Endoscopic Mucosal Resection (EMR) Clinical Professor of Medicine St. Louis University Midwest Therapeutic Endoscopy Consultants St. Louis, Missouri, USA

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Endoscopic Mucosal Resection (EMR) Clinical Professor of Medicine St. Louis University Midwest Therapeutic Endoscopy Consultants St. Louis, Missouri, USA Clinical Professor of Medicine St. Louis University Midwest Therapeutic Endoscopy Consultants St. Louis, Missouri, USA Giuseppe Aliperti, MD, FACP Slide 2 Endoscopic Mucosal Resection (EMR) Major advance in minimally invasive surgery of the GI tract based on the following realities: Endoscopy provides visualization/access to GI mucosa, where most cancers originate Resection/retrieval of tissue allows pathologic examination (as opposed to ablation) First perfected in Japan for resection of superficial gastric cancer, very high in that Country unlike the West, where colon cancer (arising in polyps) is much more common Slide 3 Most gastric cancers begin in slightly elevated, flat, or slightly depressed mucosal dysplastic lesions, difficult to grasp with a simple wire snare. Most mucosal polyps, by projecting into the lumen, are easy to grasp with wire snares at the polyp base for resection with electrocautery Endoscopic Mucosal Resection (EMR) Slide 4 Japanese endoscopists have adapted and perfected methods to raise the neoplastic mucosal area in order to allow snaring or dissection with sharp- tipped instruments Most use fluid injection into the submucosal layer to elevate the mucosa and allow it to be grasped with the snare Some use specially fitted scope caps that lift the lesion by suction Endoscopic Mucosal Resection (EMR) Slide 5 The success of EMR in the stomach prompted endoscopists to expand the method to the: Esophagus, where early cancer and premalignant dysplasia also tends to be non-polypoid and flat Colon, where some neoplastic lesions are flat or sessile Duodenum Major papilla Endoscopic Mucosal Resection (EMR) Slide 6 EMR: techniques Special caps designed to fit the tip of the endoscope allow endoscopic suction to lift the mucosa to be ensnared Removal of large lesions in 1 piece (en bloc) is achieved with electrocautery wire- knives of different shapes that dissect around and under the diseased mucosa Slide 7 High-Grade Dysplasia (HGD), Superficial Cancer in Barrett's Esophagus Incresed detection rates with screening/surveillance Difficult area in clinical decision making HGD difficult to distinguish histologically from invasive adenocarcinoma intra-(T1m) or sub-mucosal (T1sm) In specimens of esophagectomy for HGD >30% harbor invasive cancer Esophagectomy has a high morbidity/mortality (2-7% in expert centers, 20% in others age/comorbidities in older patients where HGD is more frequent) Slide 8 Endoscopic Ablative Therapies (non-resective) methods based on rates of lymph node metastasis: absent in HGD, very low in confined invasive cancers 1-2-3 photodynamic therapy argon plasma coagulation Both successful 4-5, but cannot assure: Confinement to the mucosa T1m vs. T1sm Removal of the entire lesion - there is no specimen EUS accuracy, excellent for invasion beyond submucosa and lymph node detection - is only 75-85% in distinguishing between mucosal [T1m] and submucosal [T1sm] disease Slide 9 EMR for Staging in Barrett's Esophagus: General Concepts EMR allows removal of large pathology specimens extending into the mid-submucosa, a big staging advantage over ablative methods 6 Depth of cancer invasion can be made with great accuracy Disease confined to mucosa with clear margins is considered cured Patients with submucosal invasion (T1sm) are usually referred for surgery/chemo Ell et al Gastroenterol 2000;118:670-677 Slide 10 EMR performed to stage patients with HGD/T1m (confined to mucosa) CA by EUS 7 48 pts, 8 to surgery for submucosal (T1sm) disease by EUS: 7/8 T1sm, one T1m, overstaged 40 with T1m by EUS: 25 had HGD, 15 had adenoCA - All underwent EMR for definitive staging (no complications) EMR changed the staging in 30%: 19/25 with apparent HGD by EUS were T1m1, 4/25 T1m2, 2/25 T1m3 6/15 with T1m CA were T1sm (submucosal invasion) instead and were sent to surgery additional therapy required for residual/recurrent HGD, CA EMR for Staging in Barrett's Esophagus Lightdale et al Gastrointest Endosc. 