Long-term outcomes of endoscopic submucosal dissection for early gastric cancer: a single-center experience

Early gastric cancer of young patients treated by endoscopic submucosal dissection: focusing on the different characteristics and prognosis of elderly patients

BACKGROUND

A small portion of patients are diagnosed with early gastric cancer (EGC) and undergo endoscopic submucosal dissection (ESD) at a young age. However, their clinical outcomes are rarely known.

AIM

We investigated to identify the feasibility and clinical outcomes of ESD for EGC focusing on young patients.

METHODS

We analyzed the clinical characteristics and outscomes of patients who had undergone ESD for the treatment of EGC at < 50 years of age. We enrolled patients who had been diagnosed with EGC and had undergone ESD between 2006 and 2020. We divided them by age as follows: ≤ 50 and > 50 years into the young age (YA) and other age (OA) groups, respectively.

RESULTS

Altogether, 1681 patients underwent ESD for EGC (YA group: 124 [7.4%], OA group: 1557 [92.6%]). The YA group had less severe atrophy and more undifferentiated (37.1% vs. 13.9%, P < 0.001) and diffuse type (25% vs. 7.7%, P < 0.001) histology. The curative resection rate was not significantly different between the groups. However, among 1075 patients who had achieved curative resection and had been followed-up for > 12 months, the YA group had a lower incidence of MGN (5.2% vs. 17.5%, P = 0.004) and MGC (2.6% vs. 10.9%, P = 0.019) than those exhibited by the OA group. The YA group was a significant negative predictor of MGN (odds ratio [OR]: 2.983, 95% confidence interval [CI] 1.060-8.393, P = 0.038), and marginally negative predictor in MGC (OR: 3.909, 95% CI: 0.939-16.281, P = 0.061).

CONCLUSION

ESD is a favorable and effective therapeutic modality for EGC patients aged < 50 years, once curative resection is achieved.

Characteristics of early gastric tumors with different differentiation and predictors of long-term outcomes after endoscopic submucosal dissection

BACKGROUND

Gastric cancer is a common malignant tumor of the digestive tract, and endoscopic submucosal dissection (ESD) is the preferred treatment for early-stage gastric cancer. The analysis of the epidemiological characteristics of gastric mucosal tumors with different differentiation degrees and the influencing factors of long-term ESD efficacy may have certain significance for revealing the development of gastric cancer and ESD.

AIM

To analyze the features of gastric mucosal tumors at different differentiation levels, and to explore the prognostic factors of ESD.

METHODS

We retrospectively studied 301 lesions in 285 patients at The Second Affiliated Hospital of Xi'an Jiaotong University from 2014 to 2021, according to the latest Japanese guidelines (sixth edition), and divided them into low-grade intraepithelial neoplasia (LGIN), high-grade intraepithelial neoplasia (HGIN), and differentiated and undifferentiated early carcinoma. They are followed up by endoscopy, chest and abdominal computed tomography at 3, 6 and 12 months after ESD. We compared clinicopathologic characteristics, ESD efficacy, and complications with different degrees of differentiation, and analyzed the related factors associated with ESD.

RESULTS

HGIN and differentiated carcinoma patients were significantly older compared with LGIN patients (P < 0.001) and accounted for more 0-IIc (P < 0.001), atrophic gastritis was common (P < 0.001), and irregular microvascular patterns (IMVPs) and demarcation lines (DLs) were more obvious (P < 0.001). There was more infiltration in the undifferentiated carcinoma tissue (P < 0.001), more abnormal folds and poorer mucosal peristalsis (P < 0.001), and more obvious IMVPs, irregular microsurface patterns and DLs (P < 0.05) than in the LGIN and HGIN tissues. The disease-free survival rates at 2, 5, and 8 years after ESD were 95.0%, 90.1%, and 86.9%, respectively. Undifferentiated lesions (HR 5.066), white moss (HR 7.187), incomplete resection (HR 3.658), and multiple primary cancers (HR 2.462) were significantly associated with poor prognosis.

CONCLUSION

Differentiations of gastric mucosal tumors have different epidemiological and endoscopic characteristics, which are closely related to the safety and efficacy of ESD.

Impact of endoscopic surveillance on the early diagnosis and endoscopic resection likelihood of gastric cancer

BACKGROUND

Endoscopy could help detect early gastric cancer (EGC) and improve the prognosis of patients. The aim of this study was to analyze the impact of endoscopy and endoscopic surveillance on the early detection of gastric cancer (GC), GC staging, and treatment selection.

METHODS

Patients with GC diagnosed at our center from 2010 to 2022 were retrospectively analyzed and allocated to the short-interval group (had received endoscopy within 3 years before diagnosis), the long-interval group (had received endoscopy more than 3 years before diagnosis), and the unchecked group (had not received endoscopy before diagnosis). The differences in GC staging and treatment modalities among the three groups were analyzed, and the differences in the clinical and pathological features of EGC were further analyzed.

RESULTS

One thousand and twenty-five GC patients were included, with 395 cases of EGC and 630 cases of advanced GC. The proportions of EGC in the short-interval, long-interval, and unchecked groups were 98.0%, 84.2%, and 29.8%, respectively (p < 0.001). Among the 387 lesions of 367 EGC patients were resected by endoscopic submucosal dissection (ESD), 341 (88.1%) exhibited curative resection, and 46 (11.9%) involved noncurative resections. Lesions of EGC differed significantly in diameter, depth of invasion, and curative resection rate (p = 0.033, 0.019, and 0.005, respectively). In the short-interval group, 87.8% of the lesions were ≤ 2 cm, 95.6% of the invasion depths were confined to the mucosal layer, and 96.7% of the eCura scores were A or B. Compared with the unchecked group, they had smaller diameters (RR = 0.419, 95% CI 0.234-0.752), shallower invasion depths (RR = 0.286, 95% CI 0.105-0.777), and a higher curative resection rate (RR = 0.215, 95% CI 0.068-0.676).

CONCLUSION

Endoscopic surveillance at 3-year intervals can help detect EGC, and the EGC lesions found have smaller diameters and shallower depths of invasion, helping improve the curative resection rate of ESD.

The optimal interval of surveillance gastroscopy after endoscopic resection for gastric neoplasia: a multicenter cohort study

BACKGROUND/AIMS

Due to the possible metachronous recurrence of gastric neoplasia, surveillance gastroscopy is mandatory after endoscopic resection for gastric neoplasia. However, there is no consensus on the surveillance gastroscopy interval. This study aimed to find an optimal interval of surveillance gastroscopy and to investigate the risk factors for metachronous gastric neoplasia.

METHODS

Medical records were reviewed retrospectively in patients who underwent endoscopic resection for gastric neoplasia in 3 teaching hospitals from June 2012 to July 2022. Patients were divided into two groups; annual surveillance vs. biannual surveillance. The incidence of metachronous gastric neoplasia was identified, and the risk factors for metachronous gastric neoplasia were investigated.

RESULTS

Among the 1,533 patients who underwent endoscopic resection for gastric neoplasia, 677 patients were enrolled in this study (annual surveillance 302, biannual surveillance 375). Metachronous gastric neoplasia was observed in 61 patients (annual surveillance 26/302, biannual surveillance 32/375, P = 0.989), and metachronous gastric adenocarcinoma was observed in 26 patients (annual surveillance 13/302, biannual surveillance 13/375, P = 0.582). All the lesions were removed by endoscopic resection successfully. In a multivariate analysis, severe atrophic gastritis on gastroscopy was an independent risk factor for metachronous gastric adenocarcinoma (odds ratio 3.8, 95% confidence interval 1.4‒10.1; P = 0.008).

CONCLUSIONS

Meticulous observation to detect the metachronous gastric neoplasia is necessary for patients with severe atrophic gastritis during follow-up gastroscopy after endoscopic resection for gastric neoplasia. Annual surveillance gastroscopy might be enough after endoscopic resection for gastric neoplasia.

Short-term efficacy of additional laparoscopic-assisted radical gastrectomy after non-curative endoscopic submucosal dissection for early gastric cancer

OBJECTIVE

To investigate short-term efficacy of direct laparoscopic-assisted radical gastrectomy (LAG) versus non-curative endoscopic submucosal dissection (ESD) plus additional LAG for early gastric cancer.

MATERIALS AND METHODS

286 patients were retrospectively assigned into two groups: direct LAG group (n = 255) and additional LAG (ESD plus LAG, n = 31) group. A 1:2 propensity score matching was performed to equalize relevant confounding factors between two groups for analysis.

RESULTS

Ninety-three patients were successfully matched, including 62 in the direct LAG group and 31 in the additional LAG group. A significant (P = 0.013) difference existed in the drainage removal time between the additional LAG and direct LAG group (7 d vs. 6 d). Age, sex, tumor location and surgical approach were significantly (P < 0.05) associated with complications, with age ≥ 60 years (P = 0.002) and total gastrectomy (P = 0.011) as significant independent risk factors. A significant (P = 0.023) difference existed in the surgical time between the early and late groups (193.3 ± 37.6 min vs. 165.5 ± 25.1 min).

CONCLUSION

Additional LAG (D1 + lymphadenectomy) after ESD may be safe and effective even though non-curative ESD may prolong the drainage removal time and increase the difficulty of surgery.

