Endoscopic Submucosal Dissection in Early-Stage Colorectal Cancer

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals exploring the latest innovative research and clinical advances in the field of oncology.

Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a Medical Oncologist, Director of International Programs for the Cancer Institute and Co-Director for the Sarcoma Program at Cleveland Clinic. Today I'm happy to be joined by Dr. Emre Gorgun, Vice Chair of the Department of Colorectal Surgery. This is his fifth episode on this podcast, and the most recent episode was on organ preservation in rectal cancer, and that episode is still available for you to listen to.

He's here today to discuss the safety of endoscopic submucosal dissection in early stage colorectal cancer, so welcome back for the fifth episode. So you've gone through this four times already, but remind us what you do here at Cleveland Clinic.

Emre Gorgun, MD: Absolutely. Thank you Dale for having me, and it is a great pleasure and honor, especially being here at the fifth time, it's really a true pleasure chatting with-

Dale Shepard, MD, PhD: The first five-time guest.

Emre Gorgun, MD: That's correct, that's correct. Well, you indicated and thank you for the introduction, I'm the Vice Chair at the Department of Colorectal Surgery and Co-Director of the Endoluminal Surgery Center, where we do a lot of these advanced, innovative endoscopic management of GI tract diseases. I focus mostly as a colorectal surgeon in the lower GI in the colon and the last part of our intestine, the rectum portion of our intestine, and do manage a lot of diseases of this anatomical location.

In addition to that, of course, I'm a busy robotic and laparoscopic and open surgeon. Our practice focuses a lot management of rectal cancer, low anterior resections, resection of the rectum, removal of the rectum, and putting things back together so our patients can function properly again and continue to have good bowel functions.

Of course, right colon, left colon, there is cancer of these organs, and in these circumstances also, robotically or laparoscopically we remove these parts of our intestines and put them back together. Again sometimes these require temporary bags, but we do our best to avoid any intestinal stoma bags so patients have good quality of life.

Dale Shepard, MD, PhD: I think when people think about colorectal cancers and colon surgeries, they oftentimes think of those stomas and ostomy bags and things. How has the world shifted away from that? If you think about a few years ago versus now, how much of a reality is that now?

Emre Gorgun, MD: Yeah. There's a huge improvement and a large number of changes. First of all, of course, stoma bags are not end of the world. They sometimes are life-saving and provide a great quality of life for our patients, but compared to the last decade or so, we have gone and made a lot of progress. Less and less we use stomas, but a lot of new adjuvant treatments, chemotherapy, radiation therapies, and we probably going to talk a little bit during the rest of this podcast with endoluminal approaches, endoscopic approaches. So we try to do more and more aggressive in organ preservation not to necessarily remove that organ segment, but endoscopically or medically with chemotherapy, with medications to treat diseases. This is one aspect.

Another aspect, for example, in rectal cancer treatment, we do a large amount of sphincter preserving operations, so really protect the sphincters, and not necessarily remove entire donut or this control muscle from the body and we do shave the cancer. Maybe that's not the exactly right word, but of course oncologically safe, from cancer surgical standpoint safe and preserve our controlled muscles where we can really hand saw a more upstream intestinal part down to the anal canal and do cancer operations with sphincter preservation.

So, that's really a lot of improvement on the medicine side and on surgical side that we provide. We help our patients with improved quality of life. So less and less intestinal stomas, that's certainly the reality nowadays.

Dale Shepard, MD, PhD: Much like on the medical oncology side, we have a lot of things other than chemo, but that's the first thing everyone thinks about.

Emre Gorgun, MD: Yes, like immunotherapy, biologic treatments, exactly. There's huge improvements there too. I can't be mesmerized enough how much we can treat locally advanced diseases nowadays compared to years ago. That's a very good point. For example, rectal cancer, I think we talked about that a little bit last podcast, but 50% of our rectal cancers are now, initially at least, managed non-operatively. That used to be 100 patients that we used to operate, only we operate 50 of them. That's a huge improvement. That's a lot of rectums that are preserved, there's a lot of improved quality of life, and it's a lot of healthcare savings on our healthcare system too.

Dale Shepard, MD, PhD: Yeah. So much as you suggested, we're going to talk about endoscopic submucosal dissection and treatment of early stage colorectal cancer. So a lot of different people might be listening in, give us sort of a background. What exactly is this procedure? How are we able to help patients by doing an endoscopic surgery?

