Horizontal Margin Research Articles

Very low rate of residual neoplasia after non-curative endoscopic submucosal dissection: a western single-center experience.

Short and long outcomes of endoscopic submucosal dissection (ESD) are now well described. However, the outcome of non-curative ESDs is scarcely reported. To describe our experience with non-curative ESDs, assessing the presence of residual lesion in the endoscopic follow-up or surgery. Data of all the patients submitted to ESD between January 2015 and June 2020 in our tertiary Center was prospectively recorded. Among non-curative ESDs, the presence of residual neoplasia after complementary surgical treatment or in the endoscopic follow-up was assessed. In that period, a total of 388 ESDs were performed in the esophagus (n = 13), stomach (n = 222), colon (n = 20), rectum (n = 132), and duodenum (n = 1). Median follow-up was 30 months (range 4-69 months). ESD was technically successful in 376 lesions (97%). From 325 neoplastic epithelial lesions and 18 neoplastic submucosal tumors, 61 (17.8%) did not fulfill curative criteria entirely. Positive horizontal margins (n = 28), positive vertical margins (n = 10) and submucosal invasion >SM1 (n = 14) were the main causes of non-curative ESD. Among patients with non-curative ESDs, 20 were operated and 33 were already followed-up by endoscopy, and only seven (13%, corresponding to 2% of the total number of successful neoplastic ESDs) had residual neoplasia. Our real-life experience showed that the vast majority of non-curative ESD did not actually have residual neoplasia in the follow-up.

Transhepatic Direct Approach to the “Limit of the Division of the Hepatic Ducts” Leads to a High R0 Resection Rate in Perihilar Cholangiocarcinoma

BackgroundPrevious studies have shown that curative resection (R0 resection) was among the most crucial factors for the long-term survival of patients with PHCC. To achieve R0 resection, we performed the transhepatic direct approach and resection on the limits of division of the hepatic ducts. Although a recent report showed that the resection margin (RM) status impacted PHCC patients’ survival, it is still unclear whether RM is an important clinical factor. ObjectiveTo describe a technique of transhepatic direct approach and resection on the limit of division of hepatic ducts, investigate its short-term surgical outcome, and validate whether the radial margin (RM) would have a clinical impact on long-term survival of perihilar cholangiocarcinoma (PHCC) patients. MethodsConsecutive PHCC patients (n = 211) who had undergone major hepatectomy with extrahepatic bile duct resection, without pancreaticoduodenectomy, in our department were retrospectively evaluated. ResultsR0 resection rate was 92% and 86% for invasive cancer-free and both invasive cancer-free and high-grade dysplasia-free resection, respectively. Overall 5-year survival rate was 46.9%. Univariate analysis showed that preoperative serum carcinoembryonic antigen level (> 7.0 mg/dl), pathological lymph node metastasis, and portal vein invasion were independent risk factors, but R status on both resection margin and bile duct margin was not an independent risk factor for survival. ConclusionThe transhepatic direct approach to the limits of division of the bile ducts leads to the highest R0 resection rate in the horizontal margin of PHCC. Further examination will be needed to determine the adjuvant therapy for PHCC to improve patient survival.

Real-World Experience of Endoscopic Submucosal Dissection for Ulcerative Colitis-Associated Neoplasia

Introduction: Patients with ulcerative colitis (UC) have an increased risk of colorectal cancer. Some studies have recently investigated endoscopic resection of UC-associated neoplasia (UCAN), but the indications for endoscopic resection of UCAN remain controversial. This study sought to clarify the problems encountered in endoscopic submucosal dissection (ESD) for UCAN. Methods: Seventeen lesions in 12 patients with UCAN (UCAN group) and 913 epithelial lesions in 824 control patients without UC (non-UC group) were evaluated. Both groups underwent ESD between January 2010 and December 2017 at Toranomon Hospital, Tokyo, Japan. Treatment outcomes of the 2 groups were compared retrospectively. Results: Univariate analysis showed that the mean tumor size was significantly smaller in the UCAN group than in the non-UC group (25.1 ± 26.7 mm vs. 31.9 ± 19.0; p = 0.0023); however, the R0 resection rate was significantly lower in the UCAN group (70.6 vs. 92.9%; p = 0.001). Multivariate analysis showed a significantly lower negative horizontal margin rate in the UCAN group (odds ratio 11.3, 95% confidence interval 3.588–34.525; p = 0.000). Discussion/Conclusion: ESD for UCAN is associated with a low-negative horizontal margin rate. When performing ESD for UCAN, it is important to evaluate the accuracy of the UCAN demarcation line, especially for flat lesions, using white-light imaging and chromoendoscopy as well as other modalities, including biopsy of surrounding tissues.

