JOURNAL OF LAPAROENDOSCOPIC SURGERY Volume 1, Number 2, 1991 Mary Ann Liebert, Inc., Publishers
Endoscopie Treatment for Upper Gastrointestinal Cancers
Laser :
HISAO TAJIRI, M.D.1 and YANAO OGURO, M.D.2
ABSTRACT We report the effective clinical use of endoscopie laser in Japan using the results of a nationwide survey and our own experience with more than 100 cases. The Nd:YAG laser and argon dye laser with hematoporphyrin derivative (photodynamic therapy) were most commonly used in digestive endoscopy and were investigated as new modalities of cancer therapy. Photodynamic therapy was fairly effective, especially in superficial esophageal cancer and the ill-defined lesions of early gastric cancer. Endoscopie laser treatment was carried out on 80 patients with 86 lesions of early gastric cancer at our hospital, and the following tumor types were proven highly curable by this means: focal cancer, Ha and so-called "gastritis-like" tumors less than 2 cm in size. The Nd:YAG laser provides a new approach to palliative treatment, such as recanalization of neoplastic obstruction in the advanced stage of gastrointestinal cancers.
INTRODUCTION
probably Although management gastrointestinal endoscopy, general surgery is
of
still the most common modality for most clinicians in the refinements in endoscopy have stimulated support for this recent cancer,
tool. Laser in particular, has become widely used with excellent results. Laser endoscopy was introduced in Japan in 1976 as a new tool for hemostasis of gastrointestinal bleeding. Its use has subsequently been extended to the treatment of gastrointestinal cancer. This usage has sharpened '2 an awareness of its indications and problems. Although still in its early developmental stage, progressive features of this method appear from time to time. We report the clinical use of laser endoscopie treatment on upper gastrointestinal cancers in Japan and the authors' experience with more than 100 cases.
TYPES OF LASERS There
are
two
types of lasers primarily used
(neodymium: yttrium
aluminum
garnet)
therapeutic devices in gastroenterology. The Nd:YAG currently the most common of the two. A quartz fiber
as
laser is
'Department of Internal Medicine, National Cancer Center Hospital, Tokyo, Japan department of the Und Internal Medicine, National Defense Medical College, Saitama, Japan 71
TAJIRI AND OGURO
transmits laser energy through a fiberoptic endoscope. The Nd:YAG laser is delivered through a noncontact endoprobe at powers of 40 to 60 W Awith a duration of 0.5 s and through a contact endoprobe at powers of 15 to 30 W with a duration of 1 to 2 s.3 The frequency of the laser radiation is varied, depending on the size and depth of the lesion. The argon dye laser is commonly used in conjunction with a hematoporphyrin derivative (HpD). This is called photodynamic therapy (PDT). For PDT, HpD, a photosensitive agent, is given intravenously 2.5 to 3.0 mg/kg 60 to 72 hours before the treatment and is still highly concentrated in the cancerous lesion when PDT is administered.5
LASER THERAPY IN GASTROINTESTINAL CANCER IN JAPAN
By October 1986, 1,859 cases of gastrointestinal cancer in Japan had been treated by endoscopie laser, as curative or palliative treatment.2 Curative treatment was performed in 1,158 cases, mostly gastric cancer at an early stage. As palliative treatment, hemostasis of bleeding from hemorrhagic tumors in 134 cases, recanalization of neoplastic obstruction in 334 cases, and tumor reduction in 233 cases also were attempted. either
LASER THERAPY IN EARLY GASTRIC CANCER The nationwide results of endoscopie laser therapy without surgery are shown in Table 1. In 452 of 568 followed up for more than one year after the last treatment, no recurrence of gastric cancer was observed; however, 116 cases had recurrence in that time period. In 256 other cases, it was too early to evaluate efficacy. From 1980 to April 1989, 80 patients with early gastric cancer were treated by laser endoscopie therapy at the authors' hospital and 86 lesions were diagnosed endoscopically (Table 2). Macroscopically, 42 of these 86 were elevated lesions of either type Ha or lia + lie, while the remaining 44 were depressed type lie. The mean age of the 80 patients was 71 years (range, 43-90). Of 86 lesions, we treated 74 by Nd:YAG laser, 7 with photodynamic therapy (PDT), and the remaining 5 with a combination of the two methods. The clinical course of the patients is shown in Table 3. After laser treatment, 14 of the 86 lesions were resected. Of the 72 unresected lesions, 50 were followed up for more than 1 year after the laser endoscopie treatment, 14 for less than one year, and the remaining 8 patients (with 8 lesions) died of other diseases within the year. Histologically, no residue of cancer cells was demonstrated in 7 of the 14 resected cases. Endoscopie examinations were conducted on 50 of the 72 unresected lesions for more than one year, and 47 were found free of recurrent cancer by biopsy, while the remaining three lesions showed remnant cancer. cases
Table 1. Endoscopic Laser Therapy of Early Gastric Cancer Curative Procedure: Unresected Cases
as
Local
Therapeutic results Type of lasers Nd:YAG PDT Others Total
(a)
(b)
(c)
Total
401 30
108 3 5 116
227 22
736 55 33 824
21
452d
"Negative biopsy result for more than one year. bPositive biopsy result after one year follow-up. cFollow-up period less than one year. "Effective
rate:
80% (452/568).
