Positive Vertical Margin Research Articles

Mo1554 Grading Atrophic Gastritis by a New Quantitative Method Using Confocal LASER Endomicroscopy Probe (P-CLE): First Results of a Prospective Cohort Study

Mo1553 Is the Recent Who Pathological Classification for Gastric Cancer Helpful in Applying to Endoscopic Resection? Hae Won Kim*, Jie-Hyun Kim, Hyunki Kim, Hoguen Kim, Yong Chan Lee, Sang Kil Lee, Sung Kwan Shin, Yong Hoon Kim, Jun Chul Park, DA Hyun Jung, Jae Jun Park, Young Hoon Youn, Hyojin Park, Sung Hoon Noh, Seung Ho Choi Gastroenterology, Seoul, Korea (the Republic of); pathology, Yonsei university college of medicine, Seoul, Korea (the Republic of); Surgery, Yonsei college of medicine, Seoul, Korea (the Republic of) Background/Aims: Endoscopic resection (ER) has been performed in early gastric cancer with undifferentiated histology (UD-EGC) based on Japanese classification. Whereas, we previously found that different approach is necessary between poorly differentiated (PD) & signet ring cell carcinoma (SRC) for curative resection. However, according to 2010 WHO classification, diffuse type PD and SRC are categorized into the same group as poorly cohesive carcinoma. Thus, we assessed whether the WHO classification is helpful to perform ER of UD-EGC. Methods: Among 3,419 EGC underwent surgery, we analyzed the clinicopathologic features of 1,295 lesions with SRC and PD. We recategorized into intestinal PD, poorly cohesive carcinoma (SRC, diffuse PD), and compared in terms of clinical behavior such as lymph node metastasis (LNM). We also recategorized 190 lesions (63 PD; 127 SRC) treated by ER into intestinal PD, poorly cohesive carcinoma (SRC, diffuse PD), and compared in terms of outcomes of ER. Results: According to surgical data, the rate of LNM was high in order from intestinal PD, diffuse PD and SRC (15.8%, 13.5%, and 6.3%). Similarly, the rate of LVI was significantly lowest in SRC compared with diffuse and intestinal PD. When compared between diffuse PD and SRC categorized as poorly cohesive carcinoma, the rate of LNM and LVI was significantly higher in diffuse PD than SRC. According to ER data, there was no recurrence in all of them if curatively resected. However, the most common cause of non-curative resection was different between SRC and PD irrespective of intestinal or diffuse type. The most common cause was positive lateral margin in SRC, whereas positive vertical margin in both intestinal and diffuse PD. Conclusions: Clinical behaviors are different between diffuse PD and SRC categorized as poorly cohesive carcinoma in WHO classification. Considering LNM and outcomes of ER, the recent WHO classification may not be helpful to perform ER for UD-EGC.

Salvage endoscopic submucosal dissection for the treatment of esophageal squamous cell carcinoma after local treatment failure with chemotherapy, radiotherapy, or chemoradiotherapy.

148 Background: Chemotherapy (CT), radiotherapy (RT), and chemoradiotherapy (CRT) are efficacious treatment options for esophageal squamous cell carcinoma (ESCC). However, local treatment failure remains a major problem. In this study, we applied endoscopic submucosal dissection (ESD) for the treatment of ESCC after local treatment failure with CT, RT, or CRT. The efficacy, safety, and feasibility of salvage ESD were assessed. Methods: Between 2008 and 2014, 611 patients underwent ESD for superficial ESCC in our hospital. Of them, 14 required salvage ESD: 7 for local treatment failure after CT, 4 after CRT, and 3 after RT. Each patient was treated with CT using 5-fluorouracil + cisplatin or RT, which consisted of >50 Gy of irradiation with or without concurrent CT. The following clinical findings were confirmed in all patients: no evidence of lymph node or distant metastasis after treatment, and an endoscopically resectable lesion. Results: The male to female ratio was 11:3 and the mean age was 64.9 (44-81) years. Clinical stages before treatment were T1b/T2/T3/T4 in 10/1/2/1, N0/1 in 7/7, and M0/1 in 13/1, respectively. The mean tumor size was 18.6 mm, and the mean procedure time was 45.7 min. En bloc resection was achieved in 100% of cases, and the R0 resection rate was 78.6%. Histopathological assessment of specimens taken at salvage ESD revealed that 6 lesions (42.9%) had invaded the submucosal layer and had been resected noncuratively because of a positive vertical margin (n = 2) or positive lymphovascular invasion (n = 5). No immediate or delayed complications, including major bleeding or perforation, and no ESD-related deaths occurred. At a mean follow-up period of 26.5 (range, 5–55) months, local recurrence had developed at the treatment site in 2 patient. Overall, 10 patients were still alive. The remaining 4 had developed lymph node metastasis, 2 of whom had died from it. Conclusions: Salvage ESD is an option for ESCC patients with local treatment failure after CT, RT, or CRT.

