Resection Of Early Gastric Cancer Research Articles

Clinical significance of a papillary adenocarcinoma component in early gastric cancer: a single-center retrospective analysis of 628 surgically resected early gastric cancers

We recently reported that the presence of a papillary adenocarcinoma (pap) component was an independent risk factor for lymphatic involvement in endoscopically resected early gastric cancer (EGC). This study aimed to investigate the potential association between the presence of a pap component in EGC and lymph node metastasis (LNM). In order to evaluate the association between LNM and clinicopathological features, including a pap component, we reviewed 628 surgically resected EGCs at our institution between 2009 and 2012. Clinicopathological features included age, gender, tumor location, macroscopic type, tumor size, histological type, depth, ulcerative findings, and lymphatic and venous involvement. In addition, the association between clinicopathological features and lymphatic involvement was also evaluated. LNM was observed in 52 cases (8.3%). Univariate analyses revealed a significant correlation between a pap component and LNM as well as tumor size, depth, macroscopic type, a poorly differentiated adenocarcinoma component, and lymphatic and venous involvement. The percentage of positive LNM among the EGC cases with a pap component was significantly higher than in those without the component (18.2 vs. 7.3%, P=0.010). Via multivariate analyses lymphatic involvement was identified as the strongest risk factor for LNM [odds ratio (OR) 14.1] and a pap component was revealed as an independent risk factor for lymphatic involvement (OR 3.1). Our study revealed that EGC cases with a pap component were at higher risk of lymphatic involvement and showed a higher percentage of positive LNM. More attention should be paid to a pap component in EGC.

Influencing factors contributing to curative resection of early gastric endoscopy

Objective To analyze risk factors contributing to curative resection of early gastric en- doscopy effects, and to increase the likelihood of curative endoscopic resection of early gastric cancer. Methods During October 2008 to March 2013, data of endoscopic resection of early gastric cancer （ inclu- ding the high-grade intraepithelial neoplasia） were collected. The six factors including gender, age, lesion location, lesion size, lesion type of morphology and with ulceration were analyzed whether they were associat- ed with en bloc resectability and curability of endoscopic resection（ER） ; The main causes of non-curative resection were also analyzed. Results From the included 94 cases including 94 lesions of early gastric canc- er. Twenty cases were diagnosed as high-grade intraepithelial neoplasia,70 lesions were diagnosed as cancer limited in mucosal layer, and four lesions were diagnosed as cancer infiltrating superficial submucosal layer （500 μm form mucosal muscularis）. Five lesions were treated by EMR and 89 lesions were resected by ESD. ER en bloc resection rate was 95.7% （90/94） and the curative resection rate was 79. 8% （75/94）. The curative resection of the lesions in diameter more than 3. 0cm was significantly lower than the lesions in diameter no more than 2. 0 cm （P = 0. 022, OR = 0. 108,95 % CI： 0. 0160-0. 721 ）. And the curative resection of the lesions with ulceration was significantly lower than the lesions without ulceration （ P = 0. 047, OR = 0. 149,95% CI： 0. 023-0. 971 ）. Non-curative resection is mainly due to the positive side edge of the residual tumor cells. Conclusion Lesions in diameter more than 3.0cm and with ulceration were the risk factors to curation resection of ER for early gastric cancer Key words: Early gastric cancer; Endoscopic resection; Curative Resection; Risk factors

Sa1647 Predictors of Lymph Node Metastasis and Residual Tumor in Non-Curative Endoscopic Resection of Early Gastric Cancer

Surgical treatment is recommended after non-curative endoscopic resection of early gastric cancer (EGC). However, only a part of the patients is found to have lymph node (LN) metastasis or residual tumor. This study aimed to identify the risk factors of LN metastasis and residual tumor in patients received non-curative endoscopic resection.

Sa1632 Is New Criteria for Mixed Histology Is Necessary for Endoscopic Resection in Early Gastric Cancer?

Sa1632 Is New Criteria for Mixed Histology Is Necessary for Endoscopic Resection in Early Gastric Cancer?

