Indications For Endoscopic Mucosal Resection Research Articles

Appropriate endoscopic treatment selection and surveillance for superficial non-ampullary duodenal epithelial tumors

Objectives Superficial nonampullary duodenal epithelial tumors (SNADETs) have become frequently detected and referred for endoscopic resection (ER). However, optimal treatment methods and long-term outcomes after ER of SNADETs have not been fully elucidated. We aimed to clarify them by analyzing our large cohort of patients with SNADETs. Materials and methods We enrolled 190 consecutive tumors from 189 patients undergoing ER between January 2004 and September 2019. Cases were stratified into endoscopic submucosal dissection (ESD), conventional endoscopic mucosal resection, (CEMR) and underwater endoscopic mucosal resection (UEMR). Baseline characteristics and short-term outcomes were compared between the groups. Long-term outcomes were also investigated with a median follow-up of 36 months. Results ESD significantly exceeded CEMR (96.4% vs. 52.9%; p = .0026) and UEMR (96.4% vs. 50.0%; p = .0008) in complete resection rates for 11- to 20-mm lesions; the differences were not significant for lesions ≤10 mm. Local recurrence only occurred in patients with an incomplete resection. Only patients with submucosal invasion died from the primary neoplasms. The 3- and 5-year disease-free survivals were 91.3% and 83.5%. Conclusions While tumors ≤10 mm seem to be good indications for endoscopic mucosal resection, ESD should be considered for larger tumors to better achieve complete resection. Patients with submucosal invasive carcinomas have a great risk of cancer death. Therefore, a close follow-up and an additional treatment are desirable.

Long-term Outcome after Endoscopic Resection for Early Gastric Cancer in Korea

Endoscopic resection is accepted as the standard treatment for early gastric cancer (EGC) without lymph-node metastasis. The indications for endoscopic submucosal dissection (ESD) have been expanded from the standard indications of endoscopic mucosal resection. Recently, clinical data supporting further expansion of ESD have been accumulating. In Korea, recent large scale studies have reported favorable long-term outcomes for EGCs that meet the expanded indications, with 5-year overall survival rates similar to those of EGCs meeting the absolute indication. Additionally, several reports on comparison of long-term outcome after endoscopic resection versus surgical treatment have been published. This review elucidates the feasibility of endoscopic resection for EGC, based on evidence from long-term outcome in Korea. There are still some limitations associated with retrospective analyses and subsequent biased analysis of outcome based on the post-treatment diagnostic groups and problematic follow-up loss. (Korean J Helicobacter Up Gastrointest Res 2016;16:1-5)

Giant Polypoid Tumor Expressing on the Pyloric Ring

A 66-year-old Japanese man was referred to our hospital because of suspected duodenal cancer. Upper gastric endoscopy revealed a giant polypoid-type tumor that extended from the duodenum bulb to the pyloric ring. A computed tomography scan revealed a slightly enhanced lobular tumor protruding into the duodenum bulb. Positron emission tomography showed an accumulation of 18F-fluorodeoxyglucose in the area extending from the antrum of the stomach to the duodenum bulb. Since an endoscopic ultrasound test suggested that the tumor might invade the muscular tunic, indications of endoscopic mucosal resection were not favored, and the tumor was curatively removed via distal gastrectomy. The histopathologic diagnosis was papillary adenocarcinoma, and the invasion depth was the mucosal layer without vascular invasion, which was different from the preoperative diagnosis. Our case suggests the difficulties in precise diagnosis of the invasion depth of the giant polypoid cancer.