Clinical and endoscopic features of metachronous gastric cancer with possible lymph node metastasis after endoscopic submucosal dissection and Helicobacter pylori eradication

BACKGROUND

Several studies have reported the metachronous gastric cancers (MGCs) with possible lymph node metastasis (LNM) after endoscopic submucosal dissection (ESD) and Helicobacter pylori (H. pylori) eradication in which a curative ESD had not been achieved. There have been no published reports of evaluations of the features of patients with MGC with possible LNM after ESD and H. pylori eradication.

METHODS

We identified 264 patients with 369 MGCs after H. pylori eradication among the 4354 patients with 5059 early gastric cancers (EGCs) who underwent ESD between 1999 and 2017 and divided them into two groups: patients with MGCs with possible LNM (Group I) and patients with MGCs undergone curative ESD (Group II). We retrospectively compared the features of patients with MGCs and patients with EGCs at index ESD in the two groups.

RESULT

Group I consisted of 20 patients with 21 MGCs, and Group II consisted of 244 patients with 348 MGCs. Group I lesions were significantly more common in the posterior wall than in the lesser curvature (odds ratio [OR] = 3.97; 95% confidence intervals [CI] 1.20-13.10). Development of Group I was significantly more common in patients with a body mass index (BMI) < 19.0 kg/m2 than in patients with a BMI ≥ 19.0 kg/m2 at index ESD (OR = 4.44; 95% CI 1.30-15.20).

CONCLUSIONS

During surveillance endoscopy after gastric ESD and H. pylori eradication, the posterior wall should be carefully examined to detect MGCs early. Lower BMI may be associated with the development of MGCs with possible LNM.

American Society for Gastrointestinal Endoscopy guideline on endoscopic submucosal dissection for the management of early esophageal and gastric cancers: methodology and review of evidence

This document from the American Society for Gastrointestinal Endoscopy (ASGE) provides a full description of the methodology used in the review of the evidence used to inform the final guidance outlined in the accompanying Summary and Recommendations document regarding the role of endoscopic submucosal dissection (ESD) in the management of early esophageal and gastric cancers. This guideline used the Grading of Recommendations, Assessment, Development and Evaluation framework and specifically addresses the role of ESD versus EMR and/or surgery, where applicable, for the management of early esophageal squamous cell carcinoma (ESCC), esophageal adenocarcinoma (EAC), and gastric adenocarcinoma (GAC) and their corresponding precursor lesions. For ESCC, the ASGE suggests ESD over EMR for patients with early-stage, well-differentiated, nonulcerated cancer >15 mm, whereas in patients with similar lesions ≤15 mm, the ASGE suggests either ESD or EMR. The ASGE suggests against surgery for such patients with ESCC, whenever possible. For EAC, the ASGE suggests ESD over EMR for patients with early-stage, well-differentiated, nonulcerated cancer >20 mm, whereas in patients with similar lesions measuring ≤20 mm, the ASGE suggests either ESD or EMR. For GAC, the ASGE suggests ESD over EMR for patients with early-stage, well or moderately differentiated, nonulcerated intestinal type cancer measuring 20 to 30 mm, whereas for patients with similar lesions <20 mm, the ASGE suggests either ESD or EMR. The ASGE suggests against surgery for patients with such lesions measuring ≤30 mm, whereas for lesions that are poorly differentiated, regardless of size, the ASGE suggests surgical evaluation over endosic approaches.

American Society for Gastrointestinal Endoscopy guideline on endoscopic submucosal dissection for the management of early esophageal and gastric cancers: summary and recommendations

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based summary and recommendations regarding the role of endoscopic submucosal dissection (ESD) in the management of early esophageal and gastric cancers. It is accompanied by the document subtitled "Methodology and Review of Evidence," which provides a detailed account of the methodology used for the evidence review. This guideline was developed using the Grading of Recommendations, Assessment, Development and Evaluation framework and specifically addresses the role of ESD versus EMR and/or surgery, where applicable, for the management of early esophageal squamous cell carcinoma (ESCC), esophageal adenocarcinoma (EAC), and gastric adenocarcinoma (GAC) and their corresponding precursor lesions. For ESCC, the ASGE suggests ESD over EMR for patients with early-stage, well-differentiated, nonulcerated cancer >15 mm, whereas in patients with similar lesions ≤15 mm, the ASGE suggests either ESD or EMR. The ASGE suggests against surgery for such patients with ESCC, whenever possible. For EAC, the ASGE suggests ESD over EMR for patients with early-stage, well-differentiated, nonulcerated cancer >20 mm, whereas in patients with similar lesions measuring ≤20 mm, the ASGE suggests either ESD or EMR. For GAC, the ASGE suggests ESD over EMR for patients with early-stage, well- or moderately differentiated, nonulcerated intestinal type cancer measuring 20 to 30 mm, whereas for patients with similar lesions <20 mm, the ASGE suggests either ESD or EMR. The ASGE suggests against surgery for patients with such lesions measuring ≤30 mm, whereas for lesions that are poorly differentiated, regardless of size, we suggest surgical evaluation over endoscopic approaches.

Knowledge, attitude, and practice of monitoring early gastric cancer after endoscopic submucosal dissection

BACKGROUND

Early gastric cancer (EGC) is typically treated with endoscopic submucosal dissection (ESD). However, recurrence may occur after ESD, requiring surveillance.

AIM

To examine the knowledge, attitude, and practice (KAP) of EGC survivors following ESD regarding gastric cancer recurrence.

METHODS

This cross-sectional study was conducted between June 1, 2022 and October 1, 2022 in Zhejiang, China. A total of 400 EGC survivors who underwent ESD at the Affiliated Jinhua Hospital, Zhejiang University School of Medicine participated in this study. A self-administered questionnaire was developed to assess KAP monitoring gastric cancer after ESD.

RESULTS

The average scores for KAP were 3.34, 23.76, and 5.75 out of 5, 30, and 11, respectively. Pearson correlation analysis revealed positive and significant correlations between knowledge and attitude, knowledge and practice, and attitude and practice (r = 0.405, 0.511, and 0.458, respectively; all P < 0.001). Multivariate logistic regression analysis showed that knowledge, attitude, 13-24 mo since the last ESD (vs ≤ 12 mo since the last ESD), and ≥ 25 mo since the last ESD (vs ≤ 12 mo since the last ESD) were independent predictors of proactive practice (odds ratio = 1.916, 1.253, 3.296, and 5.768, respectively, all P < 0.0001).

CONCLUSION

EGC survivors showed inadequate knowledge, positive attitude, and poor practices in monitoring recurrences after ESD. Adequate knowledge, positive attitude, and a longer time since the last ESD were associated with practice.

Comparison of the clinical and prognosis risk factors between endoscopic resection and radical gastrectomy for early-stage gastric cancer

AIM

This study aimed to explore the efficacy and safety of endoscopic submucosal dissection/endoscopic mucosal resection (ESD/EMR), laparoscopic-assisted radical gastrectomy (LARG), and open radical gastrectomy (ORG) in early-stage gastric cancer.

METHODS

A total of 417 patients with early-stage gastric cancer who were admitted in two hospitals from January 1, 2014 to July 31, 2017 were selected; the patients were divided into the ESD/EMR group (139 cases), LARG group (108 cases), and ORG group (170 cases) according to the operation methods used. The baseline data, economic cost of health, oncologic characteristics, postoperative complications, 5-year overall survival and disease-free survival, and risk factors of death were compared and analyzed.

RESULTS

No significant difference was observed in the baseline data among the three patient groups (P > 0.05). The total hospitalization days, operation time, postoperative fluid intake time, hospitalization expenses, and proportion of antibiotic use rate in the ESD/EMR group were lesser than those in other groups (P < 0.05). The LARG group has a longer operation time and higher hospitalization expenses compared with the ORG group (P < 0.05), but the total hospitalization days, postoperative fluid intake time, proportion of antibiotic use, and lung infection status were consistent. The ESD/EMR group had a lower incidence of incision site infection and postoperative abdominal distension compared with that of the surgery groups (P < 0.05). Five patients required radical surgery after undergoing ESD/EMR (The patients had residual tissue margin cancer), while none of the patients had switched to ORG during LARG. Surgery had advantages over ESD/EMR in terms of lymph node dissection (P < 0.05). No significant differences were observed in the postoperative complications such as upper gastrointestinal bleeding, perforation, incision hernia, reoperation and recurrence (P > 0.05). The 5-year postoperative survival rates of patients in the three groups were 94.2% (ESD/EMR), 93.5% (LARG), and 94.7% (ORG), respectively, with no significant differences (P > 0.05). The binary logistics multivariate analysis showed that the tumor size, invasion depth, vascular invasion, and differentiated degree were risk factors for death in patients with gastric cancer.

CONCLUSIONS

No significant difference was observed between ESD/EMR and radical surgery. However, standardized criteria for excluding metastatic lymph nodes should be established to promote ESD/EMR.

Long-term Survival After Endoscopic Resection For Gastric Cancer: Real-world Evidence From a Multicenter Prospective Cohort

BACKGROUND & AIMS

We aimed to clarify the long-term outcomes of endoscopic resection (ER) for early gastric cancers (EGCs) based on pathological curability in a multicenter prospective cohort study.

