Indications For Endoscopic Mucosal Resection Research Articles

Laparoscopic Intragastric Full‐thickness Excision (LIFE) of Posterior Gastric Lesions under Flexible Endoscopic Control—A Feasibility Study

We have developed a new technique for treatment of intramucosal carcinoma which exceeds the standard indication for endoscopic mucosal resection and carcinoma invading the submucosa without lymph node metastasis that are located in the posterior wall of the stomach, which we refer to as laparoscopic intragastric full-thickness excision (LIFE) under flexible endoscopic control. Three pigs were used for the study. Three trocars were used. The first trocar (trocar # 1) was placed in the subumbilical region to introduce the videoscope, whereas the second and third trocars (trocar # 2 and trocar # 3) were punctured percutaneously into the abdominal cavity. A straight needle with 3-0 silk suture was attached to a T-bar on the wire side and inserted into the abdominal cavity. An area adjacent to the lesion in the posterior wall of the stomach was pierced by the straight needle, which was then pulled into the stomach using the forceps of the endoscope. The T-bar, after being passed through the abdominal wall, was fixed outside the gastric wall, and trocar # 3 was repositioned in the stomach by the percutaneous transgastric route. The posterior wall of the stomach was pulled inward by the T-bar, and the lesion was removed by several excisions with laparoscopic stapling devices inserted through trocar # 3; extraction of the specimen was achieved through trocar # 3. The gastrotomy site was suture-closed using instruments positioned through trocar # 2 and trocar # 3 under laparoscopy. Based on a feasibility study in pigs, the LIFE procedure can be performed for lesions of the posterior wall of the stomach.

Laparoscopic Intragastric Full-thickness Excision (LIFE) of Early Gastric Cancer Under Flexible Endoscopic Control—Introduction of New Technique Using Animal

We have developed a new method for the treatment of stomach lesions in early gastric cancer, which we refer to as laparoscopic intragastric full-thickness excision under flexible endoscopic control. In this procedure, the diseased lesion of the gastric wall is pulled inwards and removed under endoscopy and laparoscopy guidance. A lesion in the anterior wall of the stomach, for which a direct percutaneous transgastric puncture can be performed, is a good indication for laparoscopic intragastric full-thickness excision, similarly to the lesion-lifting method. The purpose of the study is to describe the surgical techniques in the procedure and to assess the clinical relevance of the approach. Three trocars are used in the normal procedure. To perform sentinel lymph node navigation surgery, indocyanine green is injected into the submucosal layer in 4 quadrants under endoscopy. The periphery of the lesion is punctured with the first trocar (trocar(1)) by the percutaneous transgastric route. The wire of the T-bar is introduced into the stomach through trocar(1). The tip of the wire is pulled into the stomach using the forceps of the endoscope. The T-bar, after passing through the abdominal wall, is fixed outside the gastric wall. The second trocar (trocar(2)) is placed at the subumbilical region in the abdominal cavity to accommodate the laparoscope, whereas the third trocars (trocar(3)) are percutaneously punctured into the abdominal cavity. The indocyanine green-colored sentinel lymph node is detected using instruments positioned through trocar(1) and trocar(3), and the absence of lymph node metastasis is quickly confirmed by pathologic examination. Trocar(3) is repositioned in the stomach by the percutaneous transgastric route. The stomach anterior wall is pulled inwards by the T-bar, and the lesion is removed by several excisions with laparoscopic stapling devices inserted through trocar(3); extraction of the specimen is achieved through trocar(3). The gastrotomy site is sutured using instruments positioned through trocar(1) and trocar(3) under laparoscopy. The stomach surgery is performed under gastroscopic guidance, whereas the intra-abdominal procedures are performed under laparoscopy. On the basis of the introduction of new technique using pigs, we believe that this procedure is useful for intramucosal carcinoma, which exceeds the standard indication for endoscopic mucosal resection, and for carcinoma invading the submucosa without lymph node metastasis.