Clinical outcome of endoscopic mucosal resection for esophageal squamous cell cancer invading muscularis mucosa and submucosal layer

When a tumor invades the muscularis mucosa and submucosal layer (T1a-MM and T1b in Japan), esophageal squamous cell cancer poses 10-50% risk of lymph node metastasis. By this stage of esophageal cancer, surgery, although very invasive, is the standard radical therapy for the patients. Endoscopic mucosal resection (EMR) is the absolutely curable treatment for cancer in the superficial mucosal layer. Because of its minimal invasiveness, the indications of EMR may be expanded to include the treatment of T1a-MM and T1b esophageal carcinoma. To date, the clinical outcomes of EMR for T1a-MM and T1b patients have not been fully elucidated. Here, the retrospective analysis of the clinical outcomes is reported. Between January 1994 and December 2007, 247 patients underwent EMR at Kanagawa Cancer Center. Of these individuals, 44 patients with 44 lesions fulfilled the following criteria: (i) extended EMR treatment for clinical T1a-MM and T1b tumor; (ii) diagnosis of clinical N0M0; and (iii) follow up for at least 1 year, and negative vertical margin. These patients were reviewed for their clinical features and outcomes. Statistical analyses were performed by the Kaplan-Meier methods, the Chi-square test, and the Cox proportional hazard model. P-value of <0.05 was considered statistically significant. The data were analyzed in February 2009. Based on the informed consent and their general health conditions, 44 patients decided the following treatments immediately after the EMR: 2 underwent surgery, 1 underwent adjuvant chemotherapy, and 41 selected follow up without any additional therapy. Of the 41 patients, 20 selected this course by choice, 12 because of severe concurrent diseases, 2 because of poor performance status, and 7 because of other multiple primary cancers. Twelve patients died; two were cause specific (4.5%), eight from multiple primary cancers, one from severe concurrent diseases, and one from unknown causes. No critical complications were noted. Median follow-up time was 51 months (12-126). Five patients ultimately developed lymph node metastasis. One patient with adjuvant chemotherapy required surgery, and another was treated with chemotherapy whose subsequent death was cause specific. The other three patients received chemoradiotherapy and have not shown cause-specific death. Overall and cause-specific survival rates at 5 years were 67.3% and 91.8%, respectively. Among 41 patients treated by EMR alone, only one died from primary esophageal cancer (2.4%), and overall and cause-specific survival rates at 5 years were 75.6% and 97.6%, respectively. Multivariate analysis revealed that severe concurrent diseases including multiple primary cancers and the administration of 5-fluorouracil-based chemotherapy for multiple primary cancers significantly influenced survival (P= 0.025, hazard ratio [HR] 13.1 [95% confidence interval 1.5-114]) and (P= 0.037, HR 0.213 [95% confidence interval 0.05-0.914]), respectively. Eight and six patients developed metachronous esophageal squamous cell cancer and local recurrence, respectively. With the exception of one patient, they could be retreated endoscopically. EMR is a reasonable option for the patients with T1a-MM and T1b esophageal carcinoma without clinical metastasis, especially for the individuals with severe concurrent diseases. The prognostic factors for the benefit of EMR in such cases should be further examined.

Long-term Outcome after Endoscopic Treatment for Early Gastric Cancer in Korea

The early diagnosis of gastric cancer allows patients and physicians to pursue the option of endoscopic resection, which is significantly less invasive than conventional surgical resection. Newly developed endoscopic technique and devices have helped to overcome the limitations of therapeutic endoscopy in terms of lesion size, location, and presence of fibrotic scarring. As a result, the indications for endoscopic submucosal dissection (ESD) have been expanded from the classical indication for endoscopic mucosal resection (EMR), and there is now support for a further expansion of ESD indications. Long-term follow up data are needed for the clinical application of the expanded criteria of endoscopic treatment. In Korea, the use of endoscopic treatment has been increasing, and many reports on endoscopic treatment such as EMR or ESD have been published. This review was to elucidate the feasibility of the expanded guidelines, based on evidence from long-term outcome. (Korean J Helicobacter Up Gastrointest Res 2012;12:1-7)

The New Era of Staging as a Key for an Appropriate Treatment for Esophageal Cancer