METHODS

We analyzed the long-term outcomes of 9054 patients with 10,021 EGCs undergoing ER between July 2010 and June 2012. Primary endpoint was the 5-year overall survival (OS). The hazard ratio for all-cause mortality was calculated using the Cox proportional hazards model. We also compared the 5-year OS with the expected one calculated for the surgically resected patients with EGC. If the lower limit of the 95% confidence interval (CI) of the 5-year OS exceeded the expected 5-year OS minus a margin of 5% (threshold 5-year OS), ER was considered to be effective. Pathological curability was categorized into en bloc resection, negative margins, and negative lymphovascular invasion: differentiated-type, pT1a, ulcer negative, ≤2 cm (Category A1); differentiated-type, pT1a, ulcer negative, >2 cm or ulcer positive, ≤3 cm (Category A2); undifferentiated-type, pT1a, ulcer negative, ≤2 cm (Category A3); differentiated-type, pT1b (SM1), ≤3 cm (Category B); or noncurative resections (Category C).

RESULTS

Overall, the 5-year OS was 89.0% (95% CI, 88.3%-89.6%). In a multivariate analysis, no significant differences were observed when the hazard ratio of Categories A2, A3, and B were compared with that of A1. In all the pathological curability categories, the lower limit of the 95% CI for the 5-year OS exceeded the threshold 5-year OS.

CONCLUSION

ER can be recommended as a standard treatment for patients with EGCs fulfilling Category A2, A3, and B, as well as A1 (UMIN Clinical Trial Registry, UMIN000005871).

Cellular Plasticity, Reprogramming, and Regeneration: Metaplasia in the Stomach and Beyond

The mucosa of the body of the stomach (ie, the gastric corpus) uses 2 overlapping, depth-dependent mechanisms to respond to injury. Superficial injury heals via surface cells with histopathologic changes like foveolar hyperplasia. Deeper, usually chronic, injury/inflammation, most frequently induced by the carcinogenic bacteria Helicobacter pylori, elicits glandular histopathologic alterations, initially manifesting as pyloric (also known as pseudopyloric) metaplasia. In this pyloric metaplasia, corpus glands become antrum (pylorus)-like with loss of acid-secreting parietal cells (atrophic gastritis), expansion of foveolar cells, and reprogramming of digestive enzyme-secreting chief cells into deep antral gland-like mucous cells. After acute parietal cell loss, chief cells can reprogram through an orderly stepwise progression (paligenosis) initiated by interleukin-13-secreting innate lymphoid cells (ILC2s). First, massive lysosomal activation helps mitigate reactive oxygen species and remove damaged organelles. Second, mucus and wound-healing proteins (eg, TFF2) and other transcriptional alterations are induced, at which point the reprogrammed chief cells are recognized as mucus-secreting spasmolytic polypeptide-expressing metaplasia cells. In chronic severe injury, glands with pyloric metaplasia can harbor both actively proliferating spasmolytic polypeptide-expressing metaplasia cells and eventually intestine-like cells. Gastric glands with such lineage confusion (mixed incomplete intestinal metaplasia and proliferative spasmolytic polypeptide-expressing metaplasia) may be at particular risk for progression to dysplasia and cancer. A pyloric-like pattern of metaplasia after injury also occurs in other gastrointestinal organs including esophagus, pancreas, and intestines, and the paligenosis program itself seems broadly conserved across tissues and species. Here we discuss aspects of metaplasia in stomach, incorporating data derived from animal models and work on human cells and tissues in correlation with diagnostic and clinical implications.

Risk factors for the histologic discrepancy of gastric adenomatous lesions and long-term outcome

Although endoscopic forceps biopsies (EFB) have a significant role in diagnosing gastric adenoma, there are still discrepancies between EFBs and finalized pathology results.Therefore, the objective of this study was to find the risk factors that cause this discrepancy and to analyze the effects of this discrepancy on the long-term outcome.In this study patients that had received endoscopic resection due to low-grade gastric adenoma diagnosis from EFB between January of 2011 and January of 2018 at the Chungnam National University Hospital were retrospectively analyzed. According to whether there was histological discrepancy the cumulative incidence of the metachronous lesions were analyzed.A total of 745 lesions diagnosed as low-grade gastric adenoma at EFB were enrolled, and the final pathology results were confirmed to be non-neoplastic (n = 19), low-grade adenoma (n = 614), High-grade adenoma (n = 63), and carcinoma (n = 49), and with the exception of non-neoplastic lesion, the results confirmed 84.6% (n = 614) for the concordant group and 15.4% (n = 112) for the discordant. The results of the multivariate analysis confirmed that depressed lesion (odds ratio [OR]: 2.056; 95% confidence interval [CI]: 1.130-3.451; P = .011), erythema (OR: 2.546; 95% CI: 1.604-4.030; P = .004), and a size >1.5 cm (OR: 1.903; 95% CI: 1.102-3.172; P = .018) were risk factors for discrepancy. The results also confirmed that for the average observation period of (SD) 39.12 (12.31) months, the cumulative incidence of metachronous neoplasm had a higher significance (P = 0.001) in the discordant group when compared to that of the concordant group.The factors related to the histologic discrepancy of low-grade gastric adenoma were depressed lesion, erythema and size >1.5 cm. In the groups with histological discrepancy, the cumulative incidence of the metachronous neoplasm was significantly higher and therefore closer observation of such patients after performing endoscopic resection is necessary.

Efficacy and Safety of Endoscopic Submucosal Dissection for Superficial Gastric Neoplasms: A Latin American Cohort Study

Background/Aims

Endoscopic submucosal dissection (ESD) is the preferred technique for treating early gastric cancer (EGC). However, very few studies have been conducted in South America. This study aimed to assess the efficacy and safety of ESD for EGC.

Methods

We analyzed data from a prospective cohort from 2013 to 2020. A total of 152 superficial gastric neoplasms that fulfilled the absolute or expanded criteria for ESD were included. Outcomes were en bloc, R0, and curative resection rates, incidence of adverse events, and length of procedure.

Results

The age of the enrolled patients was 68.4±11.3 years. The number of included patients based on the absolute and expanded indications was 150 and 2, respectively. En bloc, R0, and curative resections were achieved in 98.0%, 96.1%, and 89.5% of the cases, respectively. Bleeding and perforation were reported in 5.9% and 6.6% of the cases, respectively. Histopathological examination revealed low-grade dysplasia, high-grade dysplasia, well-differentiated adenocarcinoma, and poorly differentiated adenocarcinoma in 13, 20, 117, and 2 cases, respectively.

Conclusions

Our study shows that ESD performed by properly trained endoscopists in reference centers is safe and effective, with comparable therapeutic outcomes to those reported in the Eastern series.

Endoscopic diagnosis and treatment of gastric dysplasia and early cancer: Current evidence and what the future may hold

Gastric cancer accounts for a significant proportion of worldwide cancer-related morbidity and mortality. The well documented precancerous cascade provides an opportunity for clinicians to detect and treat gastric cancers at an endoscopically curable stage. In high prevalence regions such as Japan and Korea, this has led to the implementation of population screening programs. However, guidelines remain ambiguous in lower prevalence regions. In recent years, there have been many advances in the endoscopic diagnosis and treatment of early gastric cancer and precancerous lesions. More advanced endoscopic imaging has led to improved detection and characterization of gastric lesions as well as superior accuracy for delineation of margins prior to resection. In addition, promising early data on artificial intelligence in gastroscopy suggests a future role for this technology in maximizing the yield of advanced endoscopic imaging. Data on endoscopic resection (ER) are particularly robust in Japan and Korea, with high rates of curative ER and markedly reduced procedural morbidity. However, there is a shortage of data in other regions to support the applicability of protocols from these high prevalence countries. Future advances in endoscopic therapeutics will likely lead to further expansion of the current indications for ER, as both technology and proceduralist expertise continue to grow.

Upregulated hsa_circRNA_100269 inhibits the growth and metastasis of gastric cancer through inactivating PI3K/Akt axis

The pathogenesis of GC involves the complex networking of multiple signaling pathways; however, the detailed mechanisms of tumorigenesis of GC remains largely unknown. Therefore, it is necessary to explore novel diagnostic/prognostic biomarkers for GC. In this study, the levels of hsa_circRNA_100269 in gastric cancer (GC) samples and cells were examined, and its effects on the biological functions of GC cells were elucidated. The levels of hsa_circRNA_100269 in specimens/cell lines were examined using RT-qPCR. Cell models with hsa_circRNA_100269 overexpression or knockdown were generated using lentiviral vectors. Cell viability was determined by MTT assay; cell migratory/invasive activity was evaluated using wound healing/Transwell assay. Cell cycle arrest and apoptosis were assessed by flow cytometry; expression of associated markers involved in cell apoptosis, EMT and the PI3K/Akt signaling were determined by RT-qPCR/immunoblotting. In vivo study was also performed using hsa_circRNA_100269 knockout mice. Our findings revealed downregulation of hsa_circRNA_100269 in GC tissues compared to non-cancerous control. Additionally, the levels of PI3K were remarkably elevated in GC tissues, where hsa_circRNA_100269 and PI3K was negatively correlated. Moreover, the expression of hsa_circRNA_100269 was associated with histology grade and occurrence of metastasis in GC patients. In addition, hsa_circRNA_100269 was downregulated in GC cells compared to normal gastric epithelial cells. Overexpressed hsa_circRNA_100269 notably inhibited the proliferation, migration, invasion and EMT of GC cells, whereas cell cycle arrest at G0/G1 phase was promoted and cell apoptosis was enhanced. Moreover, the PI3K/Akt signaling was involved in hsa_circRNA_100269-regulated GC cell proliferation, migration, invasion, EMT and apoptosis. Knockdown of hsa_circRNA_100269 also remarkably induced tumor growth in mouse model. In summary, our findings indicated that the levels of hsa_circRNA_100269 were reduced in GC. Furthermore, hsa_circRNA_100269 could suppress the development of GC by inactivating the PI3K/Akt pathway. More importantly, hsa_circRNA_100269/PI3K/Akt axis may be a novel therapeutic candidate for GC treatment.

