Prof.MatteoNeri

DipartimentodiMedicinaeScienze

dell�invecchiamento,UniversitàG.

D�Annunzio

Resp.UOSDGastroenterologiaed

EndoscopiaDigestiva,Ospedale

SS.Annunziata,Chieti

Appropriatezzadell’Endoscopianel

CaGastrico

Overviewofpresentation

Whatshouldwedo:

• BeforeCancer– Endoscopyinprecancerouscondition(atrophicgastritis

andmetaplasia/dysplasia)

• AtEndoscopy– superficialneoplasticlesionsofthestomach:

Diagnosis,Treatment,Follow-up

• AfterGastricSurgery– Follow-up

Gastriccancer:ESMOClinicalPracticeGuidelines

fordiagnosis,treatmentandfollow-up

E.C.Smythetal,AnnOncol2016

TheprincipalcauseofGastric

CancerisH.Pylori

TheOLGA/OLGIMscore

Managementofprecancerous

conditionsinthestomach

Howtodoit

GastricCancerdetectionrates

WooJCetal,JClinGastroenterol2013

Metodologiadiesplorazionedeltratto

digestivoalto:SSSVISTAANTEROGRADA

VISTAINRETROVERSIONE

PC

GC

P

A

P

P

ANTRO

4AREE4FOTO

PC

GC

P

A

P

P

CORPOMEDIO

4AREE4FOTO

P

A

PC

GC

P

P

CORPOMEDIO- SUPERIORE

4AREE4FOTO

PC

P

A

P

P

GCFONDO- SUBCARDIAS

4AREE4FOTO

PC

P

A

P

P

CORPOMEDIO- SUPERIORE

3AREE3FOTO

PC

P

A

P

P

ANGULUS

3AREE3FOTO

YaoKetal,AnnGastroenterol2013

Domain:completenessofprocedure

- AUGIendoscopyinapatientwhohasnotundergoneaprevious

gastroscopywithinthelastthreeyearsshouldincludeinspectionofthe

esophagus,stomach,andduodenum,andshouldlastforatleastseven

minutesfromintubationtoextubation.

(N2.2)Agreement:80%.

LongerExaminationTimeImproves

DetectionofGastricCancerDuring

DiagnosticUpperGIEndoscopy

TehJletal,CGH2015

Howtoimprovevisualization:

Chromoendoscopywithindigocarmine

Technologyis important!

MagnifyingEndoscopySimpleDiagnostic

AlgorithmforGastricCancer(MESDA-G)

Muto M et al. Digestive Endoscopy 2016

Suspicious lesion

DL

IMVPand/or

IMSP

Non-cancer Cancer

Present

Present

Absent

Absent

Microvasculararchitectureand

microsurfacestructureatMEandNBI

Inflammation Advancedinflammation

Atrophy Metaplasia

Microvasculararchitectureand

microsurfacestructureatMEandNBI

thereisno

demarcationline

NO Cancer

Microvasculararchitectureand

microsurfacestructureatMEandNBI

Insidethe

demarcationline:

regularmicrovascular,

regularmicrosurface

patterns

NO Cancer

Microvasculararchitectureand

microsurfacestructureatMEandNBI

irregularmicrosurface and

irregularmicrovascular

patterns

arepresentwithinthe

demarcation

line

Cancer

Microvasculararchitectureand

microsurfacestructureatMEand

NBI

VesselsplusSurface(VS)

classificationsystem

MutoMetal,DigEndoscopy2016

Parisclassification:StomachEGC

andNodalinvasion

Gastrointestinal Endoscopy,2003

Depthofinfiltrationandinvasion

pTStage N+%

M1 0

M2 0-1

M3 2

SM1 2-3

SM2 25-27

MurataYetal,Endoscopy2008

PechHetal,WJG2012

SM 2

HGDM1

EGCIMM2

EGCIMM3

EGCSM1v- l-

Mucosa

Laminapropria

Muscularis mucosae

Submucosa

Muscularis propria

Serosa

Parisclassification:StomachEGC

andNodalinvasion

Size inmm <500μ n/N(%) >500μ n/N(%)

<10 1/31(3) 5/39(13)

10-20 4/71(6) 28/195(14)

