Early Detection and Management of Oesophageal and Gastric Tumours This document outlines techniques for early detection and management of oesophageal and gastric tumours. It discusses various imaging techniques like chromoendoscopy, magnification endoscopy, narrow-band imaging and autofluorescence imaging that can help differentiate lesions. Early detection is important for conditions like Barrett's esophagus and early gastric cancer. Management options discussed include endoscopic mucosal resection and endoscopic submucosal dissection, with ESD providing better en bloc resection rates but being more complex. The document provides an overview of current guidelines and research findings on classifying, detecting and treating premalignant and malignant conditions of the upper GI tract.

1. Early Detection and Management
of Oesophageal and Gastric
Tumours …
“Outline”
Hossam GHONEIM, MD

3. Outline
• Oesophageal Tumours
– Barrett
– Non-Barrett
• Gastric Tumours
• Early detection (New Imaging Techniques)
– Differentiation
• AFI
• Chromoscopy
• HDWL
– Characterization
• NBI
• CLE
• OCT
• Management
– EMR
– ESD

4. Oesophageal Tumours
• Barrett’s
• Non-Barrett
– Squamous cell Tumours
• Early - Advanced
– Adenocarcinoma
• Early - Advanced
• Early detection
– Who?
– How?
• Management
– EMR
– ESD

5. Barrett’s Esophagus
• Surveillance
• Advanced Imaging
• Ablative therapy

6. BE .. Surveillance
• Still subject of debate
• A direct effect on survival could not be
demonstrated
• Novel Biomarkers in progress
– On brush cytology
– Using DNA fluorescence in situ hybridization (FISH)
– For tumour suppressor genes p16 & p53, or
– For aneuploidy for chromosomes 7 &17
– Positive test correlated with an increased hazard ratio
for progression
DDW highlights, Vleggar and sierema, GIE, 2012

7. BE .. Advanced imaging
• Confocal LASER
endomicroscopy - CLE
– e-CLE with HRE yielded a 5.2
fold increase in diagnosis of
neoplasia with significantly
fewer biopsies taken.
– p-CLE with HDWL was studied
to determine optimally
treated pts. There was no
advantage for p-CLE in
detecting residual BE or
dysplasia!
• Bioimpedence spectroscopy
– Sensing the electrical
properties in inflammatory
tissue & dysplasia
DDW Highlights, GIE, 2012

8. BE .. Ablative therapy
• Cryotherapy, PTD & APC
• RFA is the most widely used
due to its high efficacy and low
complication rates.
– Length of BE is the only
variable in achieving complete
eradication of Intestinal
Metaplasia (CEIM), the longer
the more sessions needed.
– Prior fundoplication showed no
superiority to PPI as regards
CEIM and number of sessions
needed.
– Recurrence is a true concern. A
large cohort showed
recurrence of IM at 2 years to
be 32%
– Combination with EMR is
equally effective
DDW Highlights, GIE, 2012

9. Non-Barrett Tumours
Squamous Ca
“Early detection”
WHO?
– Patients with personal history of ENT sq. ca have a
39% calculated survival benefit Lee et al GIE, 2012
– Screening in more vulnerable populations

10. How?
• Certainly NOT just white light endoscopy!!
Lee at al. Endoscopy, 2010

11. HOW?
• NBI - Look for brown ..• Lugol Chromoscopy
– Requires tracheal
intubation
– Unstained pinkish lesions
– More time
– Less cost
– More senstive than NBI in
sq ca but comparable
(p=0.08)
Nagami et al. GIE, 2012
Lee at al. Endoscopy, 2010
[i] Kumagai Y, Inoue H, Nagai K, et al. Magnifying endoscopy, stereoscopic
microscopy, and the microvascular architecture of superficial esophageal
carcinoma. Endoscopy 2002;34:369-375
[ii] Tatsuya Y, Haruhiro I, Shinsuke U, et al. Narrow-band imaging system with
magnifying endoscopy for superficial esophageal lesions. Gastrointest Endosc
2004;59:288-295
IPCL pattern

12. Management
• EMR in Oesophagus
– Lesions <15mm en block
resection is achievable.
– Less time
– Less complications
– Longer follow up period!
– Shorter learning curve
– Cap, band and free-hand
techniques.
• ESD in Oesophagus
– Better for en block
resection in lesions >15mm
– More time
– More expertise
– More complications
• Perforation
• Bleeding
• Latent Stricture formation
but may be diminished by
steroid injection in the
submucosal bed
Konishi et al GIE, 2012

13. QUIZ

14. Gastric Tumours
• MALT
• GIST
• Adenocarcinoma
– classifications
– Early Gastric Cancer (EGC)
• By definition, lesions confined to the mucosa or sumucosa
regardless of Lymph node involvement
– Advanced
• Early detection
• Management
Jingjing et al. GIE, 2012

15. Gastric Adenocarcinoma
“Classifications”
 Histopathological
• Vienna classification
– Category 1: Negative for neoplasia/dysplasia
– Category 2: Indefinite for neoplasia/dysplasia
– Category 3: Noninvasive low-grade neoplasia (low-grade
adenoma/dysplasia)
– Category 4: Noninvasive high-grade neoplasia
• 4.1: High-grade adenoma/dysplasia
• 4.2: Noninvasive carcinoma (carcinoma in situ)
• 4.3: Suspicion of invasive carcinoma
– Category 5: Invasive neoplasia
• 5.1: Intramucosal carcinoma (invasion into the lamina propria or
muscularis mucosae)
• 5.2: Submucosal carcinoma or beyond
D. Morgan uptodate, 2013

16. Gastric Adenocarcinoma
“Classifications”
Morphological
• Lauren classification
– Morphologically, gastric cancers are classified as
• intestinal (well-differentiated) or
• diffuse (undifferentiated)
D. Morgan uptodate, 2013

17. Gastric Adenocarcinoma
“Classifications”
Macroscopic classification
– Borrmann system, with classifications of types I-IV
for polypoid, fungating, ulcerated, and diffusely
infiltrating tumors, respectively.
D. Morgan uptodate, 2013

18. Early Gastric Cancer (EGC)
• Paris Classification
– Type 0-I lesions are polypoid
• Type 0-Ip – protruded,
pedunculated
• Type 0-Is – protruded, sessile
– Type 0-II lesions are
nonpolypoid
• Type 0-IIa – slightly elevated
• Type 0-IIb – flat
• Type 0-IIc – slightly depressed
– Type 0-III lesions are
excavated
D. Morgan uptodate, 2013

19. EGC
 Molecular classification
• A number of molecular markers are associated with
disease progression and recurrence.
• The improved understanding of the genetic alterations
associated with EGC may in the future help better define
the classification of these tumors, their optimal
treatment, and prognosis
• Two general principles have emerged:
– Genetic pathways differ between intestinal-type and
diffuse-type tumors.
– With intestinal type tumors, some genetic changes
occur early in the preneoplastic period, whereas
others occur late or with advanced cancer
D. Morgan uptodate, 2013

20. EGC
• Kudo’s classification polyps

21. EGC .. Diagnosis
(Differentiation & characterization)
• Endoscopy with targeted & non-targeted
biopsies of suspicious lesions is the diagnostic
procedure of choice
• Accuracy of WL Endoscopy for the detection
of EGC ranges from 90 to 96 %
– Subtle erythema
– Flat, slightly depressed or slightly raised lesions
• Improved detection of abnormal lesions may
be possible with chromoendoscopy,
magnification endoscopy, NBI, and AFI
M Ciocirlan et al. DDW Highlights, GIE, 2012

22. EGC & EUS
• EUS is thought to be the
most reliable
nonsurgical method
available for evaluating
the depth of invasion of
gastric cancer,
particularly for T1
lesions
D. Morgan uptodate, 2013

23. EGC
NBI WL Endoscopy

24. QUIZ

25. EMR Vs ESD in EGC
• A meta-analysis of 15 studies found that ESD, compared with EMR,
had higher en bloc and curative resection rates (OR 13.9 and 3.5,
respectively), as well as lower rates of local recurrence (OR 0.09) for
malignant and premalignant lesions.
• A subsequent study of 239 patients with early gastric cancer found
that patients who underwent ESD had lower recurrence rates than
patients who underwent EMR (4 versus 18 percent).
• Complications were higher with ESD, however, unlike in the
oesophagus only perforation was the significant complication;
whereas, there was no significant difference as regards bleeding.
Jingjing et al. meta analysis of ESD and EMR for EGC, GIE, 2012

26. Gastric ESD
A Probst et al. Endoscopic submucosal dissection in
gastric neoplasia-experience from a European center,
Endoscopy, 2010
M Ciocirlan et al. DDW Highlights, GIE, 2012

27. Message
• Early detection is always a goal
• New imaging modalities available but the
cheaper chromoscopy also works
• ESD superior to EMR in terms of efficacy,
histological assessments and subsequent
clinical decisions, and recurrence. But, more
training, complications and time.

28. Thank You