Systematic Endoscopic Approach to Early Gastric Cancer in Clinical Practice

Early gastric cancers (EGCs) are defined as gastric cancers confined to the mucosa or submucosa, regardless of regional lymph node metastasis. The proportion of EGCs has been increasing due to the increase in screening endoscopy for gastric cancers; therefore, the paradigm shift from surgical resection to endoscopic resection as a treatment modality for selected EGCs is accelerating. For successful endoscopic resection of EGCs, it is important to detect EGCs at an early stage and to accurately predict the histological type, depth of invasion, and horizontal margins of the tumor. The diagnostic process of EGCs can be divided into three steps: presence diagnosis, qualitative diagnosis, and quantitative diagnosis. The presence diagnosis of EGCs is mainly based on two endoscopic findings: a well-demarcated lesion and irregularity in the color/surface pattern. Qualitative diagnosis refers to the prediction of histological type, which is mainly possible based on the macroscopic shape and color of the lesion. Quantitative diagnosis of EGCs consists of predicting the depth of invasion by detailed examination of the macroscopic morphology and determining horizontal margins using chromoendoscopy. Although advanced diagnostic modalities, such as endosonography or magnifying endoscopy, are helpful for the qualitative and quantitative diagnosis of EGCs, these modalities are not available in most hospitals. Therefore, it is still very important to evaluate EGCs systematically during conventional endoscopy for successful endoscopic treatment.

NFIB promotes the progression of gastric cancer by upregulating circMAP7D1 to stabilize HER2 mRNA

The present study evaluated the expression levels of nuclear factor I B (NFIB) in gastric cancer (GC) specimens and cells, and its regulatory roles were further elucidated. The expression levels of NFIB were examined in GC and paired normal specimens, and in human GC and normal gastric epithelial cells by reverse transcription‑quantitative PCR. A circular RNA (circRNA) microarray was performed to identify the novel downstream circRNA of NFIB. Cell proliferation was determined by Cell Counting Kit‑8 assay. Furthermore, cell cycle distribution and apoptosis were assessed using flow cytometry. Interactions between RNA were examined by RNA pulldown assay and the stability of target mRNA was evaluated using a mRNA stability assay. The results of the present study revealed that NFIB was upregulated in GC. Furthermore, silencing NFIB suppressed the proliferation of GC cells, whereas cell cycle arrest and apoptosis were enhanced. In addition, significant downregulation of circMAP7D1 (hsa_circ_0004093) was observed in GC cells infected with short hairpin RNA‑NFIB. These findings indicated that circMAP7D1 may be a promising downstream molecule of NFIB in GC, and further functional analyses indicated that circMAP7D1 was involved in NFIB‑modulated GC cell proliferation and apoptosis. Moreover, human epidermal growth factor receptor 2 (HER2) was identified as a novel target of circMAP7D1 in GC, and NFIB was able to increase the stability of HER2 mRNA through regulating circMAP7D1. In conclusion, the present findings indicated that NFIB expression was increased in GC. In addition, NFIB may promote the proliferation of GC cells and function through stabilizing HER2 mRNA by upregulating circMAP7D1. Notably, NFIB and its novel downstream signaling pathway may serve essential roles during the development of GC, and NFIB may be considered a promising candidate for the treatment of patients with GC.

Combination of endoscopic submucosal dissection and laparoscopic sentinel lymph node dissection in early mucinous gastric cancer: Role of lymph node metastasis

BACKGROUND

Recent evidence showed that combining endoscopic submucosal dissection (ESD) and laparoscopic sentinel lymph node dissection may avoid unnecessary gastrectomy in treating early mucinous gastric cancer (EMGC) patients with risks of positive lymph node metastasis (pLNM).

AIM

To explore the predictive factors for pLNM in EMGC, and to optimize the clinical application of combing ESD and sentinel lymph node dissection in a proper subgroup of patients with EMGC.

METHODS

Thirty-one patients with EMGC who had undergone gastrectomy with lymph node dissection were consecutively enrolled from January 1988 to December 2016. Univariate and multivariate logistic regression analyses were used to estimate the association between the rates of pLNM and clinicopathological factors, providing odds ratio (OR) with 95% confidence interval. And the association between the number of predictors and the pLNM rate was also investigated.

RESULTS

Depth of invasion (OR = 7.342, 1.127-33.256, P = 0.039), tumor diameter (OR = 9.158, 1.348-29.133, P = 0.044), and lymphatic vessel involvement (OR = 27.749, 1.821-33.143, P = 0.019) turned out to be significant and might be the independent risk factors for predicating pLNM in the multivariate analysis. For patients with 1, 2, and 3 risk factors, the pLNM rates were 9.1%, 33.3%, and 75.0%, respectively. pLNM was not detected in seven patients without any of these risk factors.

CONCLUSION

ESD might serve as a safe and sufficient treatment for intramucosal EMGC if tumor size ≤ 2 cm, and when lymphatic vessel involvement is absent by postoperative histological examination. Combining ESD and sentinel lymph node dissection could be recommended as a safe and effective treatment for EMGC patients with a potential risk of pLNM.

A Recent Argument for the Use of Endoscopic Submucosal Dissection for Early Gastric Cancers

Endoscopic submucosal dissection (ESD) has become the standard treatment method for early gastric cancers (EGCs) due to the negligible risk for lymph node metastasis (LNM) in Eastern Asian countries. According to the guidelines, the curability of EGC after endoscopic resection was classified into three groups: curative resection, expanded curative resection, and noncurative resection. In Eastern Asian countries, a structured follow-up schedule is needed for patients undergoing curative resection and expanded curative resection. Conversely, in Western countries, additional surgery may be recommended for some patients undergoing expanded curative resection (ulcerated, undifferentiated, or slight submucosal invasion) due to the potential risk for LNM, even though specimens of ESD and surgery may not be handled with the same methodology as that used in Japan, which may lead to this slightly higher risk. In noncurative resection, additional surgery is the standard method after ESD because of the risk for LNM. However, in elderly patients and/or those with severe underlying diseases, the advantages and disadvantages of additional surgery should be considered when selecting a post-ESD treatment strategy for patients undergoing noncurative resection. Risk-scoring systems for LNM may facilitate clinical decisions for these patients. However, it should be noted that when recurrence was detected in patients who were followed up with no additional treatment after ESD with noncurative resection, most of them had a poor prognosis. To select an appropriate treatment method, especially in elderly patients undergoing ESD with noncurative resection, a new tool for evaluating the condition of patients should be established.

Increased incidence of metachronous gastric neoplasm after endoscopic resection in patients with synchronous gastric neoplasm

Background

Recurrence risk is a major concern after endoscopic resection (ER) of gastric neoplasms. This study was to compare metachronous risk in patients with and without synchronous neoplasms after complete ER.

Methods

After ER for gastric neoplasms, patients were divided into those with and without synchronous neoplasm. The metachronous risk of gastric neoplasms was compared between the two groups.

Results

After ER of 678 cancers and 891 adenomas, synchronous neoplasm was found in 11.8% of cancers and 11.4% of adenomas. In the multiple (n = 182) and the single group (n = 1387), metachronous neoplasms occurred in 18.1 and 8.6%, respectively (HR 2.40; 95% CI, 1.62–3.34). When the pathology of the recurred lesion was limited to cancer, metachronous risk was also significantly higher in the multiple than in the single group (HR, 2.2; 95% CI, 1.17–3.85). In the recurred pathology of the multiple group, cancer development was frequently observed in patients with cancer compared to those with only adenomas in the synchronous lesion (67.0% vs. 13.0%, respectively; P = 0.023).

Conclusions

This study demonstrated that metachronous risk was significantly higher in patients with synchronous gastric neoplasms after ER. Therefore, meticulous examination is important in patients with synchronous neoplasm.

An evaluation of the feasibility of an expanded indication of endoscopic submucosal dissection for ulcer positive early gastric cancer: a case-control study from two medical centers

Background

Endoscopic submucosal dissection (ESD) has increasingly gained broad application in the treatment of early gastric cancer (EGC). This study aimed at evaluating the clinical significance of lymph node metastasis (LNM) in patients with ulcer positive [UL (+)] EGC and assessing the feasibility of expanded indications of ESD for such cases.

Methods

Patients with UL (+) EGC undergoing radical surgical resection between January 2012 and December 2018 were retrospectively reviewed. Associations between clinicopathological factors and the incidence of LNM were investigated by univariate and multivariate linear regression analysis.

