Curability risks by endoscopic submucosal dissection for early gastric cancer

Abstract

In a recent issue of Surgical Endoscopy, Ohnita and colleagues [1] reported the risk factors for incomplete tumor resection after endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). This identification can result in preventing pathohistologically assessed residual microscopic disease (R1) at resection margins. In 2003, the Japanese Gastric Cancer Association published recommendations for the treatment of EGC by limited surgical resection [2]. In these guidelines, strict criteria were defined to ensure the safety and efficacy of endoscopic mucosal resection (EMR) for the treatment of EGC. These criteria were: tumor size \2 cm, confined to mucosal without ulcers, and differentiated histological type. Treating patients with EMR can dramatically improve their quality of life (QOL); however, a relatively small number of patients with EGC meet these criteria. ESD was developed to expand the indications, and many patients gained substantial benefit in their QOL. However, many questions remain regarding the safety of ESD when larger undifferentiated submucosal ulcerative cancers are included for ESD. This is a very large series of ESD within a relatively short time period (2003–2008). The experience provided by these authors is valuable for institutions planning ESD, and the lessons taken from this study are important. Complications related to ESD were perforations in 21 patients (4.2%) and bleeding in 7 patients (1.4%). This morbidity rate can be considered modest and within an acceptable level. The complete tumor resection (R0) rate was high: 96%. In 476 of 495 lesions, a R0 resection was achieved. The authors exclude undifferentiated, large, submucosal cancers, and this selection may explain the high R0 rate. In another recent study, the incomplete resection rate was high: 45% [3]. However, in this report undifferentiated, ulcerative, large submucosal cancer was included, confirming the limitations of ESD. The study by Ohnita et al. [1] is limited by the absence of follow-up, which is very important to define two major risks of ESD: local recurrence and nodal recurrence. It reconfirms how carefully the EGC patients should be selected. ESD achieves a better local control than EMR regarding deeper gastric wall resection margins. However, peripheral tumor margins and nodal residual disease should be considered for achieving oncological resection quality control. Prognosis of gastric cancer with adequate open or laparoscopic surgery is excellent for early gastric cancer [4, 5]. Quality control in surgery and multimodal adjuvant treatment can substantially improve survival rates even for patients with advanced resectable stage II or III disease [6–14]. Minimally invasive approaches represent substantial progress in improving the QOL of patients. The strict selection criteria are essential for safe oncological outcomes. If there is even a modest risk of incomplete resection by ES, then laparoscopic or open gastrectomy should be considered. Despite these developments, standardized open D2 surgery is the procedure of choice for advanced gastric cancer. An improvement in oncological outcomes of advanced gastric cancer should be the first priority of biomedical sciences, whereas QOL improvement remains a secondary goal when curability has been achieved. Recent advances C. Hottenrott (&) Chirurgische Klinik St. Elisabethenkrankenhaus Ginnheimer Strase 3, Frankfurt 60487, Germany e-mail: info@gastricbreastcancer.com