Fluorodeoxyglucose-positron emission tomography (FDG-PET) and computed tomography (CT) have become the gold standard for staging of esophageal cancer by detecting distant metastases, but metastatic lymph nodes are often difficult to diagnose from the size and standardized uptake value (SUV). If we compare the diagnostic performance of endoscopic ultrasonography (EUS), CT, and FDG-PET in staging of esophageal cancer, EUS is the most sensitive method to identify the detection of regional lymph node metastases, whereas CT and FDG-PET are more specific tests. Combination study with CT, EUS and PETCT cannot make a precise diagnosis after neoadjuvant therapy (NAT). A precise staging might be determined by the fine needle aspiration biopsy (FNAB) under EUS and US screening in the neck and the abdomen even after NAT. Indication of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) for superficial cancer is sensitive because of difficulty in T1b cancer diagnosis. Detailed examination about vessel invasion and the possibility of residual tumor with dissected specimen will offer an appropriate additional therapy. New strategy like sentinel lymph node (SLN) navigation could supply more information about lymphatic routes and metastatic nodes. SLN navigation with ESD might become a new less invasive strategy for superficial esophageal cancer.

A case of immunosuppressant-resistant clinically amyopathic dermatomyositis with rapidly progressive interstitial pneumonia ameliorated after resection of gastric cancer.

A 59-year old woman had been suffering from myalgia, eruption and dyspnea on effort for a month. She was referred to our hospital because her symptoms were not improved by antibiotic therapy at a clinic. At first presentation she showed cutaneous manifestations including heliotrope eyelids and mechanic's hands, slightly elevated serum creatine kinase (CK), elevated serum C-reactive protein level, and interstitial pneumonia (IP), which led to a diagnosis as dermatomyositis. After admission to our hospital, her hypoxia due to IP progressed despite disappeared myalgia and normalized serum CK level. Intravenous steroid pulse therapy followed by oral cyclosporine and intravenous cyclophosphamide pulse therapy was not effective for the IP for more than a month. Gastroscopy revealed superficial depressed (0-IIc) type early gastric cancer. However, it was out of indication for endoscopic mucosal resection because of the histopathologic type (signet ring cell carcinoma) and possible submucosal invasion. In addition to those immunosuppressive therapies, proximal gastrectomy with total intravenous anesthesia was performed. One month after the operation, improvement of IP as well as cutaneous manifestations was confirmed by respiratory function test, pulmonary computed tomography, and discontinuance of oxygen inhalation. We conclude that this was a case of clinically amyopathic dermatomyositis with rapidly progressive IP and gastric cancer, which was ameliorated by a combination of medication (steroid, cyclosporine, and cyclophosphamide) and surgery (gastrectomy for early gastric cancer).

前胸壁皮弁で再建した下咽頭部分切除例

Endoscopic examination, including narrow-band imaging (NBI), is being increasingly used to detect early hypopharygeal cancer. Because these high-risk cases have already often undergone radiotherapy for esophageal cancer, early hypopharygeal cancer is a good indication for endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Slightly larger tumors, however, require partial hypopharyngotomy preserving the larynx. Since reconstruction with a free flap may be highly invasive, we reported using an anterior chest skin flap as a useful alternative in pharyngeal reconstruction.

The Extended Indications of Endoscopic Submucosal Dissection (ESD) for Early Gastric Cancer Are Thus Not Entirely Safe

Early gastric cancer (EGC) is defined as tumor invasion confined to the mucosa or submucosa, regardless of the presence of regional lymph node metastasis. Lymph node metastasis is the most powerful and important prognostic factor for gastric cancer. Based on the risk of lymph node metastasis in EGC obtained from a large number of surgical cases in Japan, it was suggested that the criteria for endoscopic mucosal resection (EMR) and endoscopic submucosal resection (ESD) as local treatment for EGC might be extended. However, extending the indications for EMR and ESD remains controversial because the long-term outcomes of these procedures have not been fully documented, and there is a risk for lymph node metastasis. Furthermore, current diagnostic imaging techniques are unsatisfactory for accurately predicting metastasis to lymph nodes. Moreover, the long-term results of standard radical gastrectomy including minimally invasive procedures for stage IA have been increasing and have reached 99 to 100%. To determine the true efficacy of endoscopic resection of EGC, we need more evidence of long-term follow-up, standardization of techniques, and pathological interpretation.