Results

Retrospective statistical analysis was performed on 653 EGC patients. The multivariate linear regression analysis showed that the presence of LNM was significantly associated with depth of invasion (P<0.0001) and lymphatic invasion (P<0.001). The proportion of EGC patients met absolute and expanded indication of ESD with positive LNM who were subject to the criteria of curative resection was 0.75% (4/532) and 6.67% (8/120), respectively. LNM between patients, which were subject to the absolute and expanded ESD indication, is significantly different (P=0.000274).

Conclusions

Our study revealed that 6.67% (8/120) of EGC patients who did not meet all criteria of curative resection were present with LNM. EGC patients with UL (+), differentiated adenocarcinoma, tumor invasion pathologically diagnosed as T1a, and tumor diameter ≤3 cm showed for ESD are suggested for a carefully weighed treatment.

Predictive Model of Nonneoplastic Pathology after Endoscopic Resection of Gastric Epithelial Neoplasia

Background/Aims

The rate of nonneoplastic pathology (NNP) after endoscopic resection (ER) of gastric epithelial neoplasia (GEN) has been reported to be 3%–7%. However, to date, the associations of pretreatment characteristics with NNP have not been identified. The aim of this study was to develop a predictive model for NNP after ER.

Methods

Among 817 patients who underwent ER for GEN, factors associated with NNP were identified by univariate and multivariate analyses. Weighted points considering the β coefficient were allocated to each variable that was significant in the multivariate analysis. The predictive score was calculated by the total points. The area under the receiver operating characteristic curve (AUROC) was calculated for the predictive score.

Results

The rate of NNP was 8.8%. After multivariate analysis, poor demarcation from the background, no ulceration, a flat appearance, and low-grade dysplasia were significant factors predictive of NNP. One point each was allocated for no ulcer, flat appearance, and low-grade dysplasia. Two points were allocated for poor demarcation from the background. The predictive score ranged from 0 to 5 points. Patients were categorized as being at low risk (0, 1, or 2 points) or high risk (3, 4, or 5 points) for NNP. The AUROC was 0.82 (95% confidence interval, 0.77 to 0.88; p<0.01). With a cutoff value of 2.5, the sensitivity and specificity of the score for predicting NNP were 0.72 and 0.84, respectively.

Conclusions

We developed a model to predict NNP after ER. Endoscopic re-biopsy or re-evaluation by pathologists is strongly recommended for the high-risk group.

The optimal timing of additional surgery after non-curative endoscopic resection to treat early gastric cancer: long-term follow-up study

Patients with early gastric cancer (EGC) who undergo non-curative endoscopic resection (ER) require additional surgery. The aim of the study was to validate surgical and oncological outcomes according to the timing of additional surgery after non-curative endoscopic resection. We retrospectively analyzed long-term follow-up data on the 302 patients enrolled between January 2007 and December 2014. We validated our earlier suggestion that the optimal time interval from non-curative ER to additional surgery was 29 days. All patients were divided into two groups by reference to time intervals from ER to additional surgery of ≤29days (n = 133; group A) and >29 days (n = 169; group B). The median follow-up duration was 41.98 ± 21.23 months. As in our previous study, group B exhibited better surgical outcomes. A total of 10 patients developed locoregional or distant recurrences during the follow-up period, but no significant difference was evident between the two groups. Interestingly, the survival rate was better in group B. Group B (>29 days) exhibited better surgical and oncological outcomes. Thus, additional gastrectomy after non-curative ER should be delayed for 1 month to ensure optimal surgical and oncological outcomes.

Gastric endoscopic submucosal dissection: a systematic review and meta-analysis on risk factors for poor short-term outcomes

OBJECTIVE

Endoscopic submucosal dissection (ESD) is now established as the first option to manage early gastric neoplasms, but its efficacy may vary according to diverse factors. We aimed to systematically identify risk factors for poor short-term outcomes of gastric ESD with the purpose to improve patients' selection and management.

METHODS

Three online databases (MEDLINE, ISI Web of Knowledge and Scopus) were searched (last search on June 2018) for poor outcomes of gastric ESD (deep submucosal invasion, piecemeal/incomplete resection, noncurative resection and local recurrence).

RESULTS

One hundred five studies were included referring to 52.126 ESDs. Undifferentiated histology and upper location (vs lower) were associated with submucosal invasion [odds ratio (OR) = 2.42 [95% confidence interval (CI), 1.62-3.61] and OR = 3.20 (1.04-9.86), respectively] and deep submucosal invasion [OR = 2.98 (2.02-4.39) and OR = 2.35 (1.45-3.81), respectively]. Lesion size greater than 30 mm and ulceration were associated with piecemeal resection [OR = 2.78 (1.17-6.60) and OR = 2.76 (1.23, 6.20), respectively]. Lesion size greater than 30 mm, ulceration, upper location and fibrosis were risk factors for incomplete resection [OR = 3.83 (2.68-5.49), OR = 4.06 (1.62-10.16), OR = 3.71 (2.49-5.54) and OR = 4.46 (1.66-11.96), respectively]. A noncurative resection was more often observed for lesions located in the upper third of the stomach [OR = 1.49 (1.24-1.79)], depressed morphology [OR = 1.49 (1.04-2.12)] and those outside standard criteria [OR = 3.56 (2.31-5.48)]. Older age was significantly linked with local recurrence rates [OR = 3.08 (1.13-5.02)].

CONCLUSION

Several risk factors influence poor efficacy short-term outcomes of gastric ESD that may be used to inform both patients and health providers about the expected efficacy.

Endoscopic submucosal dissection for suspected early gastric cancer: absolute versus expanded criteria in a large Western cohort (with video)

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is an effective, minimally invasive, surgery-sparing technique for the treatment of early gastric cancer (EGC). It is not well established whether EGC within the Japanese expanded criteria can be safely and effectively treated using ESD in the West. We describe the outcomes of ESD for endoscopically suspected, biopsy specimen-confirmed EGC and its adenomatous precursor lesions (pEGC) using the Vienna classification of dysplasia in a Western cohort.

METHODS

Prospective data were collected on all pEGCs undergoing ESD at a single expert endoscopy center. Outcomes were compared among pEGC, satisfying the Japanese absolute and expanded criteria, those outside criteria, and those specimens that contained low-grade dysplasia (LGD) only. Specialist GI pathologists reviewed and classified all ESD specimens. Patients were followed up at 6 and 12 months.

RESULTS

Over 71 months, 135 pEGCs in 121 patients (mean age, 72.0 years; 61.2% men) underwent ESD. Median pEGC size was 20 mm (interquartile range, 15-30), and 62 (45.9%) satisfied the expanded clinical criteria. Perforation occurred in 1.5% and postprocedural bleeding in 5.2%. Forty-two pEGCs (31.1%) contained LGD only. Rates of en bloc and R0 resection were 94.8% and 86.7%, respectively. One hundred seven pEGCs (79.2%) met the absolute or expanded criteria for endoscopic cure. Two pEGCs recurred during follow-up. Ten of 26 patients with pEGC (38.5%) outside criteria for cure underwent surgery after ESD with residual tumor detected in 3 specimens. Fifteen patients with outside criteria for pEGCs did not undergo surgery because of frailty or their expressed wish. Eleven of 15 patients have so far undergone first surveillance with 1 of 11 experiencing endoscopic and histologic recurrence.

CONCLUSIONS

ESD is a safe and effective treatment for pEGCs in a Western context. Patients who either decline or are too frail for surgery, with outside criteria resections, may benefit from ESD for local disease control. Large Western studies of ESD for pEGCs are required to define long-term patient outcomes and surveillance guidelines, particularly where pathology shows LGD or high-grade dysplasia only. (Clinical trial registration number: NCT02306707.).

Safety and effectiveness of endoscopic mucosal resection or endoscopic submucosal dissection for gastric neoplasia within 2 days' hospital stay

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have been well-established methods of treating upper gastrointestinal neoplasia. The aim of this study was to identify the safety and effectiveness of endoscopic treatment for gastric neoplasia within a 2-day hospital stay.Between 2004 and 2015, a total of 914 patients with gastric neoplasia were treated with EMR or ESD within 2 days of hospitalization. The neoplasia sites, en bloc resection rates, pathology, local residual neoplasia rates, and major complications were evaluated retrospectively.The mean age was 63.4 years old, and 636 (69.6%) patients were male. Adenoma was the most common final diagnosis (60.9%), followed by adenocarcinoma (28.9%). The first follow-up endoscopy was performed 4.9 ± 1.1 months after the procedure, and an average of 4.4 endoscopic examinations were performed for 7.16 years (range, 2.1 to 10.2 years). Additional surgery was performed in 11 (1.2%) cases based on post-procedure pathology results. On follow-up endoscopy, a mean of 5.9 months after the procedure, there were 18 residual neoplasia cases (EMR = 13, ESD = 5). Only 4 (0.4%) patients returned to the emergency unit with delayed bleeding, but all 4 cases were successfully controlled with endoscopic treatment. There were no other complications such as delayed perforation or aspiration pneumonia during the 2 days in hospital.EMR and ESD within only 2 days in hospital showed safe and effective outcomes in terms of managing early gastric neoplasia with low complication and local residual rates.