Sa1527 Long-Term Outcomes of Non-Curative Endoscopic Resection of Early Gastric Cancer

We evaluated the clinical characteristics and long-term outcomes of patients undergoing non-curative endoscopic resection for early gastric cancer (EGC) and investigated the incidence and patterns of recurrence in patients who underwent non-curative endoscopic resection without additional treatment for differentiated EGC.

Sa1507 Long-Term Outcomes of Endoscopic Resection for Early Gastric Cancer: Appropriate Surveillance Strategy Based on the Incidence and Patterns of Local, Metachronous and Extragastric Recurrence

Sa1507 Long-Term Outcomes of Endoscopic Resection for Early Gastric Cancer: Appropriate Surveillance Strategy Based on the Incidence and Patterns of Local, Metachronous and Extragastric Recurrence

Sa1910 Serum Pepsinogen I/II Ration Could Predict the Development of Metachronous Gastric Cancer After Endoscopic Resection for Early Gastric Cancer; Retrospective, Single Tertiary Center Study

Sa1910 Serum Pepsinogen I/II Ration Could Predict the Development of Metachronous Gastric Cancer After Endoscopic Resection for Early Gastric Cancer; Retrospective, Single Tertiary Center Study

Sa1515 Size Discrepancy Between Endoscopic Size and Pathologic Size Is Not Negligible in Endoscopic Resection for Early Gastric Cancer

Accurate tumor size measurement is critical for selecting proper candidates for endoscopic resection (ER) of early gastric cancer (EGC). However, size discrepancy between endoscopic size and pathologic size often occurs during ER for EGC. The purposes of this study were to investigate the clinicopathological characteristics related to size discrepancy and the clinical implications of size discrepancies in terms of therapeutic outcomes.

Sa1644 Feasibility of Non-Exposed Endoscopic Wall-Inversion Surgery (NEWS) With Sentinel Node Navigation Surgery (Snns) As a New Method of Minimally Invasive Local Resection for Early Gastric Cancer: a Porcine Survival Study

Non-exposed endoscopic wall-inversion surgery (NEWS) has been developed as endoscopic full-thickness resection without transluminal communication to avoid intraabdominal infection or tumor seeding. We aimed to investigate feasibility and safety of NEWS with sentinel node navigation surgery (SNNS), which can minimize the area of lymph node dissection for early gastric cancer (EGC), in a porcine survival study for a week.

Follow-up outcomes of endoscopic resection for early gastric cancer with undifferentiated histology

The application of endoscopic resection (ER) for undifferentiated-type early gastric cancer (UD-EGC) remains controversial. The aim was to examine long-term outcomes of ER for UD-EGC. Furthermore, we investigated whether long-term outcomes of ER differed between poorly differentiated adenocarcinoma (PD) and signet ring cell carcinoma (SRC). From 2001 to 2011, 209 lesions in 209 patients with UD-EGC (82 PD; 127 SRC) were treated by ER. We retrospectively assessed the clinical outcomes of ER in 209 patients. The survival rate and disease-free survival rates after ER were evaluated as long-term outcomes. The en bloc resection and curative resection (CR) rates were 91.4 and 55.0%, respectively. The en bloc and CR rates in PD were 90.2 and 45.1%, whereas those in SRC were 92.1 and 61.4%. For patients with PD who underwent non-curative resections, 51.1% were vertical-cut end-positive and for those with SRC, 63.3% were lateral-cut end-positive, a statistically significant difference. In those patients where CR was achieved, no case of local recurrence or distant metastasis was observed during the follow-up period (32.7±22.2months). The 3- and 5-year survival rates were 99.0 and 98.6%, with no significant difference between CR patients with SRC and PD. ER may yield good long-term outcomes for UD-EGC if CR is achieved, with no difference between PD and SRC. However, to increase the current CR rate of ER, stricter criteria for performing ER in UD-EGC may be required.

Commentary: independent risk factors for recurrent neoplasia after endoscopic resection of early gastric cancer – authors' reply

Commentary: independent risk factors for recurrent neoplasia after endoscopic resection of early gastric cancer – authors' reply

Commentary: independent risk factors for recurrent neoplasia after endoscopic resection of early gastric cancer

Commentary: independent risk factors for recurrent neoplasia after endoscopic resection of early gastric cancer

Future perspective of gastric cancer endotherapy.