A Differentiating Receiver With a Transition-Detecting DFE for Dual-Rank Mobile Memory Interface

The signal integrity of dual-rank LPDDR5 interface is challenged by reflections from the stub of the inactive rank within the redistribution layer (RDL). These reflections arrive at the active rank within the unit-interval of the data-rate and distort not only the post-cursor but also the pre-cursor of the signal that the decision feedback equalizer (DFE) cannot remove. We introduce a differentiating receiver that restores data through edge information to eliminate the reflective distortions, including the pre-cursor, and a transition-detecting DFE to address remaining inter-symbol interference. A prototype receiver, fabricated in a 65 nm CMOS process, eliminates pre-cursor distortion with a reflection flight time of 50 ps and 70 ps, at 8 Gb/s and 6.4 Gb/s, resulting in a wide horizontal margin at a bit-error-rate of 10-12. The energy efficiency is 0.80 pJ/bit at 8 Gb/s.

Photodynamic Diagnosis-Assisted En Bloc Transurethral Resection of Bladder Tumor for Nonmuscle Invasive Bladder Cancer: Short-Term Oncologic and Functional Outcomes.

Background: We describe the oncologic and functional outcomes and the surgical technique of the photodynamic diagnosis (PDD)-assisted en bloc transurethral resection of bladder tumor (EBTUR) using a rectangular cutting loop. Methods: We reviewed 40 patients with carcinoma in situ-free nonmuscle invasive bladder cancer undergoing PDD-TURBT. Of 40 patients, 12 underwent photodynamic diagnosis-assisted en bloc transurethral resection of bladder tumor (PDD-EBTUR) and 28 underwent PDD-assisted conventional TURBT (cTURBT). Two groups were matched in terms of clinicopathologic background and did not include patients treated with intravesical Bacillus Calmette-Guerin. The assessment of postoperative quality of life (QoL) was based on patient-reported outcome measure, including the International Prostate Symptom Score, Functional Assessment of Cancer Therapy-Bladder (FACT-BL), and 8-item Short Form (SF-8™) questionnaires before and 1 month after TUR. This study was approved by the Ethics commitee and all participants provided informed consent. Results: PDD guidance provided substantial help for circumferent demarcation around the bladder tumor, which precedes tumor dissection. One female patient (12%) treated by PDD-EBTUR had grade II bladder perforation requiring prolonged catheterization. Pathologic assessment of horizontal and vertical margins in resected specimens by PDD-EBTUR revealed that all specimens had muscularis propria, and the rate of en bloc resection was 100%. No patient had intravesical recurrence in the PDD-EBTUR group (median follow-up, 11 months), while two patients in the PDD-cTURBT group had Ta low-grade recurrent tumors (8 months). Postoperatively, scores of daytime frequency and nocturia were increased in both groups. QoL assessment using the FACT-BL and SF-8 revealed that postoperative deterioration of bladder-specific subscale and emotional/mental scores was found in the EBTUR group but not in the cTURBT group. Conclusions: Based on the initial experience on 12 patients, we considered that PDD-EBTUR is an acceptable surgical method. Further experience and research are mandatory to determine whether this technique yields better outcomes and has true clinical advantage.

Long-term outcomes after endoscopic submucosal dissection for differentiated-type early gastric cancer that fulfilled expanded indication criteria: A prospective cohort study.

