Cold snare polypectomy for superficial non-ampullary duodenal epithelial tumor: a prospective clinical trial (pilot study)

BACKGOUND

Cold snare polypectomy (CSP) can minimize the risk of adverse events and has become a standard treatment for small colorectal polyps. CSP might also be suitable for small superficial non-ampullary duodenal epithelial tumors (SNADETs). This study aimed to evaluate the safety of CSP for SNADETs.

METHODS

The major indication criteria were as follows: (1) endoscopically diagnosed SNADET, (2) ≤ 10 mm, and (3) a single primary lesion. CSP was performed using an electrosurgical snare without electrocautery. Follow-up endoscopy and scar biopsy were performed 3 months after CSP. The primary endpoint was the delayed adverse events rate.

RESULTS

In total, 21 patients were enrolled. Two and 19 lesions were located in the duodenal bulb and 2nd portion, respectively; the median lesion size was 8 mm. CSP was attempted for all lesions; three lesions could not be resected without electrocautery and were removed by conventional endoscopic mucosal resection (EMR). The rate of spurting bleeding after CSP was 0%. The median procedure time was 12 min, the median resected specimen size was 12 mm, and the rate of en bloc resection was 81% (17/21). No adverse events were observed intraoperatively, with no delayed adverse events after CSP. Histopathology revealed 15 adenomas, 4 cancers (intramucosal), and 2 non-neoplastic lesions. The horizontal margins were negative/positive/undetermined in 9, 1, and 11 cases, respectively. All vertical margins were negative. Only one recurrence was detected by follow-up endoscopy 3 months after CSP.

CONCLUSIONS

CSP can be performed safely for small SNADETs.

CLINICAL TRIAL REGISTRATION

This trial was registered with the University Hospital Medical Information Network Clinical Trials Registry ( http://www.umin.ac.jp/ctr/index.htm ), and the registration number is UMIN000019157.

Long-term outcomes of endoscopic mucosal resection for early-stage esophageal adenocarcinoma

BACKGROUND

With growing application of endoscopic therapy for early-stage esophageal cancer, we sought to review our experience of endoscopic mucosal resections (EMRs). The aim of our study was to understand the natural course of these patients, especially with positive margins.

METHODS

A prospectively maintained database of all patients undergoing endoscopic therapies at Georgetown University Hospital for esophageal cancer was used for the analysis between 2010 and 2020.

RESULTS

Of 80 patients in the EMR database, 35 were performed as index cases for esophageal adenocarcinoma. Majority (74.3%) had a pre-treatment ultrasound confirming absence of regional adenopathy. There were no post-EMR bleeding or perforation events requiring re-intervention. Complete R0 resection was achieved in 22/35 (62.9%) after initial EMR. Thirteen patients had positive margins. Of these 13 patients, only 7 patients underwent repeat endoscopic resection, 2 underwent subsequent esophagectomy, 2 received definitive radiation given poor surgical candidacy, and 2 were lost to follow-up. Overall and 5-year survival of all patients undergoing EMR was 67.9 months and 85%, respectively. Subset analysis of the 13 patients with R1 resection demonstrated an overall survival of 49.2 months and 60% 5-year survival vs overall survival of 78.9 months and 93% 5-year survival for R0 resection. At a median follow-up of 60.5 months, cancer recurrence occurred in 3 patients. All of them were successfully managed with repeat EMR.

CONCLUSIONS

Endoscopic resections represent a safe and effective treatment for early-stage esophageal cancer. Patients with high-risk features should be counseled to undergo an esophagectomy if they are operable candidates.

Totally Endoscopic Resection of Recurrent Convexity Meningioma Following Multiple Surgeries: Oblique Trajectory to Avoid Manipulation of a Vascularized Free Flap: A Technical Note

BACKGROUND

Endoscopic surgery is widely used for intraventricular and skull base tumor resections; however, its utility is not limited to deep parts of the brain.

METHODS

A 73-year-old female presented with left-side hemiparesis and seizures due to a relapsed atypical meningioma of convexity. The tumor was located just under a synthetic bone substitute and was covered by a delicate myocutaneous free flap, preventing the usual skin incision route to approach the lesion.

