Post on 18-Oct-2020
University Mainz
Early Gastric Cancer15.6.2007
Early Gastric Cancer
Ralf KiesslichJohannes Gutenberg University Mainz, Germany
University Mainz
Early Gastric Cancer15.6.2007
DIAGNOSIS
University Mainz
15.6.2007Early Gastric Cancer
Unmask lesions
- Chromoendoscopy
- NBI
Red flag technology
- Autofluorescence
Surface and detail analysis
- Magnifying endoscopy
- High resolution endoscopy
In vivo histology: Cellular architecture
- Endocytoscopy (surface)
- Endomicroscopy (whole mucosal layer)
Tissue architecture
- OCT
University Mainz
Early Gastric Cancer15.6.2007
CHROMOENDOSCOPY
University Mainz
15.6.2007Early Gastric Cancer
Type O-I: Protruted type
Type O-IIa: Superficial elevated type
Type O-IIb: Flat type
Type O-IIc: Superficial depressed type
Type O-III: Excavated type
Japanese Classification
University Mainz
15.6.2007Early Gastric Cancer
Type I
University Mainz
15.6.2007Early Gastric Cancer
Type IIa
University Mainz
15.6.2007Early Gastric Cancer
Type IIa+IIc
University Mainz
15.6.2007Early Gastric Cancer
Magnifying Endoscopy
University Mainz
Early Gastric Cancer15.6.2007
High risk population
University Mainz
15.6.2007Early Gastric Cancer
Hereditary diffuse gastric
Hereditary diffuse gastric cancer is defined by germline
mutations in the E-cadherin gene, CDH-1.
Penetrance is 70%.
Congo red/methylene blue detected carcinoma foci 4-10
mm in size but not foci <4 mm.
Chromogastroscopy represents an improved
surveillance technique that can be safely considered
alongside prophylactic gastrectomy.
Shaw et al. Gut 2005
University Mainz
15.6.2007Early Gastric Cancer
Shaw et al. Gut 2005
University Mainz
Early Gastric Cancer15.6.2007
Filter Technology
NBI – FICE - SURFACE
University Mainz
15.6.2007Early Gastric Cancer
B G R
ConventionalFilter
B G R
NBIFilter
B
G R
Narrow Band Imaging
University Mainz
15.6.2007Early Gastric Cancer
Kara et al. Gastrointest Endosc 2006
NBI of HGD in Barrett‘s
Prediction of HGDSensitivity 94%; Specificity 76%
University Mainz
15.6.2007Early Gastric Cancer
Tamai et al. Endoscopy 2006
University Mainz
15.6.2007Early Gastric Cancer
Tamai et al. Endoscopy 2006
University Mainz
15.6.2007Early Gastric Cancer
Differentiated
Undifferentiated
University Mainz
Early Gastric Cancer15.6.2007
HDTV & HD+
University Mainz
15.6.2007Early Gastric Cancer
Pentax-EPKi
University Mainz
15.6.2007Early Gastric Cancer
Pentax-EPKi
University Mainz
15.6.2007Early Gastric Cancer
Pentax-EPKi
University Mainz
15.6.2007Early Gastric Cancer
University Mainz
15.6.2007Early Gastric Cancer
Autofluorescence & Video endoscopy
University Mainz
15.6.2007Early Gastric Cancer
Chromoendoscopy
Autofluorescence
Uedo et al. GI Endosc 2005
University Mainz
15.6.2007Early Gastric Cancer
Uedo et al. GI Endosc 2005
University Mainz
Early Gastric Cancer15.6.2007
ENDOMICROSCOPY
University Mainz
15.6.2007Early Gastric Cancer
Field of view: 475x475µmRange: 0-250µmLateral resolution: <1µm
Endomicroscopy
University Mainz
15.6.2007Early Gastric Cancer
University Mainz
15.6.2007Early Gastric Cancer
Helicobacter pylori
Kiesslich et al., Gastroenterology 2005
University Mainz
15.6.2007Early Gastric Cancer
Final histology: poorly differentiated adenocarcinoma