Outweighing the benefits and weakness of endoscopic submucosal dissection for early gastric cancer in the west

Endoscopic submucosal dissection (ESD) is believed to provide higher curability than endoscopic mucosal resection (EMR) in the treatment of early gastric cancer [1, 2]. But whether ESD can expand the indications of EMR without increasing the risk of incomplete tumor resection (R1) is controversial. In the West, significantly fewer patients than in Asian countries such as Japan and Korea receive a diagnosis of early gastric cancer (EGC). Early diagnosis not only offers an excellent prognosis but also allows a minimally invasive treatment approach that substantially improves the quality of life (QOL). The much higher incidence of EGC in East Asia explains the advances in the development of ESD and EMR. Because of the low detection rate of EGC in the West, relatively few Western institutions apply these techniques, so reports for the treatment of EGC with modern approaches are considered with interest. In the July issue of Surgical Endoscopy, Catalano and colleagues [3] reported on their experience with ESD in Verona, Italy. After experience with 36 EMRs during the initial period (2001–2005), the authors moved to ESD and reported on 12 ESD procedures between May 2005 and April 2007. Histologic examination of the resected specimens showed complete removal of the tumor (R0) in 92% of the cases compared with only 56% in the EMR group. In the ESD group, one patient experienced bleeding and perforation. During a mean follow-up period of 31 months, no patients with a pathologically confirmed complete resection experienced local or distant recurrence. The authors conclude that ESD can be performed with safety and efficacy in the Western world. This first report on ESD in the West confirms the central role of experience in achieving positive results. But whether the higher curability rate with ESD than with EMR is attributed to ESD or better selection of patients in the ESD group and a more careful approach after substantial experience with EMR is difficult to infer from this small study. A prospective study based on a protocol is required for robust conclusions. Apparently, ESD offers increased curability in one dimension (deeper gastric wall excision). However, resection in the other two dimensions is similar. Thus, the criteria for EMR in terms of tumor size, histologic type (exclusion of undifferentiated or diffuse-type cancer), and the presence of ulceration also should be met in the performance of ESD. Minimally invasive approaches, particularly endoscopic resection, provide substantially better QOL than conventional open surgery for gastrointestinal cancer. But the excellent oncologic outcomes for patients with early gastric cancer treated using open or laparoscopic gastrectomy makes essential the careful selection of patients for ESD. Excellent oncologic outcomes with ESD should be ensured with very careful patient selection. Indeed, solid evidence suggests excellent oncologic outcomes for patients with early-stage disease treated using either open or laparoscopic surgery [4–7]. Besides treatment of cancer at an early stage, quality control in surgery and multimodal adjuvant treatment can substantially improve survival rates even for patients with advanced resectable stage 2 or 3 disease [8–14]. Yet, in the Western world, open surgery still remains the standard of care for early gastric cancer. J. Spiliotis Department of Surgery, Metaxa Anticancer Hospital, Piraeus, Greece

Early Gastric Cancer

The purpose of this study was to evaluate the frequency of lymph node metastasis according to the depth of tumor infiltration of the mucosa and submucosa. Currently some endoscopists extend the indication for endoscopic mucosal resection in gastric cancer to the submucosa. However, the decision between endoscopic mucosectomy or gastrectomy with lymphadenectomy for early gastric cancer depends especially on the probability of lymph node metastasis. One hundred twenty-six patients either had subtotal resection (n = 29) or total gastrectomy (n = 97) for T1 gastric cancer. The median number of resected lymph nodes was 21 (1-63). In the histopathologic analysis of the specimens the tumors were differentiated according to their wall penetration in the upper (m1), middle (m2), lower (m3) third of the mucosa or submucosa (sm1, sm2, sm3). The greatest diameter of the lesions, the Grading and the Goseki-, Ming-, WHO-, and Laurén classification were determined. Patients with m1 (n = 3) and m2 (n = 5) layer infiltration had no lymphatic metastasis compared with 13% for m3 (n = 39). The rate of lymphatic metastasis in submucosal carcinomas was 21% for sm1 (n = 29), 16% for sm2 (n = 23) and 40% for sm3 (n = 25). Carcinomas with papillary differentiation, Grading G1 or <1 cm in diameter had no lymph node metastasis. The size of tumor <2 cm or > or =2 cm showed independent influence on the rate of lymph node metastasis. Endoscopic mucosectomy in m3 carcinoma is questionable and in all submucosal carcinomas and lesions > or =2 cm it is not indicated.