RESULTS

The tumor was successfully removed using an endoscope without damaging the flap.

CONCLUSIONS

With the aid of an endoscope, a superficial meningioma could be removed with the affected dura through a small craniotomy.

Current Endoscopic Resection Techniques for Gastrointestinal Lesions: Endoscopic Mucosal Resection, Submucosal Dissection, and Full-Thickness Resection

Background

Endoscopic resection of dysplastic lesions in early stages of cancer reduces mortality rates and is recommended by many national guidelines throughout the world. Snare polypectomy and endoscopic mucosal resection (EMR) are established techniques of polyp removal. The advantages of these methods are their relatively short procedure times and acceptable complication rates. The latter include delayed bleeding in 0.9% and a perforation risk of 0.4-1.3%, depending on the size and location of the resected lesion. EMR is a recent modification of endoscopic resection. A limited number of studies suggest that larger lesions can be removed en bloc with low complication rates and short procedure times. Novel techniques such as endoscopic submucosal dissection (ESD) are used to enhance en bloc resection rates for larger, flat, or sessile lesions. Endoscopic full-thickness resection (EFTR) is employed for non-lifting lesions or those not easily amenable to resection. Procedures such as ESD or EFTR are emerging standards for lesions inaccessible to EMR techniques.

Summary

Endoscopic treatment is now regarded as first-line therapy for benign lesions.

Key Message

Endoscopic resection of dysplastic lesions or early stages of cancer is recommended. A plethora of different techniques can be used dependent on the lesions.

Transanal minimally invasive surgery using laparoscopic instruments of the rectum: A review

Transanal minimally invasive surgery (TAMIS) was first described in 2010 as an alternative to transanal endoscopic microsurgery (TEM). The TAMIS technique can be access to the proximal and mid-rectum for resection of benign and early-stage malignant rectal lesions and also used for noncurative intent surgery of more advanced lesions in patients who are not candidates for radical surgery. TAMIS has a shorter learning curve, reduced device setup time, flexibility in instrument use, and versatility in application than TEM. Also, TAMIS shows similar results in a view of the operation time, conversion rate, reoperation rate, and complication to TEM. For these reasons, TAMIS is an easily accessible, technically feasible, and cost-effective alternative to TEM. Overall, TAMIS has enabled the performance of high-quality local excision of rectal lesions by many colorectal surgeons. As TAMIS becomes more broadly utilized such as pelvic abscess drainage, rectal stenosis, and treatment of anastomotic dehiscence, the acquisition of appropriate training must be ensured, and the continued assessment and assurance of outcome must be maintained.

Current Treatment Strategy for Superficial Nonampullary Duodenal Epithelial Tumors

Endoscopic submucosal dissection (ESD) is the standard treatment method for esophageal, gastric, and colorectal cancers. However, it has not been standardized for duodenal lesions because of its high complication rates. Recently, minimally invasive and simple methods such as cold snare polypectomy and underwater endoscopic mucosal resection have been utilized more for superficial nonampullary duodenal epithelial tumors (SNADETs). Although the rate of complications associated with duodenal ESD has been gradually decreasing because of technical advancements, performing ESD for all SNADETs is unnecessary. As such, the appropriate treatment plan for SNADETs should be chosen according to the lesion type, patient condition, and endoscopist’s skill.

Effectiveness and safety of over-the-scope clip in closing perforations after duodenal surgery

BACKGROUND

Endoscopic resection of duodenal subepithelial lesions (SELs) is a difficult procedure with a high risk of perforation. At present, dealing with perforation after endoscopic resection of duodenal SELs is still considered a great challenge.

AIM

To evaluate the effectiveness and safety of an over-the-scope clip (OTSC) in the treatment of perforation post-endoscopic resection of duodenal SELs.

METHODS

From May 2015 to November 2019, 18 patients with perforation following endoscopic resection of duodenal SELs were treated with OTSCs. Data comprising the rate of complete resection, closure of intraprocedural perforation, delayed bleeding, delayed perforation, and postoperative infection were extracted.