Endoscopic Submucosal Dissection for Superficial Esophageal Squamous Cell Carcinoma and Adenocarcinoma

Introduction: The Japanese Esophageal Association recommended the indication of endoscopic mucosal resection (EMR) as cancers limited to the intraepithelial layer (m1) or proper mucosal layer (m2). However, these lesions often spread laterally, going beyond the limitation of en-bloc resectability by conventional EMR methods. The lesions resected in a piecemeal manner by conventional EMR methods are prone to recur locally. Therefore, we developed a novel method: an endoscopic submucosal dissection (ESD) with a hook knife.

Intraluminal Endoscopic Surgery: The Scioto Returns

Intraluminal Endoscopic Surgery: The Scioto Returns

Expansion of the indications for endoscopic mucosal resection in patients with superficial esophageal carcinoma

Endoscopic mucosal resection (EMR) is a minimally invasive local treatment for superficial esophageal carcinoma (SEC). The use of EMR in patients with m3 or sm1 SEC remains controversial, however. The aim of this retrospective study was to evaluate the histopathological risk factors for lymph-node metastasis and recurrence in patients with m3 or sm1 SEC. The study subjects were 43 patients with m3 or sm1 esophageal squamous-cell carcinomas: 23 patients were treated surgically (the surgery group), and 20 were treated by EMR (the EMR group). We assessed the following variables of the specimens resected by surgery or EMR: tumor depth, maximal surface diameter of the tumor (superficial size), maximum diameter of tumor invasion at the lamina muscularis mucosae (LMM invasion width), and lymphatic invasion. The relationships of these variables to lymph-node metastasis and recurrence were examined. In the surgery group, lymph-node metastasis was found in four patients, all of whom had tumors with lymphatic invasion, a superficial size of at least 25 mm, and an LMM invasion width of at least 2500 microm. In the EMR group, no patient met all three of these criteria, and there was no evidence of lymph-node metastasis or distant metastasis on follow-up after EMR (median follow-up 39 months). In patients with m3 or sm1 SEC, tumors that have lymphatic invasion, larger superficial size, and wider LMM invasion are associated with a high risk for lymph-node metastasis. EMR might be indicated for the treatment of patients with m3 or sm1 SECs without these characteristics.

Endoscopic mucosal resection of early gastric cancer: Experiences in Korea.

Endoscopic mucosal resection (EMR) has been established as one of the treatment options for early gastric cancer (EGC). However, there are many uncertain areas such as indications of EMR, best treatment methods, management of complications and follow-up methods after the procedure. Most studies on this topic have been carried out by researchers in Japan. In Korea, gastric cancer is the most common malignant disease, and the second leading cause of cancer death. In these days, EMR for EGC is widely performed in many centers in Korea. In this review, we will provide an overview of the techniques and outcomes of EMR in Korea.

Reply to Hurlstone et al.

We would like to thank Dr. Hurlstone and his colleagues for his discerning comments about the place of high-magnification chromoscopic colonoscopy (HMCC) and endoscopic ultrasonography in establishing the indication for endoscopic mucosal resection (EMR) for early colonic neoplasia. As mentioned by Hurlstone et al., many publications, including Western papers, have assessed the feasibility, reproducibility, and safety of EMR in the treatment of colonic polyps. EMR is currently regarded as a curative method of treatment for well-differentiated colonic cancer limited to the mucosa or invading less than one-third of the submucosa (sm1). In assessing the results with this method, our study was specifically designed to analyze both local recurrences and the risk of distant metastases after EMR procedures carried out exclusively in patients with early colorectal cancer.

Assessment of lymph node micrometastasis in early gastric cancer in relation to sentinel nodes