Emre Gorgun, MD: Yeah, in the past, any cancer or any abnormal lesion in the colon or rectum was treated by taking that segment out of the body or removing that segment by surgery and completely eliminating that. Of course, when you do that, cut a segment off, you need to somehow bring two loose ends back together and make a connection in what we call anastomosis. So you can imagine that's a major undertake, it's a major surgery for any human being, whether young or old, and it has its consequences in terms of healing time, quality of life alterations and possible complications if that connection site doesn't heal well.

So that's a lot of undertake for a human being, and nowadays there are more of these innovative endoscopic less invasive methods that we can even use our natural orifices like anus. Go through the anus with a scope, with a flexible endoscope and find that spot that is abnormal in our intestine and carve that area out with our endoscopic techniques, as we refer them as advanced endoscopy.

The reason that we call it advanced endoscopy, because traditionally, historically, endoscopy's more designed for diagnostic purposes, just to go there, see what it is, maybe take a little bite for biopsy and get out. It wasn't necessarily early on designed to really treat diseases, but now with a lot of technical improvements in innovations, we have such good tools that we can be more involved, more innovative and technically advanced, that we can not only look with a camera endoscopically, but we can really carve that out. We can chisel that off the intestinal lining and remove these lesions. So specifically speaking, endoscopic submucosal dissection is such a technique which helps us to do and accomplish these removals of complex lesions in the colon or rectum, or as a matter of fact in the upper GI system as well.

If you can focus as I'm a colorectal surgeon to the lower GI and colon and rectum, we talking about colon cancer for example, and we know that there's a large number of colon cancer in the especially young age group as well, which is less than age of 50, and there's large screening colonoscopies now. A lot of gastroenterologists go in and screen our populations, our friends, our family members at a younger age starting at 45 now or in high-risk patients even younger, and they find these lesions, they can be polyps, pre-cancers or at some stage maybe even early cancer.

Even nowadays, early cancers we can manage them and remove them from the colon lining by these endoscopic techniques, also mentioned ESD. So what endoscopic submucosal dissection stands for, ESD, means is that endoscopically now with our scopes, with our colonoscopes, we go in through the anus, find that lesion in the colon, submucosally inject or deliver a little fluid under that lesion, it may be an early cancer, lift it up and create a cushion under that lesion. Using, again, these innovative new type of knives and make a circumferential cut around that lesion, and subsequently get under that lesion, create a pocket with the tip of the scope and dissect, cut that lesion off the colonic wall and then completely remove that and then retrieve it. So, that's really basically an innovative colon cancer management performed endoscopically.

Now this technique is really I can say fairly cutting edge, which is new and some might be worried about the consequences like if that a really good cancer treatment, but we know if it's an early cancer like a T1 with minimal depth of invasion or the cancer having deeper roots into the deeper colon segments, that's certainly an acceptable treatment option.

Dale Shepard, MD, PhD: With your description, you made it seem easier than it must be. Is it one, are you using ... kind of a technical question, but out of curiosity, is it one tool that you're using to cut? Or if you think laparoscopically, you have a couple of tools. I mean, there's only so much you can get through the scope. Are you using one knife, you have multiple tools? How does this work?

Emre Gorgun, MD: Yeah, thank you for that question. We do have double-channel endoscopes, but most endoscopes that we can work with that can reach to the cecum right side of the colon, they have single channel. We have one cutting tool only, but you're right, I mean, this is like operating almost one hand tied in the back and then you're trying to operate with one hand, because we have one single channel basically for most of our endoscopes.

But what we use is a cap, like a little plastic clear cap that we place at the end of the scope, so that kind of helps us to retract. Then using the instrument through the channel, we can still cut, or again, the innovative refined instruments we now use overtubes where we can actually bring an additional channel and deliver it even in the right colon. We use these overtube or endoluminal platforms.

So, this is still work in progress. We are working with other companies to develop these tools and devices, how we can bring, for example, a grasper, the additional tool, almost like laparoscopic tools into the colon and retract, put some tension against the specimen that we are trying to remove, and that's why we call this endoluminal surgery, to be honest with you. That's where the definition or term comes from. But yeah, otherwise you're right, it's almost operating one-handed operation-

Dale Shepard, MD, PhD: With one hand without-

Emre Gorgun, MD: ... having that retraction.

Dale Shepard, MD, PhD: ... with a moving target.

Emre Gorgun, MD: Yep, some actually refer that as almost like being a rhinoceros, digging in with your nose without be you able to use your four arms, so that's right.

Dale Shepard, MD, PhD: Yeah. So I mean, given the technical nature of this, how widely adapted has this become?

