Vertical Margin Research Articles

Feasibility of endoscopic mucosal resection as salvage treatment for patients with local failure after definitive chemoradiotherapy for stage IB, II, and III esophageal squamous cell cancer

Local failure after definitive chemoradiotherapy (CRT) for stage IB, II, and III esophageal cancer is one of the causes of poor outcome. Endoscopic mucosal resection (EMR) is an effective treatment for superficial esophageal cancer. However, its feasibility as a salvage treatment for local recurrent or residual tumors after definitive CRT for stage IB, II, and III esophageal cancer remains unclear. Between January 2000 and February 2008, 274 patients with stage IB, II, and III esophageal squamous cell cancer excluding T4 received definitive CRT at the National Cancer Center Hospital, Japan. Of these patients, nine patients with local recurrence after achieving complete response and two patients with residual tumor underwent salvage EMR. The technique of salvage EMR involved a strip biopsy method. We retrospectively reviewed the 11 patients (13 lesions). Characteristics of all 11 patients were as follows: median age of 69 (range: 45-78); male/female: 10/1; baseline clinical stage (Union for International Cancer Control 7th) IB/IIA/IIB/III: 1/3/7/0. The depth of resected tumor was limited to the mucosal layer in seven lesions and submucosal in six lesions. En bloc resection was performed on six lesions (46%). The vertical margin was free of cancer cells in 11 lesions (84.6%). No major complications, such as hemorrhage requiring blood transfusion and perforation, were experienced. At a median follow-up period of 38.9 months (range: 5.3-94 months) after salvage EMR, no recurrence was detected in six patients (54%). Local recurrence was detected in five patients (27%). Of these patients, two had lung metastasis simultaneously, and one was also detected lung metastasis 2 months after the detection of local recurrence. The 5-year survival rate after salvage EMR was 41.6%. Salvage EMR is a feasible treatment option for local recurrent or residual lesions after definitive chemotherapy and/or radiotherapy for stage IB, II, and III esophageal squamous cell cancer.

Flexible spectral imaging color enhancement for determining the demarcation of early gastric cancer and precancerous lesions

Objective To evaluate the flexible spectral imaging color enhancement （FICE） system for determine the margin of early gastric cancer and precancerous lesions. Methods From February 2008 to October 2011, a total of 51 patients with early gastric cancer or high-grade intraepithelial neoplasm who received ESD were enrolled and randomly divided into experimental group to determine lesion margin by FICE （n = 26） and control group to identify lesion margin by indigo carmine （n = 25 ）. Histological complete resection rate （the lateral and vertical margins were free of cancer）, operation time, complications, post-ESD ulcer-healing rates and local recurrence were assessed. Results The histological complete resection rate, a- cute minor bleeding rate and post-ESD abdominal pain rate in experimental group were 2. 3% （24/26）, 88.5% （23/26）, 15.4% （4/26） and 73.1% （19/26）, which were not significantly different from those of control group, i.e., 92.0% （23/25）, 84.0% （21/25）,12.0% （3/25） and 72.0% （18/25） （P〉 0.05 ）. The mean operation time of in experimental group was shorter than that of control group （ P 〈 0.05 ）. No massive bleeding, delayed bleeding or perforation occurred in either group. Follow-up showed no local residue or recurrence. Conclusion FICE is safe and effective to determine the tumor demarcation of early gastric cancer and high-grade intraepithelial neoplasm, and needs less operation time. Key words: Chromoendoscopy; Early gastric cancer; Endoscopic submucosal dissection

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.

Repeat endoscopic submucosal dissection for recurrent gastric cancers after endoscopic submucosal dissection

To clarify the safety and efficacy of repeat endoscopic submucosal dissection (re-ESD) for locally recurrent gastric cancers after ESD. A retrospective evaluation was performed of the therapeutic efficacy, complications and follow-up results from ESD treatment for early gastric cancers in 521 consecutive patients with 616 lesions at St. Luke`s International Hospital between April 2004 and November 2012. In addition, tumor size, the size of resected specimens and the operation time were compared between re-ESD and initial ESD procedures. A flex knife was used as the primary surgical device and a hook knife was used in cases with severe fibrosis in the submucosal layer. Continuous variables were analyzed using the non-parametric Mann-Whitney U test and are expressed as medians (range). Categorical variables were analyzed using a Fisher's exact test and are reported as proportions. Statistical significance was defined as a P-value less than 0.05. The number of cases in the re-ESD group and the initial ESD group were 5 and 611, respectively. The median time interval from the initial ESD to re-ESD was 14 (range, 4-44 mo). En bloc resection with free lateral and vertical margins was successfully performed in all re-ESD cases without any complications. No local or distant recurrence was observed during the median follow-up period of 48 (range, 11-56 mo). Tumor size was not significantly different between the re-ESD group and the initial ESD group (median 22 mm vs 11 mm, P = 0.09), although the size of resected specimens was significantly larger in the re-ESD group (median 47 mm vs 34 mm, P < 0.05). There was a non-significant increase observed in re-ESD operation time compared to initial ESD (median 202 min vs 67 min, respectively, P = 0.06). Despite the low patient number and short follow-up, the results suggest that re-ESD is a safe and effective endoscopic treatment for recurrent gastric cancer after ESD.