72
7
256
LASER ENDOSCOPIC TREATMENT FOR GI CANCERS Table 2. Type
of Lasers and Specification of 80 Patients Gastric Cancer Treated by Laser Endoscopy
with
Early
Macroscopic type Type of lasers
Elevated
Depressed
Total
Nd:YAG PDT Nd:YAG + PDT Total
39(2) 2(0) KD 42(3)
35 (5)
74(7) 7(2) 5(3) 86(12)
5(2) 4(2) 44(9)
Numbers in parentheses show resected cases. Source: National Cancer Center Hospital, Tokyo, Table 3. Macroscopic Type
Macroscopic
type and size (mm) Focal cancer in adenoma Ha 20 ê 21 â I 20 ê 21 S lía + Ik 20 ê 21 < Ile (gastritislike) 20 ê 21 =§ Ile (ulcerative) 20 ê 21 S Total
and
Unresected cases:
Endoscopie Treatment for Upper Gastrointestinal Cancers
Laser :
HISAO TAJIRI, M.D.1 and YANAO OGURO, M.D.2
ABSTRACT We report the effective clinical use of endoscopie laser in Japan using the results of a nationwide survey and our own experience with more than 100 cases. The Nd:YAG laser and argon dye laser with hematoporphyrin derivative (photodynamic therapy) were most commonly used in digestive endoscopy and were investigated as new modalities of cancer therapy. Photodynamic therapy was fairly effective, especially in superficial esophageal cancer and the ill-defined lesions of early gastric cancer. Endoscopie laser treatment was carried out on 80 patients with 86 lesions of early gastric cancer at our hospital, and the following tumor types were proven highly curable by this means: focal cancer, Ha and so-called "gastritis-like" tumors less than 2 cm in size. The Nd:YAG laser provides a new approach to palliative treatment, such as recanalization of neoplastic obstruction in the advanced stage of gastrointestinal cancers.
INTRODUCTION
probably Although management gastrointestinal endoscopy, general surgery is
of
still the most common modality for most clinicians in the refinements in endoscopy have stimulated support for this recent cancer,
tool. Laser in particular, has become widely used with excellent results. Laser endoscopy was introduced in Japan in 1976 as a new tool for hemostasis of gastrointestinal bleeding. Its use has subsequently been extended to the treatment of gastrointestinal cancer. This usage has sharpened '2 an awareness of its indications and problems. Although still in its early developmental stage, progressive features of this method appear from time to time. We report the clinical use of laser endoscopie treatment on upper gastrointestinal cancers in Japan and the authors' experience with more than 100 cases.
