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Management of Early Gastric Cancer

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

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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

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