RESULTS

The rate of complete removal of duodenal SELs and successful closure of the perforation was 100%. The median perforation size was 1 cm in diameter. Seventeen patients had minor intraoperative bleeding, while the remaining 1 patient had considerable amount of bleeding during the procedure. Seven patients had postoperative abdominal infections, of which 1 patient developed an abscess in the right iliac fossa and another patient developed septic shock. All 18 patients recovered and were discharged. No delayed bleeding or perforation was reported. The mean time taken to resume normal diet after the procedure was 6.5 d. The mean postoperative hospital stay was 9.5 d. No residual or recurrent lesions were detected during the follow-up period (15-66 mo).

CONCLUSION

Closing a perforation after endoscopic resection of duodenal SELs with OTSCs seems to be an effective and reasonably safe therapeutic method.

Endoscopic management of colorectal polyps: From benign to malignant polyps

Colorectal cancer (CRC) is the third most common cancer worldwide and the second leading cause of cancer related death in the world. The early detection and removal of CRC precursor lesions has been shown to reduce the incidence of CRC and cancer-related mortality. Endoscopic resection has become the first-line treatment for the removal of most precursor benign colorectal lesions and selected malignant polyps. Detailed lesion assessment is the first critical step in the evaluation and management of colorectal polyps. Polyp size, location and both macro- and micro- features provide important information regarding histological grade and endoscopic resectability. Benign polyps and even malignant polyps with superficial submucosal invasion and favorable histological features can be adequately removed endoscopically. When compared to surgery, endoscopic resection is associated with lower morbidity, mortality, and higher patient quality of life. Conversely, malignant polyps with deep submucosal invasion and/or high risk for lymph node metastasis will require surgery. From a practical standpoint, the most appropriate strategy for each patient will need to be individualized, based not only on polyp- and patient-related characteristics, but also on local resources and expertise availability. In this review, we provide a broad overview and present a potential decision tree algorithm for the evaluation and management of colorectal polyps that can be widely adopted into clinical practice.

Transanal endoscopic microsurgical submucosal dissection (TEM-ESD): A novel approach to the local treatment of early rectal cancer

BACKGROUND

Complete local resection is currently the treatment of choice for low-risk early rectal cancer; however, the ideal resection technique for such tumours is still debated. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) is a new technique which combines the ergonomic advantages of transanal endoscopic microsurgery (TEM) with the minimally invasive approach of endoscopic submucosal dissection (ESD). The aim of our study was to assess the feasibility, safety, and long-term outcomes of TEM-ESD in treating early rectal cancer.

MATERIALS AND METHODS

We retrospectively analysed all cases of rectal adenocarcinomas treated with TEM-ESD in Karlsruhe Municipal Hospital between 2012 and 2019, as well as the perioperative and follow-up data of the patients.

RESULTS

We identified 40 cases (19 low-risk and 21 high-risk carcinomas) matching our criteria. The median size of the lesions was 3.8 cm and the median operating time 48.5 min. En bloc resection was possible in all cases, while histologically complete resection was confirmed in 18 of 19 low-risk tumours and in 30 out of all lesions. The resection was curative in 19 cases. No scarring of the mesorectum was reported during the completion of total mesorectal excision for high-risk tumours. There was only 1 case of local recurrence among patients treated with curative intent, with an overall survival rate of 100% and a disease-free survival rate of 96% at both 2 and 5 years for these patients.

CONCLUSION

TEM-ESD is a safe and feasible therapeutic option for resecting early rectal cancer, offering very good long-term outcomes.

Impact of non-curative endoscopic submucosal dissection on short- and long-term outcome of subsequent laparoscopic gastrectomy for pT1 gastric cancer

BACKGROUND

The feasibility and oncological safety of non-curative endoscopic submucosal dissection (ESD) prior to additional gastrectomy for early gastric cancer (EGC) are still unclear. The aim of this study was to evaluate the impact of non-curative ESD on short- and long-term outcomes of subsequent laparoscopic gastrectomy (LG) for pathological T1 (pT1) EGC.

METHODS

We retrospectively investigated 422 patients who underwent LG for pT1 EGC between January 2007 and December 2017 at our center. Eighty-five of these patients underwent ESD with curative intent before surgery. Using propensity-score matching for sex, age, body mass index, American society of anesthesiologists score, history of previous abdominal surgery, tumor location, mucosal/submucosal infiltration, histology, lymph node metastasis, extent of lymph node dissection, operative method, lymphatic invasion, and venous invasion, the clinicopathologic and survival data of these patients were compared.