Clinical outcomes of early gastric cancer with lymphovascular invasion or positive vertical resection margin after endoscopic submucosal dissection.

In early gastric cancer (EGC) cases with lymphovascular invasion or positive vertical margins after endoscopic submucosal dissection (ESD), additional radical gastrectomy is performed on principle. However, an additional surgery is often difficult to consider if the surgical approach itself is challenging or the patient refuses surgery. In such cases, only close surveillance is performed without additional surgical procedures. This study aimed to examine the difference in clinical prognosis of EGC cases with lymphovascular invasion or positive vertical margins after ESD either with or without surgery. We retrospectively studied 83 patients with lymphovascular invasion or positive vertical margins after ESD from July 2005 to November 2013. Of the 83 patients, 45 (54.2%) underwent radical additional gastrectomy (surgical group) and 38 (45.8%) were under close surveillance without surgical or endoscopic treatments (close surveillance group.) The cancer-free survival period was 78.3 ± 3.4 months in the surgical group and 64.5 ± 4.6 months in the close surveillance group. The recurrence rates did not significantly differ between the 2 groups, at 7.9% in the surgical group and 6.7% in the non-surgical group. Close surveillance may be suggested as an option for EGC patients for whom a surgical approach is difficult, who exhibit a positive vertical margin after ESD, and who have no lymphovascular or deep submucosa invasion after ESD.

Risk factors for local recurrence in patients with positive lateral resection margins after endoscopic submucosal dissection for early gastric cancer.

With the widespread use of endoscopic submucosal dissection (ESD) in patients with early gastric cancer (EGC), the number of cases with incomplete resection due to positive lateral resection margins (LM+) is increasing. Local recurrence, which occurs frequently in LM+ cases, is an important issue. This study aimed to clarify the clinicopathological factors related to tumor recurrence in LM+ cases after ESD for EGC. From January 2005 to December 2012, a total of 1,083 patients with EGC underwent ESD at our hospital. Of these, cases with a pathological diagnosis of LM+ were included in this study. Patients with positive vertical resection margins, those who underwent surgical resection immediately or were followed up for less than 6 months after ESD, were excluded. A total of 55 LM+ cases after ESD for EGC were enrolled. Incorrect delineation of a lesion that extended pathologically beyond the ESD marking dots was the main cause of LM+. Local recurrence was found in 20 (36.4 %) patients (median follow-up period, 23 months). Local recurrence rates related to LM+ length were as follows: 7/29 (24.1 %) in 2 mm, 6/16 (37.5 %) in 4 mm, 1/3 (33.3 %) in 6 mm, 4/5 (80 %) in 8 mm, and 2/2 (100 %) in ≥ 10 mm. In multivariate analysis, tumor size > 2 cm (OR 4.48, 95 % CI 1.18-16.99, p = 0.027), and LM+ length > 6 mm (OR 7.65, 95 % CI 1.15-50.70, p = 0.035) were independent risk factors for tumor recurrence. To decrease the risk of LM+, it is highly important to accurately delineate the lateral margins during ESD; when the final histopathological result is LM+, cases with LM+ length >6 mm or tumor size > 2 cm should be considered for additional surgical resection or re-ESD because of a high risk of tumor recurrence.

Comparison between the location and the histomorphological/immunohistochemical characteristics of noninvasive neoplasms of the ampulla of Vater.

