Review

A minimally invasive treatment for early GI cancers

Lady Katherine Mejía-Pérez, MD, Seiichiro Abe, MD, Tyler Stevens, MD, Mansour A. Parsi, MD, Sunguk N. Jang, MD, Ichiro Oda, MD, John J. Vargo, MD, MPH, Yutaka Saito, MD, PhD and Amit Bhatt, MD
Cleveland Clinic Journal of Medicine September 2017, 84 (9) 707-717; DOI: https://doi.org/10.3949/ccjm.84a.16063

Article Figures & Data

Figures

  • FIGURE 1
    FIGURE 1

    Endoscopic submucosal dissection, a minimally invasive treatment for early-stage cancers of the gastrointestinal system, involves the following steps:

    1. Marking the circumference of the tumor

    2. Lifting the tumor by injecting saline or another inert substance beneath it

    3. Cutting around the outside of the tumor margin

    4. Dissecting and removing the tumor

  • FIGURE 2
    FIGURE 2

    Treatment algorithm based on the histopathologic evaluation after resection of early gastric tumors.

    Based on information from the Japanese Gastric Cancer Association, reference 9.

Tables

  • TABLE 1

    Indications for endoscopic resection for gastric tumorsa

    Absolute indication for EMR or ESDExpanded criteria for ESD
    Histologic typeDifferentiatedDifferentiatedDifferentiatedUndifferentiated
    Tumor diameter≤ 2 cm> 2 cm≤ 3 cm< 2 cm
    Ulcerative findingsNegativeNegativePositiveNegative
    Depth of invasionT1aT1aT1aT1a

    • ↵a Endoscopic resection here refers to endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD).

    • Based on information from the Japanese Gastric Cancer Association, reference 9.

  • TABLE 2

    Advantages and disadvantages of available treatments for early gastrointestinal neoplasms

    Treatment categoryTreatmentAdvantagesDisadvantages
    EndoscopicEndoscopic submucosal dissection (ESD)Noninvasive
    Achieves en bloc resection of lesions regardless of size or fibrosis
    Allows margin evaluation
    Lower cost vs surgery    		Higher cost compared with EMR
    Longer procedural time compared with EMR
    Specialized training and facilities needed
    Risk of recurrence
    Endoscopic mucosal resection (EMR)Noninvasive
    Cost-effective
    Decreased procedural time
    Decreased length of stay
    More local experience and data than with ESD    		No histologic margin control
    No resection of fibrotic lesions
    Risk of recurrence
    SurgicalSurgical excisionLower rates of recurrence
    Not limited by size, fibrosis, or depth of involvement    		Invasive
    More procedure-associated comorbidity
    Longer hospital length of stay
    Higher cost
  • TABLE 3

    Indications for endoscopic resection of squamous cell cancer of the esophagusa

    Absolute indicationsRelative indications
    Depth of invasionM1, M2M3, SM1 (< 200 pm)
    Circumference≤ 2/3≤ 3/4
    Paris classification0-II

    • ↵a Endoscopic resection here refers to endoscopic mucosal resection or endoscopic submucosal dissection

    • M1 = intraepithelial carcinoma; M2 = tumor located between M1 and M3; M3 = tumor extremely close to or infiltrating the muscularis mucosa; SM1 = submucosally invasive tumor that extends up to 200 μm below the lower border of the muscularis mucosa

    • Based on information from the Japan Esophageal Society, reference 15.

  • TABLE 4

    Indications for endoscopic resection of colorectal lesions

    Type of lesionTumor size (mm)
    < 1010–2020–30> 30
    LST-NGEMREMRESDESD
    LST-GEMREMREMRESD
    Intramucosal villous tumorEMREMREMRESD
    Intramucosal tumor with nonlifting signEMREMR or ESDESDESD
    Rectal carcinoid tumorEMRESD or surgerySurgerySurgery

    • EMR = endoscopic mucosal resection; ESD = endoscopic submucosal dissection; LST-G = laterally spreading tumor, granular type; LST-NG = laterally spreading tumor, nongranular type

    • Based on information from the Japanese Society of Gastroenterology, reference 61.

  • TABLE 5

    Indications for endoscopic submucosal dissection for colorectal cancer

    Lesions for which en bloc resection with endoscopic mucosal resection is unlikely to succeed
    Laterally spreading tumor, nongranular type
    Lesions with a Vi-type pit pattern
    Carcinoma with shallow T1 invasion
    Large depressed-type tumors
    Large protruding-type tumors suspected to be malignant
    Mucosal tumors with submucosal fibrosis
    Sporadic localized tumors in conditions of chronic inflammation
    Local residual or recurrent early carcinomas after endoscopic resection

    • Based on information from the Japan Gastroenterological Endoscopy Society, reference 32.

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