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.

Clinical Usefulness of Magnifying Chromoendoscopy and Magnifying Narrow Band Imaging Endoscopy for Predicting the Submucosal Invasion of Early Colorectal Cancers

Clinical Usefulness of Magnifying Chromoendoscopy and Magnifying Narrow Band Imaging Endoscopy for Predicting the Submucosal Invasion of Early Colorectal Cancers

Long-term follow up of endoscopic resection for type 3 gastric NET

To clarify the short and long-term results and to prove the usefulness of endoscopic resection in type 3 gastric neuroendocrine tumors (NETs). Of the 119 type 3 gastric NETs diagnosed from January 1996 to September 2011, 50 patients treated with endoscopic resection were enrolled in this study. For endoscopic resection, endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) was used. Therapeutic efficacy, complications, and follow-up results were evaluated retrospectively. EMR was performed in 41 cases and ESD in 9 cases. Pathologically complete resection was performed in 40 cases (80.0%) and incomplete resection specimens were observed in 10 cases (7 vs 3 patients in the EMR vs ESD group, P = 0.249). Upon analysis of the incomplete resection group, lateral or vertical margin invasion was found in six cases (14.6%) in the EMR group and in one case in the ESD group (11.1%). Lymphovascular invasions were observed in two cases (22.2%) in the ESD group and in one case (2.4%) in the EMR group (P = 0.080). During the follow-up period (43.73; 13-60 mo), there was no evidence of tumor recurrence in either the pathologically complete resection group or the incomplete resection group. No recurrence was reported during follow-up. In addition, no mortality was reported in either the complete resection group or the incomplete resection group for the duration of the follow-up period. Less than 2 cm sized confined submucosal layer type 3 gastric NET with no evidence of lymphovascular invasion, endoscopic treatment could be considered at initial treatment.

High-penetration optical coherence tomography and enhanced depth imaging in presumed retinal pigment epithelial hamartoma.

To report on high-penetrating swept source optical coherence tomography (SS-OCT) imaging and enhanced depth imaging in an eye with presumed retinal pigment epithelial hamartoma . A 60-year-old man with presumed retinal pigment epithelial hamartoma underwent complete ophthalmologic examination, including fluorescein angiography, indocyanine green angiography, enhanced depth imaging OCT, and SS-OCT. In the left eye, there were six darkly pigmented, nodular, circumscribed lesions in the macular area. The margins were well defined and were not associated with changes such as edema, exudation, or hemorrhage. Fluorescein angiography revealed a minimally dilated feeding artery and draining vein in each lesion. Spectral domain OCT demonstrated an elevation of the retina at the site of the lesions with greatly enhanced optical reflectivity of the inner surface and complete shadowing of optical transmission with crisp vertical margins. However, enhanced depth imaging OCT and SS-OCT revealed deeper retinal layer structures in the pigmented lesions. Intraretinal lesions showed superficial involvement and preretinal extension with or without superficial hyporeflective regions. Enhanced depth imaging OCT and SS-OCT revealed deeper retinal layer structures in the pigmented lesions in a case with presumed retinal pigment epithelial hamartoma. Enhanced depth imaging OCT and SS-OCT are useful for visualization of intraretinal structures in these lesions, leading to further investigation of the origin and development of retinal pigment epithelial hamartoma.