Efficacy and safety of endoscopic submucosal dissection for papillary adenocarcinoma-type early gastric cancer

Endoscopic submucosal dissection (ESD) has increasingly been used to treat early gastric cancer (EGC); however, its efficacy in treating papillary adenocarcinoma-type EGC remains unknown.We sought to identify risk factors for lymph node (LN) metastasis in papillary adenocarcinoma-type EGC and evaluate the clinical outcome after ESD.This study retrospectively reviewed the medical records of patients who were diagnosed with EGC in our hospital from January 2009 to December 2016. In total, 85 patients had papillary adenocarcinoma-type EGC, of whom 52 and 33 underwent surgical treatment and ESD, respectively. This study analyzed the LN metastasis risk factors and clinical outcomes between these 2 groups and with those of an existing ESD indication group.LN metastasis occurred in 13 (25.0%) of 52 patients who underwent surgery. Multivariate analysis indicated that lymphovascular invasion was an independent risk factor (odds ratio: 20.624; 95% confidence interval: 19.628-21.497; P = .001). Of 33 patients who underwent ESD, 21 (63.6%) had an absolute indication and 12 (36.4%) had an expanded indication. All 3 (9.1%) patients with non-curative resection underwent additional surgery. The clinical outcomes were compared to those of 926 patients who underwent ESD of non-papillary adenocarcinoma-type EGC. There were no significant differences in curative resection rate (P = .327), procedure-related complication (P = .853), local recurrence (P = 1.000), or overall survival (P = 1.000).ESD of papillary adenocarcinoma-type EGC showed an acceptable outcome in comparison to an existing ESD indication group. However, these patients exhibit a relatively higher risk of LN metastasis.

Surgical Compliance and Outcomes in Gastric Cancer: a population-based cohort study

Background: Surgical resection is one of curative treatment for gastric cancer (GC), however, a set of patients show poor surgical compliance in the USA. We aimed to identify the risk factors associated with surgical compliance and investigate the difference in survival.

Methods: GC patients diagnosed between 1973 and 2014 were identified from the Surveillance Epidemiology and End Results (SEER) databases. Based on different surgical compliance and treatment regimen, patients were classified into three subgroups: surgical compliance group, surgical noncompliance group, and non-surgical group. Multivariable Logistic regression analysis was adopted to identify the factors related to surgical compliance; Multivariable Cox regression was used to investigate the prognostic factors. Overall survival (OS) and cancer-specific survival (CSS) were analyzed using the Kaplan-Meier estimator method.

Results: Of 79374 GC patients who were recommended for surgical therapy, 15201(19.2%) cases did not perform surgery. Poor compliance of surgery was related to old age, American Indian/Alaska Native race, poor grading/late staging, single/widowed status, lower socioeconomic status and earlier time of diagnosis. As expected, GC patients of surgical compliance group showed significantly more favorable survival than the other two groups (P<0.0001); notably, the outcome of surgical noncompliance group came close to that of non-surgical group.

Conclusion: GC patients of poor surgical compliance demonstrated adverse survival, which was comparable to that of non-surgical patients. The poor surgical compliance was associated with older age, American Indian/Alaska Native race, poor tissue differentiation/advanced stage of tumor, single/widowed status, lower socioeconomic status and earlier time of diagnosis.

Short-term outcomes of multicenter prospective cohort study of gastric endoscopic resection: 'Real-world evidence' in Japan

OBJECTIVES

A Japanese multicenter prospective cohort study examining endoscopic resection (ER) for early gastric cancer (EGC) has been conducted using a Web registry developed to determine the short-term and long-term outcomes based on absolute and expanded indications. We hereby present the short-term outcomes of this study.

METHODS

All consecutive patients with EGC or suspected EGC undergoing ER at 41 participating institutions between July 2010 and June 2012 were enrolled and prospectively registered into the Web registry. The baseline characteristics were entered before ER, and the short-term outcomes were collected at 6 months following ER.

RESULTS

Nine thousand six hundred and sixteen patients with 10 821 lesions underwent ER (endoscopic submucosal dissection [ESD]: 99.4%). The median procedure time was 76 min, and R0 resections were achieved for 91.6% of the lesions. Postoperative bleeding and intraoperative perforation occurred in 4.4% and 2.3% of the patients, respectively. Significant independent factors correlated with a longer procedure time (120 min or longer) were as follows: tumor size >20 mm, upper-third location, middle-third location, local recurrent lesion, ulcer findings, gastric tube, male gender, and submucosa. Histopathologically, 10 031 lesions were identified as common-type gastric cancers. The median tumor size was 15 mm. Noncurative resections were diagnosed for 18.3% of the lesions. Additional surgery was performed for 48.6% (824 lesions) of the 1695 noncurative ER lesions with a possible risk of lymph node (LN) metastasis. Among them, 64 (7.8%) exhibited LN metastasis.

CONCLUSIONS

This multicenter prospective study showed favorable short-term outcomes for gastric ESD.

CT-quantified muscle and fat change in patients after surgery or endoscopic resection for early gastric cancer and its impact on long-term outcomes

The purpose of this study was to evaluate the impact of the body composition changes on patients' long-term outcomes after endoscopic resection or surgery for mucosal gastric cancer.This case-control study included 96 patients who underwent endoscopic resection or surgery after propensity score matching. Areas of fat and muscle measured on CT were compared between the 2 groups. The effects of the variables on disease-free and overall survival were assessed using Cox-regression analysis and Kaplan-Meier survival analysis.The median overall survival of the surgical and endoscopic resection groups was 91.1 and 93.9 months (P = .080). Fat area was decreased significantly more after surgery (P < .001). The number of patients with sarcopenia was increased in the surgery group. Kaplan-Meier plot showed that overall survival was significantly correlated with post-treatment sarcopenia (P = .049).CT-based body composition analysis was helpful to evaluate the change in fat and muscle areas after treatment of early gastric cancer. The losses of fat and muscle after treatment were negatively associated with the patient overall survival.

Long-Term Clinical Outcomes of Endoscopic Submucosal Dissection in Patients with Early Gastric Cancer: A Prospective Multicenter Cohort Study

Background/Aims

Endoscopic submucosal dissection (ESD) has been regarded as a curative treatment for early gastric cancer (EGC) in indicated cases. The aim of this study was to evaluate the nationwide long-term clinical outcomes of ESD for EGC in Korea.

Methods

A prospective multicenter cohort study was performed to evaluate the long-term efficacy of ESD for EGC within pre-defined indications at 12 institutes in Korea. The cases that met the expanded criteria upon pathological review after ESD were followed for 5 years. The primary outcome was 5-year disease specific free survival.

Results

Six hundred ninety-seven patients with 722 EGCs treated with ESD were prospectively enrolled and followed for 5 years. Complete resection was achieved in 81.3% of the cases, and curative resection was achieved in 86.1%. During the 5-year follow-up, the overall survival rate was 96.6%, and the disease specific free survival rate was 90.6%. Local recurrence developed in 0.9%, and metachronous tumor development occurred in 7.8%; both conditions were treated by endoscopic or surgical treatment. Distant metastasis developed in 0.5% during follow-up.

Conclusions

ESD showed excellent long-term clinical outcomes and can be accepted as a curative treatment for patients with EGC who meet the expanded criteria in final pathology studies.

Outcomes of Endoscopic Submucosal Dissection for Early Gastric Cancer with Undifferentiated-Type Histology: A Clinical Simulation Using a Non-Selected Surgical Cohort

Background/Aims

Outcomes of endoscopic submucosal dissection (ESD) for undifferentiated-type early gastric cancer (EGC) need to be further evaluated. We aimed to simulate the outcomes of ESD for undifferentiated-type EGC from a surgical database.

Methods

Among 802 patients who underwent gastrectomy with endoscopic biopsy for poorly differentiated adenocarcinoma (PD-type) or signet ring cell carcinoma (SRC-type), ESD candidates meeting the expanded indication (n=280) were selected by reviewing the endoscopic images. According to the surgical pathologic results, the outcomes of the ESD simulation were evaluated.

Results

Among the candidates, 104 (37.1%) were PD-type and 176 (62.9%) were SRC-type. The curative resection (CR) rate was 42.1%. Among the patients with CR, three patients (2.5%) showed lymph node metastasis (LNM). Three EGCs with CR and LNM were mucosal cancers ≥1.0 cm in size. The CR rate was higher in the SRC-type than in the PD-type (48.3% vs 31.7%, respectively, p=0.007). In the SRC-type, the CR rate was increased, with a smaller size criterion for the ESD indication, but was similar between the 1.0 cm and 0.6 cm criteria (63.3% and 63.6%, respectively), whereas the CR rate was below 50% in all of the different tumor size criteria (2.0 to 0.6 cm) in the PD-type.

Conclusions

In undifferentiated-type EGC, ESD should be considered in selected patients with tumor sizes ＜1 cm and SRC histology.

Predictive factors for lymph node metastasis and defining a subgroup treatable for laparoscopic lymph node dissection after endoscopic submucosal dissection in poorly differentiated early gastric cancer

AIM

To investigate the predictive factors of lymph node metastasis (LNM) in poorly differentiated early gastric cancer (EGC); to guide the individual application of a combination of endoscopic submucosal dissection (ESD) and laparoscopic lymph node dissection (LLND) in a suitable subgroup of patients with poorly differentiated EGC.

METHODS

We retrospectively analyzed 138 patients with poorly differentiated EGC who underwent gastrectomy with lymphadenectomy between January 1990 and December 2015. The association between the clinicopathological factors and the presence of LNM was retrospectively analyzed by univariate and multivariate logistic regression analyses. Odds ratios (OR) with 95% confidence interval (95%CI) were calculated. We further examined the relationship between the positive number of the significant predictive factors and the LNM rate.

