Solitary Early Gastric Cancer Research Articles

Usefulness of epinephrine-added injection solution to reduce procedure time for gastric endoscopic submucosal dissection.

Background and study aims Epinephrine-added submucosal injection solution is used to facilitate hemostasis of non-variceal upper gastrointestinal bleeding and to prevent delayed bleeding of large pedunculated colorectal lesions. However, its benefit in gastric endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) is unclear. The effectiveness of epinephrine-added injection solution for outcomes of gastric ESD was examined using propensity score matching analysis. Patients and methods A total of 1,599 patients with solitary EGC (83 with non-epinephrine-added solution and 1,516 with epinephrine-added solution) between 2011 and 2018 were enrolled. Propensity scores were calculated to balance the distribution of baseline characteristics: age, sex, tumor location, specimen size, presence of ulcer scar, tumor depth, histological tumor type, and operators’ experience, and 1:3 matching was performed. En bloc resection rate, mean procedure time, delayed bleeding rate, and perforation rate were compared between the non-epinephrine (n = 79) and epinephrine (n = 237) groups. Results Mean procedure time was significantly shorter in the epinephrine group than in the non-epinephrine group (60 vs. 78 min, P < 0.001). No significant difference was found in the rate of en bloc resection (both 99 %), incidence of delayed bleeding (both 6 %), or perforation (0 vs. 0.8 %) between the two groups. In multiple linear regression analysis, use of epinephrine-added solution was independently associated with short procedure time ( P < 0.001) after adjustment for other covariates. Conclusion The results suggest that epinephrine-added injection solution is useful for reduction of gastric ESD procedure time, warranting validation in a randomized controlled trial.

Continued Aspirin Treatment May Be a Risk Factor of Delayed Bleeding after Gastric Endoscopic Submucosal Dissection under Heparin Replacement: A Retrospective Multicenter Study.

Objective Gastric endoscopic submucosal dissection (ESD) under heparin replacement (HR) of warfarin reportedly has a high risk of delayed bleeding (24-57%). It is possible that the delayed bleeding risk may have changed over the years. We evaluated the current risk of delayed bleeding after gastric ESD under HR of anticoagulant agents. Methods We retrospectively reviewed the delayed bleeding rate and analyzed the risk factors for delayed bleeding. Patients Consecutive patients who underwent gastric ESD under HR of anticoagulant agents from July 2015 to June 2017. Results A total of 32 patients with a solitary early gastric cancer and taking anticoagulant agents were analyzed, including 24 patients on warfarin (the warfarin group) and 8 patients on direct oral anticoagulants (the DOAC group). Three (9.4%) patients experienced delayed bleeding: three (12.5%) patients in the warfarin group and no patients in the DOAC group. Continued aspirin treatment was identified to be a risk factor of delayed bleeding (p=0.01). Conclusion Careful management may be required for patients undergoing gastric ESD under continued aspirin treatment in addition to HR of anticoagulant agents; although the delayed bleeding risk after gastric ESD under HR of anticoagulant agents might have decreased over the years.

Predictive risk factors associated with synchronous multiple early gastric cancer.

The aim of this study was to elucidate the predictive risk factors of synchronous multiple early gastric cancer regardless of the treatment modality.Patients who underwent early gastric cancer treatment between July 2005 and June 2015 were retrospectively reviewed. In total, 1529 patients who were treated for early gastric cancer were included. We analyzed the patient's data to find predictive factors of synchronous multiple early gastric cancer compared to solitary early gastric cancer. Further analysis was performed to verify the difference between endoscopic and surgical treatment groups.Among the 1529 patients, synchronous multiple early gastric cancer was diagnosed in 68 (4.4%) patients. Significant differences in sex (P = .004), gross appearance (P = .038), depth of invasion (P = .007), and lymphovascular invasion (P = .039) were found between patients with solitary early gastric cancer and synchronous multiple early gastric cancer by univariate analysis. In multivariate analysis, male sex (odds ratio, 2.475; P = .011) and submucosal invasion (odds ratio, 1.850; P = .033) were independent predictive risk factors of synchronous multiple early gastric cancer. In addition, in multivariate analysis, significant differences in age, tumor size, longitudinal location, depth of invasion, and histology were found between patients groups depending on the mode of treatment.Male sex and submucosal invasion were predictive risk factors of synchronous multiple early gastric cancer. Patients with these factors should undergo more meticulous endoscopic surveillance.