Unexpected endoscopic full-thickness resection of a duodenal neuroendocrine tumor

A 57-year-old man underwent endoscopy for investigation of a duodenal polyp. Endoscopy revealed a hemispheric submucosal tumor, about 5 mm in diameter, in the anterior wall of the duodenal bulb. Endoscopic biopsy disclosed a neuroendocrine tumor histologically, therefore endoscopic mucosal resection was conducted. The tumor was effectively and evenly elevated after injection of a mixture of 0.2% hyaluronic acid and glycerol at a ratio of 1:1 into the submucosal layer. A small amount of indigo-carmine dye was also added for coloration of injection fluid. The lesion was completely resected en bloc with a snare after submucosal fluid injection. Immediately, muscle-fiber-like tissues were identified in the marginal area of the resected defect above the blue-colored layer, which suggested perforation. The defect was completely closed with a total of 9 endoclips, and no symptoms associated with peritonitis appeared thereafter. Histologically, the horizontal and vertical margins of the resected specimen were free of tumor and muscularis propria was also seen in the resected specimen. Generally, endoscopic mucosal resection is considered to be theoretically successful if the mucosal defect is colored blue. The blue layer in this case, however, had been created by unplanned injection into the subserosal rather than the submucosal layer.

Therapeutic Outcomes of Endoscopic Submucosal Dissection in Undifferentiated-type Early Gastric Cancer

Endoscopic submucosal dissection (ESD) has been accepted as a standard treatment of early gastric cancer (EGC). However, the indication of ESD in undifferentiated-type EGC was controversial. The aim of this study was to evaluate the therapeutic outcomes of ESD in undifferentiated-type EGC according to expanded indication. At Soonchunhyang University Bucheon Hospital, a total of 82 lesions in 81 patients with undifferentiated-type EGC were treated with ESD. The therapeutic outcomes of ESD were evaluated by resection method (en bloc resection; piecemeal resection), histologic curative resection, complications and recurrence rates after ESD. The rate on en bloc resection and complete resection rate were 87.8% (72/82) and 80.5% (66/82), respectively. In signet ring cell carcinoma, the complete resection rate was higher than those in poorly differentiated adenocarcinoma and poorly differentiated adenocarcinoma with signet ring cell features, but there was no statistical significance (89.3% vs. 75.0%, 76.7%; p=0.347). The lateral margin positivity rate in poorly differentiated adenocarcinoma, signet ring cell carcinoma and poorly differentiated adenocarcinoma with signet ring cell features were 12.5%, 3.6% and 13.3%, respectively (p=0.395). The vertical margin positivity rate were 12.5%, 3.6% and 10.0%, respectively (p=0.485). The overall recurrence rate was 3.0% during a mean follow-up period of 37.4 months. ESD may be considered as a feasible treatment for undifferentiated-type EGC according to expanded indication. The therapeutic outcome of ESD in undifferentiated-type EGC is likely to be favorable, though further longer follow-up studies are needed.

Risk factors of residual or recurrent tumor in patients with a tumor-positive resection margin after endoscopic resection of early gastric cancer

In cases with a tumor-positive resection margin after endoscopic resection of early gastric cancer (EGC), not all patients are found to have residual or recurrent tumor. The aim of this study was to identify risk factors associated with residual/recurrent tumor in patients with incomplete endoscopic resection of EGC. A retrospective analysis was performed on consecutive patients who underwent endoscopic resection of EGC at a single institution in South Korea. Patients with a tumor-positive resection margin in the specimen were divided into two groups, with and without residual/recurrent tumor, and the clinicopathologic characteristics were compared. A total of 102 patients with a tumor-positive lateral or vertical resection margin after endoscopic mucosal resection (n = 10) or submucosal dissection (n = 92) were enrolled. Overall, the rate of residual/recurrent tumor was 33.3 % (34/102): 17 residual tumors in 46 patients who immediately underwent additional endoscopic or surgical resection, and 17 recurrent tumors in 56 patients who were initially followed up with regular endoscopy during a median period of 17 (range = 2-70) months. Univariate analysis showed that the presence of ulcer, the direction of the tumor-positive resection margin, and length of lateral resection margin involvement by the tumor were associated with the incidence of residual/recurrent tumor. In multivariate analysis, total length (cm) of lateral resection margin involvement was the only independent risk factor for residual/recurrent tumor (OR 2.05; 95 % CI 1.22-3.44, p = 0.006). Patients with extensive tumor involvement of a lateral resection margin after endoscopic resection of EGC should consider additional endoscopic or surgical resection due to a high risk of residual/recurrent tumor.