Endoscopic resection for T1a-MM and T1b-SM1 squamous cell carcinoma of the esophagus.

In Japan, the first paper on endoscopic resection (ER) for squamous cell carcinoma (SCC) of the esophagus confined to the mucosa was reported as endoscopic mucosal resection (EMR) in 1988. Since publication of that article, ER has been recommended as the standard treatment for squamous and mucosal cancer of the esophagus. T1a-EP and T1a-LPM esophageal cancer seldom involves lymph node metastasis. However, in cases of T1a-MM and T1b-SM1 esophageal cancer with lymph node metastasis (10% to 30%), the indication of ER is limited. The risk factors for lymph node metastasis in T1a-MM and T1b-SM1 esophageal cancer were cleared by clinical and pathological studies. Endoscopic findings such as type 0-I or type 0-III, size of 50mm or more, and pathological findings such as lymphatic permeation, venous permeation, poorly differentiated SCC and INFb or INFc were suggestive of high risk for lymph node metastasis. In addition, histopathological findings of small cancer nests, defined as "budding" or "droplet infiltration," suggest frequent lymph node metastasis. In cases of T1a-MM and T1b-SM1 esophageal cancer with high risk of lymph node metastasis, adjuvant therapy including chemoradiotherapy and radical esophagectomy are recommended after ER. A recent advance in ER for esophageal cancer is the establishment of endoscopic submucosal dissection (ESD). It has allowed us to perform an en-block resection of a large mucosal lesion of the esophagus and detailed histopathological examination. However, ESD requires more difficult manipulation than EMR. The indication of EMR or ESD is sought.

A Phase II Trial of Chemoradiotherapy for Stage I Esophageal Squamous Cell Carcinoma: Japan Clinical Oncology Group Study (JCOG9708)

The study objective was to evaluate the efficacy and toxicity of chemoradiotherapy with 5-fluorouracil (5-FU) plus cisplatin in patients with Stage I esophageal squamous cell carcinoma (ESCC). The primary endpoint was proportion of complete response (%CR). Patients with Stage I (T1N0M0) ESCC, aged 20-75 years, without indication of endoscopic mucosal resection were eligible. Treatment consisted of cisplatin 70 mg/m(2) (day 1) and 5-FU 700 mg/m(2)/day (days 1-4) combined with 30 Gy radiotherapy (2 Gy/day, 5 days/week, days 1-21). The cycle was repeated twice with 1-week split. Salvage surgery was recommended for residual tumor or local recurrence. From December 1997 to June 2000, 72 patients were enrolled. No ineligible patient or major protocol violation was observed. There were 63 CRs for %CR of 87.5% [95% confidence interval (CI): 77.6-94.1]. Six patients with residual tumor successfully underwent esophagectomy. There was no Grade 4 toxicity. Four-year survival proportion was 80.5% (95% CI: 71.3-89.7), and 4-year major relapse-free survival proportion was 68% (95% CI: 57.3-78.8) (mucosal recurrence removed by endoscopy was not counted as an event). High CR proportion and survival proportion with mild toxicity suggest that this regimen could be considered as a candidate of new standard treatment to be compared with surgery in patients with Stage I ESCC.