The development of endoscopic resection and reduced surgical procedures has progressed in recent years. Lymph node micrometastases can be cited as one of the problems with reduced operations. In this study, we investigated clinicopathological findings and sentinel lymph nodes (SNs) for associations with micrometastases. We discuss the indications for endoscopic mucosal resection (EMR), reduced surgery, and sentinel node navigation surgery (SNNS) based on the results. Immunostaining with anti-cytokeratin antibodies was used as the method of exploring for micrometastases. Comparisons and assessments were made in regard to the presence or absence of micrometastases and various clinicopathological factors. The relationship between the clinicopathological factors and micrometastases was investigated in 120 patients with pT1pN0 gastric cancer. Significant differences in depth of invasion (mucosal [m] versus submucosal [sm]) and histological type (differentiated versus undifferentiated) were observed in both univariate analysis and multivariate analysis. Micrometastases were observed in 32% of the sm cancers, and they were observed in group 2 lymph nodes (no. 7) in 8%. They tended to be more common in the undifferentiated type. The micrometastatic lymph nodes were restricted to blue nodes (BNs) and lymph nodes within the dye flow area of patent blue (used intraoperatively explore for SNs). It is considered that the indications for current EMR and reduced surgery in early gastric cancer are valid from the standpoint of micrometastases. But if the SNNS that has been studied in recent years is introduced, the lymphatic basin dissection method seems valid only if the case is s-pN0 early cancer.

Detection of lymph node micrometastasis in pN0 early gastric cancer: Efficacy of duplex RT-PCR with MUC2 and TFF1 in mucosal cancer

We previously reported that MUC2 is a useful marker in the detection of lymph node micrometastasis (LMM) in gastric cancer. To improve the detection rate, we focused on a TFF1 gene. We used the duplex reverse transcriptase-polymerase chain reaction (RT-PCR) method with MUC2 and TFF1 genes to detect LMM in histologically node negative (pN0) early gastric cancer (EGC) and evaluated their effectiveness. A total of 310 lymph nodes from 33 patients with pN0 EGC were analyzed. All carcinoma specimens were positive for MUC2 and/or TFF1. The positive rate of TFF1 was significantly higher than MUC2 in the undifferentiated carcinoma specimens (p=0.002). The detection rate of duplex RT-PCR with MUC2 and TFF1 was higher than that of MUC2 or TFF1 alone. In mucosal cancer, 7 cases were positive for duplex RT-PCR. Of these 7 cases, 3 were MUC2-positive/TFF1-negative while 4 were MUC2-negative/TFF1-positive. LMMs were not detected in elevated-type primary mucosal cancers with a 20-30-mm diameter. The duplex RT-PCR assay with both MUC2 and TFF1 provides a higher LMM detection rate than either MUC2 or TFF1 alone, especially in mucosal gastric cancer. LMM detected in this manner may prove useful in broadening the indications for endoscopic mucosal resection in elevated-type cancer.

Evaluation of significance of endoscopic mucosal resection (EMR) in early esophageal cancer

4088 Background: Radical surgery for esophageal cancer is very invasive. Endoscopic mucosal resection (EMR), which conserves the esophagus, is a minimally invasive and attractive therapeutic modality for early stage esophageal cancer. However, when the tumor reaches the deep mucosal or submucosal layer (“T1b” according to TNM classification), the incidence of lymph node metastasis (LNM) increases up to 10–50%. Therefore, the indications of EMR have to be clarified. Methods: Retrospective analysis was performed regarding the clinical course of 41 patients who were diagnosed as having cT1bN0M0 esophageal cancer and underwent EMR between 1994 and 2004 at our hospital. Statistical analysis was performed by the log-rank and Kaplan-Meier methods. Results: Thirty nine patients were selected and followed up without any additional therapy after obtaining written informed consent. Twenty patients (51%) had multiple primary cancers, 10 died, and 29 are still alive. MST of the dead patients was 22 months, and 7 of them (70%) died of advanced multiple primary cancers, while death was cause specific in only one case (due to LNM). The survival curves showed no significant differences between the patients with early multiple primary cancers and those without multiple cancers patients (MST = 72 months, p < 0.7784). In most of the dead patients and 23 of the surviving patients, the local lesion was well controlled without any recurrence. Conclusions: Many patients with early esophageal cancer who underwent EMR tended to die of multiple primary cancers. When the patient had early multiple primary cancers, the prognosis was not different from those without such cancer and the local lesion was well controlled. We concluded that EMR is a very useful therapeutic modality for local control as it is minimally invasive, especially in patients with multiple primary cancers. No significant financial relationships to disclose.