Endoscopic resection of early gastric cancer (EGC) has proven safety and efficacy, and is the established standard of care in Japan. In the past decade, it is increasingly established worldwide. The endoscopic submucosal dissection (ESD) is superior to endoscopic mucosal resection (EMR) technique as it is designed to provide adequate staging and long-term curative therapy-based on the en bloc R0 specimen irrespective of the size and/or location of the tumor coupled with the reliable pathological specimen. However, ESD is still requiring skilled and experienced endoscopist to perform because of complex procedures, higher complication and causing long-time consuming. The learning and application of these relatively complex endoscopic techniques for EGC has been shown across the world. Thus, a standardized ESD training system is urgently needed to disseminate safe and effective ESD technique to practices with limited ESD experience. In recent years, several innovations providing solutions to easier and safer performance of ESD have emerged. Those increase control of surgical effectors manipulating the target tissue, and enhance performance in complex surgical tasks. Very recently, the use of the laparoscopic and endoscopic cooperative surgery (LECS) procedure is indicated for EGC that would be difficult to treat with ESD. As an ultimate gastric cancer endotherapy with a reasonable surgical time, LECS might be promising method at this stage. The indications for LECS for EGC could be expanded in the future, which could result in increasingly successful gastric cancer treatment.

Endoscopic Submucosal Dissection for Malignant Esophageal Lesions

The incidence of esophageal cancer has been increasing while the prognosis remains very poor. Endoscopic submucosal dissection (ESD) was developed in Japan for en bloc resection of early gastric cancer with excellent results. The use of ESD in early squamous cell cancer (SCC) of the esophagus in Japan has been increasing with long-term results comparable to those in early gastric cancer. The use of ESD in Barrett's neoplasia in western countries has been challenged by the low complete resection rates and the risk of metachronous lesions from surrounding non-dysplastic Barrett's epithelium. Efforts to combine ESD with other treatment modalities such as radiofrequency ablation in Barrett's neoplasia and chemoradiation in SCC appear to be promising. The use of steroid therapy (local or systemic) has been demonstrated to prevent post-ESD stenosis, which is the most common complication after esophageal ESD.

Size discrepancy between endoscopic size and pathologic size is not negligible in endoscopic resection for early gastric cancer

Accurate tumor size measurement is critical for selecting proper candidates for endoscopic resection (ER) of early gastric cancer (EGC). However, size discrepancy between endoscopic size and pathologic size often occurs during ER for EGC. The purposes of this study were to investigate the clinicopathological characteristics related to size discrepancy and the clinical implications of size discrepancies in terms of therapeutic outcomes. Between April 2006 and June 2013, a total of 820 patients with 826 EGCs underwent ER. Enrolled lesions were categorized into the following three groups based on size discrepancy between endoscopic size and pathologic size: well-estimated (N = 308), underestimated (N = 215), or overestimated (N = 303) lesions. The well-estimated group was defined as lesions with a ratio of endoscopic size to pathologic size from 0.7 to 1.3. The overall median size discrepancy was 5.0 mm (interquartile range 2.0-9.0). Size, location, macroscopic type, primary tumor stage, and histology differed significantly between the three groups. Larger size [odds ratio (OR) 5.07, 95 % confidence interval (CI) 3.38-7.59, p < 0.001], flat/depressed type (OR 1.71, 95% CI 1.15-2.55, p = 0.008), and undifferentiated histology (OR 2.24, 95% CI 1.31-3.83, p = 0.003) were independent risk factors for endoscopic size underestimation in multivariate analysis. Smaller size (OR 10.95, 95% CI 4.64-25.87, p < 0.001) was the only independent predictor for endoscopic overestimation of size. Significantly lower complete resection and curative resection rates were detected in the underestimated group compared with the well-estimated group, while the complete resection rate in the overestimated group tended to be higher than in the well-estimated group. There was no significant difference of curative resection rate between the overestimated and the well-estimated groups. Larger size, flat/depressed type, and undifferentiated histology of EGC carry a significant risk for endoscopic underestimation of lesion size, which results in the lower rates of complete and curative resections for EGC. Further studies to reduce size discrepancy are warranted.