RESULTS

The tumor diameter (OR = 13.438, 95%CI: 1.773-25.673, P = 0.029), lymphatic vessel involvement (LVI) (OR = 38.521, 95%CI: 1.975-68.212, P = 0.015) and depth of invasion (OR = 14.981, 95%CI: 1.617-52.844, P = 0.024) were found to be independent risk factors for LNM by multivariate analysis. For the 138 patients diagnosed with poorly differentiated EGC, 21 (15.2%) had LNM. For patients with one, two and three of the risk factors, the LNM rates were 7.7%, 47.6% and 64.3%, respectively. LNM was not found in 77 patients that did not have one or more of the three risk factors.

CONCLUSION

ESD might be sufficient treatment for intramucosal poorly differentiated EGC if the tumor is less than or equal to 2 cm in size and when LVI is absent upon postoperative histological examination. ESD with LLND may lead to the elimination of unnecessary gastrectomy in poorly differentiated EGC.

Long-Term Outcomes of Using Endoscopic Submucosal Dissection to Treat Early Gastric Cancer

Endoscopic submucosal dissection (ESD) is becoming the main procedure for the resection of early gastric cancer (EGC). The absolute indications for treating EGC with endoscopic resection were established by the Japanese Gastric Cancer Association and have been generally accepted. However, the absolute indications for treating EGC are rather strict, and expanded indications have been developed. Many studies have reported favorable long-term outcomes for patients who received curative resection for the expanded indication. ESD preserves the stomach, thereby improving patients’ quality of life compared to surgery; however, a generally higher incidence of metachronous gastric cancer has been reported after ESD for EGC. Therefore, clinicians must pay careful attention during surveillance endoscopy, even after a curative ESD.

A Risk-Scoring Model for Predicting Lymph Node Metastasis in Early Gastric Cancer Patients: a Retrospective Study and External Validation

BACKGROUND

The possibility of lymph node metastasis (LNM) is critical to the assessment of the indication for endoscopic submucosal dissection. Thus, the aim of this study is to identify the risk factors for LNM and construct a risk-scoring model for patients with early gastric cancer to guide treatment.

METHODS

A retrospective examination of reports and studies carried out January 2000 and December 2014 was conducted. A risk-scoring model for predicting LNM was developed based on the data thus collected. In addition, the model is subject to verification and validation by three institutions.

RESULTS

Of the 1029 patients, 228 patients (22%) had LNM. Multivariate analysis showed that female, depressed type, undifferentiated type, submucosa, tumor size, and lymphovascular invasion were significantly associated with LNM. An 11-point risk-scoring model was used to predict LNM risk. An area under the receiver operating characteristic (AUROC) of the risk-scoring model was plotted using the development set and the AUROC of the model [0.76 (95% CI 0.73-0.80)] to predict LNM risk. After internal and external validation, the AUROC curve for predicting LNM was 0.77 (95% CI 0.68-0.86), 0.82 (95% CI 0.72-0.91), and 0.82 (95% CI 0.70-0.94), respectively.

CONCLUSIONS

A risk-scoring model for predicting LNM was developed and validated. It could help with personalized care for patients with EGC.

Application of artificial intelligence using a convolutional neural network for detecting gastric cancer in endoscopic images

BACKGROUND

Image recognition using artificial intelligence with deep learning through convolutional neural networks (CNNs) has dramatically improved and been increasingly applied to medical fields for diagnostic imaging. We developed a CNN that can automatically detect gastric cancer in endoscopic images.

METHODS

A CNN-based diagnostic system was constructed based on Single Shot MultiBox Detector architecture and trained using 13,584 endoscopic images of gastric cancer. To evaluate the diagnostic accuracy, an independent test set of 2296 stomach images collected from 69 consecutive patients with 77 gastric cancer lesions was applied to the constructed CNN.

RESULTS

The CNN required 47 s to analyze 2296 test images. The CNN correctly diagnosed 71 of 77 gastric cancer lesions with an overall sensitivity of 92.2%, and 161 non-cancerous lesions were detected as gastric cancer, resulting in a positive predictive value of 30.6%. Seventy of the 71 lesions (98.6%) with a diameter of 6 mm or more as well as all invasive cancers were correctly detected. All missed lesions were superficially depressed and differentiated-type intramucosal cancers that were difficult to distinguish from gastritis even for experienced endoscopists. Nearly half of the false-positive lesions were gastritis with changes in color tone or an irregular mucosal surface.

CONCLUSION

The constructed CNN system for detecting gastric cancer could process numerous stored endoscopic images in a very short time with a clinically relevant diagnostic ability. It may be well applicable to daily clinical practice to reduce the burden of endoscopists.

Comparing outcomes for endoscopic submucosal dissection between Eastern and Western countries: A systematic review and meta-analysis

AIM

To compare endoscopic submucosal dissection (ESD) outcomes between Eastern and Western countries.

METHODS

A systematic review and meta-analysis was performed using PubMed, MEDLINE, Web of Science, CINAHL and EBM reviews to identify studies published between 1990 and February 2016. The primary outcome was the efficacy of ESD based on information about either curative resection, en bloc or R0 resection rates. Secondary outcomes were complication rates, local recurrence rates and procedure times.

RESULTS

Overall, 238 publications including 84318 patients and 89512 gastrointestinal lesions resected using ESD were identified. 90% of the identified studies reporting ESD on 87296 lesions were conducted in Eastern countries and 10% of the identified studies reporting ESD outcomes in 2216 lesions were from Western countries. Meta-analyses showed higher pooled percentage of curative, en bloc, and R0 resection in the Eastern studies; 82% (CI: 81%-84%), 95% (CI: 94%-96%) and 89% (CI: 88%-91%) compared to Western studies; 71% (CI: 61%-81%), 85% (CI: 81%-89%) and 74% (CI: 67%-81%) respectively. The percentage of perforation requiring surgery was significantly greater in the Western countries (0.53%; CI: 0.10-1.16) compared to Eastern countries (0.01%; CI: 0%-0.05%). ESD procedure times were longer in Western countries (110 min vs 77 min).

CONCLUSION

Eastern countries show better ESD outcomes compared to Western countries. Availability of local ESD expertise and regional outcomes should be considered for decision making to treat gastrointestinal lesions with ESD.

Endoscopic submucosal dissection in the West: Current status and future directions

Endoscopic submucosal dissection (ESD) was first conceptually described almost 30 years ago in Japan and is now widely practiced throughout East Asia. ESD expands the boundaries of endoscopic resection (ER) by allowing en bloc resection of large early neoplastic lesions within the gastrointestinal tract (GIT). This offers advantages over other ER techniques by facilitating definitive histological staging and curative treatment of early cancer in selected cases. Indeed, the experience of ESD in Eastern countries is significant, and excellent outcomes from high-volume centers are reported. The potential benefits of ESD are recognized by Western endoscopists, but its adoption has been limited. A number of factors contribute to this, including epidemiological differences in GIT neoplasia between Western and Eastern populations and limitations in training opportunities. In this review, we discuss the role of ESD, its current status and the future in Western endoscopic practice.

Long-term outcome of endoscopic submucosal dissection is comparable to that of surgery for early gastric cancer: a propensity-matched analysis

BACKGROUND

Data concerning the long-term outcomes of endoscopic submucosal dissection (ESD) versus surgery for early gastric cancer (EGC) are limited. We aimed to compare the long-term outcomes of ESD and surgery for patients with EGC.

METHODS

Data were reviewed from patients treated by ESD or surgery for EGC in 2005-2010. The primary outcome was overall survival (OS). Secondary outcomes were disease-specific survival (DSS), disease-free survival (DFS), recurrence-free survival (RFS), treatment-related complications, and hospital stay duration.

RESULTS

Among 617 patients, 342 underwent ESD and 275 underwent surgery. The 5-year OS rates were similar between the ESD group and the surgery group (96.9% vs 98.1%, P = 0.581). In a propensity-score-matched analysis of 117 pairs, there were no significant differences in the OS rates (96.5% vs 99.1%, P = 0.125) and DSS rates (100% vs 99.1%, P = 0.317) between the ESD group and the surgery group. The ESD group had a significantly lower DFS rate (90.3% vs 98.0%, P = 0.002), a significantly lower RFS rate (95.1% vs 98.0%, P = 0.033), a significantly higher early complication rate (6.7% vs 1.5%, P < 0.001), a significantly lower late complication rate (0% vs 9.1%, P < 0.001), and a significantly shorter median hospital stay (3 days vs 10 days, P < 0.001) than the surgery group.

CONCLUSIONS

ESD and surgery have comparable OS rates in patients with EGC. ESD has benefits, including a lower late complication rate and shorter hospital stay. However, RFS and DFS rates might be lower after ESD than after surgery.

Preoperative predictors of beyond endoscopic submucosal dissection indication or lymphovascular invasion in endoscopic resection for early gastric cancer

BACKGROUND

To successfully resect early gastric cancer (EGC), prediction of lymph node metastasis is essential. Beyond endoscopic submucosal dissection (ESD) indication or lymphovascular invasion (LVI) are known risk factors associated with lymph node metastasis. However, accurate prediction of tumor invasion depth or LVI is impossible before endoscopic resection even when endoscopic ultrasound is used. The aim of this study was to identify the predictive factors associated with beyond ESD indication or LVI after ESD for EGC.