RESULTS

The median follow-up period was 60 (range 2-168) months. Using propensity-score matching from a total of 422 patients, 75 patients were selected in the Non-ESD and the ESD cohorts each. There were no significant differences in terms of characteristics and clinicopathological findings between the two groups. Furthermore, there were no significant differences in postoperative morbidity (13.3% vs. 17.3%; P = 0.497) and mortality (1.3% vs. 0%; P = 0.316). Both the 5-year overall survival ratio (88.8% vs. 86.9%; P = 0.757) and 5-year disease-specific survival ratio (97.1% vs. 98.4%; P = 0.333) were similar in the two groups.

CONCLUSION

Short- and long-term outcomes of LG in patients with pT1 EGC are not related to preoperative ESD history. Even for non-curative resections, ESD prior to surgery is feasible in terms of oncological and surgical outcomes in pT1 EGC.

Efficacy of Sodium Carboxymethylcellulose Compared to Sodium Hyaluronate as Submucosal Injectant for Gastric Endoscopic Submucosal Dissection: A Randomized Controlled Trial

INTRODUCTION

Sodium hyaluronate (SH) is a useful submucosal injectant for gastric endoscopic submucosal dissection (ESD). On the other hand, sodium carboxymethylcellulose (SCMC), which has high viscosity, has also been applied clinically. We evaluated the efficacy of SCMC compared to that of SH in gastric ESD.

METHODS

A prospective randomized controlled trial was conducted to assess the efficacy of 1.0% SCMC as the injectant (SCMC group) compared to 0.4% SH (SH group) for ESD of gastric neoplasms. The primary end point was the procedure time of ESD. Secondary end points were treatment outcomes such as en bloc and R0 resection rates, number of hemostases, amount of injectant, ease of treatment (visual analog scale, 1-10 points), adverse events, and rate of ulcer healing 8 weeks after ESD.

RESULTS

A total of 60 patients were enrolled between October 2014 and October 2018, and 30 patients were allocated in each group. The procedure time (mean ± SD, minutes) was not significantly different between the SCMC (74.7 ± 54.5) and SH groups (67.1 ± 41.4) (p = 0.547). Furthermore, there were no differences between the 2 groups in terms of en bloc and R0 resection rates, number of hemostases, amount of injectant, ease of treatment, and rate of ulcer healing. No serious adverse events were observed in either group.

CONCLUSION

SCMC was comparable to SH in terms of procedure time, treatment outcome, and ease and safety of treatment in gastric ESD. Further studies are needed to demonstrate the differences between the 2 injectants.

Ureteral fibroepithelial polyp: A case report

Ureteral fibroepithelial polyps are rare, accounting for approximately 2–6% of all ureteral tumors. They can be diagnosed by ultrasonography, computed tomography, and retrograde pyelography; however, diagnosis can be difficult. Management is by resection of the polyp, and endoscopic resection is the standard treatment. Partial ureteral resection and ureteral reconstruction may be necessary depending on the size and location of the polyp. Imaging follow-ups for approximately a year post-surgery are recommended. This clinical case report aimed to highlight a case of a fibroepithelial ureteral polyp that was managed by endoscopic resection.

Bleeding after endoscopic resection between direct oral anticoagulants or warfarin: Systematic review and meta-analysis

BACKGROUND AND AIM

Oral anticoagulants are risk factors for post-endoscopic resection bleeding. We aimed to conduct a systematic review and meta-analysis for the risks of post-procedural bleeding (PPB) for direct oral anticoagulants (DOACs) and warfarin following endoscopic resection.

METHODS

Two independent reviewers searched PubMed, Web of Science, Embase, and Cochrane Library. The Newcastle-Ottawa Scale score was used to assess the quality of the studies, the pooled odds ratio (OR) to present PPB results, and the funnel plots to assess publication bias. The Higgins I² statistic was employed to determine the variation across studies due to heterogeneity.