To determine useful factors when selecting an appropriate procedure for noninvasive ampullary neoplasia, we investigated the relationship between the location and the histomorphological/immunohistochemical characteristics of 56 noninvasive ampullary neoplasms obtained by endoscopic papillectomy (EP). All subjects were classified according to histomorphology and location of neoplasms, and we evaluated the characteristics of each classified group using complementary immunohistochemical procedures. The CK20-positive rates of each location type were also evaluated. Subjects presented with 52 intestinal-type adenomas (low/high grade, 32:20) and 4 noninvasive pancreatobiliary papillary neoplasms (low/high grade, 1:3). Twenty-seven periampullary (peri-AMP)-type tumors and 23 extended-type tumors comprised the intestinal type, and the intra-ampullary (intra-AMP) type was composed of 4 pancreatobiliary and 2 intestinal histomorphological types. The CK20-positive rates of these 3 location types differed significantly (peri-AMP type, 50.6% ± 21.0%; extended type, 35.4% ± 18.6%; intra-AMP type, 6.9% ± 6.3%). The CK20-positive rate for intestinal-type tumors of the intra-AMP location type was lower than that of the peri-AMP location type. Intestinal-type tumors without CDX2 expression included extended and intra-AMP types, which are tumors that may show positive vertical margins when EP is performed. In this study, we found that an understanding of pancreatobiliary-type histology is an important aspect for the investigation of tumors involving the common channel of the ampulla. Furthermore, immunostaining of CDX2 and CK20 provides beneficial information if considering whether to perform an EP.

Risk Factors for Residual Cancer and Lymph Node Metastasis After Noncurative Endoscopic Resection of Early Colorectal Cancer

Endoscopic resection could be a curative treatment for early colorectal cancer without the possibility of lymph node metastasis. However, if the resection margin is positive, and there is a risk of lymph node metastasis, additional surgery should be performed. The aim of this study was to investigate the characteristics of patients who underwent additional surgery to determine risk factors associated with residual tumor and lymph node metastasis. This study is a retrospective analysis. This study was conducted at a tertiary academic hospital. We evaluated 85 patients who underwent additional surgery with curative intent after endoscopic resection for early colorectal cancer at the Samsung Medical Center, Seoul, South Korea, between January 2001 and April 2010. We identified risk factors associated with residual tumor or lymph node metastasis in surgical specimens after noncurative endoscopic resection for early colorectal cancer. Among 85 patients who underwent additional surgery after noncurative endoscopic resection, 76 (89.4%) had submucosal invasion greater than 1000 μm. Twenty-one (24.7%) and 25 patients (29.4%) had a positive lateral or vertical resection margin, and 11 patients (12.9%) had inadequate lifting sign. After additional surgery, patients were divided into 2 groups according to the presence or absence of residual tumor and/or lymph node metastasis. There was no significant difference between the groups in positive lateral margin, but there was a significant difference in positive vertical margin (p = 0.015 with an OR of 15.02). In patients with inadequate lifting sign, the OR was 13.68 (p = 0.013). This study was limited by its retrospective nature. There is a greater need for additional surgery in cases with positive vertical resection margin or inadequate lifting sign, because the risk of residual tumor and lymph node metastasis is higher than in other cases.

Clinical Impact of Endoscopic Submucosal Dissection for Early Gastric Cancer

Aim: The aim of this study was to examine the safety and efficacy of endoscopic submucosal dissection (ESD) for early gastric cancer based on approximately 10 years’ experience. Methods: Endoscopic submucosal dissection was performed in 1272 patients with early gastric cancer (1657 lesions). We examined en bloc resection rate, curative resection rate, local recurrence rate, procedure time, and complications. Results: The overall en bloc resection rate was 98.6% for all lesions treated by ESD. The median procedure time of the operation was 54.3 minutes (range 5 - 632 min). The incidence of positive horizontal and vertical margins was 3.8% and 4.0%, respectively. The incidence was 2.5% each for perforation and postoperative bleeding. There were no deaths related to ESD. Local recurrence was observed in 10 lesions (0.06%). Conclusion: Since the procedure time and incidence of complications have been reduced, endoscopic submucosal dissection has been considered a standard treatment for early gastric cancer.