Endoscopic submucosal dissection with sentinel node navigation surgery for early gastric cancer

We combined endoscopic submucosal dissection (ESD) and sentinel node navigation surgery with the purpose of achieving complete resection of early gastric cancer while preserving the organ and assessing pathological nodal status. A total of 13 patients with cT1( ≤ 3 cm)N0 early gastric cancer underwent combined ESD and sentinel node navigation surgery (ESN) at a single tertiary referral center. Sentinel node navigation surgery using indocyanine green was performed during ESD and all suspected sentinel nodes were removed laparoscopically and examined intraoperatively. ESN was converted to gastrectomy with D2 dissection if there was evidence of metastasis on frozen section. ESN was completed in 12 patients and in 1 patient was converted to gastrectomy after sentinel node navigation surgery. En bloc tumor resection was achieved in all cases. Two patients underwent additional gastrectomy because they had tumor-positive vertical margins. In all cases ESN was conducted without intraoperative or postoperative adverse events. ESN is a feasible minimally invasive procedure that allows en bloc tumor resection to be achieved while assessing the pathological status of the lymph nodes.

Multiple Glass Ceilings

Both vertical (between job levels) and horizontal (within job levels) mobility can be sources of wage growth. We find that the glass ceiling operates at both margins. The unexplained part of the wage gap grows across job levels (glass ceiling at the vertical margin) and across the deciles of the intra‐job‐level wage distribution (glass ceiling at the horizontal margin). This implies that women face many glass ceilings, one for each job level above the second, and that the glass ceiling is a pervasive phenomenon. In the Netherlands it affects about 88 percent of jobs, and 81 percent of Dutch women in employment work in job levels where a glass ceiling is present.

Treatment outcomes according to endoscopic treatment modalities for rectal carcinoid tumors

Despite a growing understanding of the clinical effectiveness of endoscopic treatment for small rectal carcinoid tumors, there is still controversy concerning the best endoscopic treatment for resecting rectal carcinoid tumors easily and effectively. The objective of the present study was to compare the therapeutic efficacy and safety of endoscopic submucosal resection with a ligation device (ESMR-L) with endoscopic submucosal dissection (ESD) for rectal carcinoid tumors. In addition, a conventional snare-based endoscopic mucosal resection (EMR) was included in the study and compared with both ESMR-L and ESD. A retrospective analysis was performed in 115 patients who underwent endoscopic resection of a rectal carcinoid tumor between January 2005 and June 2011. These patients were classified into three groups according to the type of endoscopic procedure: EMR group (n=33), ESMR-L group (n=40) and ESD group (n=44). The complete resection rate of the EMR group was significantly lower than those of the ESMR-L and ESD groups (77.4 vs. 100 and 97.7%, P=0.002 and P=0.007). Tumor-free vertical margins were significantly greater in the ESMR-L and ESD groups than in the EMR group (ESMR-L and ESD vs. EMR group, P=0.013 and P=0.041). The curative resection rate of rectal carcinoid tumors in the EMR group was 77.4%, which was significantly lower than that of the ESMR-L (95%, 38/40) and EDS groups (97.7%, 43/44) (77.4% vs. 95%, P=0.036 and 77.4% vs. 97.7%, P=0.007). Our results show that ESMR-L and ESD might be superior to conventional EMR for the treatment of small rectal carcinoid tumors.

Application and evaluation of submucosal tunneling endoscopic resection of gastric submucosal tumors originating from the muscularis propria layer

To evaluate the clinical value of submucosal tunneling endoscopic resection(STER) for gastric submucosal tumor(SMT) originating from the muscularis propria (MP) layer. Clinicopathological data of 23 cases with gastric SMT originating from the MP layer treated with STER from September 2010 to December 2011 were analyzed retrospectively. There were 13 males and 10 females. The age ranged from 28 to 73(mean, 52.4) years old. Of the 23 SMTs, 11 were located in the cardia adjacent to the gastric body, 4 in the cardia adjacent to the fundus, 5 in the lesser curvature of gastric body and 3 in the gastric antrum of greater curvature. All the SMTs originating from the MP layer, 14 were located in the superficial MP layer and 9 in the deep MP layer(including 5 gastric SMTs close to serosa). En bloc STER was performed successfully in all the patients. The mean lesion size was 2.1 cm(range 1.5-3.2 cm). The mean procedure time was 54.8 min(range 30-125 min). Pathological examination showed that the lesions were leiomyomas(n=10), stromal tumors(n=8), glomus tumor(n=2), Schwannoma(n=2), and calcifying fibrous tumor(n=1). Both lateral and vertical margins were negative in all the cases. Three patients developed pneumothorax and subcutaneous emphysema and 5 pneumoperitoneum. One patient developed effusion under the left half of the diaphragm and secondary infection. All of them recovered uneventfully after conservative treatments. No delayed bleeding or GI tract leakage was noticed. None of the 23 cases encountered submucosal hematoma or infection. No tumor residual or recurrence was found during the follow up(range, 3-18 months). STER is a safe, effective for appropriate lesions in the MP layer of the stomach. En bloc resection and accurate histopathological evaluations can be achieved.

