I am Jun Haeng Lee at Samsung Medical Center, Seoul Korea. My topic today is Diagnostic and Therapeutic Endoscopy for Early Gastric Cancer. This slide shows the Korean cancer statistics in 2014. As you can see, gastric cancer is the most common malignant disease in males, and the number 4 in females. The incidence is still high, but two third of all gastric cancers are curatively treated. The incidence of gastric cancer in Korea is slowly decreasing, but the mortality rate is rapidly decreasing. In 2013, the mortality/incidence ratio was 0.31 in Korea. This pictures shows the estimated gastric cancer incidence and mortality in 2012. Korea and Mongolia is number one and two in the incidence of gastric cancer. The survival rate is highest in Korea followed by Japan. It is probably due to early detection by screening program and high surgical and endoscopic techniques. +++++ First topic is endoscopic diagnosis of early gastric cancer. EGC is defined as a gastric cancer limited in the mucosa or submucosal layer regardless of lymph node metastasis. It is classified as protruded, superficial, and excavated types. The superficial type is further divided into flat elevated 2a, just flat 2b, and slightly depressed 2c types. The most common type is 2c You can see in the cartoon, EGC can have a lot of fold abnormalities and border changes. Typical abnormal folds in EGC includes abrupt tapering, abrupt interruption, clubbing and fusion. There are a few blind areas in the stomach. In order to observe the whole stomach without blind area, initial endoscopy training is very important Left-hand side is a Koken simulator video clip and you can compare with the real patient endoscopy using Pentax i10c gastroscope. As you can see, it is quite similar. Beginners can learn a lot of technical tips with gastroscopy box simulator training. Due to time limitation, I will move into case discussions. The first case is EGC 2a. A 79 years old male patient was referred for the further evaluation of gastric neoplastic lesion detected in the screening endoscopy. It was a 2cm sized pale slightly elevated lesion in the greater curvature side of the gastric antrum. Biopsy was not done in the screening center but the patient had a history of adenoma. He did not receive any treatment for gastric adenoma with low grade dysplasia for two years. / We performed endoscopy and the biopsy was atypical glands with high grade dysplasia and focal carcinomatous transformation. Endoscopic submucosal dissection was done with Pentax i10c gastroscope, and the final pathology was moderately differentiated tubular adenocarcinoma, 20mm in long diameter, and limited in the mucosal layer. The second case is EGC 2b Can you see the border of this superficial cancer? Do you agree with me? Subtotal gastrectomy was done. And the size was more than 5cm, but its was limited in the muscularis mucosa. The next case is a very young patient. A 19 year old female student visited a local clinic due to an episode of melena. In the initial endoscopy, a flat elevated lesion was found in the esophagogastric junction. The biopsy was reported as at least high grade dysplasia. Immediate follow-up endoscopy was done at the same clinic and the biopsy result was tubular adenocarcinoma well differentiated. After referral to Samsung Medical Center, we repeated endoscopy again and the biopsy result was tubular adenocarcinoma moderately differentiated. What would you recommend? Total gastrectomy, or proximal gastrectomy or endoscopic treatment? My option was ESD. Endoscopic submucosal dissection was done by professor Yang Won Min of our institution. Standard procedures were followed. The final pathology was 16mm sized EGC IIa limited in the mucosal layer. In the follow up endoscopy, ESD ulcer was completely healed. The other gastric mucosa was completely normal and there was no evidence of Helicobacter pylori infection in Giemsa staining and serology. The final case is mixed type EGC. On the anterior wall of the mid-antrum, an ulcer with blurred edge and heaped up margin was found. In the second endoscopy after referral, it looked like a flat elevated lesion with mild depression on the top. The central depressed area is much less in the second endoscopy. I think it is due to PPI. The patient started to take PPI after the initial endoscopy. Subtotal gastrectomy was done and it was a deep submucosal cancer. +++++ Next topic is ESD for EGC in Korea. There are two types of indications. Absolute indication means differentiated type mucosal cancer without ulcer and not bigger than 2 cm. Expanded indications include differentiated type EGCs bigger than 2 cm and selected cases of undifferentiated type EGCs. This is a real world statistics. Among 355 early gastric cancers initially treated by ESD, 120 cases, this is 34 percent, belonged to the beyond absolute indication group. Some of them require surgery. Ten percent of patients in the absolute indication group were initially treated by surgery, and you can see the reason in the box at the right hand-side corner. Suspicious lymphadenopathy is the most common reason for surgery. In Korea, ESD candidates are usually selected by the absolute indications. After ESD, expanded criteria is applied to determine whether the resection was curative. There are controversies about the safety of ESD for expanded indication cases. ItĄŻs partially because Korean studies consistently showed higher risk of lymph node metastasis in expanded indication cases than Japanese data. IĄŻll show you some examples. Korean practice guideline