RESULTS

We reviewed 30 articles. PPB occurred in 586 patients on DOACs and 1782 on warfarin. The patients on DOACs had a significantly lower overall risk of PPB compared with those on warfarin (OR, 0.867, 95% confidence interval, 0.771-0.975; P = 0.017, I²  = 1.6%). Cumulative meta-analysis showed that the PPB rate of DOACs has the trend to be lower than that of warfarin with publication year and sample size. For the subgroup of endoscopic submucosal dissection, the PPB of DOACs was significantly lower than that of warfarin (OR, 0.786; 95% confidence interval, 0.633-0.976; P = 0.029, I²  = 0%). No significant difference was observed between DOACs and warfarin for anticoagulant strategies, endoscopic procedures, and lesion location.

CONCLUSIONS

Compared with warfarin, DOACs have the possibility to significantly decrease the risk of PPB following endoscopic resection, especially for endoscopic submucosal dissection.

Endoscopic resection of esophageal and gastric submucosal tumors from the muscularis propria layer: submucosal tunneling endoscopic resection versus endoscopic submucosal excavation: A systematic review and meta-analysis

BACKGROUND

Submucosal tunneling endoscopic resection (STER) and endoscopic submucosal excavation (ESE) are less-invasive therapeutic alternatives to surgical resection for the removal of esophageal or gastric submucosal tumors (SMTs). This study aimed to comparing STER versus ESE for the resection of esophageal and gastric SMTs from the muscularis propria.

METHODS

This systematic review and meta-analysis was reported in accordance with PRISMA guidelines through December 2020. Pooled outcome measures included complete resection, en bloc resection, bleeding, perforation, adverse events, recurrence, procedure duration, and length of hospital stay. Risk ratio (RR) and mean difference (MD) was calculated as well as Peto time-to-event analyses to determine recurrence rate.

RESULTS

Five retrospective cohort studies (n = 269 STER versus n = 319 ESE) were included. There was no difference in rates of complete resection [RR: 1.01 (95% CI 0.94, 1.07)], en bloc resection [RR: 0.95 (95% CI 0.84, 1.08)], recurrence [OR: 1.18 (95% CI 0.33, 4.16)], and total adverse events [RR: 1.33 (95% CI 0.78, 2.27)]. Specific adverse events including rates of perforation [RR: 0.57 (95% CI 0.12, 2.74)] and bleeding [RR: 1.21 (95% CI 0.30, 4.88)] were not different between STER and ESE. There was a statistical difference when evaluating procedure time, with the STER group presenting significantly larger values [MD: 24.62 min (95% CI 20.04, 29.20)].

CONCLUSION

STER and ESE were associated with similar efficacy and safety; however, ESE was associated with a significantly decreased time to complete the procedure.

A rare case of Epstein-Barr virus-positive early gastric carcinoma with lymphoid stroma successfully treated by endoscopic submucosal dissection alone

Gastric carcinoma with lymphoid stroma (GCLS), a rare subset of gastric cancer, has a low frequency of lymphovascular invasion and a relatively better prognosis compared with conventional gastric cancer. We herein report a rare case of early GCLS successfully treated by endoscopic submucosal dissection alone. The lesion was located in the upper gastric body and approximately 9 mm in size. We assessed that the lesion was within an absolute indication for endoscopic resection. We performed endoscopic submucosal dissection and succeeded in en bloc resection. A histopathological assessment disclosed that the carcinoma was poorly differentiated with massive infiltration of lymphocyte and invaded the submucosal layer massively at 1000 μm in depth. There were no visible lymphovascular invasions in the specimen. Since the Epstein-Barr virus (EBV)-encoded small RNA in situ hybridization revealed that cancer cells were positive for EBV, the patient was finally diagnosed with EBV-positive GCLS. We persuaded the patient to receive an additional surgery; however, the patient refused to undergo it. The patient has been followed for more than 5 years without recurrence.

Efficacy of Endoscopic Submucosal Dissection for Superficial Gastric Neoplasia in a Large Cohort in North America

BACKGROUND & AIMS

Endoscopic submucosal dissection (ESD) is a widely accepted treatment option for superficial gastric neoplasia in Asia, but there are few data on outcomes of gastric ESD from North America. We aimed to evaluate the safety and efficacy of gastric ESD in North America.