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.

Endoscopic submucosal dissection of early gastric neoplasia with a water jet–assisted knife: a Western, single-center experience

Endoscopic submucosal dissection (ESD) of early gastric neoplasia has not yet been established in Western countries because of a lack of data and the difficult, time-consuming, and hazardous nature of the method. Some of the technical limitations may be overcome by use of a water jet-assisted knife, which allows a combination of a high-pressure water jet and electrosurgical interventions. To evaluate the efficacy and safety of water jet-assisted ESD (WESD) with a water jet-assisted knife in selected patients with early gastric neoplasia. Single-center, prospective study. This study involved 29 consecutive patients (13 female; median age 61 years; age range 35-93 years) with early gastric neoplasia that met the expanded criteria of the Japanese Gastric Cancer Association. Histology of biopsies had shown gastric adenocarcinoma in 21 cases, adenoma in 8 case, and suspicion of a GI stromal tumor in 1 case. The median maximal diameter of the lesions was 20 mm (range 10-40 mm). All procedures were done with patients under sedation with propofol. The water jet-assisted knife was used for setting coagulation markers around the neoplastic lesions, then for circumferential incision and dissection in combination with repeated submucosal injection of saline solution with a water jet system. Bleeding was treated with diathermia by use of the water jet-assisted knife or hemostatic forceps in case of failure or larger vessels. Clips were used for closure of perforations. Complete resection of neoplasia, procedure time, complication and recurrence rates. According to endoscopic criteria, complete resection of the targeted area could be achieved in all cases, with an en bloc resection rate of 90%. The median procedure duration was 74 minutes (range 15-402 minutes). Exchange of the device was needed in only 10 cases because of severe bleeding from larger vessels, which could be managed by use of hemostatic forceps. The 30-day morbidity rate was 4 of 30 (13.8%) because of postprocedure pain in 3 cases and delayed bleeding in 1 case. A 93-year-old patient died the night after WESD without evidence of a procedure-related complication. Histology of the resected specimens showed adenocarcinoma in 20 cases, adenoma in 7, no neoplasia in 2, and a plasmacytoma in 1. Complete resection (R0) was histologically confirmed in 18 of 28 patients (64.3%) with resected neoplastic specimens. A horizontal or vertical neoplasia-free margin could not be confirmed in 9 cases and 1 case, respectively. Complete local remission of neoplasia was achieved in 25 of 28 patients (89.3%) who were followed over a median period of 22 months (range 6-44 months). In 1 patient, a metachronous gastric adenocarcinoma was identified 54 weeks after initial WESD. Noncontrolled study with a limited number of patients. The use of a water jet-assisted knife simplifies ESD because exchange of devices is rarely needed. WESD promises to be effective and safe. The study demonstrates that the high rates of en bloc resection of early gastric neoplasia reported in Asia can be reproduced in Western referral centers. However, histology may not always confirm complete resection of horizontal tumor margins. In spite of the unfavorable histology results, the high rate of complete local remission of neoplasia promises that surgical treatment of early gastric neoplasia can be avoided in the majority of cases.

Sa1644 Outcomes and Long Term Prognosis of Endoscopic Submucosal Dissection for Early Gastric Cancer

