University Mainz. Early Gastric Cancer. Ralf Kiesslich. Johannes Gutenberg University Mainz, Germany. Early Gastric Cancer 15.6.

Transcription

1 Ralf Kiesslich Johannes Gutenberg University Mainz, Germany

2 DIAGNOSIS

3 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

4 CHROMOENDOSCOPY

5 Japanese Classification 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

6 Type I

7 Type IIa

8 Type IIa+IIc

9 Magnifying Endoscopy

10 High risk population

11 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

12 Shaw et al. Gut 2005

13 Filter Technology NBI FICE - SURFACE

14 Narrow Band Imaging Conventional Filter B G R B G R NBI Filter B G R

15 NBI of HGD in Barrett s University Mainz Prediction of HGD Sensitivity 94%; Specificity 76% Kara et al. Gastrointest Endosc 2006

16 Tamai et al. Endoscopy 2006

17 Tamai et al. Endoscopy 2006

18 Differentiated Undifferentiated

19 HDTV & HD+

20 Pentax-EPKi

21 Pentax-EPKi

22 Pentax-EPKi

23

24 Autofluorescence & Video endoscopy

25 Autofluorescence Chromoendoscopy Uedo et al. GI Endosc 2005

26 Uedo et al. GI Endosc 2005

27 ENDOMICROSCOPY

28 Endomicroscopy Field of view: 475x475µm Range: 0-250µm Lateral resolution: <1µm

29

30 Helicobacter pylori Kiesslich et al., Gastroenterology 2005

31 Gastritis Metaplasia - Cancer Intestinale Metaplasia Tumor Tumor vessel Final histology: poorly differentiated adenocarcinoma

32 Well differentiated Adenocarcinoma

33 Subtle Changes

34 Normal gastric architecture Malignant transformation

35 Signet ring cells

36 Gastritis Metaplasia - 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

37 MALT Lymphoma

38

39 MALT-Lymphoma

40 MALT-Lymphoma

41 Endosonography & OCT

42 Mini-Probes Endosonography Accuracy 65-87% Rösch, Gastrointest Clin North Am 1995

43 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 microns; Penetration depth <2.5mm

44 OCT: Barrett Esophagus Barrett s epithelium Squamous Epithelium Prediction of Barrett s Epithelium: Sensitivity 97%; Specificity 92% Poneros et al. Gastroenterology 2001 Image: Rabenstein, Ell, Wiesbaden 2005

45 Gastric Cancer?

46 THERAPY

47 Gotoda, Gastric Cancer 2007

48 EMR

49

50 Classic Guidelines Recurrence rates: 3-36%! Gotoda, Gastric Cancer 2007

51 Crucial question Lymphovascular invasion

52 Gotoda, Gastric Cancer 2007

53 Extended Guidelines Gotoda, Gastric Cancer 2007

54 ESD

55 ESD - Instruments Gotoda, Gastric Cancer 2007

56

57 Bleeding

58 Perforation

59 Perforation

60 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

61 THANK YOU