Increased Risk of Lymph Node Metastasis in Mucosal Gastric Cancer with Extra Indication for Endoscopic Mucosal Resection

Selected cases of clinical mucosal gastric cancer can be treated endoscopically. But mucosal gastric cancer, which has a higher incidence of lymph node metastasis, should be treated by gastrectomy with lymph node dissection. Laparoscopy-assisted gastrectomy is usually indicated for the surgical treatment of mucosal gastric cancer. From April 2005 to December 2007, 148 consecutive patients with clinical mucosal gastric cancer who underwent laparoscopy-assisted gastrectomy were investigated to clarify the clinicopathologic findings in this patient group. Of the patients who underwent gastrectomy, 93 (63%) had tumors>20 mm in diameter and 92 (62%) had undifferentiated cancer. The frequency of lymph node metastasis was 8% (12 patients). One patient had second-compartment lymph node metastasis (station 8a). In patients with lymph node metastasis, 11 (92%) had an ulcer scar and 11 (92%) had undifferentiated tumors. None of the patients met the criteria for extended endoscopic submucosal dissection. The incidence of lymph node metastasis in patients with mucosal gastric cancer in whom gastrectomy is indicated is higher than reported previously. More careful consideration is needed for the possibility of lymph node metastasis in this era of endoscopic submucosal dissection.

Total endoscopic resection of Barrett esophagus

Barrett's esophagus with high grade intraepithelial neoplasia is associated with disease progression at rates of greater than 10% per year. Endoscopic resection is a lower risk alternative to surgery for the management of high grade intraepithelial neoplasia and intramucosal cancer. Two endoscopic approaches have been used, namely localized resection of the lesion and total endoscopic resection of all Barrett's mucosa. The latter strategy removes all at-risk mucosa. Currently it is performed mainly using piecemeal endoscopic mucosal resection techniques. In recent years endoscopic submucosal dissection has been attempted to obtain en bloc resection. This review will describe the techniques of total endoscopic resection, and summarize the key published data.

T2066 Endoscopic Mucosal Resection for Undifferentiated Intramucosal Gastric Cancer: Different Indications Between Signet Ring Cell Carcinoma and Poorly Differentiated Adenocarcinoma

Background) Small undifferentiated gastric cancer limited to the mucosal layer has been proposed as an extended indication for endoscopic mucosal resection (EMR). However, there is limited data about the difference of lymph node metastasis (LNM) in different histological subtypes between intramucosal signet ring cell carcinoma (SRC) and poorly differentiated adenocarcinoma (PDC). The aim of this study was to identify risk factors of the LNM and to suggest appropriate indications for EMR for undifferentiated intramucosal cancers. Method) We reviewed medical records of 2128 patients with intramucosal gastric cancers treated with gastrectomy and regional lymph node dissection at the Samsung Medical Center from 1994 to 2005. Clinicopathological factors related to LNM for intramucosal SRC and PDC were evaluated in comparison to differentiated intramucosal gastric cancers (DAC). Results) Out of 2128 intramucosal gastric cancers, 9 of 1243 (0.7%) cases of DAC, 20 of 594 (3.4%) cases of SRC and 18 of 291 (6.2%) cases of PDC had LNM. LNM increased significantly in SRC (OR=4.18 95% CI: 1.64-10.6) and PDC (OR=12.4 95% CI: 4.83-32.1) compared to DAC as determined by multivariate analysis. Tumor size (OR =3.36, 95% CI: 1.07-10.5) and lymphovascular invasion (OR=13.6 95% CI: 4.65-40.1) were other significant risk factors associated with LNM. None of 175 SRCs less than 20 mm in size (95% CI: 02.09) and none of 21 PDCs less than 10mm in size (95%CI: 0-16.11) without lymphovascular invasion had LNM. Conclusion) Histological subtype, tumor size and lymphovascular invasion are risk factors of LNM in undifferentiated intramucosal gastric cancers. Intramucosal SRC has an intermediate LNM risk between the differentiated type and PDC. SRCs less than 20 mm and PDCs less than 10 mm in size without lymphovascular invasion are possible candidates for EMR.

