1. Treatment of superficial neoplastic lesion of esophagus
경희의료원 소화기 내과
R3 조창현/ R1 이은정/ Pf 장재영

2. Background 국내의 식도암 전체 암 중 1.7% ( 남자; 2.8%, 여자; 0.3% ) 사망률 2.4% ( 7th )
조기 진단
점막층 ; 5년 생존율이 90∼100%,
점막하층 국한 : 65∼75%
Increasing globally, particulary in asia

3. Contents
Definition
Staging work up
Treatment
Case review

4. Definition Noninvasive neoplastic lesion (dysplasia/adenoma)
Invasive, T1 ( invasion is limited to mucosa and submucosa
Nonobstructive, asymptomatic, & by screening
The Paris endoscopic classification of superficial neoplastic lesions

5. Esophagus—LN invasion
m1+m2
M3+sm1
sm2+sm3
No (%)
5/352 (<2%)
86/449 (19%)
393/889
(44%)
The Paris endoscopic classification of superficial neoplastic lesions

6. Staging work up

7. Staging w/u 5 year survival rate
Enzinger, PC. Esophageal cancer. N Engl J Med 2003; 349:2241

9. EUS T stage —accuracy : 89 % Tumors >5 cm, stenotic or GE ↓
N stage —accuracy : 80 %
Imaging, FNAB
Malignant LNs ; >1 cm, round, hypoechoic

10. T staging
Endoscopy 2003; 35 (5): 429–436

11. N staging
Van Vliet, EP, Staging investigations for oesophageal cancer: a meta-analysis.
Br J Cancer 2008; 98:547

12. CT Distant metastatic disease
Limited value for locoregional tumor staging
Differentiate depth ( T 42 % ) ↓
Sensitivity for LN ↓

13. PET CT Distant metastatic disease Accuracy for locoregional depth ↓
Regional LNs ↓

14. Option Laparoscopy Preop evaluation
No metastasis & tumor of GE junction
Bronchoscopy
No metastasis & tumor of carina

15. Work up

17. Superficial neoplastic lesion of esophagus
Treatment
Superficial neoplastic lesion of esophagus

18. Treatment of superficial neoplastic lesion of esophagus
Esophagectomy
EMR, ESD

19. Esophagus invasion —LN invasion %
m1+m2
m3+sm1
sm2+sm3
No (%)
5/352 (<2%)
86/449 (19%)
393/889
(44%)
EMR
Possible
Uncertain
Surgical
The Paris endoscopic classification of superficial neoplastic lesions

20. Esophagectomy Maximize cure chance
M1,M2,M3,SM15year recurrence free:97 %
SM2, SM  %
QOL ?
Dysphagia, cough, reflux
Op mortality rate : 4 ~ 10 %
Periop morbidity rate : 26 ~ 41 %
Esophageal Cancer N Engl J Med 2003;349:

22. EMR , ESD Potentially curative option Histologic Dx Cx ↓
Technique, devices ↑

23. m1,m2
World J. Surg. 25, 424–431, 2001

24. m3 Katada C et al. EMR for ESCC invading the muscularis mucosae.
Endoscopy 2007; 39: 779~783

25. Cause−specific Kaplan±Meier survival curve in patients with esophageal squamous cell carcinoma invading the muscularis mucosa.

26. m3,sm1
GI ENDOSCOPY VOLUME 59, NO. 2, 2004

28. Superficial neoplastic lesion of esophagus
Case Reviews
Superficial neoplastic lesion of esophagus

29. Case 1 Preop stage T1b, N0, M0 Postop stage T1a, N0, M0 ESD
SM invasion ↑
기술적으로 어려움
Esophagectomy
Indication
Morta, Morbidity ↑

30. Case 2 Preop stage T1b, N0, M0 Postop stage T1b, N0, M0 ESD
SM invasion ↑
기술적으로 어려움
LN mets 가능성 ↑
PostESD chemoRT
Esophagectomy
Indication
환자 거부
Morta, Morbidity ↑