no dysplasia on subsequent biopsies. Endoscopic surveillance intervals ranged from every 2 months to every 16 months. Only 1 patient had high grade dysplasia (HGD) with an incidence of 14.3 patients per 1000 person-year. 11 patients had histologic evidence of esophagitis on the index EGD (46%). Patients without dysplasia on the 2nd EGD were more likely to have had histologic evidence of esophagitis on the 1st EGD. None of the patients with LGD on the 2nd EGD had histologic evidence of esophagitis on the 1st EGD. All patients with persistent IND or documented progression of dysplasia had a hiatal hernia. Patients who progressed to LGD or continued to have IND were more likely to be on a PPI. Immunohistochemical staining for biomarkers was performed on the initial biopsy of 12 out of 14 patients who had a second EGD. p53, ␣-methylacylcoenzyme A racemase (AMACR), and beta-catenin were positive in 9 (75%), 7 (58%), and 6 (50%) patients. All 3 markers were positive in the patient who progressed to HGD. Re-examination of H&E slides by 2 pathologists confirmed indefinite of dysplasia in 12 out of 13 patients. Conclusions: Patients with IND may be at low risk of progression to HGD. Significant variation in endoscopic surveillance patterns for IND was found. Biomarkers may help predict progression of dysplasia. More research is needed to better understand this population and guide resource utilization in patients with BE.
Tu1588 Usefulness of Japan Esophageal Society Classification of Magnified Endoscopy for the Diagnosis of Superficial Esophageal Squamous Cell Carcinoma Tsuneo Oyama*1, Ryu Ishihara2, Manabu Takeuchi3, Dai Hirasawa4, Miwako Arima5, Haruhiro Inoue6, Kenichi Goda7, Akihisa Tomori1, Kumiko Momma8 1 Gastroenterology, Saku Central Hospital, Saku, Japan; 2Osaka medical center, Osaka, Japan; 3Niigata University, NIigata, Japan; 4 Sendai open, Sendai, Japan; 5Saitama cancer center, Saitama, Japan; 6 Yokohama northern, Yokohama, Japan; 7Jikei University, Tokyo, Japan; 8Komagome, Tokyo, Japan The usefulness of magnified endoscopy for the diagnosis of invasion depth of esophageal squamous cell carcinoma (SCC) has been reported. There are two different classifications established by Inoue and Arima. However, both classifications are a little bit complicated for beginners. Therefore, Japan esophageal society decided to put the two classifications together and make a new classification. Aim: The aim of this study is to clarify the usefulness of this new classification for the diagnosis of invasion depth of esophageal SCC. Design: A prospective multicenter study. Patients and Methods: New classification; this new classification is composed of two major criteria. One is the shape and width of vessels and the other is the size of avascular area (AVA). The vessels observed by magnified endoscopy were classified into two groups, Type A and B. Type A is the vessels with mild or no atypia of intra papillary capillary loops (IPCL). And Type B is that with atypia including dilatation, meandering, caliber change and uneven form in each vessel. A lesion with Type A and B vessels strongly suggests intraepithelial neoplasia (IN) and SCC, respectively. Type B was subclassified into 3 groups, B1, B2 and B3. Type B1, B2 and B3 were composed by loop like, non-loop and large vessels 3 times or more than B2, respectively. And, the invasion depth of B1, B2 and B3 was diagnosed as T1aEP or LPM, T1aMM or T1bSM1 and T1bSM2, respectively. AVA was defined as an area without or poor in vessels. AVA was divided into three groups according to the size. AVA-small, AVA-middle and AVA-large were defined as 0.5mm or less, between 0.5 and 3mm and 3mm or larger. Each AVA suggested the invasion depth as T1aEP or LPM, T1aMM or T1bSM1 and T1bSM2, respectively. A prospective study on diagnosis of the invasion depth according to the new classification had been carried out by Saku central, Osaka, Sendai, Niigata University and Saitama cancer center hospital. 210 consecutive patients who had superficial esophageal SCC and treated by ESD were enrolled to this study. All of the cases were diagnosed using this new classification, and the endoscopic findings and pictures were recorded. The invasion depth was diagnosed as T1aEP or LPM, T1aMM or
T1bSM1 and T1bSM2. T1bSM1 was defined as submucosal invaded cancer 200 micrometer or less. Result159 of 172 lesions diagnosed as T1aEP-LPM were correct (92%). The remaining 7 and 6 lesions were T1aMM-SM1 and T1bSM2. 21 of 28 lesions diagnosed as T1aMM-T1bSM1 were correct (75%). And remaining 4 and 3 lesions was T1aEP-LPM and T1bSM2, respectively. 10 of 10 lesions diagnosed as T1bSM2 was correct (100%). The average of accuracy was 90% (190/210). Conclusion: The new classification of magnified endoscopy is simple and useful for diagnosis of invasion depth of esophageal SCC.