Evaluation of the Indication for Endoscopic Mucosal Resection in the Lesions of Submucosal Invading Colorectal Cancer. Sigmoid Colon Is Also the Risk Factor of Lymph Node Metastasis

Aim: Colorectal submucosal invading cancer (sm cancer) is a boundary lesion between endoscopic mucosal resection (EMR) and conventional surgery with regional lymph-node (LN) resection. Because the frequency of LN metastasis is about 10% in the lesion of sm cancer, a large number of cases with this lesion can be cured by EMR. In the present study, we assess the correlation between LN metastasis and parameters, and extract significant factors by multivariate statistical analysis from these parameters and clarify the indication of EMR. Patients and Methods: During the period from July 1985 to April 2005, a total of 426 lesions of sm cancers were detected. We treated 266 carcinomas endoscopically and 160 carcinomas surgically. 123 sm cancers, which were resected endoscopically as the initial treatment, were followed by surgical colectomy because of the possibility of LN metastasis. 283 sm cancers were finally selected for this study. The depth of vertical invasion in the submucosal layer was measured from muscularis mucosae to the deepest cancer gland in micrometer. The patterns of infiltrating growth into the submucosal layer were further divided into two groups: expanding growth with a distinct border, and infiltrating growth with an indistinct border. Result: 1. As for patterns of invasion, the frequencies of LN metastasis in the groups of expanding growth and infiltrating growth were 0.8% (1/119) and 11.6% (19/164), respectively (p = 0.0011). 2. The frequencies of LN metastasis in the lesions of lymphatic permeation positive and venous invasion positive were 14/84 (1.73%, p = 0.0002) and 6/68 (8.8%, p = 0.5912) respectively. 3. As for the location of cancer, LN metastasis is statistically significant high rate in the sigmoid colon (Odds ratio: 3.178, 95% CI: 1.226-8.237). 4.There was no significant relationship between depth of vertical invasion and LN metastasis (P = 0.3432). 5. The results of multivariate statistical analysis from these significant parameters were as follows: infiltrating growth pattern (Odds ratio:14.113, 95% CI:1.73-115.149, p = 0.013); lymphatic permeation positive (Odds ratio:6.319, 95%CI: 2.083-19.169, p = 0.001); sigmoid colon (Odds ratio:4.901, 95% CI:1.664-14.435, p = 0.004). Conclusion: The significant factors which extracted by multivariate statistical analysis were infiltrating growth pattern, lymphatic permeation positive and tumor location of sigmoid colon. The frequencies of LN metastasis were 8/24 (33.3%) in the cancers with all these three factors on the one hand and 0/62(0%) in the cancers with none of these three factors on the other hand (p = 0.0001).

INDICATIONS FOR ENDOSCOPIC MUCOSAL RESECTION FOR EARLY COLORECTAL CANCER: SHOULD THEY BE STRICT OR SHOULD THEY BE EXPANDED?

Endoscopic technologies have been developed greatly. As for early gastric cancer, the indications for endoscopic mucosal resection for early colorectal cancer have been widened recently. Technological advances can support wider and deeper resections using endoscopy but the remaining problem for the endoscopic management of cancer is lymph node metastasis. I discuss here the indication for endoscopic mucosal resection for early colorectal cancer to bring into focus the risk factors for metastasis to lymph nodes.

Is It Possible to Perform EMR in Poorly Differentiated Type of Early Gastric Cancer?