METHODS

We analyzed data from 347 patients who underwent gastric ESD at 25 centers, from 2010 through 2019. We collected data on patient demographics, lesion characteristics, procedure details and related adverse events, treatment outcomes, local recurrence, and vital status at the last follow up. For the 277 patients with available follow-up data, the median interval between initial ESD and last clinical or endoscopic evaluation was 364 days. The primary endpoint was the rate of en bloc and R0 resection. Secondary outcomes included curative resection, rates of adverse events and recurrence, and gastric cancer-related death.

RESULTS

Ninety patients (26%) had low-grade adenomas or dysplasia, 82 patients (24%) had high-grade dysplasia, 139 patients (40%) had early gastric cancer, and 36 patients (10%) had neuroendocrine tumors. Proportions of en bloc and R0 resection for all lesions were 92%/82%, for early gastric cancers were 94%/75%, for adenomas and low-grade dysplasia were 93%/ 92%, for high-grade dysplasia were 89%/ 87%, and for neuroendocrine tumors were 92%/75%. Intraprocedural perforation occurred in 6.6% of patients; 82% of these were treated successfully with endoscopic therapy. Delayed bleeding occurred in 2.6% of patients. No delayed perforation or procedure-related deaths were observed. There were local recurrences in 3.9% of cases; all occurred after non-curative ESD resection. Metachronous lesions were identified in 14 patients (6.9%). One of 277 patients with clinical follow up died of metachronous gastric cancer that occurred 2.5 years after the initial ESD.

CONCLUSIONS

ESD is a highly effective treatment for superficial gastric neoplasia and should be considered as a viable option for patients in North America. The risk of local recurrence is low and occurs exclusively after non-curative resection. Careful endoscopic surveillance is necessary to identify and treat metachronous lesions.

Clinicopathological significance of primitive phenotypes in early gastric cancer with differentiated histology

Background

Certain gastric cancers exhibit some primitive phenotypes, which may indicate a high malignancy. In histologically differentiated early gastric cancer (EGC), the presence and the clinicopathological significance of the primitive phenotype remain unclear.

Methods

Using immunohistochemical staining we detected the expression of three primitive phenotypic markers SALL4, Glypican-3(GPC3), and AFP in whole tissue sections of differentiated EGC (gastrectomy specimens, n = 302). For those cases with primitive phenotypes, we analyzed their clinicopathological features and evaluated whether the criteria for endoscopic resection were met.

Results

We found that 9.3% (28/302) of all differentiated EGC cases have primitive phenotypes, and most of these cases (25/28) exhibit a histomorphology similar to conventional differentiated EGC. Patients with primitive phenotypes had a deeper invasion, a higher rate of ulcer and lymphatic invasion than cases without primitive phenotype. Moreover, patients with primitive phenotypes displayed a significantly higher frequency of LNM than those without (57.1% vs 8.8%, P < 0.001). Multivariate analysis revealed that presence of primitive phenotypes was an independent risk factor for LNM (P = 0.001, HR 6.977, 95% CI: 2.199–22.138). Interestingly, we found 2 cases with primitive phenotypes developed LNM, and they both met the expanded indications of endoscopic resection for differentiated EGC.

Conclusions

A small number of differentiated EGC have primitive phenotypes, which were closely related to LNM and were an independent risk factor for LNM. Given its highly aggressive behavior, differentiated EGC with primitive phenotypes should be evaluated with stricter criteria before endoscopic resection, or considered to give an additional surgical operation after endoscopic resection.

Comparison of endoscopic therapies for rectal neuroendocrine tumors: endoscopic submucosal dissection with myectomy versus endoscopic submucosal dissection

BACKGROUND

Endoscopic submucosal dissection (ESD) has been a valuable treatment of choice for rectal neuroendocrine tumors (NETs). However, the vertical margin may remain positive after ESD because the neuroendocrine tumors develop in a submucosal tumor (SMT)-like way. Endoscopic submucosal dissection with myectomy (ESD-ME), a new method for rectal NETs, may overcome this problem.