Tu1616 The Efficacy of Salvage Endoscopic Submucosal Dissection in Patients With Recurrent or Residual Tumor After Chemoradiotherapy for Esophageal Squamous Cell Carcinoma

Local recurrent or residual tumor after chemoradiotherapy (CRT) for esophageal squamous cell carcinoma remains an important problem. Although salvage esophagectomy after CRT is the only curative possibility, it carries a higher mortality and morbidity rate than primary surgery. If the carcinoma is a superficial lesion that is limited to the superficial submucosal layer, endoscopic mucosal resection (EMR) may be effective as salvage treatment. However, salvage EMR has problems: lifting is not easy because of submucosal fibrosis; it has a low complete en bloc resection rate; and a positive vertical margin can occur in submucosal invasive cancer.

Endoscopic Resection for Rectal Carcinoid Tumors: Comparision of Polypectomy and Endoscopic Submucosal Resection with Band Ligation

Background/AimsRectal carcinoid tumors, at diagnosis, are as small as 10 mm or less in about 80% of patients. These tumors are generally removed by endoscopic resection. The aim of this study was to compare treatment efficacy and safety between endoscopic submucosal resection with band ligation (ESMR-L) and conventional polypectomy.MethodsBetween January 2005 and September 2010, a total of 88 patients, who visited at Busan Paik Hospital and Kosin University Gospel Hospital for endoscopic resection of rectal carcinoid, were reviewed, retrospectively.ResultsThirty-three cases were treated by ESMR-L, and 55 cases by conventional polypectomy. There were no significant difference in the size of tumor between ESMR-L group and polypectomy group (6.02±2.36 vs. 6.49±3.24 mm, p=0.474). The rate of positive resection margin was significantly lower in ESMR-L group (2/33, 6.1%) than in polypectomy group (19/55, 34.5%; p=0.002). The rate of positive vertical resection margin, among others, was markedly lower in ESMR-L group (1/33, 3.0%) compared to polypectomy group (19/55, 34.5%; p<0.001).ConclusionsESMR-L, rather than conventional polypectomy, is a useful treatment option for removal of rectal carcinoid tumors less than 10 mm in diameter.

Clinical Outcomes of Gastrectomy after Incomplete EMR/ESD

PurposeEndoscopic resection is widely accepted as standard treatment for early gastric cancer (EGC) without lymph node metastasis. The procedure is minimally invasive, safe, and convenient. However, surgery is sometimes needed after endoscopic mucosal resection/endoscopic submucosal dissection endoscopic mucosal resection (EMR)/endoscopic submucosal dissection (ESD) due to perforation, bleeding, or incomplete resection. We evaluated the role of surgery after incomplete resection.Materials and MethodsWe retrospectively studied 29 patients with gastric cancer who underwent a gastrectomy after incomplete EMR/ESD from 2006 to 2010 at Korea University Hospital.ResultsThere were 13 incomplete resection cases, seven bleeding cases, three metachronous lesion cases, three recurrence cases, two perforation cases, and one lymphatic invasion case. Among the incomplete resection cases, a positive vertical margin was found in 10, a positive lateral margin in two, and a positive vertical and lateral margin in one case. Most cases (9/13) were diagnosed as mucosal tumors by endoscopic ultrasonography, but only three cases were confirmed as mucosal tumors on final pathology. The positive residual tumor rate was two of 13. The lymph node metastasis rate was three of 13. All lymph node metastasis cases were submucosal tumors with positive lymphatic invasion and no residual tumor in the gastrectomy specimen. No cases of recurrence were observed after curative resection.ConclusionsA gastrectomy is required for patients with incomplete resection following EMR/ESD due to the risk of residual tumor and lymph node metastasis.

Is Surgical Treatment Necessary after Non-curative Endoscopic Resection for Early Gastric Cancer?