TYPES OF LASERS There
are
two
types of lasers primarily used
(neodymium: yttrium
aluminum
garnet)
therapeutic devices in gastroenterology. The Nd:YAG currently the most common of the two. A quartz fiber
as
laser is
'Department of Internal Medicine, National Cancer Center Hospital, Tokyo, Japan department of the Und Internal Medicine, National Defense Medical College, Saitama, Japan 71
TAJIRI AND OGURO
transmits laser energy through a fiberoptic endoscope. The Nd:YAG laser is delivered through a noncontact endoprobe at powers of 40 to 60 W Awith a duration of 0.5 s and through a contact endoprobe at powers of 15 to 30 W with a duration of 1 to 2 s.3 The frequency of the laser radiation is varied, depending on the size and depth of the lesion. The argon dye laser is commonly used in conjunction with a hematoporphyrin derivative (HpD). This is called photodynamic therapy (PDT). For PDT, HpD, a photosensitive agent, is given intravenously 2.5 to 3.0 mg/kg 60 to 72 hours before the treatment and is still highly concentrated in the cancerous lesion when PDT is administered.5
LASER THERAPY IN GASTROINTESTINAL CANCER IN JAPAN
By October 1986, 1,859 cases of gastrointestinal cancer in Japan had been treated by endoscopie laser, as curative or palliative treatment.2 Curative treatment was performed in 1,158 cases, mostly gastric cancer at an early stage. As palliative treatment, hemostasis of bleeding from hemorrhagic tumors in 134 cases, recanalization of neoplastic obstruction in 334 cases, and tumor reduction in 233 cases also were attempted. either
LASER THERAPY IN EARLY GASTRIC CANCER The nationwide results of endoscopie laser therapy without surgery are shown in Table 1. In 452 of 568 followed up for more than one year after the last treatment, no recurrence of gastric cancer was observed; however, 116 cases had recurrence in that time period. In 256 other cases, it was too early to evaluate efficacy. From 1980 to April 1989, 80 patients with early gastric cancer were treated by laser endoscopie therapy at the authors' hospital and 86 lesions were diagnosed endoscopically (Table 2). Macroscopically, 42 of these 86 were elevated lesions of either type Ha or lia + lie, while the remaining 44 were depressed type lie. The mean age of the 80 patients was 71 years (range, 43-90). Of 86 lesions, we treated 74 by Nd:YAG laser, 7 with photodynamic therapy (PDT), and the remaining 5 with a combination of the two methods. The clinical course of the patients is shown in Table 3. After laser treatment, 14 of the 86 lesions were resected. Of the 72 unresected lesions, 50 were followed up for more than 1 year after the laser endoscopie treatment, 14 for less than one year, and the remaining 8 patients (with 8 lesions) died of other diseases within the year. Histologically, no residue of cancer cells was demonstrated in 7 of the 14 resected cases. Endoscopie examinations were conducted on 50 of the 72 unresected lesions for more than one year, and 47 were found free of recurrent cancer by biopsy, while the remaining three lesions showed remnant cancer. cases
Table 1. Endoscopic Laser Therapy of Early Gastric Cancer Curative Procedure: Unresected Cases
as
Local
Therapeutic results Type of lasers Nd:YAG PDT Others Total
(a)
(b)
(c)
Total
401 30
108 3 5 116
227 22
736 55 33 824
21
452d
"Negative biopsy result for more than one year. bPositive biopsy result after one year follow-up. cFollow-up period less than one year. "Effective
rate:
80% (452/568).
72
7
256
LASER ENDOSCOPIC TREATMENT FOR GI CANCERS Table 2. Type
of Lasers and Specification of 80 Patients Gastric Cancer Treated by Laser Endoscopy
with
Early
Macroscopic type Type of lasers
Elevated
Depressed
Total
Nd:YAG PDT Nd:YAG + PDT Total
39(2) 2(0) KD 42(3)
35 (5)
74(7) 7(2) 5(3) 86(12)
5(2) 4(2) 44(9)
Numbers in parentheses show resected cases. Source: National Cancer Center Hospital, Tokyo, Table 3. Macroscopic Type
Macroscopic
type and size (mm) Focal cancer in adenoma Ha 20 ê 21 â I 20 ê 21 S lía + Ik 20 ê 21 < Ile (gastritislike) 20 ê 21 =§ Ile (ulcerative) 20 ê 21 S Total
and
Unresected cases:
