Risk stratification and management of non-curative resection after endoscopic submucosal dissection for early gastric cancer

Risk factors and a nomogram for predicting local recurrence in adult patients with early gastric cancer after endoscopic submucosal dissection

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is an effective treatment method for early gastric cancers. The aim of this study was to evaluate the risk factors of recurrence for patients with early gastric cancer after ESD and construct a nomogram for predicting recurrence.

METHODS

A retrospective observational study was conducted on patients with early gastric cancer who underwent ESD at Beijing Friendship Hospital between 2013 and 2018. The risk factors of gastric cancer recurrence after ESD were analyzed by univariate and multivariate Cox regression.

RESULTS

A total of 238 patients with a median follow-up period of 70.5-month were enrolled in the study. Risk factors for recurrence included diabetes (HR = 3.68), alcohol consumption history (HR = 5.73), complications (HR = 5.22), lymphatic invasion (HR = 13.09) and multiple lesions (HR = 4.34). The analysis of the receiver operating characteristic curve, calibration curve, and model consistency index demonstrates that the graphical representation exhibits a good predictive capability.

CONCLUSIONS

Based on identified risk factors, this study developed the first nomogram with high accuracy to predict the recurrence of early gastric cancer after ESD. This model offers valuable guidance to clinicians for identifying high-risk patient groups and planning more intensive follow-up strategies.

Therapeutic approach to non-curative resection after endoscopic treatment in early gastric cancer

Background: Endoscopic resection is indicated for early or superficial gastrointestinal neoplasms with a negligible risk of lymph node metastasis. This procedure could preserve the organ while allowing en bloc resection of tumors, irrespective of the size and location of the lesion. Histological evaluation of the resected specimen determines whether curative resection, which implies a favorable long-term outcome, was achieved. If the resected specimen reveals non-curative, additional treatment is necessary as it is strongly associated with recurrence.Current Concepts: Surgical resection is recommended after non-curative resection of gastrointestinal neoplasms. However, rather than surgical resection, additional endoscopic treatment can be recommended if non-curative resection is solely because of the positive involvement at the horizontal resection margin without any other findings compatible with the non-curative resection criteria.Discussion and Conclusion: Adopting precise indications of endoscopic resection is important to reduce the risk of non-curative resection. If curative resection is not achieved after endoscopic resection, additional treatment should be considered to prevent local recurrence as well as lymph node metastasis.

Very low rate of residual neoplasia after non-curative endoscopic submucosal dissection: a western single-center experience

BACKGROUND

Short and long outcomes of endoscopic submucosal dissection (ESD) are now well described. However, the outcome of non-curative ESDs is scarcely reported.

OBJECTIVE

To describe our experience with non-curative ESDs, assessing the presence of residual lesion in the endoscopic follow-up or surgery.

METHODS

Data of all the patients submitted to ESD between January 2015 and June 2020 in our tertiary Center was prospectively recorded. Among non-curative ESDs, the presence of residual neoplasia after complementary surgical treatment or in the endoscopic follow-up was assessed.

RESULTS

In that period, a total of 388 ESDs were performed in the esophagus (n = 13), stomach (n = 222), colon (n = 20), rectum (n = 132), and duodenum (n = 1). Median follow-up was 30 months (range 4-69 months). ESD was technically successful in 376 lesions (97%). From 325 neoplastic epithelial lesions and 18 neoplastic submucosal tumors, 61 (17.8%) did not fulfill curative criteria entirely. Positive horizontal margins (n = 28), positive vertical margins (n = 10) and submucosal invasion >SM1 (n = 14) were the main causes of non-curative ESD. Among patients with non-curative ESDs, 20 were operated and 33 were already followed-up by endoscopy, and only seven (13%, corresponding to 2% of the total number of successful neoplastic ESDs) had residual neoplasia.

CONCLUSION

Our real-life experience showed that the vast majority of non-curative ESD did not actually have residual neoplasia in the follow-up.

Endoscopic Resection of Gastric Cancer

With improvements in the early detection of early gastric cancer (EGC) and advances in therapeutic techniques, endoscopic resection (ER) for EGC has become widely adopted in East Asian and Western countries. Endoscopic submucosal dissection has higher rates of en bloc, complete, and curative resections with lower rates of local recurrence than that of endoscopic mucosal resection. ER is a minimally invasive method with low morbidity that provides excellent outcomes. ER for EGC is a safe, effective method, preserving organ function and thus maintaining the patient's quality of life, and is recognized as the first-line treatment of EGC in selected patients.