Clinicopathologic factors and outcomes of histologic discrepancy between differentiated and undifferentiated types after endoscopic resection of early gastric cancer

Histologic discrepancies among specimens obtained by forceps biopsy and endoscopic resection (ER) between the differentiated and undifferentiated types often occur in early gastric cancer (EGC). This study aimed to evaluate the predictive clinicopathologic characteristics and clinical implications of histologic discrepancies in EGC. From August 2005 to March 2012, 596 lesions from 579 patients underwent ER for EGC. The lesions studied were diagnosed as the differentiated histologic type from forceps biopsy specimens. The lesions were grouped according to the occurrence of histologic discrepancy between the differentiated and undifferentiated types in specimens obtained by ER as concordant (n = 570) or discordant (n = 26). The main outcome measures were en bloc resection, complete resection, and curative resection rates. The histologic discrepancy rate was 4.4% among the studied lesions. Larger size, lesion location in the mid third of the stomach, easy friability, exudates, and submucosal invasion shown on endoscopic ultrasound were significantly related to histologic discrepancy in the univariate analysis. In the multivariate analysis, lesion location in the mid third of the stomach [odds ratio (OR) 5.34, 95% confidence interval (CI) 1.59-19.13] and easy friability (OR 29.26, 95% CI 2.30 to >999.9) were significant factors associated with histologic discrepancy. The complete resection and curative resection rates were significantly lower and the additional operation rates after ER were significantly higher in the discordant group. The EGCs with histologic discrepancy between the differentiated and undifferentiated types changed the therapeutic outcomes of ER. Easily friable lesions located in the mid third of the stomach carry a significant risk for histologic discrepancy in undifferentiated histology when ER of EGCs is performed.

Failure of Helicobacter pylori eradication and age are independent risk factors for recurrent neoplasia after endoscopic resection of early gastric cancer in 283 patients

Whether the incidence of metachronous gastric dysplasia and cancer could be decreased by eradication of Helicobacter pylori after endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). To compare the incidence of metachronous gastric lesion in the eradicated group and the persistent group. Second end point is to evaluate the risk factors for metachronous gastric lesions after ESD for EGC. In a single centre, between May 2007 and May 2010, the patients who had evidence of H. pylori infection at the time of ESD for EGC were included, and the follow-up data were analysed retrospectively. We enrolled 283 patients who have shown H. pylori infection at the time of ESD for EGC. Successful eradication was achieved for 214 patients (75.6%) (Eradicated group), and 69 patients (24.4%) showed persistent H. pylori infection (Persistent group). Metachronous gastric lesions developed in 13 (18.8%) in the persistent group and 18 (8.4%) in the eradicated group (P=0.016). In the ≥60-year-old group, the cumulative incidence of metachronous gastric cancer showed a significant increase (P=0.012). Cumulative hazard ratio of subsequent gastric metachronous lesions differed between the eradication group and the persistent infection group (OR=2.322, 95% CI=1.136-4.744, P=0.021), and ≥60 age at the time of endoscopic resection (OR=2.803, 95% CI=1.207-6.509, P=0.016). Both persistent H. pylori infection and old age (≥60) are independent risk factors for the increased incidence of metachronous gastric cancer.

Long-term outcomes of endoscopic resection for early gastric cancer: Appropriate surveillance strategy based on the incidence and patterns of local, metachronous, and extragastric recurrence.

