Diapositiva 1 - Ospedale Sacro Cuore Don Calabria

Dr. Paolo Bocus
Direttore U.O.C. di Gastroenterologia ed Endoscopia Digestiva
Ospedale Sacro Cuore – Don Calabria
Negrar (VR)
Endoscopia Diagnostica
(Ecoendoscopia Diagnostica)
13 Dicembre 2016
Diagnosi endoscopica
Missed cancers 7,2%
2004
Missed cancers 7,8%
2014
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Studio retrospettivo inglese di coorte, basato sulla popolazione, ha identificato pazienti con diagnosi di
cancro dell’esofago tra aprile 2011 e marzo 2012 utilizzando due database connessi (National
Oesophago-Gastric Cancer Audit and Hospital Episode Statistics).
Il main outcome era la percentuale di precedenti endoscopie nei 3 - 36 mesi prima della diagnosi di
cancro.
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6943 nuovi casi identificati, dei quali 7.8 % (95 % CI 7.1 - 8.4) erano stati sottoposti ad endoscopia nei 3 36 mesi precedenti la diagnosi.
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Stadio 0/1:
Stadio 2
Stadio 3-4
34.0 % endoscopia nei 3-36 mesi precedenti
10.0 %
4.5 %.
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Stadio 0/1
22.1 % diagnosticati dopo ≥ 3 endoscopie nei precedenti tre anni.
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Pazienti con un tumore dell’esofago cervicale sono stati sottoposti ad un numero maggiore di
endoscopie nei 3 - 12 mesi precedenti (P = 0.040).
La diagnosi più frequente è stata un’ulcera esofagea (48.2 % dei reperti).
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Il cancro dell’esofago può non essere individuato in circa il 7.8 % dei pazienti con successiva diagnosi di
cancro.
Chadwick G, et al. Endoscopy 2014 Volume 46, Issue 7; Pages 553-60
Cancers Rarely Missed by Upper Endoscopy
From Reuters Health Information
Cancers Rarely Missed by Upper GI Endoscopy
By Will Boggs, MD
NEW YORK (Reuters Health) Jan 29 - In Western populations, cancer is very rarely missed on esophagogastroduodenoscopy (EGD), say researchers
from Australia in the American Journal of Gastroenterology.
"Although EGD remains an imperfect test, false-negative examinations are uncommon, particularly in those with a completely normal EGD," Dr.
Spiro C. Raftopoulos from Sir Charles Gairdner Hospital, Perth, Western Australia, told Reuters Health in an email.
In an advance online article published January 12th, he and his colleagues note that in reports from Japan, rates of missed upper GI cancers
are as high as 25%, but "these studies are not necessarily applicable to the West."
In their analysis of data on 28,064 EGDs done in Australia from 1990 to 2004, the researchers identified only 29 cases of missed cancer, 26
possible missed cancers (detected more than a year after EGD), and 75 latent cancers (diagnosed at least 3 years after a normal
EGD).
Only 8 patients with a missed cancer had their EGD read as completely normal; most of those with missed cancers (72.4%) had an abnormality
described at the site of the cancer. The missed cancer rate (i.e., the number of missed cancers divided by the total number of cancers diagnosed
during the study period) was 1.1% for normal EGDs and 3.5% for all EGDs.
The only significant factor associated with a missed cancer was an alarm symptom of either dysphagia or suspected bleeding.
The likelihood of missed or new cancer was independent of operator type or equipment used, the researchers note.
"Given that false-negatives do occur, this needs to be incorporated into the clinical decision making in patients with ongoing
symptoms after EGD, and where appropriate, they should undergo repeat examination to rule out a missed cancer," Dr. Raftopoulos
said.
"In particular, those patients with alarm symptoms (dysphagia, unintentional and sustained weight loss, suspected bleeding) who present for
endoscopy, I now have a much lower threshold to biopsy any abnormality seen, and if symptoms are persistent, I follow these patients up with an
early repeat endoscopy, and consider further investigations such as cross-sectional imaging (e.g., CT chest/thorax)," he added.