Intestinale Metaplasia
Tumor vessel
Tumor
Gastritis – Metaplasia - Cancer
University Mainz
15.6.2007Early Gastric Cancer
Well differentiated Adenocarcinoma
University Mainz
15.6.2007Early Gastric Cancer
Subtle Changes
University Mainz
15.6.2007Early Gastric Cancer
Normal gastric architecture Malignant transformation
University Mainz
15.6.2007Early Gastric Cancer
Signet ring cells
University Mainz
15.6.2007Early Gastric Cancer
Prospective blinded evaluation predicting gastric cancer
(132 locations)
Sensitivity 84%; Specificity 95%; Accuracy 80%
Inter-observer agreement by kappa statistics
for sites (antrum, corpus, cardia) presence of
intestinal metaplasia and cancer:
0.83, 0.89, and 0.63
Yeoh et al., DDW 2005
Gastritis – Metaplasia - Cancer
University Mainz
Early Gastric Cancer15.6.2007
MALT Lymphoma
University Mainz
15.6.2007Early Gastric Cancer
University Mainz
15.6.2007Early Gastric Cancer
MALT-Lymphoma
University Mainz
15.6.2007Early Gastric Cancer
MALT-Lymphoma
University Mainz
Early Gastric Cancer15.6.2007
Endosonography & OCT
University Mainz
15.6.2007Early Gastric Cancer
Rösch, Gastrointest Clin North Am 1995
Accuracy 65-87%
Mini-Probes Endosonography
University Mainz
15.6.2007Early Gastric Cancer
Optical Coherence Tomography
OCT provides noninvasive, subsurface high-resolution imaging
of tissue microstructure.
In contrast to ultrasound, OCT utilizes light instead of sound
reflectivity, which provides a 10-fold higher resolution
Resolution 10-20 microns; Penetration depth <2.5mm
University Mainz
15.6.2007Early Gastric Cancer
OCT: Barrett Esophagus
Prediction of Barrett‘s Epithelium:
Sensitivity 97%; Specificity 92%
Poneros et al. Gastroenterology 2001Image: Rabenstein, Ell, Wiesbaden 2005
Barrett‘s epithelium
Squamous Epithelium
University Mainz
15.6.2007Early Gastric Cancer
Gastric Cancer?
University Mainz
Early Gastric Cancer15.6.2007
THERAPY
University Mainz
15.6.2007Early Gastric Cancer
Gotoda, Gastric Cancer 2007
University Mainz
Early Gastric Cancer15.6.2007
EMR
University Mainz
15.6.2007Early Gastric Cancer
University Mainz
15.6.2007Early Gastric Cancer
Classic Guidelines
Recurrence rates: 3-36%!Gotoda, Gastric Cancer 2007
University Mainz
Early Gastric Cancer15.6.2007
Crucial question
Lymphovascular invasion
University Mainz
15.6.2007Early Gastric Cancer
Gotoda, Gastric Cancer 2007
University Mainz
15.6.2007Early Gastric Cancer
„Extended“ Guidelines
Gotoda, Gastric Cancer 2007
University Mainz
Early Gastric Cancer15.6.2007
ESD
University Mainz
15.6.2007Early Gastric Cancer
Gotoda, Gastric Cancer 2007
ESD - Instruments
University Mainz
15.6.2007Early Gastric Cancer
University Mainz
15.6.2007Early Gastric Cancer
Bleeding
University Mainz
15.6.2007Early Gastric Cancer
Perforation
University Mainz
15.6.2007Early Gastric Cancer
Perforation
University Mainz
15.6.2007Early Gastric Cancer
Conclusions
Diagnosis
Chromoendoscopy helps to characterize gastric lesions (size, type)
Magnifying endoscopy adds surface detail
HDTV (HD+) will replace conventional video endoscopy
Endomicroscopy – see histology in vivo
Therapy
EMR/ESD for selected cases and trained endoscopists
University Mainz
15.6.2007Early Gastric Cancer
THANK YOU