[Clinical Practice Guideline for Endoscopic Resection of Early Gastrointestinal Cancer]

Although surgery was the standard treatment for early gastrointestinal cancers, endoscopic resection is now a standard treatment for early gastrointestinal cancers without regional lymph node metastasis. High-definition white light endoscopy, chromoendoscopy, and image-enhanced endoscopy such as narrow band imaging are performed to assess the edge and depth of early gastrointestinal cancers for delineation of resection boundaries and prediction of the possibility of lymph node metastasis before the decision of endoscopic resection. Endoscopic mucosal resection and/or endoscopic submucosal dissection can be performed to remove early gastrointestinal cancers completely by en bloc fashion. Histopathological evaluation should be carefully made to investigate the presence of risk factors for lymph node metastasis such as depth of cancer invasion and lymphovascular invasion. Additional treatment such as radical surgery with regional lymphadenectomy should be considered if the endoscopically resected specimen shows risk factors for lymph node metastasis. This is the first Korean clinical practice guideline for endoscopic resection of early gastrointestinal cancer. This guideline was developed by using mainly de novo methods and encompasses endoscopic management of superficial esophageal squamous cell carcinoma, early gastric cancer, and early colorectal cancer. This guideline will be revised as new data on early gastrointestinal cancer are collected.

Clinical practice guideline for endoscopic resection of early gastrointestinal cancer

Although surgery was the standard treatment for early gastrointestinal cancers, endoscopic resection is now a standard treatment for early gastrointestinal cancers without regional lymph node metastasis. High-definition white light endoscopy, chromoendoscopy, and image-enhanced endoscopy such as narrow band imaging are performed to assess the edge and depth of early gastrointestinal cancers for delineation of resection boundaries and prediction of the possibility of lymph node metastasis before the decision of endoscopic resection. Endoscopic mucosal resection and/or endoscopic submucosal dissection can be performed to remove early gastrointestinal cancers completely by en bloc fashion. Histopathological evaluation should be carefully made to investigate the presence of risk factors for lymph node metastasis such as depth of cancer invasion and lymphovascular invasion. Additional treatment such as radical surgery with regional lymphadenectomy should be considered if the endoscopically resected specimen shows risk factors for lymph node metastasis. This is the first Korean clinical practice guideline for endoscopic resection of early gastrointestinal cancer. This guideline was developed by using mainly de novo methods and encompasses endoscopic management of superficial esophageal squamous cell carcinoma, early gastric cancer, and early colorectal cancer. This guideline will be revised as new data on early gastrointestinal cancer are collected.

Prevalence and risk factors for lymph node metastasis after noncurative endoscopic resection for early gastric cancer: a systematic review and meta-analysis

BACKGROUND

Additional surgery for all patients with noncurative resection after endoscopic resection (ER) for early gastric cancer (EGC) may be excessive due to the relatively low rate of lymph node metastasis (LNM) in such patients. However, the prevalence and risk factors for LNM after noncurative ER have not been consistent across studies.

METHODS

We performed a systematic review of electronic databases through August 10, 2018 to identify cohort studies with patients who underwent additional surgery after noncurative ER for EGC. The prevalence of LNM in such patients was extracted for all studies. Odds ratios (ORs) were combined using random-effects meta-analyses to assess the risk of LNM, when possible.

RESULTS

We identified 24 studies comprising 3877 patients with 311 having LNM (pooled prevalence, 8.1%). The risk of LNM was significantly increased in lymphatic invasion (OR [95% confidence interval] = 4.22 [2.88-6.19]), lymphovascular invasion (LVI) (4.17 [2.90-5.99]), vascular invasion (2.38 [1.65-3.44]), positive vertical margin (2.16 [1.59-2.93]), submucosal invasion depth of ≥ 500 μm (2.14 [1.48-3.09]), and tumor size > 30 mm (1.77 [1.31-2.40]). In contrast, there was no significant association between undifferentiated-type or ulceration (scar) and LNM. When studies were restricted to those that evaluated the adjusted OR, the risk of vascular invasion for LNM did not reach statistical significance.

CONCLUSIONS

Several pathological factors, most notably lymphatic invasion and LVI, were associated with LNM in patients with noncurative resection after ER for EGC. Lymphatic and vascular invasion should be assessed separately instead of LVI (PROSPERO CRD42018109996).

High-Risk Comorbidity Influences Prognosis in Early Gastric Cancer after Noncurative Endoscopic Submucosal Dissection: A Retrospective Study

BACKGROUND

There are few studies reporting the clinical outcomes of noncurative endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) from the perspective of patient health condition/status. Thus, the aim of this study was to investigate clinical outcomes of noncurative ESD considering not only curability but also patient factors such as advanced age, comorbidities, and nutritional status.

METHODS

Between April 2007 and March 2012, 95 patients who underwent noncurative ESD for EGC were enrolled in the study. Patients were categorized by treatment after ESD: additional gastrectomy (49 patients) and follow-up (46 patients). Clinical outcomes were evaluated between the 2 groups for overall survival (OS).

RESULTS

The absence of lymphovascular involvement and age ≥80 years were significantly associated with decision-making for observation after noncurative ESD. The OS rates were higher in female patients, patients with better Eastern Cooperative Oncology Group performance status (≤1) or low-risk comorbidity (Charlson Comorbidity Index [CCI ≤ 2]), patients with ulcerative findings, and those who underwent radical gastrectomy. Multivariate Cox proportional hazards analysis indicated that presence of a high-risk comorbidity (CCI ≥ 3) was a significant prognostic factor (hazard ratio: 16.43, p = 0.024) in patients who underwent noncurative ESD for EGC.