Background and AimEndoscopic resection for early gastric cancer (EGC) is widely performed. However, there is still a paucity of strong evidence regarding long‐term outcomes after endoscopic submucosal dissection (ESD) for the expanded indication criteria of the Japanese guidelines (ver. 2010).MethodsEndoscopic submucosal dissection was performed in patients with EGC that met the expanded indication criteria: (i) cT1a, differentiated‐type EGC of 2 to 5 cm, ulcer negative or (ii) cT1a, differentiated‐type EGC of ≤3 cm, ulcer positive. Patients whose pathological examination fulfilled the curative resection criteria were then enrolled in this cohort study: negative vertical margin, negative lymphovascular invasion, and (i) pT1a, differentiated‐type, and ulcer negative; (ii) pT1a, differentiated‐type, ≤3 cm, and ulcer positive; or (iii) pT1b1 (<500‐μm submucosal invasion), differentiated‐type, and ≤3 cm. Patients with only a positive horizontal margin as a noncurative factor were included for follow‐up.ResultsFrom September 2003 to February 2012, a total of 356 patients underwent ESD, and 214 were enrolled in the survival analysis. One hundred twenty patients (56%) had >2 cm in diameter and ulcer‐negative lesions, and 94 (44%) had ≤3 cm and ulcer‐positive lesions. The vital status at 5 years after ESD was confirmed in all (100%) patients. No local or metastatic recurrence was detected; however, 26 metachronous gastric cancers developed, and 1 patient died of metachronous gastric cancer. The 5‐year disease‐specific and overall survival rates were 99.5% (95% confidence interval [CI], 97.2%–100%) and 93.9% (95% CI, 89.8%–96.4%), respectively.ConclusionESD for EGC that fulfills the expanded criteria is feasible and shows favorable long‐term outcomes.

Clinical applicability of gastroscopy with narrow-band imaging for the diagnosis of Helicobacter pylori gastritis, precancerous gastric lesion, and neoplasia.

Premalignant gastric lesions such as atrophic gastritis and intestinal metaplasia frequently occur in subjects with long-term Helicobacter pylori (H. pylori) infection. The regular arrangement of collecting venules (RAC) is seen in the normal gastric corpus, whereas mucosal swelling and redness without RAC are observed in H. pylori-infected mucosa. Despite successful H. pylori eradication, the presence of atrophic gastritis and/or gastric intestinal metaplasia (GIM) is a risk factor for gastric cancer. With the development of advanced imaging technologies, recent studies have reported the usefulness of narrow-band imaging (NBI) for endoscopic diagnosis of atrophic gastritis and GIM. Using NBI endoscopy with magnification (M-NBI), atrophic gastritis is presented as irregular coiled microvessels and loss of gastric pits. Typical M-NBI endoscopic findings of GIM are a light blue crest and a white opaque substance. Based on the microvascular patterns, fine network, core vascular, and unclear patterns are useful for predicting gastric dysplasia in polypoid lesions. For diagnosis of early gastric cancer (EGC), a systematic classification using M-NBI endoscopy has been proposed on the basis of the presence of a demarcation line and an irregular microvascular/microsurface pattern. Furthermore, M-NBI endoscopy has been found to be more accurate for determining the horizontal margin of EGC compared to conventional endoscopy. In this review, we present up-to-date results on the clinical usefulness of gastroscopy with NBI for the diagnosis of H. pylori gastritis, precancerous gastric lesion, and neoplasia.

A rare case of esophageal adenocarcinoma with urinary bladder metastasis.

A 75-year-old man was admitted to our hospital for treatment of esophageal cancer (EC) in March 2017. Esophagogastroduodenoscopy revealed Barrett's esophagus and superficial, distal EC (type 0-IIc). Tumor biopsy showed esophageal adenocarcinoma. Computed tomography revealed no lymph node metastasis but did reveal a 19-mm tumor on the right side of the urinary bladder. Bladder cancer (BC) was also suspected, and the patient underwent endoscopic submucosal dissection for EC and transurethral resection of the bladder tumor. The pathological diagnosis of EC was moderately to poorly differentiated adenocarcinoma (tub2), pT1b (SM), ly0, v0. The pathological horizontal margin was negative and the vertical margin was positive. Additional esophagectomy and lymph node dissection were indicated for curability. Esophagectomy was difficult because the patient had severe cardiovascular disease, so follow-up observation was adopted. BC was classified as urothelial carcinoma Ta, ly0, v0. After 32months, multiple tumors were found in the bladder, and BC recurrence was suspected. Transurethral resection of the bladder was performed again for seven tumors, and pathological diagnosis was poorly differentiated adenocarcinoma (tub2). The immunohistochemical features matched those of EC. We diagnosed EC metastasis in the urinary bladder. Bladder adenocarcinoma is difficult to distinguish from metastasis from other organs, especially the upper gastrointestinal tract, and cytomorphological features and appropriate clinical history are required.

Risk of recurrence when cutting into intramucosal (pT1a) cancer from the cutting-plane side during gastric endoscopic submucosal dissection.

