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Management of Early Gastric Cancer

Management of Early Gastric Cancer

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Management of Early Gastric Cancer

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  1. Management of Early Gastric Cancer Charing Chong Division of Upper GI Surgery Department of Surgery Prince of Wales Hospital The Chinese University of Hong Kong

  2. Early Gastric Cancer • Definition – tumour confined to the gastric mucosa or submucosa • Convention management – Gastrectomy

  3. Conventional Open Gastrectomy vs Laparoscopic Assisted Gastrectomy

  4. PWH experience - Laparoscopic assisted gastrectomy • 2003 - 2005 • 25 patients • Laparoscopic D2 subtotal gastrectomy • Mean OT time: 330 mins • Hospital stay: 7 days • Complication • Minor anastomotic leak (1) • Anastomotic bleeding (1) • No conversion

  5. Minimal Invasive Treatment Options of EGC Local - regional Treatment Local Treatment Endoscopic Resection (EMR/ESD) Laparoscopic AssistedGastrectomy (LAG)

  6. How to choose • Major factors predicting the survival: • lymph node status • depth of wall invasion • Risk of LN metastasis in EGC is very low • Mucosa: 1 – 3% • Submucosal: 11 – 20% • Risk of gastrectomy and negative effect on patient’s quality of life

  7. Endoscopic Mucosal Resection (EMR)

  8. EMR - Classification- Pulling or suction methods Injection and Cut Technique Injection, Lift and Cut Technique Cap Technique Ligation Technique Soetikno;J Clin Oncol; 2005

  9. Survival: 99% 5-year and 10-year disease specific survival Complications: Perforation 0 - 1.5% Bleeding 6 -15% Local recurrence EMR - Results Tanabe et al; GIE; 2002 Hamanaka et al; Dig Endosc; 2005 Uedo et al; Gastric Cancer; 2006

  10. EMR - Limitation- Local recurrence after conventional EMR Author Methods Recurrence rate Tanabe et al Strip Biopsy, EAM 3.5% (15/423) Kawaguchi et al Strip Biopsy, EMR-C 35.3% (97/266) Ida et al EMR+Laser 6.7% (11/165) Chonan et al EMR 10.9% (21/193) Hirao et al ERHSE 2.3% (8/349) Mitsunaga et al Strip Biopsy 18.2% (54/296) Strip Biopsy 8.5% (53/620) NCCH (1988-1998)

  11. EMR – Limitation- en-bloc resection Piecemeal resection One piece resection

  12. EMR – Limitation- tumor size

  13. Endoscopic Resection– changing criteria Gotoda; Gastric Cancer; 2000

  14. Management Strategy for Early Gastric Cancer Guidelines for the Treatment of Gastric Cancer; The Japanese Gastric Cancer Association; 2001

  15. Endoscopic Submucosal Dissection (ESD)

  16. ESD - Procedures • Marking of the periphery of the lesion with needle knife • Injection of diluted epinephrine to raise the submucosal layer • Circumferential mucosal cutting • Subumucoal dissection • Specimen resected in one -piece

  17. ESD - Results

  18. PWH experience - ESD • 2004 to 2006 • 25 ESD performed for early gastric cancer • Mean duration: 84.3 mins • Hospital stay: 3 days • Mean size of the specimen: 8.5 cm2 • Perforation - 0 (0%); Bleeding - 1 (4%); Margins involved - 1 (4%); • Mean follow-up: 12 months • No local recurrence

  19. Early Gastric Cancer Mucosal Tumour Submucosal Tumour Intestinal Type Diffuse Type Intestinal Type > 30mm No Ulceration Ulceration Sm 1, < 30 mm < 30 mm > 30 mm Endoscopic Resection Endoscopic Resection Laparoscopic Surgery Conclusion