METHODS

Between Jan 2011 and Feb 2015, 532 lesions from 506 patients who received ESD for EGCs were included. We reviewed the data of patients diagnosed as EGCs without ulceration or those smaller than 3 cm with ulceration.

RESULTS

The incidence of EGCs found to be beyond expanded ESD indications or present of LVI after ESD was 11.1% (59/532). On multivariable analysis, endoscopic features of SM invasion, surface color changes, and elevated lesions were associated with beyond ESD indication or LVI. In particular, submucosal (SM) invasive features such as SM tumor-like marginal elevation [odds ratio (OR) 17.2; 95% confidence interval (CI) 2.0-146.7], fusion of convergent folds (OR 12.9; 95% CI 3.9-42.1), irregular surface (OR 17.8; 95% CI 5.6-56.8), and discoloration of the tumor surface (OR 16.1; 95% CI 2.4-105.9) were significant risk factors for beyond ESD indication or LVI.

CONCLUSIONS

The decision to proceed with endoscopic resection for EGCs with endoscopic features of SM invasion, surface color changes, or elevated forms must be made cautiously.

Endoscopic submucosal dissection for papillary adenocarcinoma of the stomach: is it really safe?

BACKGROUND

Papillary adenocarcinoma of the stomach has been treated according to the same endoscopic submucosal dissection (ESD) indication criteria as other differentiated-type adenocarcinomas. We aimed to compare lymph node metastasis (LNM) in patients with early gastric cancer (EGC) with papillary adenocarcinoma (EGC-P) with that in patients with EGC with nonpapillary adenocarcinoma (EGC-NP) and to consider the potential limitation of current ESD indication criteria in the treatment of EGC-P.

METHODS

In total, 1583 patients who underwent gastrectomy for EGC from 2005 to 2014 were included. Clinicopathologic characteristics of 56 patients with EGC-P were compared with those of 1527 patients with EGC-NP. The safety of ESD was evaluated, by application of current ESD indication criteria to EGC-P.

RESULTS

The frequency of submucosal invasion was significantly higher in EGC-P than in both EGC-NP with differentiated-type histologic appearance and EGC-NP with undifferentiated-type histologic appearance (71.4% vs 50.8% and 37.6%, respectively). In addition, the frequency of LNM in EGC-P was 17.9%, higher than that in both EGC-NP with differentiated-type histologic appearance and EGC-NP with undifferentiated-type histologic appearance (9.7% and 11.1%, respectively). When the current ESD indication criteria were applied to the 56 patients with EGC-P, 17 patients met the current indications. Of these patients, two (11.8%) had LNM and three (17.6%) had lymphovascular invasion (LVI). When LNM and LVI were combined, one of seven patients (16.7%) meeting the absolute ESD indications and three of ten patients (30.0%) meeting the expanded ESD indications would not be cured after ESD.

CONCLUSIONS

The use of ESD should be more carefully applied in patients with EGC-P meeting the ESD indication criteria, especially the expanded indication criteria, after pretreatment workup compared with other differentiated-type adenocarcinomas, owing to the higher frequencies of submucosal invasion, LNM, and LVI in EGC-P.

Endoscopic submucosal dissection for undifferentiated-type early gastric cancer: short- and long-term outcomes

BACKGROUND AND AIMS

Application of endoscopic submucosal dissection (ESD) for undifferentiated-type early gastric cancers (EGCs) remains controversial owing to limited data regarding long-term outcomes. We aimed to evaluate the feasibility of ESD for undifferentiated-type EGCs that meet the expanded criteria (EC).

METHODS

We performed a retrospective analysis of 66 patients who underwent ESD for undifferentiated-type EGC between January 2005 and December 2014. We evaluated the rates of en bloc, complete, and curative resections along with overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS).

RESULTS

Of the 66 patients, the EC group included 38 patients and the beyond-EC group included 28 patients. The overall rates of en bloc, complete, and curative resection of the 66 lesions were 92.4% (61/66), 65.2% (43/66), and 48.5% (32/66), respectively. Of the 34 patients with non-curative resection, 18 underwent additional surgery. Local remnant cancer was detected in 1 patient (1/18, 5.6%), and none of the 18 patients had lymph node metastasis. On multivariate analysis, tumors > 2 cm [odd ratio (OR) 6.183, 95% confidence interval (CI) 1.279-29.880, p = 0.023) and submucosal invasion depth (OR 6.226, 95% CI 1.881-20.606, p = 0.003) were independent predictors of incomplete resection. All 26 patients with more than 1 year of follow-up after curative resection survived without any evidence of local or distant recurrences over a median follow-up period of 36 months. The OS, DSS, and RFS rates of patients with curative ESD were 93.8, 100, and 100%, respectively.

CONCLUSIONS

ESD may have favorable long-term outcomes in patients with undifferentiated-type EGC after curative resection.

Risk factors for early metachronous tumor development after endoscopic resection for early gastric cancer

BACKGROUND

Metachronous gastric tumor (MGT) is one of major concerns after endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). Optimal follow-up strategy has not been yet well-established. The aim of this study was to identify the different clinical features of the patients according to the time interval to development of MGT.

METHODS

Among 1,780 consecutive patients with EGC who underwent ESD between 2005 and 2014, 115 patients with MGT were retrospectively reviewed. MGT was defined as secondary gastric cancer or dysplasia detected > 1 year after initial ESD. Clinicopathological factors associated with early development of MGT were evaluated.

RESULTS

The median interval to development of MGT was 37 months. In univariate analysis, the median interval to MGT was shorter if EGC lesion was non-elevated type (39.4 vs 57.0 months, p = 0.011), or synchronous primary lesion was absent (39.8 vs 51.4 months, p = 0.050). In multivariate Cox's proportional hazards analysis, the hazard ratios for early occurrence of MGT were 1.966 (95% CI: 1.141-3.386, p = 0.015) and 1.911 (95% CI: 1.163-3.141, p = 0.011), respectively. There was no significant difference in overall survival after diagnosis of MGT between the early occurrence group and the late occurrence group.

CONCLUSIONS

Non-elevated gross type and absence of synchronous gastric tumor were independent risk factors for early development of MGT. Meticulous endoscopic inspection is especially important for the detection of MGT during the early follow-up period in patients with these initial tumor characteristics.

Factors associated with the efficacy of miniprobe endoscopic ultrasonography after conventional endoscopy for the prediction of invasion depth of early gastric cancer

BACKGROUND

This study aimed to compare the accuracy of conventional endoscopy (CE) and endoscopic ultrasonography (EUS) to predict tumor invasion depth and to determine factors associated with higher accuracy of additional miniprobe EUS after CE.

METHODS

Between May 2009 and February 2015, 273 lesions in 266 patients were subjected to miniprobe EUS after CE and curative treatment for well-to-moderately differentiated early gastric cancer (EGC). We reviewed preoperative CE and EUS findings and compared them to the pathologic findings.

RESULTS

The accuracy of CE and EUS to estimate the invasion depth of EGCs was 78.8% (215/273) and 83.9% (229/273) (p = .124), respectively. Using multivariate analysis, irregular depressed surface (odds ratio [OR] 8.11; 95% confidence interval [CI]: 2.79-23.53), fold change (OR 7.22; 95% CI: 2.33-22.38), size >2 cm (OR 2.72; 95% CI: 1.15-6.42) and ulcer scar (OR 2.64; 95% CI: 1.07-6.49) were associated with the higher accuracy of EUS than that of CE.

CONCLUSIONS

Routine assessment using miniprobe EUS did not increase the accuracy of predicting invasion depth, compared to CE. However, EUS could be helpful in the treatment decision-making process for EGCs with lesions having irregular surfaces, fold change, size >2 cm, or ulcer scar.

Short-Term Outcomes of Endoscopic Submucosal Dissection in Patients with Early Gastric Cancer: A Prospective Multicenter Cohort Study

BACKGROUND/AIMS

Endoscopic submucosal dissection (ESD) is an effective treatment for early gastric cancer (EGC) that has demonstrated a minimal risk of lymph node metastasis in retrospective studies. We sought to prospectively evaluate the short-term outcomes of ESD treatment in EGCs.

METHODS

A prospective multicenter cohort study of neoplasms 3 cm or less in diameter at endoscopic size evaluation was performed in 12 Korean ESD study grouprelated university hospitals and the National Cancer Center. Resected specimens were evaluated by the central pathologic review board.

RESULTS

A patient cohort (n=712) with a total of 737 EGCs was analyzed. The margin-free en bloc resection rate was 97.3%, and curative resection of 640 lesions (86.8%) was achieved. Lower curative resection rates were associated with lesions 2 to 3 cm in size prior to ESD compared with lesions 2 cm or less in size (78.6% vs 88.1%, respectively, p=0.009). Significant factors associated with noncurative resection were moderately or poorly differentiated histological type, posterior wall tumor location, tumor size larger than 3 cm, ulceration, and submucosal invasion. Delayed bleeding occurred in 49 patients (6.9%), and 12 patients (1.7%) exhibited perforations.

CONCLUSIONS

ESD is an effective treatment with a high curative resection rate for EGCs that meets relatively conservative pre-ESD indications. Long-term survival outcomes should be evaluated in followup studies.