Multiple Primary Malignancies in Patients with Multiple Early Gastric Cancer.

PurposeThis study aimed to investigate the correlation between multiple early gastric cancer (MEGC) and multiple primary malignancies during the follow-up of patients with gastrectomy.Materials and MethodsThe number of primary tumors detected in other organs after gastrectomy for early gastric cancer (EGC) has been increasing because of improved survival and surveillance programs. A total of 3,129 patients underwent radical gastrectomy for treatment of EGC at Samsung Medical Center from January 2000 to December 2005. Of these, 3,057 patients were selected and their medical records were retrospectively analyzed.ResultsAmong the 3,057 patients, 148 (4.8%) had MEGC, 84.5% were male, 57.4% were over 60 years old, 42.6% had a macroscopic type EGC IIb main lesion, and 68.9% had well-differentiated tumors with a significantly high incidence of MEGC. There were no differences between patients with solitary early gastric cancer (SEGC) and those with MEGC with regard to overall survival or recurrence-free survival, but MEGC was an independent risk factor for metachronous primary malignancies in other organs (P=0.004, hazard ratio [HR]=2.444).ConclusionsMEGC is not a risk factor for poor prognosis after curative gastrectomy, but it is a risk factor for metachronous primary malignancies in other organs during postoperative follow-up; therefore, careful surveillance is needed.

Factors associated with incomplete gastric endoscopic submucosal dissection due to misdiagnosis.

Background and study aims: Endoscopic submucosal dissection (ESD) is widely accepted for treating early gastric cancer (EGC); however, there can be cases of incomplete resection due to not only technical problems, but also misdiagnosis. Our aim was to identify factors associated with incomplete gastric ESD due to misdiagnosis. Patients and methods: A total of 2,268 patients with solitary EGCs at initial onset underwent ESD with curative intent at our hospital from 1999 to 2008. We retrospectively assessed the clinicopathological factors by comparing the two groups of incomplete ESD cases due to misdiagnosis (cases with a positive lateral margins [LM] [Group A] or those with a positive vertical margins [VM] [Group B]) with complete ESD cases using multivariable analysis. Results: Complete ESD was achieved in 2,097 patients. The 171 patients with incomplete ESDs were divided into 109 with a positive LM and 80 with a positive VM (overlapped). Except 49 cases with a positive LM due to technical problems, a positive LM due to misdiagnosis was identified in 60 cases (Group A). Excluding 32 cases with a positive VM due to technical problems, a positive VM due to misdiagnosis was found in 48 cases (Group B). Significant independent factors (odds ratios [OR]; 95 % confidence intervals [CI]) for each group were as follows: Group A: size > 20 mm (5.4; 3.0 – 9.9), undifferentiated-type (4.1; 1.8 – 9.0), submucosal invasion (2.0; 1.1 – 3.4) and location of upper/middle (1.9; 1.0 – 3.6); Group B: size > 20 mm (3.0; 1.6 – 5.5), undifferentiated-type (3.0; 1.1 – 8.0) and location of upper/middle (2.4; 1.2 – 4.8). Conclusions: Endoscopists must be aware of these factors associated with incomplete gastric ESD due to misdiagnosis to further decrease their incidence.

Risk stratification and predictive risk-scoring model for lymph node metastasis in early gastric cancer.

We are increasingly experiencing difficulty in deciding whether to perform gastrectomy after noncurative endoscopic resection of early gastric cancer (EGC) for patients at high risk for surgery. If the differences in risk for lymph node metastasis (LNM) on the basis of noncurative status are understood, the decision becomes easier. The present study aimed to stratify the LNM risk and develop and validate a risk-scoring model for predicting LNM. By retrospectively reviewing 3131 patients with solitary EGC who underwent gastrectomy with lymphadenectomy at our institution between July 1997 and May 2013, LNM risk was stratified and a risk-scoring model was developed on the basis of the identified independent risk factors for LNM. The scoring was validated using 352 other surgically resected EGC cases. The discriminatory accuracy of the scoring was measured by area under receiver operating characteristic curve (AUROC). LNM was detected in 386 of 3131 cases. LNM risk in each subgroup, stratified by the identified independent risk factors, such as tumor size, depth, histological type, ulcerative findings, and lymphovascular involvement, considerably varied from 0% to>50% even among the current guidelines' noncurative subgroups. An 11-point scoring model was built, and AUROCs were 0.84 (95% confidence interval, 0.82-0.86) and 0.82 (0.75-0.88) in the development and validation sets, respectively. The present study revealed detailed LNM risk stratification data, and developed and validated an 11-point scoring model.