During endoscopic submucosal dissection (ESD), procedural difficulty and poor visibility of the cutting plane sometimes cause the operator to cut into the lesion from the cutting-plane side, making the vertical margin positive (VM1) or unclear (VMX). In the present study, we evaluated the risk of recurrence of gastric cancer with VM1 /VMX after ESD. In total, 1723 consecutive gastric cancers treated by ESD at Osaka International Cancer Institute from July 2012 to December 2017 were included in this retrospective cohort study. Among them, 231 submucosal or more deeply invasive gastric cancers were excluded because nontechnical factors may contribute to VM1 /VMX in such lesions. To quantify the risk of cutting into cancer from the cutting-plane side during ESD, the proportion of lesions with VM1 /VMX among the pT1a gastric cancers treated by ESD was calculated. The proportion of recurrence among these cases was calculated after exclusion of lesions with positive lymphovascular invasion or a positive horizontal margin in order to eliminate the obvious risk factors for recurrence. Among 1492 pT1a gastric cancers treated by ESD, 28 lesions (1.9 %; 95 % confidence interval [CI] 1.3 % - 2.7 %) histologically showed VM1 /VMX. No local recurrence (0.0 %; 95 %CI 0.0 % - 12.2 %) occurred among 23 cases. The median follow-up period was 41 months (range 10 - 84 months). No local recurrence was detected in pT1a gastric cancers after VM1 /VMX resection by ESD. Surveillance endoscopy could be adopted for such cases without additional surgery.

Predictors of lymph node metastasis and residual tumor in early gastric cancer patients after noncurative endoscopic resection: a systematic review and meta-analysis.

Background:It is challenging to identify the prevalence of lymph node metastasis (LNM) and residual tumor in patients with early gastric cancer (EGC) who underwent noncurative endoscopic resection (ER). This present meta-analysis was aimed to establish imperative potential predictive factors in order to select the optimal treatment method.Methods:A systematic literature search of PubMed, Embase, and Cochrane Library databases was performed through 1 February 2019 to identify relevant studies, which investigated risk factors for LNM and residual tumor in patients with EGC who underwent noncurative ER. Eligible data were systematically reviewed through a meta-analysis.Results:Overall, 12 studies investigating the risk factor of LNM were included, totaling 3015 patients, 7 of which also involved cancer residues. After the present meta-analysis, six predictors, including tumor size >30 mm, tumor invasion depth (⩾500 μm from the muscularis mucosae), macroscopic appearance, undifferentiated histopathological type, positive vertical margin, and presence of lymphovascular invasion (including lymphatic invasion and vascular invasion) were significantly associated with LNM, whereas tumor size >30 mm, positive horizontal margin, and positive vertical margin were identified as significant predictors for the risk of residual tumor. No evidence of publication bias was observed.Conclusions:Six and three variables were established as significant risk factors for LNM and residual tumor in patients with EGC who underwent noncurative ER, respectively. Patients with EGC who present these risk factors after noncurative ER are strongly suggested to receive additional surgery, while others might be suitable for strict follow-up. This might shed some new light on the selection of follow-up treatment for noncurative ER.

"Personalized Excision" of Malignant Melanoma-Need for a Paradigm Shift in the Beginning Era of Personalized Medicine.

The premises on which guidelines for the excision of primary cutaneous melanoma are based are illogical and fail to take into account peculiarities of the individual lesion. The horizontal margins of excision continue to be adjusted to the vertical thickness of the neoplasm, and recommended clinical margins do not reflect the histopathologic borders of melanoma. Micrographically controlled surgery has become accepted for acral melanomas and melanomas of the face and neck but not for melanomas on the trunk, arms, and legs, although the latter tend to be more sharply confined. Extending margins of excision for the purpose of removing inapparent metastases is fallacious because the latter are rare, their localization cannot be foretold, and satellite metastases are usually associated with distant metastases, so that patients do not profit from early removal of cutaneous lesions. The only meaningful objective of excision is complete removal of the primary melanoma. The success of excision must be controlled histopathologically. Because of limitations of the method, a histopathologic safety margin should be observed that must depend on the characteristics of the individual lesion. In sharply confined melanomas, a histopathologic margin of at least 1 mm is sufficient. In the case of poor demarcation, with solitary atypical melanocytes extending far beyond the bulk of the lesion, a broader histopathologic safety margin is advisable. Special caution should be exercised in the presence of regression and for desmoplastic melanomas, acral melanomas, and melanomas on the face and scalp. Instead of wide and deep excisions with standardized margins, "personalized excisions" are required for primary cutaneous melanoma. The concept of clinical safety margins is a relic of former times that has no place in modern medicine.