Tu1589 Outcome of Endoscopic Submucosal Dissection for Barrett’s Esophageal High Grade Dysplasia and Cancer Tsuneo Oyama*, Takaaki Kishino Gastroenterology, Saku Central Hospital, Saku, Japan Endoscopic Submucosal Dissection (ESD) is widely accepted as the first choice treatment for the superficial gastric cancer and esophageal Squamous cell carcinoma in Japan. However, the outcome of ESD for esophageal adenocarcinoma is unknown. Aim: The aim of this study is to clarify the feasibility and outcome of ESD for esophageal adenocarcinoma. Design: A single center, retrospective study. Patients and Method: thirty six lesions of BEA (Barrett’s esophageal adenocarcinoma) from thirty patients were treated by ESD from 2000 to 2010. The lateral extension of all cases was diagnosed by magnified endoscopy. Both of surface and vascular pattern were observed, and the lateral extension was diagnosed by the difference of such patterns. Biopsies were taken when the diagnosis of lateral extension was difficult. ESD procedure; marks were placed 3mm outside of lateral extension using magnified endoscopy. Glycerol was injected into submucosal layer to make space in submucosal layer. Mucosal incision and submucosal dissection was performed by Hook knife. A transparent hood was used in all cases to keep good visual field during ESD. Generator was ICC 200 or VIO 300D. Patients characteristics were ad follows; Male 26, Female 4, Age: 66 (32-88), Result: 1. En bloc resection rate was 100%. R0 resection rate was 95% (34/36). The reason why R0 wasn’t achieved was misdiagnosis of lateral extension under non-neoplastic squamous cell epithelium. Two cases of R1 resection were treated by re-ESD. There wasn’t local recurrence in one case, however the other case had a local recurrence, 2mm in size. 2. Complications: Perforation rate was 0%. Delayed perforation rate was 3% (1/36). The only perforated case could be treated by antibiotics and fast without operation. 3. The macroscopic type of BEA was as follows; 0-I : 7 , 0-IIa :17 , 0-IIb : 4 , 0-IIc : 8, and 44% (16/36) BEA had IIb spreading. Only 4 cases of the 16 IIb spreading were diagnosed by conventional endoscopy, and 14 of 16 were diagnosed by magnified endoscopy. Therefore, magnified endoscopy was useful for the diagnosis of IIb spreading. 4. Resected size was 40(19-134) mm,Tumor size was 13 (1-94) mm. Invasion depth: Mucosal and submucosal adenocarcinoma was 29 and 7, respectively. 5. Synchronous cancer rate was 20%(6/30), Metachronous cancer rate was 3% (1/30), one case had synchronous and metachronous BEA. Surveillance EGD was performed one to twice a year, and the mean observation duration was 47 (2 - 129) months. Conclusion: There were no severe complications in ESD for BEA, and the R0 resection rate was 95% (34/36). Therefore, ESD is one of a good selection for the endoscopic treatment of Barrett’s high grade dysplasia and mucosal adenocarcinoma.
Tu1590 Usefulness of Oral Prednisolone in Treatment of Esophageal Stricture Following Endoscopic Submucosal Dissection for Superficial Esophageal Epithelial Neoplasms Naoyuki Yamaguchi* Department of Endoscopy and **Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan Objective: Endoscopic submucosal dissection (ESD) permits removal of esophageal epithelial neoplasms en bloc, but postprocedural stricture was commonly occurred following ESD for superficially extendsive tumors. Endoscopic balloon dilatation (EBD) has been a treatment choice for the stricture management, but certain cases are refractory requiring multiple EBD sessions. We sought to disclose the effectiveness of oral prednisolone in controlling the postprocedural esophageal stricture. Design: This was an observation study of a single centre cohort. Patients Consecutive patients who underwent complete circular or semicircular ESD for esophageal squamous cell carcinoma involving more than three quarter of the lumen and with nominal risks of nodal metastasis were enrolled in this study. The eligible patients were treated by either the preemptive EBD or oral prednisolone. Results: Preemptive EBD was applied in 26 patients, which was started on the third post-ESD day and was performed twice a week for 48 weeks until post ESD ulcer healed up. Twenty-five patients was safely given prednisolone orally; the initial dose was 30 mg daily on the third post-ESD day, tapered gradually, and then discontinued 616 weeks later. EBD was applied on demand whenever dysphagia was appeared. En bloc ESD with tumor-free margins was safely achieved in each case. In the preemptive EBD group, median EBD sessions required for dysphagia relief were 12.0 and
AB456 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012
www.giejournal.org