Indication for endoscopic mucosal resection in early signet ring cell gastric cancer

The aim of this study was to compare the clinicopathological characteristics of an early signet ring cell carcinoma (SRC) with an early undifferentiated carcinoma (mucinous, poorly differentiated adenocarcinoma) and early differentiated carcinoma (well or moderately differentiated tubular adenocarcinoma, papillary adenocarcinoma) and find indications for endoscopic mucosal resection (EMR) in early SRC. 1520 patients with early gastric cancer (EGC), who underwent a curative gastrectomy, were analyzed retrospectively. Among them, 388 patients with SRC were compared with 253 patients with undifferentiated carcinoma (UDC) and 879 with a differentiated carcinoma (DC). SRC was more common in young female patients than UDC. SRC had a tendency to be confined to the mucosa, with smaller size than UDC. The lymph node metastasis rate for SRC was lower than that for UDC, but similar to that of DC. Multivariate analysis revealed lymph node metastasis (LNM) to be associated with the depth of invasion, tumor size, histological type, and lymphatic involvement. SRC had no LNM in the case of a mucosal tumor, smaller than 2 cm, and in the absence of lymphatic involvement. The prognosis of SRC was more favorable than UDC. Early SRC has different characteristics from early UDC. In view of the lower rate of lymph node metastasis and better prognosis, we suggest that EMR can be performed on patients with early SRC limited to the mucosa, less than 2cm in size, and with no lymphatic involvement.

Endoscopic treatment of esophageal mucosal carcinomas: indications and outcomes

The indications for endoscopic mucosal resection (EMR) and treatment outcomes are discussed for 402 patients (336 men and 66 women with 527 lesions) who had squamous-cell carcinoma of superficial type and with no lymph-node metastasis (N0) on clinical evaluation. The patients were followed-up for at least 2 years after EMR, conducted between January 1988 and December 2004. They were classified according to the depth of tumor invasion as follows: m1 cancer in 179 patients, m2 in 137, m3 in 61, and sm1 in 25. The number of lesions treated at the initial session of EMR was one in 317 patients (79%) and multiple lesions in 85 (21%). For the resection technique, a two-channel scope method was used in 318 patients (79%) and the cap method in 84 (21%). In patients with m3 or sm1 cancers, additional treatments included follow-up observations in 62 patients (72%) (m3 in 52 and sm1 in 10), chemoradiotherapy or radiotherapy in 17 (20%) (m3 in 7 and sm1 in 10), chemotherapy in 3 (3%) (m3 in 2 and sm1 in 1), and surgery in 4 (5%) (sm1 in 4). With regard to complications, only 5 patients (1.2%) with difficult-to-control bleeding were considered to have bleeding; a hemostatic clip was used in 1, a Sengstaken-Blakemore tube insertion in 1, and repeated argon plasma coagulation (APC) in 3. Of the 402 patients undergoing EMR, 1 (0.2%) had perforation. Despite no evidence of esophageal perforation, mediastinal emphysema occurred in 10 patients (2.3%) who underwent piecemeal resection because of large lesions. Of the 34 patients with mucosal defects occupying more than three quarters of the circumference of the esophagus, 29 (85%) had esophageal strictures. Local recurrence was found in 19 (5.4%) of the 349 patients in whom esophageal mucosal cancer was clinically considered to be completely resected and treatment completed. All patients with local recurrence had undergone piecemeal resection. Of the 402 patients who underwent EMR, 71 (18%) had a total of 111 metachronous esophageal cancers. Among the 71 patients with metachronous esophageal cancers, EMR was performed in 67 patients (107 lesions); 104 lesions were mucosal cancers and 3 were submucosal cancers (1 sm1 cancer and 2 sm2 cancers). Regarding prognosis: (1) m1 and m2 cancer: Of the 316 patients who underwent EMR for m1 or m2 cancer, 12 (4%) had local recurrence. There were 39 deaths (12%). Two patients refused further treatment after EMR, and finally died of advanced esophageal cancer. (2) m3 and sm1 cancer: Local recurrence was found in 7 (11%) of 61 patients with m3 cancer. Lymph-node metastasis was found in 2 patients (3%) and bone metastasis was found in 1. There were 17 deaths (28%); 3 patients died of recurring esophageal cancer. Lymph-node metastasis was found in 3 (12%) of 25 patients with sm1 cancer. There were 7 deaths (28%); no patient died of esophageal cancer.