Risk Factors and Clinical Outcomes of Non-Curative Resection in Patients with Early Gastric Cancer Treated with Endoscopic Submucosal Dissection: A Retrospective Multicenter Study in Korea.

Background/AimsThe purpose of this study was to investigate the risk factors and long-term clinical outcomes of non-curative resection (NCR) in a large-scale patient population. MethodsWe retrospectively analyzed the clinical data of 3,094 patients who underwent endoscopic submucosal dissection (ESD) of early gastric cancer from March 2005 to March 2018 at 13 institutions in Korea. We analyzed the risk factors for NCR and the survival between patients with curative resection and those with NCR with no additional treatment. ResultsThe NCR rate was 21.4% (661/3,094). In multivariate regression analysis, the risk factors affecting NCR with ESD were old age, undifferentiated tumor, tumor location in the upper body, tumor size ≥2 cm, and presence of an ulcer. In Cox proportional hazard regression analysis, tumor size ≥2 cm, submucosal invasion, positive horizontal margin, and lymphovascular invasion were risk factors for local recurrence. In Kaplan-Meier analysis, there was no statistically significant difference in the overall survival between the two groups (log-rank p=0.788). However, disease-specific survival was significantly lower in the NCR group (log-rank p=0.038). ConclusionsClinicians should be aware of the risk factors for NCR and local recurrence after ESD for early gastric cancer, and should consider providing additional treatment after NCR.

Новые подходы к методике трансуретрального удаления опухолей мочевого пузыря большого размера единым блоком

to develop optimal techniques of en-bloc resection of large non-muscle invasive bladder tumors, determine the proper method of specimen extraction and assess the quality of specimens obtained by different techniques. A total of 12 patients with primary cT1 bladder cancer underwent transurethral en-bloc resection between January 2018 and March 2019 were enrolled into the study. Tumor size ranged from 3.5 cm to 6.2 cm. For removal and extraction of large bladder tumors using thulium fiber en-bloc laser three different techniques were developed: "swiss cheese technique", "crown and root technique" and "three steps technique" technique". The main pathologic criteria used for assessment of removal technique were tumor grade (G), depth of invasion (T), presence of carcinoma in situ (CIS), variant histology (VH), lymphovascular invasion (LVI), presence of detrusor muscle. Additional criteria were horizontal and vertical resection margin, subclassification of T1-stage and presence of focal necrosis in tumor. Among the techniques developed and tested, the best quality of specimens for morphological evaluation was obtained using the combined "crown and root technique". First step is electroresection of the exophytic part of the tumor into pieces, and the next step is en-bloc laser resection (using thulium fiber or holmium laser) of the tumor base. Overall, the quality of all specimens obtained using three techniques met the current requirements of pathologic study. En-bloc resection techniques of large bladder tumors allow obtaining specimen suitable for proper morphological evaluation and correct tumor staging. Further studies are required to evaluate the impact of these techniques on long-term results of treatment options.

Additional laparoscopic gastrectomy after noncurative endoscopic submucosal dissection for early gastric cancer: A single-center experience.

BACKGROUNDThe necessity of additional gastrectomy for early gastric cancer (EGC) patients who do not meet curative criteria after endoscopic submucosal dissection (ESD) is controversial.AIMTo examine the clinicopathologic characteristics of patients who underwent additional laparoscopic gastrectomy after ESD and to determine the appropriate strategy for treating those after noncurative ESD.METHODSWe retrospectively studied 45 patients with EGC who underwent additional laparoscopic gastrectomy after noncurative ESD from January 2013 to January 2019 at the Cancer Hospital of the Chinese Academy of Medical Sciences. We analyzed the patients’ clinicopathological data and identified the predictors of residual cancer (RC) and lymph node metastasis (LNM).RESULTSSurgical specimens showed RC in ten (22.2%) patients and LNM in five (11.1%). Multivariate analysis revealed that positive horizontal margin [odds ratio (OR) = 13.393, 95% confidence interval (CI): 1.435-125, P = 0.023] and neural invasion (OR = 14.714, 95%CI: 1.087-199, P = 0.043) were independent risk factors for RC. Undifferentiated type was an independent risk factor for LNM (OR = 12.000, 95%CI: 1.197-120, P = 0.035). Tumors in all patients with LNM showed submucosal invasion more than 500 µm. Postoperative complications after additional laparoscopic gastrectomy occurred in five (11.1%) patients, and no deaths occurred among patients with complications.CONCLUSIONGastrectomy is necessary not only for patients who have a positive margin after ESD, but also for cases with neural invasion, undifferentiated type, and submucosal invasion more than 500 µm. Laparoscopic gastrectomy is a safe, minimally invasive, and feasible procedure for additional surgery after noncurative ESD. However, further studies are needed to apply these results to clinical practice.

