KINGCA and KGCA. 위암학회 학술행사. EndoTODAY 이준행

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[위암학회 학술행사. KINGCA and KGCA] - 終

★ 대한위암학회 연보

★ Journal of Gastric Cancer

[2025-5-8] IGCC 2025

IGCC 2025 website
2025-5-8. Subnote
Ladies and Gentlemen, it’s a great honor for me to talk here today. This is our baseline. Pretreatment staging of gastric cancer is integral in selecting patients for appropriate, evidence-based treatment. Recently, KGCA released a revised version of the previous 5th evidence-based gastric cancer guideline in JGC. The first three statements are about staging. The accuracy of EUS in a recent Cochrane review, the differentiation between T1a vs. T1b, the sensitivity was 87%, and the specificity was 75%. In the evaluation of lymph node, the sensitivity is 83% which is acceptable, but the specificity was less than expectation, 67 percent. This case shows our typical approach for initially metastatic cancer. After endoscopy and detailed pathologic evaluation, CT and PET was done. The initial regimen was XELOX with Opdivo. This is the overall treatment algorithm in the recent Korean guideline. Regarding the staging, EUS and PET/CT are mentioned as optional modalities. When do we need EUS for initial staging of gastric cancer? I’d like to split my discussion into two parts. Role of EUS before ESD In a recent audit for gastric cancer treatment in Korea, surgical resection was done in 60%, and endoscopic resection was done in 40%. More than 10 thousands cases of EGC were annually treated by ESD not only in tertiary hospitals but also in general hospitals. At my institution at Samsung Medical Center, gastric ESD is done about 1,000 cases a year. In the recent 5 years, the rate of gastric cancer among ESD cases was 73%. The rate of additional surgery after ESD for gastric cancer was 15%. The accuracy of EUS in the Yonsei University Severance hospital study, EUS T staging was correct in 63%. The rate of over-staging was quite high, 36%. The good news is that the major factors for incorrect EUS diagnosis were undifferentiated type histology and larger tumor size, which are usually out of the indications of endoscopic treatment. Cases A forty-five years old man was referred for a small elevated type lesion with slightly unclear margin. The histology was tubular adenocarcinoma, moderately differentiated. The third hyperechoic layer looked interrupted, which suggested submucosal invasion. Surgery was recommended at the local hospital. What would you recommend? I suggested diagnostic ESD but the patient wanted surgical treatment. [Click] Final pathology was EGC with SM2 submucosal invasion without lymph node metastasis. In the review process of this case, I found some areas of submucosal invasion in the initial endoscopic forceps biopsy specimen. The existence of submucosal invasion is not formally reported in the forceps biopsy pathology. In my opinion, definite submucosal invasion in forceps biopsy can be considered as strong indicator for surgery rather than ESD. I hope pathologists report these findings in their formal report. The second case. A fifty-nine years old man was referred. In EUS, the third hyperechoic layer was interrupted, so surgery was previously recommended. However, I recommended a diagnostic ESD. The ESD procedure was done as usual. And the final pathology was EGC with mixed histology, 28mm and the depth of invasion was muscularis mucosa. There was no recurrence. I’d like to introduce an interesting real-world experience of EUS before ESD. Professor Lee at Korean National Cancer Center evaluated the effectiveness of an EUS-based plan compared to an endoscopy-based plan. Overall, the appropriate treatment selection were 75% in the endoscopy-based plan and 71% in the EUS-based plan. [Click] For endoscopic mucosal cancers, the appropriate treatment selection rates in the endoscopy-based plan were 88%, while the use of an EUS-based plan decreased this rate to 81%. The authors concluded that EUS may not be necessary before treating differentiated-type EGC, especially in endoscopically presumed mucosal cancers. European guideline also said that precise endoscopic evaluation is sufficient with EUS reserved only for selected cases. Based on previous discussion, I can say that endoscopic evaluation without EUS is sufficient for mucosal cancer with differentiated type histology. However, indications of ESD is expanding in terms of depth of invasion and histological types. For EGCs with differentiated type histology, ESD is frequently performed for small submucosal cancers when the depth of invasion is less than 500 um. Recently, diagnostic value of EUS for suspected submucosal cancers was evaluated in Japan. The overall accuracy for SM1 invasion was 58% for conventional endoscopy and 75% for EUS. However, the rate of over-staging among indicated cancers were quite high, 26%. This is the treatment outcome or the previous study. Based on EUS findings of SM2 or more, surgery was done in 72 patients. Among them, 16 cases were actually mucosal or SM1 cancers. They suggested that mucosal or SM1 lesion is suspected in conventional endoscopy, EUS does not change the final diagnosis. If SM2 or deeper lesion is suspected in conventional endoscopy, additional information from EUS can influence their final diagnosis. Staging T1a and T1b with EUS is quite tricky and an operator-dependent procedure. In this interesting study from China, saline injection before EUS improved the diagnostic accuracy for T1b staging in superficial esophageal cancer. Diagnostic accuracy was 93% in saline injection EUS and 65% in conventional EUS. Professor Park at 상계백 hospital examined the efficacy of saline-injection EUS in EGC. The diagnostic accuracy in this small single center study was like this. Although it is less than esophageal cancer, saline injection helps. Randomized multicenter clinical trial is on-going by professor Kim of Samsung Medical Center. This is a typical example. In conventional EUS, it looks like SM cancer, but after saline injection there was no evidence of submucosal invasion. In the final pathology, it was a poorly differentiated tubular adenocarcinoma limited in the mucosa. Are there more factors influencing the treatment option other than depth of invasion by conventional endoscopy and EUS? In order to predict the risk of non-curative ESD, we developed a risk scoring system. We found six independent variables such as pathology, size, axial location, circumferential location, macroscopic morphology, and ulcer. Based on the relative risk we made a score for each variables. This is the correlation between the total risk score and the predicted risk of non-curative ESD requiring gastrectomy. These factors can be considered when choosing the initial treatment options for early gastric cancers. I’d like to briefly comment on the clinical importance of submucosal invasion found in the forceps biopsy. A 51 years old male patients was referred for an 1.5cm-sized EGC 2c with shallow central erosion. ESD was initially considered. However, submucosal invasion was clearly seen in the forceps biopsy. What would you do? I recommended surgery and the final surgical pathology was SM2 invasion without lymph node metastasis. SM2 invasion. Until now, it is not clear whether evidence of submucosal invasion in forceps biopsy is a contraindication of ESD. Further data is required, but I usually send the patient to surgeons especially for borderline cases with SM invasion in forceps biopsy. EUS in AGC In western countries, preoperative therapy is generally recommended for tumors that are staged on EUS as T3-4 or as lymph node-positive disease (N+), whereas immediate surgery is generally recommended for T1-2N0 tumors. In eastern countries, upfront surgery followed by adjuvant chemotherapy is more commonly used for most advanced gastric cancers without definite distant metastasis. So, the role of EUS is different in East and West. This is a famous neoadjuvant chemotherapy trial for advanced gastric cancer in Korea. Even in this trial, clinical staging was mostly based on CT findings without EUS. Non-interventional EUS is mostly reserved for borderline early gastric cancers in Korea. Ladies and gentlemen, I’d like to conclude my talk by saying that gastric cancer staging is mostly based on conventional endoscopy, CT and PET/CT. EUS has some role in selecting patients for ESD, especially when SM cancer is suspected. The role of diagnostic ESD in increasing. Thank you very much for your attention.