METHODS

From August 2013 to August 2020, the medical records of 69 patients (72 rectal neuroendocrine tumors) who received endoscopic submucosal dissection (ESD) or endoscopic submucosal dissection with myectomy (ESD-ME) for rectal NETs were investigated retrospectively. The characteristics of the patients and tumors, the rate of complete resection, and the rate of complications were analyzed retrospectively.

RESULTS

The ESD-ME group contained 27 patients (12 males, 15 females; age range 29-72 years) and the ESD group contained 42 patients (21 males, 21 females; age range 29-71 years). Both groups had similar mean rectal neuroendocrine tumor diameters (ESD-ME 6.1 ± 1.8 mm, ESD 6.7 ± 2.6 mm; P = 0.219). The procedure time was not different significantly between groups (ESD-ME 21.1 ± 6.3, ESD 19.3 ± 3.1; P = 0.115). The endoscopic complete resection rate did not differ significantly between the ESD-ME and ESD groups (100% for each). The histological complete resection rate was 100% (27 of 27) in the ESD-ME group and 81.0% (34 of 42) in the ESD group (P = 0.043). Delayed bleeding occurred in 1 ESD-ME patient (3.7%) and in 2 ESD patients (4.8%) (P = 1.000). Perforation occurred in 1 ESD-ME patient (3.7%) and the patient was successfully managed by conservative measure, and there was no perforation after ESD (P = 0.391).

CONCLUSIONS

When compared with ESD, ESD-ME resulted in a higher histological complete resection rate, had a similar complication rate, and took similar time to perform. ESD-ME can be considered an effective and safe resection method for rectal NETs < 16 mm in diameter without metastasis.

Validity of endoscopic resection for clinically diagnosed T1a-MM/T1b-SM1 N0 M0 esophageal squamous cell carcinoma

BACKGROUND

Previous guidelines have not described clear recommendations for performing endoscopic resection (ER) of T1a-muscularis mucosa (MM)/T1b-submucosal (SM1) cancers that have invaded ≤ 200 μm because these are considered to have a non-negligible risk of metastasis based on previous analyses of pathologically diagnosed (p)MM/SM1 cancers. Considering that the indication for ER is determined based on a clinical diagnosis, the applicability of ER should be investigated in clinical (c)MM/SM1 but not pMM/SM1 cancers. This study aimed to evaluate validity of ER for cMM/SM1 cancers.

METHODS

In total, 175 cMM/SM1 esophageal squamous cell carcinoma cases that were endoscopically or surgically resected between January 2008 and December 2018 were identified from a prospectively maintained database. We histologically evaluated resected specimens and divided them into low- (n = 92) and high-risk (n = 83) cancers for metastasis.

RESULTS

Univariate analysis showed that longer tumor length and larger circumferential extent were significantly correlated with high-risk cancer (P < 0.001). Multivariate analysis showed that tumor circumference was an independent predictor of high-risk cancer (P = 0.036). The proportion of low-risk cancers among cases with ≤ 3/4, > 3/4 and < 1, and whole circumferential extent were 59, 17, and 14%, respectively, and the post-ER stricture rates of these groups were 12, 33, and 100%, respectively.

CONCLUSION

ER is the first-line treatment for cMM/SM1 cancers with ≤ 3/4 circumferential extent considering that 59% of cMM/SM1 cancers were low-risk cancers for which ER is mostly curative. ER is not recommended for whole circumferential cMM/SM1 cancers given the low proportion of low-risk cancers and the high risk of stricture after ER.

Subepithelial spread of early gastric cancer is common and extends more than expected

BACKGROUNDS

The clinical significance of subepithelial (SE) spread from early gastric cancer (EGC) is poorly understood. Thus, we evaluated the proportion and extent of SE spread from EGC, as well as related risk factors.

METHODS

We reviewed medical records and pathological specimens from patients with EGC who underwent surgery or endoscopic resection between January 2016 and December 2016 at Chungnam National University Hospital.

RESULTS

A total of 404 patients were reviewed and SE spread was identified for 142 patients (35.1%). The presence of SE spread was associated with gender, histological type, location, endoscopic appearance, color change, presence of lymphovascular invasion, and invasion depth. Multivariable analysis revealed that SE spread was only independently associated with histological type. The distance of SE spread was significantly different between histological types, and the maximum distance was 17 mm.