Effect of horizontal margin status and risk of local recurrence after endoscopic submucosal dissection for superficial esophageal cancer.

Background and AimEndoscopic submucosal dissection (ESD) sometimes results in en bloc resection with a positive or inconclusive horizontal margin (HM1 or HMX, respectively) on histological evaluation. The specific risk for such situations is unclear. We therefore investigated the outcome of ESD with HM1 or HMX.MethodsThis single‐center retrospective study was performed at Osaka International Cancer Institute. A total of 886 esophageal squamous cell carcinoma lesions in 749 patients treated from April 2005 to June 2015 were evaluated according to the following inclusion criteria: en bloc resection with no residual lesion, HM1 or HMX status, no prior treatment, and no additional treatment. We classified HM1 and HMX into type A, in which cancer was exposed on the HM, and type B, in which the HM status was unclear because of mechanical or thermal damage. We further classified type B according to the distance between the cancer and the edge of the specimen: type B1, <1 mm and type B2, ≥1 mm.ResultsThe resection margin was judged as HM1 or HMX in 5.0% (39/767; 95% confidence interval, 3.5–6.6%) of the en bloc resected specimens. Of 39 lesions, 30 fulfilled the inclusion criteria. Local recurrence developed in 8 of 30 lesions (26.7%). The local recurrence rates for types A, B1, and B2 were 40% (6/15 lesions), 28.5% (2/7 lesions), and 0.0% (0/8 lesions), respectively.ConclusionsAlthough a statistical analysis was not conducted because of the limited events, the pathological HM status may be a useful predictor of local recurrence.

Mo1205 HORIZONTAL MARGIN STATUS ON PATHOLOGIC EXAMINATION AND RISK OF LOCAL RECURRENCE AFTER ENDOSCOPIC SUBMUCOSAL DISSECTION FOR SUPERFICIAL ESOPHAGUS CANCER

Endoscopic submucosal dissection (ESD) enables complete removal of cancer and reduces local recurrence after the treatment for superficial esophageal squamous cell carcinoma (ESCC). However, ESD sometimes results in en bloc resection with positive or inconclusive horizontal margin (HM1 or HMX) on histologic evaluation. The specific risk for such situation is not clarified. We therefore investigated the outcome after ESD with HM1 or HMX.

A 10.4-Gb/s 1-Tap Decision Feedback Equalizer With Different Pull-Up and Pull-Down Tap Weights for Asymmetric Memory Interfaces

In asymmetric memory systems, the pull-up and pull-down data from the channel can have different amounts of inter-symbol interference (ISI), so they cannot be fully corrected by an equalizer which uses a single tap weight. We introduce a receiver-side single-ended 1-tap asymmetric decision-feedback equalizer (DFE) with a weight selection multiplexer, which allows the application of a different weight to each direction of data value transition. Implemented in a 55-nm CMOS technology, our DFE compensated for asymmetric ISI in a 10.4-Gb/s signal from a channel with an insertion loss of −8.3 dB, leading to a 50% wider horizontal margin at a bit-error-rate of 10−12 than symmetric correction. The energy efficiency is 0.16 pJ/bit.