Novel strategy of endoscopic submucosal dissection using an insulation-tipped knife for early gastric cancer: near-side approach method.

Background and study aims: Endoscopic submucosal dissection (ESD) using insulation-tipped knives (IT knives) to treat gastric lesions located on the greater curvature of the gastric body remains technically challenging because of the associated bleeding, control of which can be difficult and time consuming. To eliminate these difficulties, we developed a novel strategy which we have called the “near-side approach method” and assessed its utility. Patients and methods: We reviewed patients who underwent ESD for solitary early gastric cancer located on the greater curvature of the gastric body from January 2003 to September 2014. The technical results of ESD were compared between the group treated with the novel near-side approach method and the group treated with the conventional method. Results: This study included 238 patients with 238 lesions, 118 of which were removed using the near-side approach method and 120 of which were removed using the conventional method. The median procedure time was 92 minutes for the near-side approach method and 120 minutes for the conventional method. The procedure time was significantly shorter in the near-side approach method arm. Although, the procedure time required by an experienced endoscopist was not significantly different between the two groups (100 vs. 110 minutes), the near-side approach group showed significantly shorter procedure time for a less-experienced endoscopist (90 vs. 120 minutes). Conclusions: The near-side approach method appears to require less time to complete gastric ESD than the conventional method using IT knives for technically challenging lesions located on the greater curvature of the gastric body, especially if the procedure is performed by less-experienced endoscopists.

Increased incidence of secondary gastric neoplasia in patients with early gastric cancer and coexisting gastric neoplasia at the initial endoscopic evaluation.

Multiple synchronous gastric cancers are found in up to 14% of affected patients. The aim of this study was to determine the incidence of secondary gastric neoplasia including missed synchronous gastric neoplasia in this patient group compared with that after a single cancer resection. Four hundred and forty patients who underwent endoscopic resection for early gastric cancer (EGC) were divided into two groups: those with or without synchronous gastric neoplasia at the initial assessment. Secondary gastric neoplasia was defined as missed synchronous gastric neoplasia or metachronous gastric neoplasia. We compared the clinicopathological characteristics and the incidence of secondary gastric neoplasia between the two groups. Synchronous gastric neoplasias were found in 34 patients (7.7%) at the initial endoscopic examination of EGC. Secondary gastric neoplasias were found in 67 of 440 patients (15.2%) during the follow-up period (median 24.0 months). The incidence of secondary gastric neoplasia and missed synchronous gastric neoplasia was higher in those patients with synchronous gastric neoplasia than in those with a solitary EGC at the initial treatment (P<0.01). Between the two groups, the risk of the secondary neoplasia was significantly higher within 1 year after endoscopic resection (P<0.01), but not after 1 year (P=0.20). EGC with synchronous gastric neoplasia at the initial endoscopic examination was associated with an increased risk of secondary gastric neoplasia. These patients should be evaluated carefully with a shorter interval after the initial treatment.