Outcomes and Long Term Prognosis of Endoscopic Submucosal Dissection for Early Gastric Cancer Ken Ohnita*, Hajime Isomoto, Kayoko Matsushima, Yuko Akazawa, Naoyuki Yamaguchi, Hitoshi Nishiyama, Eiichiro Fukuda, Fuminao Takeshima, Saburo Shikuwa, Kazuhiko Nakao Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan; Internal Medicine, Sankokai Miyazaki Hospital, Isahaya, Japan Backgrounds: Endoscopic submucosal dissection (ESD) yields high rate of curative resection of early gastric cancer (EGC). However, little information is available on the long term outcomes of ESD in a large number of patients. Patients and method: A total of 1332 EGCs in 1209 consecutive patients were treated by ESD from January 2001 to December 2010. The indication criteria (group A) were defined as differentiated -type mucosal cancer without ulceration 2 cm in diameter. Expanded indication criteria (group B) were defined as follows; differentiated -type mucosal cancer without ulceration irrespective of tumor size, differentiated -type mucosal cancer with ulceration 3 cm in diameter, differentiated -type minute ( 500 m from the muscularis mucosae, sm1) submucosal invasive cancer 3 cm in size, and undifferentiated-type mucosal cancer without ulceration 2 cm in diameter with no lymphaticvascular involvement. Out of indication (group C) were defined as except for group A and B. The early outcomes (perforation and bleeding rate and curability) were assessed in 1209 patients. Resections were considered curative when a tumor was excised by en bloc and was within the indication or expanded indication criteria with tumor-free lateral and vertical margins and no lymphovascular invasion. Long-term outcomes were assessed in 319 patients for over 5-year follow-up. Overall survival rates among the three groups were compared. We compared the overall survival rates in different age groups. Results: Short-term outcomes were as follows; The 617 (46.3%) lesions were defined as group A , 507 (38.1%) lesions were defined as group B, and the 208 (15.6%) lesions were defined as group C. Curative resection rate were 96.6% (596/617) in group A and 91.5% (464/507) in group B. Total perforation rate was 2.9% (39/1332), which was higher in group B than in group A (4.3% [22/507] versus 1.8% [11/617], p 0.05). Total bleeding rate was 2.0% (26/1332), which was significantly higher in group C than in group A (4.8% [10/208] versus 1.1% [7/617], p 0.01) and in group B (4.8% [10/208] versus 1.8% [9/507], p 0.05). In analysis of long term outcomes, median term of observation was 66 months (1106 months). In the 53 patients out of group C, 26 patients had additional surgery. Of the 266 patients with group A or group B, 41 patients died of nongastric cancer disease. Of the 53 patients with group C, 11 patients died (one patient died of gastric cancer). The 5-year survival rates in three groups were not significantly different. However, the 5-year survival rates in the patients over 80 years old (59.2%) were lower than the younger age-group (under 60 years old; 88.4%, sixties; 93.5%, seventies; 82.7%) (p 0.01). Conclusions: Expanded indication of ESD for early gastric cancer is appropriate, but it is necessary to consider the basal disease in elder patients.

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 as salvage treatment for patients with local failure after definitive chemoradiotherapy for stage II or III esophageal squamous cell cancer.

109 Background: Local failure after definitive chemotherapy and/or radiotherapy for stage II or III esophageal cancer is one of the causes of poor outcome. Endoscopic resection (ER) is an effective treatment for superficial esophageal cancer. However, its curative potential and safety remain unclear for local recurrent or residual tumor. Methods: Two hundred and sixty patients (pts.) who received definitive chemotherapy and/or radiotherapy for stage II or III esophageal squamous cell cancer between January 2000 and July 2007 were retrospectively reviewed. Results: Characteristics of all patients were as follows: median age of 65 (range 35-86); male/female: 226/34; performance status 0/1/2:117/141/2; clinical stage IIA/IIB/III: 64/70/126; regimen of chemoradiotherapy/radiotherapy: 235/15; and radiation dose 50.4/60/&gt;66 Gy: 31/218/10. Of 260pts, 170 (65%) achieved complete response after chemoradiotherapy. Median survival time was 38.5 months and 5-year survival rate was 43.5%. While 81 of them had recurrent disease, 39 had locoregional recurrence without distant metastasis. While 86 of 260 pts (33%) had residual disease after chemoradiotherapy, 68 had only locoregional disease. Of the 107 pts who had only locoregional recurrent or residual tumor, 15 (14%) underwent salvage ER (17 lesions in total). Tumor depth was limited in mucosal layer in 10 lesions and submucosal in 7 lesions. En bloc resection was performed in 9 lesions (52.9%). The vertical margin was free from cancer cells in 15 lesions (88.2%). No major complications, such as hemorrhage requiring blood transfusion and perforation, were experienced. Only one pt experienced minor hemorrhage 16 days after EMR, and was treated by endoscopic treatment. At a median follow-up period of 40.0 months (range, 0.7-94 months) after salvage ER, no recurrence was detected in 9 pts. (60%). Local recurrence was detected in 4 pts. (27%). The clinical courses of the remaining 2 pts were unknown. Three-year survival rate after salvage ER was 58%. Conclusions: Salvage ER is feasible and one of the promising treatments for local recurrent or residual esophageal cancer after chemoradiotherapy or radiotherapy.