Am J Gastroenterol 2010
Cancro squamocellulare superficiale
Imparare a:
Riconoscere la lesione
Definire i margini della lesione
Determinare il livello di infiltrazione della lesione ed il
rischio di interessamento linfonodale
Imparare ad utilizzare:
Endoscopia ad alta risoluzione
Cromoendoscopia elettronica (NBI FICE I-Scan AFI)
Cromoendoscopia con coloranti vitali
Le classificazioni di
Parigi (lesioni visibili)
Praga (Barrett)
Inoue (Squamocellulare)
Siewert
I protocolli bioptici di
Seattle e Levine (e del registro del Barrett EBRA!)
NBI (Narrow Band Imaging)
FICE (spectral image processing technology for High Contrast Imaging)
I-Scan
AFI (Autofluorescence Imaging)
Paris Classification of Superficial Neoplastic Lesions in the Digestive Tract
Protocollo di Seattle
Time consuming
Risk of bleeding
Poor adherence
Costs
BSG Guidelines 2005
Wang KK AmJG 2008
Spechler SJ Gastroenterology 2011
Curves WL EUR J Gastro Hep 2008
Abrams JA Clin Gastro Hep 2009
Wani S Gastroenterology 2011
Anamnesi
• Precedenti neoplasie capo-collo
• Forti fumatori, bevitori
• Regioni ad alto rischio
Molta attenzione
Adenocarcinoma in Barrett
Barrett “lungo” e bx con HGD su area rilevata Parigi IIa a 27 cm
Pit Pattern
Pit Pattern
Ac Acetico in Barrett
Blu di Metilene in Barrett
Cromoendoscopia con coloranti
Cromoendoscopia con Lugol in BE
Cromoendoscopia con Lugol in SCC
Indaco Carminio
Endoscopic tri-modal imaging is more effective than standard endoscopy in
identifying early-stage neoplasia in Barrett's esophagus.
Trimodal endoscopy
Trimodal endoscopy (TME) is a combination of autofluorescence endoscopy (AFI)
with high-magnification endoscopy (HME) and narrow-band imaging (NBI).
Curvers WL et al. Gastroenterology. 2010 Oct;139(4):1106-14.
Classificazione dei coloranti
Coloranti Vitali
Coloranti di contrasto
Coloranti reattivi
Per Tatuaggio
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•
•
•
•
•
Lugol
Blu di metilene
Cresyl violetto
Blu di toluidina
Indaco di Carminio
Acido acetico
Rosso Congo
Rosso Fenolo
• Inchiostro di China
Classificazione dei coloranti
Colorante
Azione
Non colora
Uso Clinico
Lugol
Interagisce con i vacuoli di
glicogeno dell’ epitelio
malpighiano
Displasia
Cellule infiammatorie
Neoplasia squamosa
mucosa colonnare
Ca squamoso dell’esofago
Esofagite da reflusso
EB (delinea epitelio squamoso
da ep colonnare
Blu di
Metilene
Cellule di tipo intestinale
assorbenti
Epitelio squamoso e gastrico
Mucosa colonnare
Metaplasia intestinale gastrica
Barrett (colora l’epitelio
specializzato colonnare e non la
mucosa di tipo gastrico)
Indaco di
Carminio
Mette in rilievo la
superficie mucosa senza
essere assorbito.
Utile per rilevare le irregolarità
o nodularità di parete (es. polipi
piatti del colon)
Questo ci consente di porre diagnosi e di iniziare a stadiare la lesione:
IPCL: intraepithelial papillary capillary loop
Inoue H et al. Ann. Gastroenterol 2015 Jan-Mar;28(1):41-48.
IPCL: intraepithelial papillary capillary loop
Paris classification
Inoue classification
IPCL Tipo IV
IPCL Tipo V 1
IPCL Tipo V n
Inoue H et al. Ann. Gastroenterol 2015 Jan-Mar;28(1):41-48.
Conclusions: The overall diagnostic
accuracy of both HR-E and HR-EUS with
a 20 MHz miniprobe in early
oesophageal cancer was high
(approximately 80%), with no significant
differences between the two techniques.