21-30 4/71(6) 52/273(19)

>30 6/92(7) 86/319(27)

Total 15/265(6) 171/826(21)

GastrointestinalEndoscopy,2003

Size &Submucosal invasion Ulcer +/-

Histology

Pimentel-NunesPetal,Endoscopy 2015

Superficialneoplasticlesionsofthe

stomach

ESGErecommends

endoscopicresectionforthe

treatmentofgastric

superficialneoplasticlesions

thatpossessaverylowriskof

lymphnodemetastasis

(strongrecommendation,

highqualityevidence)

EMRisanacceptableoption

forlesionssmallerthan10–

15mmwithaverylow

probabilityofadvanced

histology(Paris0-IIa)

Indicationtoendoscopicresection

accordingtotheriskoflymphnode

metastasis

Depth ofinvasion

Ulceration Differentiated Undifferentiated

T1a(M)

≤2cm >2cm ≤2cm >2cm

Ul-

≤3cm >3cm

Ul+

T1b(SM) sm1,≤500µm

Dysplasia

Absoluteindication Expanded indication

Pimentel-NunesPetalEndoscopy2015

Staging

ESD/EMR

feasible

Protrusion ordepression ofasmooth

surface

Slight marginal elevation

Smooth tapering ofconverging folds

ESD/EMR

unfeasible

Irregularsurface,markedmarginal

elevation,

abrupt cutting orfusionofconverging

folds.

EndoscopicMucosalResectionv.

SubmucosalDissection

SM 2 SM 2

Outcomesofendoscopicsubmucosaldissection

(ESD)forgastricsuperficiallesions

Outcomesofendoscopicsubmucosaldissection

(ESD)forgastricsuperficiallesions

En-bloc resection rate R0resection rate Recurrence rate

Outcomesofendoscopicsubmucosaldissection

(ESD)vsmucosaresection(EMR)

Facciorusso A et al: WJGE 2014

Perforation rate Bleeding rate

Outcomesofendoscopicsubmucosaldissection

(ESD)vsmucosaresection(EMR)

Facciorusso A et al: WJGE 2014

OutcomesofESDvs.EMR

Survivalrate

Tanabe S. et al. Gastric Cancer 2014

Cumulativeoverallsurvivalafter

exclusionofdeathsunrelatedtoGCCumulativeoverallsurvival

Criticalissues

• H.pylori infection• Survivalrate>5aa• Ageofpatients• Metachronuslesions(vs.surgery)

• Expandedindication• Cancer histology• LongFollow-up(numberofEGDS?)

ESDversussurgicalresectionfor

EGC

Ryu SJ et al. Surg Endosc 2016

•Shorterproceduretimes

•Shorterfastingperiod•sSorterhospitalstay•Lessimmediate

complications

•Higherrecurrencerate(12.3vs.2.1)

OutcomesofESDfordifferentiated-type

early gastric cancerwithhistological

heterogeneity

Absoluteindications Expandendindications

MinBHetal,GastricCancer2015

ESDandFollow-up:6vs12months

Nakajima T et al.,Gastric Cancer 2006

Managementclinico-endoscopicodell�EGC

AUGMENTEDENDOSCOPY/BIO

EUS

T1

EMR/ESD

ENBLOCK

VALUTAZIONEISTOLOGICA

EGCDIFFERENZIATO

M1,M2,M3,SM1

EGCINDIFFERENZIATO

M1,M2,M3 SM1

STADIAZIONEDIFFERENZIALET1/T2

FOLLOWUP

RESEZIONECURATIVA

≤20mm≥20mm+/-ULCEREV- L-

ANCHESE≤20mm+/-ULCEREV+L+

CHIRURGIA

RESEZIONEDIAGNOSTICA

≤20mm+/-ULCEREV- L-

FOLLOWUP

RESEZIONECURATIVA

>20mmo+ULCEREOV+L+

CHIRURGIA

RESEZIONEDIAGNOSTICA

CHIRURGIA

RESEZIONEDIAGNOSTICA

CANCROAVANZATODIFFERENZIATOINDIFFERENZIATO

SM2

CHIRURGIA

RESEZIONEDIAGNOSTICA