2 Background: Endoscopic resection (ER) has been accepted as standard treatment of EGC. However, data about long-term outcomes especially related with recurrence have not yet been enough and appropriate surveillance strategy is not established. We evaluated the patterns and risk factors of recurrence, through evaluating the long-term outcomes of ER for treatment of EGCs comparing conventional and expanded indication criteria. Methods: We performed a retrospective review of prospectively and consecutively collected database of 1,855 EGCs in 1,803 patients [1,409 lesions in the conventional indication (CI) and 446 lesions in expanded indication (EI)] underwent ER for EGCs from April 2000 to June 2011. Results: Local recurrence was occurred from five tumors (0.35%) in the CI group and one tumor (0.22%) in the EI group. The median local recurrence interval was 13.5 months (range 2-34 months). 48 (3.1%) patients developed metachronous EGCs during follow up period. The median duration until metachronous recurrence was occurred, was 27.3 months (range, 12.25-115.29 months). There was not significantly different between metachronous group and non-metachronouos group except sex and histologic differentiation. Extragastric recurrence of tumor occurred from two patients in each of the CI and EI group. The extragastric recurrence interval was 62 months in the CI group and 48 months in the EI group. At that time, endoscopic examination showed no evidence of local recurrence around ESD scar area. Conclusions: The expanded indication of ER for EGCs showed acceptable long-term outcomes. More than 5 years of close follow up is needed and CT should be performed together with endoscopy for surveillance of recurrence after ER for EGC in the conventional indication group as well as the expanded indication group.

Long-term outcome of endoscopic submucosal dissection for early gastric cancer compared to surgical resection.

120 Background: Endoscopic submucosal dissection (ESD) is now accepted as an alternative to surgery for the treatment of early gastric cancer (EGC). However, long-term clinical outcome of ESD for EGC compared to surgical resection has not been evaluated. The aim of this study is to evaluate the clinical outcome of ESD for EGC compared to surgical resection. Methods: A retrospective analysis was performed in 152 patients who underwent ESD or surgical resection for EGC according to Gotoda’s extended criteria from 2006 and 2008 in Incheon St. Mary’s Hospital and Seoul St. Mary’s Hospital, The Catholic University of Korea. Overall survival and recurrence rates were compared between the two groups. Results: A total of 56 patients underwent surgical gastrectomy and 96 patients underwent ESD. The medial follow-up was 76 months in surgical resection group and 71 months in ESD group. Metachronous recurrences including dysplasia were found in 9 patients in ESD group and none in surgical resection group (P=0.001). There was no significant difference between the groups in overall survival. Conclusions: Gotoda’s extended criteria for ESD might be acceptable for the treatment of EGC considering the oval survival. However, meticulous surveillance program should be established because metachronous recurrence is more common after ESD.

Early and long-term outcomes of endoscopic submucosal dissection for early gastric cancer in a large patient series

Endoscopic submucosal dissection (ESD) enables the curative resection of early gastric cancer (EGC); however, little information is available on the long-term outcomes of ESD. This study was conducted to clarify the clinical outcomes of a large number of patients with EGC who underwent ESD. The early outcomes were assessed in 1,209 patients and the long-term outcomes were assessed in 300 patients at a follow-up >5 years after the ESD procedure. The overall survival rates were compared between indication and expanded-indication groups, and between the patients who did or did not undergo additional surgery in an out-of-indication group. Overall survival rates were also compared among different age groups. In total, 617 lesions were classed as the indication group, 507 as the expanded-indication group and 208 as the out-of-indication group. Curative resection rates were 96.6% and 91.5% in the indication and expanded-indication groups, respectively. In terms of the long-term outcomes, 20 of the 146 patients in the indication group, 15 of the 105 patients in the expanded-indication group and one of the 23 patients who underwent additional surgery in the out-of-indication group succumbed due to causes other than gastric cancer. Among the 26 patients who did not undergo additional surgery in the out-of-indication group, 10 mortalities occurred, including one due to gastric cancer. The five-year survival rates were not significantly different between the indication and expanded-indication groups. In the out-of-indication group, the five-year survival rate for the patients who did not undergo additional surgery (65.0%) was significantly lower than that for those who did undergo additional surgery (100%) (P<0.01). The five-year survival rate of patients aged >80 years (67.1%) was significantly lower than that of the younger patients (<60 years, 91.6%; sixties, 93.0%; seventies, 84.5%) (P<0.0001). In conclusion, although expanded-indication of ESD for EGC is appropriate, comorbidities require consideration in elderly patients.