HR-E and HR-EUS provide a high level
of diagnostic accuracy for mucosal
tumours and submucosal tumours
located in the tubular part of the
oesophagus.
With submucosal tumours located at
the oesophagogastric junction or with
infiltration of the first third of the
submucosa however, the diagnostic
accuracy of both techniques is not yet
satisfactory.
Stadiazione:
la conoscenza dello stadio
della malattia è importante per
fornire al paziente delle cure il
più possibile appropriate, oltre
che per formulare una
probabile prognosi
(Wikipedia).
New TNM staging (7th ed., 2010)
Siewert Classification
Siewert Type I: adenocarcinoma of the lower esophagus with the center located within 1
cm to 5 cm above the anatomic EGJ.
Siewert Type II: true carcinoma of the cardia with the tumor center within 1 cm above and
2 cm below the EGJ.
Siewert Type III: subcardial carcinoma with the tumor center between 2 and 5 cm below
EGJ, which infiltrates the EGJ and lower esophagus from below.
Siewert type III lesions are considered
gastric cancers, and thus the NCCN
Guidelines for Gastric Cancer should be
followed. In some cases additional
esophageal resection may be needed in
order to obtain adequate margins.
2013
To EUS or not EUS?
Gerke H. Endoscopic mucosal resection for early esophageal cancer:
skip EUS and cut to the chase. Gastrointest Endosc. 2011 Apr.
Pouw RE et al. Do we still need EUS in the workup of patients with
early esophageal neoplasia? A retrospective analysis of 131 cases.
Routine use in patients with Barrett’s esophagus
without dysplasia or focal lesions cannot be
endorsed.
Its main use in Barrett’s esophagus appears to be in
the detection of more deeply invading tumors, and
metastatic lymph nodes, which would preclude the
appropriate use of endoscopic ablative therapies.
Savoy AD Wallace MB. J Clin Gastroenterol Volume 39, Number 4, April 2005
Staging Strategies
EGDS (zoom, NBI, FICE, etc)
EUS (+/- FNA)
EMR / ESD
CT/PET scan
2013
2013
Complete staging of esophageal cancer has
traditionally involved EUS and FNA in conjunction
with cross-sectional imaging.
Numerous studies have demonstrated the
superiority of EUS in both local tumor (T) and
nodal (N) staging over CT.
Accuracy for T staging approaches 90% in
superficial
and partially obstructing esophageal cancers.
The accuracy of EUS for nodal staging based
solely on
these acoustic criteria approaches 80%.
FNA of lymph nodes increases nodal staging
accuracy to 92% to 98% by using pathologic
staging as the criterion standard.
GOALS OF EUS IN BARRETT’S ESOPHAGUS WITH HGD AND CANCER
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Exclude the presence of advanced cancer that is not resectable by EMR or
ESD (>T1 disease)
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Distinguish between early cancer confined to the mucosa (T1a) and
submucosal invasion (T1b)
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Assess for lymph node metastasis
Mappaggio
+
EUS
EUS T1m Accuracy 75%
EUS staging of T1 Esophageal
Adenocarcinoma
19 studies with 1019 patients with
superficial adenocarcinoma of the
esophagus comparing EUS with surgical
or EMR pathology
–T1a: Sensitivity 85%, Specificity 87%
–T1b: Sensitivity 86%, Specificity 86 %
–Accuracy 85%
Thosami, N. et al. Gastrointest Endosc 2012;75:242-253
HFP-EUS staging of T1 Esophageal Adenocarcinoma
Seerden, T.C., et.al. Gastrointest Endo Clin N Am 21; 2011: 53-66
DIFFICULTIES IN STAGING T1/T2 LESIONS
Crypts and villi in BE are more heterogenous than layered architecture of
squamous epithelium
BE can be associated with inflammatory changes and presence of double
muscularis mucosae
Motility of Esophagus (HFP EUS)
BE lesions located in the distal esophagus/cardia EUS interpretation can be
difficult
Endoscopists experience/Technical difficulties
RESULTS:
70 relevant reports that included 1,874 patients
who had esophagectomy performed for HGD or
intramucosal carcinoma in Barrett ’ s esophagus.