[2025-3-22] 위암연수강좌 (광주)

[2024-11-28] 대한위암학회 다학제 집담회

여러분. 뭔가 새로운 것 하나를 배우기 위하여 얼마나 투자해야 할까요? 저는 수백만원을 들여 미국 학회에 가서 특별한 것을 배우지 못한 적도 있습니다. 작은 발표가 있어서 어쩔 수 없이 참석한 2014년 Chicago DDW가 마지막이었습니다. 뭔가를 조금 배우기는 했는데 전체적으로는 시간과 돈이 아까웠습니다. 특히 위암을 공부하는 저에게는 별로였습니다. Chicago symphony 연주회와 Chicago cubs 야구 게임 그리고 미술관에서 본 쇠라의 그림은 좋았는데 막상 학회가 별로였습니다. 그래서 더 이상 미국에는 안 갑니다. 일본 학회는 가끔 갑니다. 배울 점이 많으니까. 반면 국내에서 진행되는 집담회에서 많은 것을 배우고 있습니다. 모든 집담회가 다 좋은 것은 아닙니다. 1시간 정도 집담회를 하고 밥먹고 술마시는 그런 행사는 no thank you입니다. 집담회가 중요한지 술자리가 중요한지 알 수 없는 그런 행사는 사양합니다. 집담회 전 미리 식사를 하고 집담회 자체는 시간에 구애받지 않고 끝장 토론을 하는 그런 모임이 집담회답습니다. 위암학회 다학제 집담회가 바로 그러합니다. 쉬지 않고 3시간을 한 적도 있습니다.^^ 아쉽게도 저는 11월 28일 대한위암학회 다학제 집담회에 참석하지 못합니다. 질향상학회라는 QI 학회에 참석해야 하기 때문입니다. 제가 없더라도 여러분께 위암학회 집담회 참석을 추천합니다. 이혁 교수님이 다학제 집담회 담당 이사이십니다. 사전 등록을 하면 저녁 식사도 준비되는 것으로 압니다. 이동 시간 1시간을 투자하면 풍성하게 배울 수 있습니다. 자신있게 추천합니다.
대한위암학회 KGCA 홈페이지에서 사전 등록할 수 있습니다.