Emre Gorgun, MD: So this is actually extremely widely adapted, especially in the eastern countries, in Asia, in Korea and Japan or Japan and Korea, but more and more this is being picked up by Western medicine as well in Europe, as well as in the North America and in the United States. But we are certainly pioneers of this, humbly speaking, and we are proud to socialize these techniques to other colleagues of ours.

Dale Shepard, MD, PhD: So you mentioned because it's a technique that is a little bit different in nature, you did a comparison, you look back and compared the endoluminal technique to a traditional surgery, because of that concern about safety and is this really the right way to go and you can't get lymph nodes and things like that. What did you find when you did the comparison?

Emre Gorgun, MD: Yeah, so thank you for referring to our study that was presented last year at our Central Surgical Association meeting, and another version of our study was presented at the Midwest Surgical Association meeting, which are prestigious meetings. We compared patients with colon cancer treated with endoscopic submucosal dissection or endoluminal approach to patients who had colon resection or taking a segment of the colon completely removed.

Obviously it's almost like apples and oranges, but it's treating the same things. Actually in terms of disease problem, it's the same apple, but the technique is completely different. One endoscopic approach was associated with way lower complication rates, much faster recovery, patient satisfaction, completely much more satisfactory compared to large bowel resection, but the concern is the trade-off, are we losing something in terms of the oncological outcomes? And the answer was no in terms of the disease-free survival and cancer-related survival.

Dale Shepard, MD, PhD: Yeah, so patient selection, anytime you think about two different competing procedures, it makes sense that patients would prefer to have something that's not an open traditional surgery. Are there certain patients that really aren't a good fit for an endoluminal procedure? Is there certain patients you sort of sway one way or the other?

Emre Gorgun, MD: Yeah, for more advanced cancer patients, certainly at the moment this is more designed for early colon cancer patients, maybe T1 in terms of T-staging or TNM staging or tumor advancement according to the cancer guidelines. For more bulky tumors locally advanced maybe through the wall, I mean, this technique is not designed for that, but for anyone that has early flat lesion or cancer that is possibly an early colon cancer, this is a good approach.

However, of course, we can start with ESD, inject, submucosally lift, remove, and then we analyze these specimens after ESD. If the pathology shows poorly differentiated cancer with lymphovascular invasion, tumor budding, so some specific bad characteristics on pathological analysis or on biopsies that we further can analyze. If they show these unfavorable outcomes or findings, we then can proceed still oncological resection, but if they are on the favorable side, this is completely acceptable approach and that's the study about that.

We found that in this selected patients like you indicated, compared to colon resection that we did beforehand without knowing these pathological features, the outcomes were comparable completely. The disease for survival was perfectly fine. Patients lived exactly the same amount for a very well-matched group of patients in the long-term, whether that was done endoscopically, endoluminally or with removing part of the colon.

Dale Shepard, MD, PhD: What do you do from a staging standpoint to try to estimate depth of invasion, things like that prior to doing an endoluminal procedure? If you're going to do a traditional surgery, you're just going to go in and cut out what's in between two incisions.

Emre Gorgun, MD: Yeah. Yeah, CT scan is still our gold standard for colon cancer staging. CT of the abdomen pelvis, well as CT of the chest and tumor markers. CEA is currently what we routinely use. Of course, CT DNA has very promising results, but that's not currently a routine part of our practice, but this is up and coming and I think CT DNA will be a fundamental tool in the future as well that we can use for staging, as well as for monitoring these patients in the future.

But currently these are the modalities, but also endoscopic evaluation, what we call surface anatomy assessment. There are multiple classification systems like Paris, Kudo, and with these we can certainly be more precise in terms of predicting how deep they can be advanced. But at the end of the day, there is no 100% proof for staging these lesions, and if we think that it's consistent with early lesion based on all these modalities that we listed above, we can still proceed with the endoscopic approach and remove the lesion, and then get the precise pathological analysis afterwards and then decide which way we need to go.

If we say this is a little bit higher risk, that's fine. There's nothing that we have lost at that point. Even if you do bowel resection, we wouldn't lose anything. But majority of the time after ESD or endoluminal approach, we end up not finding anything in the final colon resection specimen, which is good, but with this current assessment tools, we are not quite there yet. We can't predict that upfront, so sometimes we have to proceed with bowel resection after the endoluminal surgery.

Dale Shepard, MD, PhD: It's fantastic. So, good to know that we're continuing to make good progress on the surgical front for early stage colon cancer. Appreciate you being back for the fifth time, we'll have to come up with yet another topic for you.

Emre Gorgun, MD: Can't wait to be back.

Dale Shepard, MD, PhD: So, thanks for being with us.

Emre Gorgun, MD: Thank you very much for having me, Dale.

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