Is it possible to perform EMR in poorly differentiated type of early gastric cancer? Background: Poorly differentiated type of early gastric cancer was not included absolute indication of endoscopic mucosal resection (EMR). However, studies have shown that the lymph node metastasis with poorly differentiated type of mucosal gastric cancer less than 30 mm without histologic ulceration or lymphatic-vascular invasion is extremely low. Aims: This study evaluated the clinical usefullness and limitation of EMR in poorly differentiated type of early gastric cancer. Subjects & Methods: Between February 2001 and September 2004, EMR with conventional method (conventional EMR, n = 4), EMR using cap (EMRC, n = 2) or endoscopic incision and submucosa dissection (EISD, n = 18) were performed on 24 poorly differentiated type of early gastric neoplasm (M:F = 11:13, mean age: 52.76). En bloc resection, complete resection rate, recurrence and additional therapy were evaluated. Results: 1) The en bloc resection and complete resection rate were 77.7% (7/9), 77.7% (7/9) for lesions 10 mm or less in size and 85.7% (6/7), 71.4% (5/7) between 11 and 20 mm, 75% (6/8), 37% (3/8) between 21 and 30 mm Total enbloc and complete resection rate were 79.2% (19/24) and 62.5% (15/24) 2) Complete resection rate according to location of tumor was not significantly differentiated 3) Minor bleeding including oozing occurred in 16.6% (4/24). Perforation occurred in 0% (0/24) 4) 15 cases with completely resected intramucosal cancer have been followed for a median of 15.5 months (range: 3-37 months) without recurrence 9 cases of incompletely resected lesions were 6 with vertical margin positive including submucosal invasion, 7 with lateral margin positive, 4 of both positive 4 cases with 6 with vertical margin positive underwent surgery and 1 of 6 was followed for 26 months without recurrence 2 of 3 with lateral margin positive was treated by destructed therapy argon plasma coagulation after repeated biopsy was not malignancy and 1 underwent surgery. Conclusion: Poorly differentiated type of intramucosal cancer without lymphatic-vascular invasion less than 2 cm in a diameter may be included by indication of EMR.

Endoscopic Mucosal Dissection (ESD) for Early Gastric Cancer (GC): A Prospective Study for Extension of the Indication of Endoscopic Mucosal Resection (EMR)

Background: Minimally invasive treatment such as EMR is widely noticed as a therapy for early GC. ESD is a promising EMR method which enables us to resect lesions en bloc as we like. Recently, in Japan, a guideline of treatment for GC shows some conditions of GC which are hardly associated with nodal metastasis. The aim of this study was to assess efficacy and safety of ESD against those lesions. Patients and Methods: We designed a prospective study in which ESD was applied in patients with differentiated-type GC up to 30 mm in diameter regardless of ulceration or above 30 mm without ulceration, but definite signs of submucosal invasion. According to final diagnosis after the ESD, GCs below, considered to have hardly metastasis, were followed up and otherwise were advised to be operated on additionally; differentiated-type mucosal GC above 30 mm in diameter without ulceration, and GC up to 30 mm with ulceration and/or minute submucosal invasion. The protocol was approved by the ethics committee of Osaka National Hospital, and consent to take part in the study was obtained from patients. Complete resection was defined if the lateral and basal margins were free of tumor pathologically. Followed-up endoscopic examinations are performed 1, 3, 6 months later, and then every six months. Results: Between Nov. 2001 and Nov. 2004, 180 lesions were enrolled. The average size of GC resected was 20 mm (range: 2-70 mm). Of 180 lesions, 144 (84%) were completely resected. Twenty-seven patients were recommended to have additional operation mainly because of massive submucosal invasion or lymphovascular involvement, and nodal metastasis was recognized in two of 12 patients who were actually operated on. Two of the remaining 153 patients recurred locally during follow-up period of median 19 mos (range: 3-36), and both were successfully treated by repeated ESD. No distant metastasis was noted. Perforation and bleeding were encountered in 9% and 8% of the patients respectively, which both happened more frequently in case of GC with ulceration (p < 0.05). No emergent surgery and no immediate mortality was noted. Conclusions: These results suggest that ESD is feasible for large mucosal GC without ulceration or for GC with ulceration and/or minute submucosal invasion up to 30 mm in diameter. However, to extend the indication of EMR for GC, correct pathological diagnosis obtained by en bloc resection is essential and the long-term prognosis should be investigated. Background: Minimally invasive treatment such as EMR is widely noticed as a therapy for early GC. ESD is a promising EMR method which enables us to resect lesions en bloc as we like. Recently, in Japan, a guideline of treatment for GC shows some conditions of GC which are hardly associated with nodal metastasis. The aim of this study was to assess efficacy and safety of ESD against those lesions. Patients and Methods: We designed a prospective study in which ESD was applied in patients with differentiated-type GC up to 30 mm in diameter regardless of ulceration or above 30 mm without ulceration, but definite signs of submucosal invasion. According to final diagnosis after the ESD, GCs below, considered to have hardly metastasis, were followed up and otherwise were advised to be operated on additionally; differentiated-type mucosal GC above 30 mm in diameter without ulceration, and GC up to 30 mm with ulceration and/or minute submucosal invasion. The protocol was approved by the ethics committee of Osaka National Hospital, and consent to take part in the study was obtained from patients. Complete resection was defined if the lateral and basal margins were free of tumor pathologically. Followed-up endoscopic examinations are performed 1, 3, 6 months later, and then every six months. Results: Between Nov. 2001 and Nov. 2004, 180 lesions were enrolled. The average size of GC resected was 20 mm (range: 2-70 mm). Of 180 lesions, 144 (84%) were completely resected. Twenty-seven patients were recommended to have additional operation mainly because of massive submucosal invasion or lymphovascular involvement, and nodal metastasis was recognized in two of 12 patients who were actually operated on. Two of the remaining 153 patients recurred locally during follow-up period of median 19 mos (range: 3-36), and both were successfully treated by repeated ESD. No distant metastasis was noted. Perforation and bleeding were encountered in 9% and 8% of the patients respectively, which both happened more frequently in case of GC with ulceration (p < 0.05). No emergent surgery and no immediate mortality was noted. Conclusions: These results suggest that ESD is feasible for large mucosal GC without ulceration or for GC with ulceration and/or minute submucosal invasion up to 30 mm in diameter. However, to extend the indication of EMR for GC, correct pathological diagnosis obtained by en bloc resection is essential and the long-term prognosis should be investigated.

CLINICAL USEFULNESS OF HIGH‐FREQUENCY ULTRASOUND PROBES FOR NEW INVASION DEPTH DIAGNOSIS IN SUBMUCOSAL COLORECTAL CARCINOMA

Recently it has become very important to diagnose more precisely the invasion depth of submucosal carcinoma prior to endoscopic mucosal resection (EMR) whether selecting lesion is with or without indications for EMR. This study aimed to evaluate the usefulness of high‐frequency ultrasound probes (HFUP) for preoperative diagnosis of vertical invasion depth &lt; 1000 µm or not in superficial and sessile type submucosal colorectal carcinomas. Twenty‐seven cases of superficial and sessile type submucosal colorectal carcinoma were examined with high‐frequency ultrasound probes (HFUP; 15 or 20 MHz radial‐scan ultrasound probes; Olympus Optical, Tokyo, Japan and Fujinon Omiya, Saitama, Japan) at Hiroshima University Hospital and analyzed. Diagnostic accuracy was confirmed by comparing the ultrasonic with the pathologic vertical invasion depth of specimens resected either by EMR or surgical resection. Histologic depth of submucosal invasion was defined as the distance from muscularis mucosae measured microscopically with a micrometer. When muscularis mucosae in the tumor could not be detected, we measured the invasion depth from the surface of the carcinoma to the apex of the deepest invasive portion. As a result, invasion depth between ultrasonic image and histologic findings showed a significantly close correlation. HFUP diagnosis was demonstrated as useful in determining the distance of vertical invasion and for planning a therapeutic strategy against submucosal colorectal carcinomas.

Endoscopic mucosal resection for esophageal cancer

Endoscopic mucosal resection (EMR) is at present the only endoscopic ablation treatment that provides a specimen for histologic analysis. By histologic precise evaluation of the resected specimen, the final treatment strategy for the disease can be decided. Generally, mucosal cancer with no lymph node metastasis is the best candidate for this procedure. We developed a technique of EMR by using a transparent plastic cap (EMRC) in 1992. By using this technique, any part of esophageal mucosa can be easily accessed and safely resected. In this chapter, we discuss indications for EMR, technical details of the EMRC procedure, our clinical results, and how to prevent complications. From 1989 to 2000, we have performed more than 250 cases of EMR in the esophagus. One perforation occurred in the esophagus. Insufficient submucosal saline injection was considered to be a major factor leading to the perforation. Therefore, large-volume injection is strongly recommended because it creates a large bleb and potentially reduces the risk of muscle involvement. By careful adherence to this point, EMR can be safely performed in any part of the esophagus by using a cap.