for gastric cancer was just released. The first statement is about absolute indication. Endoscopic resection is recommended for well or moderately differentiated tubular or papillary early gastric cancers meeting the following endoscopic findings: endoscopically estimated tumor size <= 2cm, endoscopically mucosal cancer, and no ulcer in the tumor. LetĄŻs talk about expanded indications. Do you think total gastrectomy was necessary for a 45 years old lady with 1 cm signet ring cell carcinoma? In my opinion, it was too much. Less invasive options should be considered. What would you recommend for a 40 years old woman with a small flat signet ring cell carcinoma? I performed ESD and the final pathology was SRC, 10 mm, limited in the lamina propria layer, clear resection margins, and no lymphatic invasion. ESD for expanded indication cases can be selectively performed in the individual cases. Flat small signet ring cell carcinomas are frequently treated by ESD in Korea. Outcome of endoscopic treatment of EGC with differentiated type histology is well established. We have ITT analysis such as comparison with surgery using propensity score matching. We also have PP analysis such as long-term follow-up data after curative resection or non-curative resection. At my institution, we performed a propensity score-matching analysis between the two groups, endoscopic resection or surgery for differentiated type EGCs. The overall survival was almost the same in the two groups. Because of the metachronous recurrences, disease free survival and recurrence free survival is better in the surgery group. However, there was no difference in the disease specific survival. Next evidence is the PP analysis. ItĄŻs a single-arm long-term follow-up data for curatively resected differentiated-type EGCs. Excluding metachronous recurrences, we experienced only one case of local recurrence, and 2 cases of extragastric recurrences. This is the overall survival. There was no statistical difference between absolute indication and expanded indication. There are the pictures of the two extragastric recurrences in our series. The top case belonged to the absolute indication group, and the lower case belonged to the expanded indication group. This is another PP analysis for non-curatively resected differentiated type EGCs. In cases with risk of lymph node metastasis, 70% were operated, and 30% were observed without surgery. In the surgery group, 11 have lymph node metastasis, which means 5.7%. In terms of the overall survival, additional surgery was related with better outcome. Survival benefit of additional surgery after non-curative resection was shown in a propensity matched study by doctor Eom at Korea National Cancer Center. As you can see at the right-hand side picture, the overall mortality of observation group was higher than that of the matched initial standard surgery patients. Maybe we are doing too much surgery after ESD. Do you think surgery is necessary for mucosal cancer with lymphovascular invasion? As you can see in the red box, in lymphovascular invasion positive patients within the traditional absolute indication ? mucosal cancer, differentiated type, no ulcer, less than 2 cm, there was no lymph node metastasis in surgery. Careful observation without additional surgery can be an option for this group of patients. +++++ Next topic is ESD for EGC with Pentax Splash M knife Splash M-knife is a new multi-functional ESD knife from Pentax company. It has a needle-type tip with hooking mechanism. AT the distal end of the knife, there is a metal plate which is useful for bleeding control even in retracted position. The length of the ESD needle is 2mm in extended position and 0.5mm in retracted position. In my recent experience with Splash M-knife, I found three advantages. First the hooking mechanism is very useful for the submucosal dissection step. When a lesion is located at difficult location and the approach is not easy, I usually used the Dual knife and IT-2 knife for a patient. But with the Splash M-knife, I can do the procedure without using the IT-2 knife. Second, the metal plate at the distal end of the Splash M-knife provides enough contact area for the bleeding control during the ESD procedure. Finally, the procedure time is much saved due to the water jet function. In a recent study from Japan, ESD using Splash-M knife appeared to reduce the usage of hemostatic forceps during the gastric ESD without increasing the adverse effects. It can reduced the total cost of the treatment. This is a typical case of early gastric cancer treated by endoscopic submucosal dissection with Pentax Splash M knife. From now on, IĄŻd like to show you a video clip of endoscopic treatment of EGC. 71 years old male was referred for the endoscopic treatment of gastric cancer. The initial biopsy was moderately differentiated tubular adenocarcinoma. These are settings for my standard ESD procedure. The procedures were done as usual. [Video] Final pathology was 11mm sized moderately differentiated tubular adenocarcinoma limited in muscularis mucosa without lymphovenous invasion. The tumor was limited in the mucosal layer above the musclaris mucosa Close up images of the moderately differentiated tubular adenocarcinoma. Ladies and gentleman. This is my last slide. The advantages of Pentax Imagina i10c gastroscope and Splash M knife for ESD includes (1) Good close-up view (2) Excellent angulation (3) 3.2mm working channel (4) Multifunctional M knife with bleeding control, hooking mechanism. Thank you for your attention.