Lymph-node metastases were found in 26
patients (1.39 % , 95 % CI 0.86 – 1.92).
No metastases were found in the 524 patients
who had a final pathology diagnosis of HGD
26 had positive lymph nodes
(1.93 % , 95 % CI 1.19 – 2.66 % ) of the 1,350
patients with a final pathology diagnosis of
intramucosal carcinoma.
Dunbar KB, Spechler SJ. The Risk of Lymph-Node Metastases in Patients With High-Grade Dysplasia or Intramucosal Carcinoma in Barrett ’ s
Esophagus: A Systematic Review. Am J Gastroenterol. 2012 Apr 10
sm1
sm2
sm3
Increasing depth of
submucosal invasion
is associated with a
disproportionately
increasing occurrence
of regional lymph node
metastases, leading to
decreasing survival.
A submucosal
cancer is not a
superficial
cancer!
Raja et al. Esophageal submucosa: The watershed for esophageal cancer. The Journal of Thoracic and Cardiovascular Surgery 2011
RISK OF LN INVOLVEMENT IN ADENOCARCINOMA OF THE ESOPHAGUS
CORRELATING WITH T-STAGE
T-STAGE
LN RISK OF MALIGNANCY
T1is/T1a (mucosa)
<2 %
T1b (submucosa)
>20%
Buskens, C.J., et. al. Gastrointest Endosc 2004; 60: 703-710
Incidence of lymph node metastases in superficial esophageal cancers according to depth of invasion
Shimada, H, et al. Prediction of lymph node status in patients with superficial esophageal carcinoma: analysis of 160 surgically resected cancers.
Am J Surg 2006; 191:250.
NO FNA
FNA
Puli et al World J Gastroenterol 2008 May 21; 14(19): 3028-3037
Puli et al World J Gastroenterol 2008 March 14; 14(10): 1479-1490
EUS-FNA of LN associated with Barrett’s with HGD and Intramucosal Adenocarcinoma
25 patients with HGD or Intramucosal Adenocarcinoma in Barrett’s referred for EUS staging
HGD in 12 patients, Intramucosal Adenocarcinoma 13 patients
5 patients had submucosal invasion by EUS
7 patients had suspicious LN.
EUS-FNA confirmed malignancy in 5
Conclusion: EUS-FNA of suspicious LN changed management in 20% of patients
Shami, V.M. Endoscopy 2006; 38: 157-161
Neoplasie avanzate
Strutture adeguate
TAKE HOME POINTS
Accorgimenti tecnici
Miglior strumento disponibile (NBI, FICE, I-Scan, AFI, EUS ETC)
Cromoendoscopia con colorazioni
Optimal Setting (sedazione, adeguato tempo per l’indagine)
Punti di difficile valutazione (cervicale, jato, ernia)
Strumento pediatrico nelle lesioni avanzate
Valutare la eventuale necessità di dilatazione (Savary) nelle lesioni
avanzate
TAKE HOME POINTS
Segnalare nel referto:
Tipo di lesione secondo la classificazione di Parigi (morfologia e dimensioni)
La sede della neoformazione rispetto agli incisivi, allo sfintere esofageo superiore
ed inferiore
Grado di coinvolgimento circonferenziale e di ostruzione al passaggio
Posizione, lunghezza ed estensione dell’esofago di Barrett + noduli o altre lesioni
visibili (Class. di Praga)
Multiple biopsie da (6 a 8 sulle lesioni) e mappaggio con protocolli adeguati
(Seattle e o Levine)
Eventualmente pinze jumbo nel fu del Barrett
TAKE HOME POINTS
EUS nella stadiazione del Barrett con HGD o Early Adenocarcinoma e nelle
forme superficiali di SCC può essere utile per:
– Escludere l’invasione nella sottomucosa >T1a (o oltre T2)
– Valutare la presenza di linfonodi sospetti e/o malattia metastatica
– Eseguire la EUS-FNA dei linfonodi sospetti (se questo dato può cambiare il
management del paziente)