Indication of endoscopic mucosal resection for early gastric cancer; are safe all patients with mucosal cancer?

Indication of endoscopic mucosal resection for early gastric cancer; are safe all patients with mucosal cancer?

Endoscopic mucosal resection for early adenocarcinoma arising in Barrett's esophagus

A 58‐year‐old man was diagnosed to have an esophageal adenocarcinoma arising in Barrett's esophagus by screening examination at the previous hospital. Endoscopically, a slightly reddish elevated lesion with a central depressed component was detected in the Barrett's epithelium. Endoscopic ultrasonography showed the thickness of the second layer of the esophagus and no enlarged lymph node. Histological examination of a biopsy specimen revealed well or moderately differentiated adenocarcinoma. From these findings, the lesion was diagnosed as a mucosal esophageal cancer, type IIa + IIc, arising in Barrett's esophagus. As he refused operation, the lesion was resected endoscopically with his informed consent. Histologically, the resected specimens showed moderately differentiated adenocarcinoma arising in Barrett's esophagus. The adenocarcinoma had invaded the superficial muscularis mucosa, but was limited to the deep one with no vessel invasion. Barrett's esophagus often has a double muscularis mucosa. Connective tissues containing vascular and lymphatic vessels exist between them. However, one consideration is whether the existence of vessels between the double muscularis mucosa and the presence of vessel invasion are risk factors for metastasis. In order for a definitive indication for endoscopic mucosal resection, the frequency of lymph node and distant metastasis in cases of early Barrett's cancer needs to be investigated.

Evaluation of Endoscopic Mucosal Resection for Superficial Esophageal Carcinoma

Esophageal superficial carcinoma safely can be resected surgically or endoscopically. We evaluated indications for endoscopic mucosal resection (EMR) and optimal treatment modality for superficial carcinoma of the esophagus based on clinical and pathologic analyses. Between January 1, 1984, and September 30, 1999, 113 patients with superficial cancer of the esophagus underwent surgical or endoscopic resection (n = 33 patients, 36 lesions). The two-channel method, esophageal EMR-tube method or EMR cap-fitted panendoscope was used. Mucosal and submucosal cancers were classified to be epithelial layer (m1), proper mucosal layer (m2), muscularis mucosae (m3), upper third of the submucosal level (sm1), middle third of the submucosal layer (sm2), or the lower third of the submucosal level (sm3) cancers, according to criteria of the Japanese Society for Esophageal Disease. Absolute indication for EMR was restricted to m1 or m2 cancers, and relative indications for EMR included m3 or sm1 lesions. In our department, indications for EMR were not related to size or circumference of lesions. Lymph vessel invasion and lymph node metastasis markedly increased in lesions that infiltrated the lamina muscularis mucosa (m3). All lesions resected with use of EMR were 0-II (flat), and the depth of invasion in 10 0-IIa or 0-IIb lesions was m1 or m2. Twenty-one 0-IIc lesions were distributed widely from m1 to sm1. All 0-IIa+IIc lesions were m3 or sm1. Preoperative diagnosis accurately was established preoperatively in 61% of patients. Complications related to EMR were detected in 21% of patients and included perforation, stenosis, and hemorrhage. Ten patients also received radiotherapy, chemotherapy, or esophagectomy with lymph node dissection after use of EMR. No such combination therapy was administered in six patients with m3 lesions, but without lymph vessel invasion. All patients treated with use of EMR, including patients with m3 cancer who did not receive additional treatment, are living without recurrence. Local resection with use of EMR could be regarded to be the preferred treatment of superficial esophageal cancers limited to the lamina propria mucosae. Endoscopic mucosal resection also could be regarded to be the preferred treatment of m3 cancer without lymph vessel invasion. Use of additional therapy, such as radiotherapy, allows the use of EMR for m3 cancer with lymph vessel invasion or sm1 cancers.

Moderator's Comment: Extension of Indications for Endoscopic Mucosal Resection of Colorectal Cancer

Moderator's Comment: Extension of Indications for Endoscopic Mucosal Resection of Colorectal Cancer