PurposeAdditional surgery is commonly recommended in gastric cancer patients who have a high risk of lymph node metastasis or a positive resection margin after endoscopic resection. We conducted this study to determine factors related to residual cancer and to determine the appropriate treatment strategy.Materials and MethodsA total of 28 patients who underwent curative gastrectomy due to non-curative endoscopic resection for early gastric cancer between January 2006 and June 2009 were enrolled in this study. Their clinicopathological findings were reviewed retrospectively and analyzed for residual cancer.ResultsOf the 28 patients, surgical specimens showed residual cancers in eight cases (28.6%) and lymph node metastasis in one case (3.8%). Based on results of the endoscopic resection method, the rate of residual cancer was significantly different between the en-bloc resection group (17.4%) and the piecemeal resection group (80.0%). The rate of residual cancer was significantly different between the diffuse type group (100%) and the intestinal type group (20%). The rate of residual cancer in the positive lateral margin group (25.0%) was significantly lower than that in the positive vertical margin group (33.3%) or in the positive lateral and vertical margin group (66.7%).ConclusionsWe recommended that patients who were lateral and vertical margin positive, had a diffuse type, or underwent piecemeal endoscopic resection, should be treated by surgery. Minimal invasive procedures can be considered for patients who were lateral margin positive and intestinal type through histopathological examination after en-bloc endoscopic resection.

Prognosis of Patients with Early Gastric Cancer Who Underwent Additional Gastrectomy After Incomplete Endoscopic Mucosal Resection

Background: In case that the early gastric cancer is not completely excised by EMR, additional gastrectomy with lymph node dissection is standard therapy. The adverse outcome of gastrectomy after incomplete EMR is one of our concerns due to the potential spread of malignant cell during procedure. Methods: We analyzed 56 consecutive patients with EGC who were treated surgically after incomplete EMR or gastric wall perforation between January 1997 and December 2005. EMR was considered incomplete when there were positive lateral margin, positive vertical margin including submucosal invasion, lymphovascular involvement or when histologic type was undifferentiated. Results: Fifty three patients were followed up for a median of 47 (range 12-115) months. Mean tumor size was 21.2 (range 8-51)mm. Reasons for subsequent gastrectomy were as follows: 30 cases of positive lateral margin; 24 cases of positive vertical margin; 8 cases of lymphovascular involvement; 12 cases of undifferentiated histologic type; 2 cases of gastric wall perforation. 21 patients had 2 reasons; 1 patient had 3 reasons. Curative resection with LN dissection was performed in 51 patients, and 2 patients underwent wedge resection. 28 patients (53%) had microscopic evidence of residual cancer in the stomach. The mean number of dissected LN was 17 (range 2-38). LN metastasis was found in 3 patients (5.8%) whose reason for surgery was submucosal invasion in 2 cases, and submucosal invasion and lymphovascular involvement in another case. There was one case of recurrence after gastrectomy (1.9%). Recurrence occurred as hematogenous metastasis 70 months after surgery, and he died 21 months after recurrence.Conclusion.This study suggests that the outcome of additional gastrectomy following incomplete EMR may be similar to that of primary gastrectomy for EGC.

A Novel Device, Countertraction-Spring, Is Easier and Safer for Endoscopic Submucosal Dissection of Mucosal Stomach Cancer

Purpose: To safely perform endoscopic submucosal dissection (ESD) with a good field of view using a spring to apply countertraction during surgery. Methods: According to basic experiments, traction forces of 1-20 gram provide effective countertraction on the gastric mucosa. We invented a novel countertraction device that consists of a stainless steel-spring that is 2 mm in diameter, 2 cm long, and has a wire diameter of 0.1 mm, an approximately 10 fold stretch distance in this range of traction forces, and a nylon loop attached to each of its ends. (1) Allowing a 5 mm margin around the mucosal lesion, the entire circumference is incised. (2) The spring, set in the middle of a 2.5-mm diameter tube that passes through the 2.8-mm forceps channel of an endoscope, is introduced into the stomach via the forceps channel. (3) Countertraction is applied by attaching one of the loops to one end of the lesion with a clip, and attaching the other loop to the healthy mucosa on the other side. (4) The submucosal layer is dissected. (5) The clip attached to the mucosa on the other side is released, and the lesion and spring are retrieved. Results: After obtaining the patients' informed consent, ESD with the novel device was performed on 5 male and 5 female patients between November 2006 and November 2007. The patients' ages ranged from 64 to 82 years (mean: 72.6), and the locations of the tumors were: Lower, Less 6; Lower, Gre, 2; Lower, Post 1; and Middle-Upper, Less 1. According to macroscopic type, there were 8 IIa cases, 1 IIa + IIc case, and 1 IIc case. Mean diameters of the lesions were 20.4 mm × 14.5 mm; mean diameters of the resected specimens were 42.7 mm x 33.9 mm; mean full-circumference incision time was 28 min; mean spring placement time was 4.7 min; and mean submucosal dissection time was 20.5 min. Dissection was possible with sufficient countertraction and a good field of view in every case. There were no complications, and the patients were discharged after a mean hospital stay of 7.8 days. With the exception of 1 case with final pathological diagnosis of adenoma (resection margin negative) and 1 case submucosal invasion 250 micrometer in which additional surgery was performed by positive vertical margin, the pathological findings showed that all of the cases were well differentiated mucosal cancers with negative resection margins and no vascular invasion, and that complete resection had been performed. Conclusion: The countertraction-spring provided favorable countertraction for submucosal dissection of mucosal stomach cancer and this device made the dissection technique easier and safer.