2004;59:AB90 Slide 11 Post-EMR Endoscopic Surveillance 240 EMR 1996-2003 8 accurate assessment of invasion depth neoplastic lesions not resected completely in most, required additional biopsies and f-u 72 EMR compared with 66 surgery for T1m/T1sm CA EMR patients older, smaller tumors, less LN mets 9 EMR: fewer complications, shorter hospital stay EMR: higher risk of tumor recurrence. Lewis et al, Mayo, GIE 2004;59:AB101 MGH/UCH, Bhave et al, MGH/UCH, GIE 2004;59:AB254 Slide 12 Post-EMR Endoscopic Surveillance 79 patients, 38 with HGD/T1m CA 10 EMR alone satisfactory in 60% pts; T1sm invasion in 18% required surgery/chemo Complete resection, clear margins not always possible EMR in 38 pts with HGD/T1m 11 changed pretreatment diagnosis in 10 (26%) negligible complications careful endoscopic surveillance was recommended Ponchon et al, France, GIE 2004;59:AB255 Conio et al, Italy, GIE 2004;59:AB253 Slide 13 EMR performed for focal lesions or for complete removal of short-segment Barrett's EMR good for superficial cancer treatment, low complications Impossible to determine clear margins in piecemeal resections After EMR, careful follow-up is required for residual or metachronous disease EMR for Barrett's Esophagus: Conclusions Slide 14 Circumferential EMR in Barrett's Esophagus All Barrett's tissue removed with special stiff monofilament snare in 22 patients with HGD/IMCA 12 Tissue removed piecemeal, median length 3cm (1.2-10) Four had residual Barrett's epithelium (1 beneath new squamous epithelium), 6 developed strictures responding to dilation Circumferential piecemeal EMR with modified multiple variceal band ligator, then multiple snare resections without removing scope in between 13 greater efficiency then cap-assisted EMR for larger resections Seewald et al, Germany, GIE 2004;59:AB101 Soehendra, Germany, DDW 2004 Slide 15 EMR Combined With Ablation Therapy Used to treat residual neoplastic tissue after EMR Photodynamic therapy (PDT) with laser after light-sensitizing drugs successful method of ablation after EMR 14 Combination of EMR and PDT 15 local remission in 26/28 pts, mean f-u 15.2 mo local recurrence common, further treated with EMR+PDT Combination of EMR and PDT 16 local remission in 18 of 22 pts over 10.6 months no complications Pacifico et al, Clin Gastr Hepatol. 2003;1:252-257 Peters et al, The Netherlands GIE 2004;59:AB251 Haringsma et al, The Netherlands GIE 2004;59:AB252 Slide 16 EMR Combined With Ablation Therapy Combination EMR/PDT for focal neoplastic lesions followed with thermal ablation by APC 17 Complete eradication of all of the Barrett's and all neoplastic tissue was achieved in 85/88 patients, mean f-u 30 months; 2 patients died of progressive disease Complications included 1 bleed after EMR, 20 symptomatic strictures, 10 "sunburns," 2 episodes of atrial fibrillation after PDT Rahmani et al (IU) GIE 2004;59:AB250 Slide 17 EMR for Other Esophageal Tumors EMR for SCCA of esophagus is widely used in Japan, less in the West, where early detection is uncommon. EMR on 39 pts with early SCCA 18 10 pts CA in situ, 19 T1m, 10 T1sm (inoperable) 9/10 with CA in situ, 19/19 patients with T1m with complete remission at mean f-u 29.7 mo 3 minor bleeding, 3 mild strictures EMR (band ligation then snare) for submucosal benign tumors