Lymph node metastasis in multiple synchronous early gastric cancer

Although endoscopic resection for early gastric cancer (EGC) is increasingly available, it has not been determined whether indications for endoscopic resection are equally acceptable for multiple EGCs. To compare the various clinicopathologic factors and risk of lymph node (LN) metastasis between multiple and solitary EGCs. Case-control study. University hospital. This study involved 1717 patients with 156 multiple and 1561 solitary EGCs. Gastrectomy with LN dissection. Incidence of LN metastasis. In multiple EGCs, main lesions had larger tumor size and deeper invasion depth than the accessory lesions (P < .001). The clinicopathologic features of multiple EGCs were similar to those of solitary EGCs with respect to tumor size, depth of invasion, lymphovascular invasion, and incidence of LN metastasis. Importantly, the risk of LN metastasis in multiple EGCs that met the indication criteria for endoscopic resection was not significantly different from that in solitary EGCs. Tumors meeting conventional indications for endoscopic resection had no risk of LN metastasis, whereas tumors meeting expanded indications showed a similar risk of LN metastasis in the two groups. In multiple EGCs, tumor size ≥3 cm and lymphovascular invasion were independent risk factors of LN metastasis. Small number of patients with multiple EGCs studied. Multiple EGCs had clinicopathologic characteristics and risk of LN metastasis similar to those of solitary EGCs. Endoscopic resection may be adopted as curative treatment for multiple EGCs that meet indications for endoscopic resection. Further studies are needed to verify the present study results.

Recurrence in early gastric cancer with lymph node metastasis

Early gastric cancer (EGC) has an excellent prognosis, but some patients with lymph node-positive disease will develop recurrence. In this study we investigated the risk factors for recurrence in this selected group of patients. The clinical and pathological records of 2368 patients who underwent gastrectomy for solitary EGC between 1980 and 1999 at the National Cancer Center Hospital, Tokyo, were examined. Two hundred and thirty-eight patients (10%) were lymph node-positive (positive for lymph node metastasis) and form the population of this study. Nineteen (8%) of the 238 patients with lymph node-positive disease developed recurrence. The most common site of recurrence was lymph node (37%), followed by liver (21%). The interval between surgery and the detection of recurrence ranged from 3 to 98 months, with a median of 26 months. Multivariate analysis demonstrated that the number of metastatic nodes was an independent risk factor for recurrence. Patients with seven or more metastatic nodes had the highest rate of recurrence, at 38%. The number of nodes positive for metastasis was the only independent risk factor for recurrence after curative surgery in patients with lymph node-positive early gastric cancer. These high-risk patients may obtain additional survival benefit if targeted with adjuvant chemotherapy.

Concepts, Rationale, and Current Outcomes of Less Invasive Surgical Strategies for Early Gastric Cancer: Data from a quarter‐century of experience in a single institution

Previously proposed criteria of less invasive surgery for early gastric cancer (EGC) were based mainly on the pathological analyses of the resected specimens; however, preoperative and intraoperative information are also obviously essential for decision making on stage-dependent patient management. Furthermore, most indications and treatment options have not been systematically integrated or evaluated by treatment outcomes. We investigate in this report the rationality of less invasive surgery employed for EGC. Distribution analyses of positive nodes were investigated among 684 patients with primary solitary EGC (379 mucosal and 305 submucosal) who underwent curative resection between 1976 and 2000. Clinicopathological factors highlighted and analyzed included clinical (preoperative and intraoperative) and pathological (postoperative) cancer depth and nodal involvement, gross form, histological type, and maximum cancer diameter, as well as postoperative morbidity and mortality. The scope of lymphadenectomy can be reduced to a modified D1 for clinically mucosal, node-negative, nonpalpable gastric cancer, or for clinically submucosal, node-negative gastric cancer < or = 1.5 cm for intestinal type, or < or = 1.0 cm for diffuse type. Otherwise, a modified D2 lymphadenectomy is sufficient. Local resection can be recommended for clinically mucosal, node-negative gastric cancer without apparent ulceration < or = 4 cm if adjacent lymph nodes are proved cancer negative by a frozen section examination. If the gastric cancer has spread beyond the above criteria, a pylorus-preserving gastrectomy (PPG) can be recommended for tumors located in the middle or lower third of the stomach, provided the distal margin of the cancer is at least 4.5 cm from the pyloric ring. The PPG can be accompanied by a modified D1 or a modified D2 lymphadenectomy according to the respective dissection criteria. Results of these less invasive strategies showed reduced morbidity and mortality, as well as no recurrence or cancer-related deaths. These results suggest that each of our criteria for less invasive surgery for EGC is realistic, well stratified, and satisfactory.