Histologic evaluation of resection specimens obtained at 293 endoscopic resections in Barrett's esophagus

Evidence-based selection criteria for endoscopic resection (ER) of Barrett's neoplasia are scarce. To study the histopathology of ER specimens of Barrett's neoplasia and correlate this with endoscopic characteristics to make recommendations for patient management. DESIGN, SETTING, INTERVENTIONS: Histology and correlating endoscopy reports of specimens obtained at 293 consecutive ERs performed at a Dutch tertiary referral center between 2000 and 2006 were reviewed. Histologic findings in ER specimens and their relation with endoscopic characteristics. A total of 150 ERs were performed for focal lesions: 16% type 0-I, 23% 0-IIa, 7% 0-IIb, 3% 0-IIc, 9% 0-IIa-IIb, and 42% 0-IIa-IIc; and 143 for flat mucosa. Histology revealed no dysplasia in 57 ERs, low-grade intraepithelial neoplasia in 52, high-grade intraepithelial neoplasia in 104, T1m in 61, and T1sm in 17; in two cancers, infiltration depth was not assessable because of artifacts. Type 0-I and 0-IIc lesions significantly more often penetrated the submucosa (P = .009): 60% were G1 cancers, 23% were G2 cancers, and 18% were G3 cancers. G2-G3 cancers significantly more often invaded the submucosa (P < .001) or had positive vertical margins (P = .015). Histology of ER specimens led to a change in diagnosis in 49% of the focal lesions and a relevant change in treatment policy in 30%. A retrospective study. ER is a valuable diagnostic tool that frequently leads to a change in treatment policy. Most endoscopically resected early Barrett's neoplasia are 0-II type, G1 mucosal neoplasia. Submucosal infiltration is more often encountered in type 0-I and 0-IIc lesions and in G2-G3 cancers.

The Role of Surgery After Incomplete Endoscopic Mucosal Resection for Early Gastric Cancer

Endoscopic mucosal resection (EMR) is a relatively new treatment option for early gastric cancer (EGC). However, cases of incomplete EMR resulting in a positive lateral margin or submucosal invasion (positive vertical margin) have been reported. We conducted this study to evaluate the role of surgery after incomplete EMR for EGC. We analyzed 19 patients who underwent gastrectomy as a result of an incomplete EMR. The patients were divided into three groups according to the type of incomplete EMR: a positive lateral margin (LM) group (n = 9), a positive vertical margin (VM) group (n = 4), and a positive lateral and vertical margin (LM + VM) group (n = 6). The positive residual tumor rate and the positive lymph node rate were 44.4% (4/9) and 0% (0/9) in the LM group, 50.0% (2/4) and 25.0% (1/4) in the VM group, and 83.3% (5/6) and 16.7% (1/6), LM + VM group, respectively. Curative resection was performed in all patients and there was no recurrence in 30.8 months of follow-up. Radical surgery is recommended for patients with a positive lateral resection margin or submucosal invasion, or both, after EMR for EGC, because of the possibility of residual tumor or lymph node metastasis.