Staging and Less Invasive Tx of Esophageal Cancer

Jun Haeng Lee

Sungkyunkwan University School of MedicineSamsung Medical Center, Seoul, Korea,

Siersema. Gastroenterol Clin N Am 2008:37:943-964

Diagnosis and staging of esophageal cancer

Siersema. Gastroenterol Clin N Am 2008:37:943-964

Different modalities have different roles

• For the evaluation of distant metastases, FDG-PET may have a higher sensitivity than CT.

• For the detection of regional and celiac lymph node metastases, EUS is most sensitive, whereas CT and FDG-PET are more specific tests.

• The combined use of FDG-PET and CT, which is increasingly being applied, could be of clinical value, with FDG-PET detecting possible metastases and CT confirming or excluding their presence and precisely determining their location.

Why accurate staging is important?

• Accurate staging is essential to select patients who will benefit from aggressive therapy and to avoid aggressive therapy in patients with distant metastases.

• Despite these efforts, metastatic spread is encountered during operation in up to 60% of patients.

• No one technology can completely stage all aspects of esophageal carcinoma with high accuracy.

Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 8th ed. Ch 44

Comparative study will not be coming.

• The current enthusiasm for neoadjuvant therapy makes it unlikely that definitive studies comparing accuracy of specific or combination staging modalities will be forthcoming.

• Staging of newly diagnosed esophageal cancer may incorporate crosssectional imaging, EUS, positron emission tomography (PET) scanning, transcutaneous ultrasound scanning of the neck, laparoscopy, and video-assisted thoracoscopy (VATS) staging.

Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 8th ed. Ch 44

Role of Endoscopy

Jun Haeng Lee

Sungkyunkwan University School of MedicineSamsung Medical Center, Seoul, Korea,

Role of endoscopy

• Location of the lesion (with respect to distance fr

om the incisors)

• Nature of the lesion (friable, firm, polypoid)

• Proximal and distal extent of the lesion

• Relationship of the lesion to the cricopharyngeus

muscle, the GEJ, and the gastric cardia

• Distensibility of the stomach

Early esophageal cancer- carcinoma in-situ. 1.2x0.4 cm. confined to the basement membrane in ESD

Esophageal cancer- usefulness of Lugol chromoendoscopy

Early esophageal cancer type I- 1.3 x 0.8 cmm, endolymphatic tumor emboli (+), LN 2/40

Advanced esophageal cancer- extension to perimuscular adventitia, LN 3/62

Esophageal cancer + EGC (M/60)

Esophageal cancer after lye stricture (F/48)

Invasive SCC (M/D), 2x1.8 cm, PM, 0/24

CT, MRI, EUS

Jun Haeng Lee

Sungkyunkwan University School of MedicineSamsung Medical Center, Seoul, Korea,

CT and MRI

• CT is much less accurate in detecting lymph node metastases and is more accurate for subdiaphragmatic lymph nodes than for mediastinal ones.

• MRI can assess mediastinal invasion and liver metastasis as well as CT can but has not demonstrated any significant advantages. Because of accessibility and its lower cost, CT is preferred.

• The main limitations of CT are its insensitivity to the identification of irresectability (T4) and its inability to identify metastatic disease in normal-sized lymph nodes.

Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 8th ed. Ch 44

Features of malignant lymph on EUS

• Size greater than 1cm• Hypoechogenicity• Distinct margins• Round shape

• No single feature independently predicted malignant status.

• When all four features were present, the accuracy in predicting malignancy was 80%.

• However, these combined features were present in only 25% of the malignant lymph nodes observed.

Accuracy of EUS in early studies

Number Accuracy (%)

T1 185 81

T2 153 76

T3 419 92

T4 153 86

N0 231 69

N1 343 89

Rosch. Gastrointest Endosc Clin N Am 1995;5:537

Eloubeidi. Am J Gastroenterol 2009;104:53-56

Limitation of EUS (1): safety concerns

Limitation of EUS (2): publication bias- positive results 만 보고되는 경향이 있다 .