Multiple Early Gastric Cancer

Purpose: Multiple early gastric cancers were found in of patients with early gastric cancer. The goal of this study was to clarify the clinicopathologic features of and to investigate treatment strategy for multiple early gastric cancer. Materials and Methods: Of 967 patients with an gastric adenocarcinoma who were treated by surgical resection during the period of at the Department of Surgery, Korea University College of Medicine, 267 patients had early gastric cancer. A retrospective analysis of the clinicopathologic differences between the main and the accessory lesions in multiple early gastric cancer was carried out. A comparative analysis was also conducted between solitary early gastric cancer and multiple early gastric cancer. Results: Of 267 patients with early gastric cancer, multiple early gastric cancers were found in 12 patients (), including 10 men and 2 women. Eleven patients with multiple early gastric cancer had one accessory lesion and 1 patient had 2 accessory lesions. Of the 13 accessory lesions, 7 () were located in the same region as the main lesion. The most frequent combination of macroscopic types for the main lesion and the accessory lesion were depressed and depressed types (6 cases, ). The most frequent histologic type of main lesion was a well differentiated adenocarcinoma in 7 () of the 12 cases; the accessory lesion was also well differentiated in 4 of those 7 cases. Of the 13 accessory lesions, 4 () had been overlooked preoperatively; most of them were located in the lower third of the stomach and were IIb or IIc type and measured less than 1 cm in diameter. Lymph node metastasis was detected in 1 patient (). The clinicopathologic features of multiple early gastric cancer were not different from those of solitary early gastric cancer. Conclusion: In multiple early gastric cancer, the main and the accessory lesions showed similar differentiation, and lymph node metastasis was less frequent than in solitary early gastric cancer. Therefore, limited procedures, including endoscopic mucosal resection, may be indicated if each lesion of the multiple early gastric cancer fits the criteria for treatment strategy.

4726 Indication of endoscopic mucosal resection for early gastric cancer of undifferentiated type.

Background and Aim: The most important factor for the prognosis of patients with early gastric cancer(EGC) is the presence or absence of regional lymph node metastasis. Endoscopic mucosal resection (EMR) is usually accepted for EGC of differentiated type in Japan, because the incidence of metastasis of intramucosal differentiated adenocarcinoma reveals a minimum probability of lymph node metastasis (<1%). However, in consideration of the complications and patient's quality of life, an expansion of EMR for the patients with undifferentiated type cancer should be discussed.To clarify whether EGC of histologically undifferentiated type is recommended for EMR as curative therapy or not, we evaluate the incidence of lymph node metastasis in patients with this type. Patients: Of 1634 patients with solitary EGC who underwent open surgery with lymph node dissection between 1982 and 1996 at National Cancer Center Hospital, 600 patients with undifferentiated adenocarcinoma were studied. Concerning these cancers, an association between the incidence of lymph node metastasis and the depth of invasion, the size of tumor, and with or without ulceration. Results: Intramucosal was found in 59% and submucosal cancer in 41%. Ulceration was detected in 77% and 75% and lymph node metastasis in 7% and 23% of these cancers, respectively. By presence and absence of ulceration, lymph node metastasis was found in 88% and 7% of intramucosal cancer, in 24% and 23% of submucosal cancer, respectively. The association between incidence of lymph node metastasis, tumor size, depth of invasion and ulceration is as follows:- Conclusion: Ulceration was found very frequently in both intramucosal and submucosal cancers, regardless of tumor size. Lymph node metastasis was found in minute cancers which were less than 10mm in tumor size. These results suggest that EGC of undifferentiated type is not recommended as an indication of EMR.

Treatment of primary multiple early gastric cancer: from the viewpoint of clinicopathologic features.