CONCLUSION

More than 30% of our patients with EGC had SE spread, which could reach up to 17 mm. Given the proportion of SE spread in these cases, a wider resection margin may be safe during endoscopic resection or surgery.

Risk of metastatic recurrence after endoscopic resection for esophageal squamous cell carcinoma invading into the muscularis mucosa or submucosa: a multicenter retrospective study

BACKGROUND

We aimed to elucidate the risk of metastatic recurrence after endoscopic resection (ER) without additional treatment for esophageal squamous cell carcinomas (ESCCs) with tumor invasion into the muscularis mucosa (pT1a-MM) or submucosa (T1b-SM).

METHODS

We retrospectively enrolled patients with pT1a-MM/pT1b-SM ESCC after ER at 21 institutions in Japan between 2006 and 2017. We compared metastatic recurrence between patients with and without additional treatment, stratified into category A (pT1a-MM with negative lymphovascular invasion [LVI] and vertical margin [VM]), B (tumor invasion into the submucosa ≤ 200 µm [pT1b-SM1] with negative LVI and VM), and C (others). Subsequently, using multivariate Cox analysis, we evaluated risk factors for metastatic recurrence after ER without additional treatment.

RESULTS

We enrolled 593 patients, and metastatic recurrence occurred in 38 patients. Metastatic recurrence after additional treatment was significantly lower than that after no additional treatment in category C (9.1% vs. 23.6% in 5 years, p = 0.001), whereas no significant difference was noted in categories A (0.0% vs. 2.6%) and B (0.0% vs. 4.3%). In patients without additional treatment after ER, risk factors for metastatic recurrence were lymphatic invasion (hazard ratio [HR], 5.61), positive VM (HR, 4.55), and tumor invasion into the submucosa > 200 μm (HR, 3.25), and, but near half of the patients with metastatic recurrence had no further recurrence after salvage treatment, resulting in excellent 5-year disease-specific survival in categories A (99.6%) and B (100.0%).

CONCLUSIONS

Closed follow-up with no additional treatment may be an acceptable option after ER in pT1a-MM/pT1b-SM1 ESCC with negative LVI and VM.

Diagnostic yield of conventional endoscopy with endoscopic ultrasonography for submucosal invasion of superficial esophageal squamous cell carcinoma: a post hoc analysis of multicenter prospective confirmatory study (JCOG0508)

BACKGROUND

Endoscopic ultrasonography (EUS) is reportedly the reliable modality to predict the depth of esophageal squamous cell carcinoma (ESCC), however, most previous studies are retrospective or single-centered. We aimed to evaluate the diagnostic ability of conventional endoscopy and EUS using the data from a multicenter prospective study of endoscopic resection (ER) followed by chemoradiotherapy for cSM1-2N0M0 ESCC (JCOG0508).

METHODS

All lesions were evaluated as cSM cancer with both conventional endoscopy and EUS before enrollment and judged as cSM1 or cSM2 in real time. We compared the clinical and pathological diagnoses for tumor depth and assessed the positive predictive value (PPV) for pSM (pSM/cSM) as the primary endpoint. We also investigated the clinical factors affecting the pathological depth of SM.

RESULTS

175 lesions were examined, and clinical diagnosis was SM1 in 114 and SM2 in 61 lesions. The pathological diagnoses of the epithelium, lamina propria mucosa, muscularis mucosae, SM1, and SM2 were 3, 31, 55, 17, and 69. The PPV for pSM was 49.1% (86/175) in all lesions, 34.2% (39/114) in cSM1 lesions, and 77.0% (47/61) in cSM2 lesions. Multivariable analysis demonstrated that cSM2 (vs. cSM1, OR 6.79) was an independent clinical factor associated with pSM.

CONCLUSIONS

While the accurate depth diagnosis in cSM ESCC was difficult to make, the clinical diagnosis of SM2 with both conventional endoscopy and EUS was significantly associated with pSM. Furthermore, diagnostic ER could be recommended to confirm the pathological diagnosis especially in cSM1 lesions with both conventional endoscopy and EUS.