Harewood GC. Am J Gastroenterol 2005:100;808-816

Limitation of EUS (3): publication bias- 직장암에서 EUS 의 성적이 점점 나쁘게 보고되고 있다

Harewood GC. Am J Gastroenterol 2005:100;808-816

Limitation of EUS (4): too subjective- T-staging by EUS is strongly influenced by the endoscopic impression

Yanai. Intern J Gastointest Cancer 2003;34:1-8

Limitation of EUS (5): lack of experience

• 식도암 병기 결정에 있어서 EUS 의 정확도 (국립암센터 , 2008 대한 Hp 학회 추계학술대회 )

• Overall T 병기 정확도 : 73.9%– 분화암보다 미분화암에서 유의하게 낮은 결과 – 표재성 식도암에서 점막암 및 점막하층암 진단

정확도 : 53.8% (miniprobe 67.3%, radial 38.8%)

• Overall N 병기 정확도 : 72.7%

Korean J Helicobacter and Upper GI Gastrointest Res 2008;8(Suppl 2): 68

Twine. Surg Endosc 2009 May 14. [Epub ahead of print]

Twine. Surg Endosc 2009 May 14. [Epub ahead of print]

Role of PET

Jun Haeng Lee

Sungkyunkwan University School of MedicineSamsung Medical Center, Seoul, Korea,

NORMAL TUMOR

• Overexpression of Glucose transporters• Higher levels of Hexokinase• Down-regulation of Glucose-6-phosphatase• Anaerobic glycolysis, less ATP per glucose molecule, more glucose molecules needed for ATP production• General increase in metabolism from high growth rates

SMC experience

Yoon YC. Radiology 2003;227:764-770

PET is very useful for distant mets

van Westreenen HL. J Clin Oncol 2004;22:3805-3812

Esophageal cancer with LN mets

BUT, less useful for locoregional mets

van Westreenen HL. J Clin Oncol 2004;22:3805-3812

♠ In the included studies, change in patient management ranged from 3% to 20% due to the addition of PET to preoperative workup.

EMR/ESD for early esophageal cancer

Jun Haeng Lee

Sungkyunkwan University School of MedicineSamsung Medical Center, Seoul, Korea,

ESD (n=243)

Intramucosal differentiated cancer (n=196)

submucosal invasion orundifferentiated cancer (n=47)

Surgery (n=34) Follow up (n=13)

No recurrence

Median follow-up: 17 months (range: 4-37 months)

Complete resection (n=182) Not assessable (n=10) Incomplete resection (n=4)

Surgery (n=3)

Follow up (n=5)

Follow up (n=2)

Surgery (n=2)

Metachronousrecurrence

(n=9)

ESD (n=8)

Surgery (n=1)

Local recurrence

(n=1)

Surgery (n=1)

ESD(n=2)

Less than two EGD

follow up (n=7)

F/U after ESD for EGC at SMC

Min. Dig Liver Dis. 2009 Mar;41(3):201-9

Surgery for mucosal cancer: 7 (2.9%)

EMR was not considered as a Tx option- NCCN treatment guideline 2008

http://www.nccn.org/

Risk of lymph node metastasis in EEC- a single center experience at Samsung Medical Center (n=197)

Kim. J Gastroenterol Hepatol 2008;23(4):619-625

Kodama. Surgery 1998;123:432-439

Risk of lymph node metastasis in EEC- a multicenter study in Japan (n=1740)

Risk of lymph node metastasis depends on the gross type of EEC

Endo. Endoscopy 1993;25:672-674

Indications for EMR for SCC

Gotoda. GIE 2008;67:805-807

Methods of endoscopic treatments - tissue retrieval techniques

• Techniques without suction

– Conventional snare polypectomy without injection

– Inject and cut

– Inject, lift and cut

– Inject, precut and cut: EMR-P

– ESD: needle knife, IT kinfe, hook knife, Flex knife

• Techniques with suction

– Suction and cut: EMR-C

– Suction and ligate: EMR-L

Modified from Endoscopy 2001;33:271-275

ESD 에 대한 용어의 정리- ESD 를 EMR 에서 분리하여 새로운 시술로 봄

• ER = EMR + ESD한시적 인정 비급여

Recurrence after EMR for EEC

Ishihara. GIE 2008;67:799-804

Esophageal ESD- M/D squamous cell carcinoma (M2)

Early esophageal cancer 0.7 cm

ESD for EEC with perforation

Pech. Gut 2007;56:1625-1634

Endoscopic resection for early squamous cell carcinoma

Take home message

• 식도암의 치료 전 병기판정의 방법은 어떠한 치료를 염두에 두는가에 따라 달라질 수 있다 .

• 각 검사법이 서로 다른 역할을 가지고 있으므로 경쟁적이기보다는 보완적인 관계로 이해할 필요가 있다 .

• 조기식도암의 내시경치료는 아직 개발단계의 시술로 향후 많은 발전이 예상된다 . 현재로서는 합병증을 줄이기 위한 다양한 노력이 필요하다 .