The treatment of multiple early gastric cancer was investigated through the clinicopathologic assessment of 61 cases of primary multiple early gastric cancer (82 accessory lesions) treated by surgical resection over a 15-year period. These cases accounted for 11.7% of all cases of early gastric cancer resected during the same period. The 61 patients included 48 men (mean age 64 years) and 13 women (61 years). Of the 82 accessory lesions, 41 (50%) were located in the same region as the main lesion. The most frequent combination of macroscopic types of the main lesion and the accessory lesion was depressed type/depressed type (28 cases). The main lesion was of the well differentiated type in 39 (64%) of the 61 cases; the accessory lesion was also well differentiated in 37 of the 39 cases. Of the 82 accessory lesions, 29 (35%) had been overlooked preoperatively; most of them were located in the middle third of the stomach and included 17 depressed and 10 flat lesions, most of which measured no more than 1 cm. Cases of multiple early gastric cancer are characterized by the predominance of male patients of advanced age (> 60 years), a combination of the same macroscopic type of the main and accessory lesions, and well differentiated carcinoma. Lymph node metastasis and vascular invasion are equally or less frequent than in cases of solitary early gastric cancer. The postoperative crude survival rate in patients with multiple gastric cancer is similar to that in those with solitary gastric cancer. Therefore we believe that multiple early gastric cancer does not require extended operative procedures. Endoscopic treatment may be indicated if each lesion fits the criteria for treatment and careful follow-up is ensured.

SELECTION OF TREATMENT FOR MULTIPLE EARLY GASTRIC CANCER FROM THE CLINICOPATHOLOGICAL POINTS OF VIEW

In order to select treatment for synchronous multiple early gastric cancer, a clinicopathological study was conducted in 143 lesions of 61 patients with synchronous multiple early gastric cancer resected surgically at our department. Results were as follows: 1) The incidence of synchronous multiple early gastric cancer was 11.7% of all early gastric cancers, and many of the patients were elderly male. 2) Forty-one (50%) of 82 accessory lesions were located at the same segment. Most of the main and accessory lesions were same macroscopic type. 4) On 61 multiple cases, 39 main lesions were well differentiated type, of which 37 accessory lesions were the same. 5) Twenty-eight (34%) of 82 accessory lesions were preoperatively missed lesions including 16 lesions of type 0IIc and 10 lesions of type 0IIb most of which were ≤1.0cm in size and located at the middle part of the stomach. 6) The incidence of lymph node metastasis or vessel invasion of synchronous multiple early gastric cancer were both lower than those of solitary early gastric cancer. We conclude that endoscopic mucosal resection or modified operation can be selected for synchronous multiple early gastric cancer using each selection criteria for treatment for solitary early gastric cancer on condition that postoperative intensive examination of remnant stomach should be performed.

INDICATIONS FOR MODIFIED GASTRECTOMY FOR EARLY GASTRIC CANCER LOCATED IN THE FUNDUS

The status of lymph node metastasis, according to clinicopathological factors such as the depth of cancer, histologic type, macroscopic type and tumor size, was evaluated in 33 patients with solitary early gastric cancer located in the fundus.No lymph node metastasis was found in mucosal cancer. Metastasis within first group nodes was noted in submucosal cancer that was less than 2.0 cm in diameter, but metastasis was present in second group nodes in submucosal cancer that was more than 2.1 cm in diameter. Therefore, proximal gastrectomy is the treatment of choice for early gastric cancer located in the fundus. Lymph node dissection of D1 was suitable for all mucosal cancers and submucosal cancers that were less than 2.0 cm in diameter. Moreover, it is necessary to undertake D1 dissection, including No.7 and No.11 lymph nodes, for submucosal cancer that is more than 2.1 cm in diameter.

CLINICAL STUDY OF 2000 OPERATIVE CASES OF EARLY GASTRIC CANCER

Two thousand cases of solitary early gastric cancer were comparatively studied by dividing into each 1000 cases for the first and latter halves. When compared to the patients group for the first half, the proportion of aged patients over 70 years old increased, while by macroscopic types, type IIc increased but type IIc + III and type III decreased in the patients group for the latter half. The ratio of elevated versus depressed type was changed to 1/4 in the latter from 1/3 in the first half, indicating an increase in depressed type. Cancers arising in the upper stomach were doubled. Furthermore, in the latter half, the lesions less than 2cm in diameter were more frequently detected, while those more than 4.1cm being less frequently found. Surgery was decreasingly carried out in the latter half, because endoscopic excision bacame common for cancers less than 1cm in diameter. Patients having lymphnode metastases tended to decrease as a whole. In addition to an increase in detection of gastric cancers by mass screening or phisical examinations, a remarkable increase in detection of early cancers by practiticing doctors was noteworthy. It can be concluded that recent gastric cancers are commonly found in early stages with smaller size, which may promises of complete treatment for the patients by surgery or endoscopic excision.