Clinical value of endoscopic submucosal dissection for superficial hypopharyngeal neoplasm (with video)

Objective To evaluate the safety and efficacy of endoscopic submucosal dissection(ESD)for superficial hypopharyngeal neoplasm. Methods Clinicopathological data of 9 patients, who received ESD for superficial hypopharyngeal neoplasm in Zhongshan Hospital affiliated to Fudan University from September 2015 to March 2018, were retrospectively analyzed. Results Nine patients including 7 males and 2 females with mean age of 61.2 years (48-80 years)were included. The mean diameter of lesions was 16.3 mm (5-27 mm), and the mean operation time was 52.2 min(30-90 min). No bleeding, perforation, emphysema or dyspnea during or after ESD occurred. The mean length of hospitalization was 4.6 days (3-7 days). Pathology indicated 1 high grade intraepithelial neoplasia and 8 squamous cell cancer, and all cases of squamous cell cancer were constrained within lamina propria. One patient had positive horizontal margin and received radiotherapy. No recurrence, metastasis or stenosis was found during 10.2 months (3-29 months)of follow-up. Conclusion ESD is a safe and effective option for superficial hypopharyngeal neoplasm. Key words: Endoscopy; Hypopharyngeal neoplasms; Endoscopic submucosal dissection

Additional gastrectomy in early-stage gastric cancer after non-curative endoscopic resection: a meta-analysis.

Background and objectiveThe role of additional gastrectomy after non-curative endoscopic resection remains uncertain. The present meta-analysis aimed to explore the risk factors for early-stage gastric-cancer patients after non-curative endoscopic resection and evaluate the efficacy of additional gastrectomy.MethodsRelevant studies that reported additional gastrectomy after non-curative endoscopic resection were comprehensively searched in MedLine, Web of Science and EMBASE. We first investigated the risk factors for residual tumor and lymph-node metastasis after non-curative endoscopic resection and then analysed the survival outcome, including 5-year overall survival (OS) and 5-year disease-free survival, of additional gastrectomy.ResultsTwenty-one studies comprising 4870 cases were included in the present study. We found that residual tumor was associated with larger tumor size (>3 cm) (odds ratio [OR] = 2.81, P < 0.001), undifferentiated tumor type (OR = 1.78, P = 0.011) and positive horizontal margin (OR = 9.78, P < 0.001). Lymph-node metastasis was associated with larger tumor size (>3 cm) (OR = 1.73, P < 0.001), elevated tumor type (OR = 1.60, P = 0.035), deeper tumor invasion (>SM1) (OR = 2.68, P < 0.001), lymphatic invasion (OR = 4.65, P < 0.001) and positive vertical margin (OR = 2.30, P < 0.001). Patients who underwent additional gastrectomy had longer 5-year OS (hazard ratio [HR] = 0.34, P < 0.001), 5-year disease-free survival (HR = 0.52, P = 0.001) and 5-year disease-specific survival (HR = 0.50, P < 0.001) than those who did not. Moreover, elderly patients also benefited from additional gastrectomy regarding 5-year OS (HR = 0.41, P = 0.001).ConclusionsAdditional gastrectomy with lymph-node dissection might improve the survival of early-stage gastric-cancer patients after non-curative endoscopic resection. However, risk stratification should be performed to avoid excessive treatment.

Treatment Results of Endoscopic Mucosal Resection with a Ligation Device for Duodenal Neuroendocrine Tumors.

Objective The vertical margin of neuroendocrine tumors (NETs) removed by endoscopic mucosal resection (EMR) is often tumor-positive. We examine the treatment results of endoscopic mucosal resection with a ligation device (EMR-L) for the removal of duodenal NETs located in the submucosal layer without metastasis. EMR-L can be performed with less technical skill, and the ligation device reduces the rate of positive vertical margin. Methods Ten consecutive patients with 10 duodenal NETs resected by EMR-L were enrolled. All of the lesions were located in the submucosal layer, were assessed to be free of metastasis, and were confirmed to be NETs pathologically by an endoscopic biopsy. The endoscopic results, pathological results, and prognosis were all examined. Results The en bloc resection rate and endoscopic complete resection rate were both 100%. Complete resection was achieved pathologically in 7 lesions (70.0%). The vertical margins were negative in all cases. Lymphatic vessel invasion was observed in three patients, all of whom underwent additional surgery with lymph node dissection (one of them also exhibited blood vessel invasion and a positive horizontal margin). No evidence of residual tumors or lymph node metastasis was observed in any of the patients. No recurrence was observed in any of the 10 patients (mean follow-up period: 18.6 months). One patient (10.0%) experienced intraoperative bleeding. Perforation occurred in 1 patient (10.0%), but the condition was managed well by conservative therapy. Conclusion EMR-L was an acceptable method for endoscopically resecting submucosal duodenal NETs, and the NETs resected by EMR-L were tumor-negative in the vertical margins.