Limited surgery for 'early' cancer of the esophagus

BACKGROUND: Early squamous cell carcinoma and early adenocarcinoma of the esophagus are potentially curable diseases. Limited surgical procedures are carried out as alternatives to either endoscopic mucosectomy or to radical esophagectomy for T1 esophageal cancer. In this stage the only indication for limited surgery with curative intent is in patients who have no evidence of lymph node metastasis as the procedure is not comprising an adequate lymphadenectomy. The depth of tumor infiltration into the mucosal and submucosal layers is correlated with the rate of nodal metastases and therefore with long-term prognosis. The crucial point is to define the right stage of T1 carcinoma for this type of therapy. METHODS: A review of the literature was performed to gather published data concerning the status of limited surgery for 'early' cancer of the esophagus. RESULTS: For mucosal esophageal cancer endoscopic mucosal resection is an alternative treatment option but requires intensive follow-up since the rate of complete resections is lower than in limited and in radical surgical procedures. On the other hand, low postinterventional morbidity and functional integrity of the tubular esophagus support the indication of endoscopic mucosal resection for mucosal cancer. The Merendino procedure may offer another option in the treatment of early esophageal cancer. Major advantages of this operation over endoscopic mucosectomy include the possibility of complete resection of the carcinoma and the entire Barrett segment. The lower postoperative morbidity and mortality compared to radical surgery are in favour of the Merendino resection. Vagal-sparing esophagectomy is another surgical option in esophageal cancer limited to the mucosa. However, both limited procedures are not appropriate in case of lymph node metastases. None of these techniques have been validated in prospective clinical studies. CONCLUSION: Procedures with limited radicality are technically feasible but should strictly be reserved for patients with mucosal cancer. Results of limited surgery should be validated in clinical studies compared to radical esophagectomy comparing functional and prognostic outcome.

Risk Factors for Occult Lymph Node Metastasis of Colorectal Cancer Invading the Submucosa and Indications for Endoscopic Mucosal Resection

Although risk factors for histologically overt lymph node metastasis in patients with early-stage colorectal cancer have been clarified, the risk factors for occult lymph node metastasis are not clear. This study was designed to clarify risk factors for lymph node metastasis, including occult metastasis, in patients with colorectal cancer invading the submucosa and to determine the criteria for endoscopic resection of early colorectal cancer. The risk factors for lymph node metastasis, including occult metastasis, were analyzed in 86 cases of surgically resected colorectal cancer invading the submucosa. The lymph nodes were assessed by immunohistochemistry with cytokeratin antibody CAM5.2. The frequencies of overt and occult metastasis to the lymph nodes were 13 percent (11/86) and 13 percent (10/75), respectively. Multivariate analysis showed vascular invasion (P = 0.001) and tumor budding (P = 0.003) to be independent risk factors for lymph node metastasis, including occult metastasis. For tumors with submucosal invasion < or =1,000 microm, no lymph node metastasis was found. The frequencies of lymph node metastasis for tumors with submucosal invasion of 1,000 to 2,000 microm and >2,000 microm were 21 and 37 percent, respectively. In considering combinations of risk factors, there was no lymph node metastasis in tumors having neither vascular invasion nor tumor budding and submucosal invasion of < or =3,000 microm. Vascular invasion, tumor budding, and the degree of submucosal invasion were significant risk factors for lymph node metastasis, including occult metastasis. These three factors can be used in combination to identify patients requiring additional surgery after endoscopic resection.