CONCLUSION

High-risk comorbidity is the primary prognostic parameter in terms of patient factors after noncurative ESD for EGC. The CCI should be considered as a prognostic factor in patients who underwent noncurative ESD for EGC.

Clinical Practice Guideline for Endoscopic Resection of Early Gastrointestinal Cancer

Although surgery was the standard treatment for early gastrointestinal cancers, endoscopic resection is now a standard treatment for early gastrointestinal cancers without regional lymph node metastasis. High-definition white light endoscopy, chromoendoscopy, and image-enhanced endoscopy such as narrow band imaging are performed to assess the edge and depth of early gastrointestinal cancers for delineation of resection boundaries and prediction of the possibility of lymph node metastasis before the decision of endoscopic resection. Endoscopic mucosal resection and/or endoscopic submucosal dissection can be performed to remove early gastrointestinal cancers completely by en bloc fashion. Histopathological evaluation should be carefully made to investigate the presence of risk factors for lymph node metastasis such as depth of cancer invasion and lymphovascular invasion. Additional treatment such as radical surgery with regional lymphadenectomy should be considered if the endoscopically resected specimen shows risk factors for lymph node metastasis. This is the first Korean clinical practice guideline for endoscopic resection of early gastrointestinal cancer. This guideline was developed by using mainly de novo methods and encompasses endoscopic management of superficial esophageal squamous cell carcinoma, early gastric cancer, and early colorectal cancer. This guideline will be revised as new data on early gastrointestinal cancer are collected.

Clinical Practice Guideline for Endoscopic Resection of Early Gastrointestinal Cancer

Although surgery was the standard treatment for early gastrointestinal cancers, endoscopic resection is now a standard treatment for early gastrointestinal cancers without regional lymph node metastasis. High-definition white light endoscopy, chromoendoscopy, and image-enhanced endoscopy such as narrow band imaging are performed to assess the edge and depth of early gastrointestinal cancers for delineation of resection boundaries and prediction of the possibility of lymph node metastasis before the decision of endoscopic resection. Endoscopic mucosal resection and/or endoscopic submucosal dissection can be performed to remove early gastrointestinal cancers completely by <i>en bloc</i> fashion. Histopathological evaluation should be carefully made to investigate the presence of risk factors for lymph node metastasis such as depth of cancer invasion and lymphovascular invasion. Additional treatment such as radical surgery with regional lymphadenectomy should be considered if the endoscopically resected specimen shows risk factors for lymph node metastasis. This is the first Korean clinical practice guideline for endoscopic resection of early gastrointestinal cancer. This guideline was developed by using mainly de novo methods and encompasses endoscopic management of superficial esophageal squamous cell carcinoma, early gastric cancer, and early colorectal cancer. This guideline will be revised as new data on early gastrointestinal cancer are collected.

Risk Factors and Clinical Outcomes of Non-Curative Resection in Patients with Early Gastric Cancer Treated with Endoscopic Submucosal Dissection: A Retrospective Multicenter Study in Korea

BACKGROUND/AIMS

The purpose of this study was to investigate the risk factors and long-term clinical outcomes of non-curative resection (NCR) in a large-scale patient population.

METHODS

We retrospectively analyzed the clinical data of 3,094 patients who underwent endoscopic submucosal dissection (ESD) of early gastric cancer from March 2005 to March 2018 at 13 institutions in Korea. We analyzed the risk factors for NCR and the survival between patients with curative resection and those with NCR with no additional treatment.

RESULTS

The NCR rate was 21.4% (661/3,094). In multivariate regression analysis, the risk factors affecting NCR with ESD were old age, undifferentiated tumor, tumor location in the upper body, tumor size ≥2 cm, and presence of an ulcer. In Cox proportional hazard regression analysis, tumor size ≥2 cm, submucosal invasion, positive horizontal margin, and lymphovascular invasion were risk factors for local recurrence. In Kaplan-Meier analysis, there was no statistically significant difference in the overall survival between the two groups (log-rank p=0.788). However, disease-specific survival was significantly lower in the NCR group (log-rank p=0.038).

CONCLUSION

Clinicians should be aware of the risk factors for NCR and local recurrence after ESD for early gastric cancer, and should consider providing additional treatment after NCR.

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.

Risk Factors Associated with Lymph Node Metastasis for Early Gastric Cancer Patients Who Underwent Non-curative Endoscopic Resection: a Systematic Review and Meta-analysis

BACKGROUND

Recently, increased evidence indicated that additional surgery should be performed in highly selected patients with non-curative endoscopic resection. In this study, we performed a systematic review and meta-analysis to evaluate the risk factors associated with lymph node metastasis for the patients with non-curative endoscopic resection of early gastric cancer.

METHODS

The related studies were identified by searching PubMed and Embase databases. According to the status of lymph node metastasis, all patients were classified into node-negative group and node-positive group. The relevant clinicopathologic factors were extracted, and the pooled odds ratio (OR) and 95% confidence interval (CIs) were assessed using a fixed effects model or random effects model.

RESULTS

A total of nine relevant studies involving 1720 early gastric cancer patients who underwent additional surgery following the non-curative endoscopic resection were included in this meta-analysis. The results indicated that deeper submucosal invasion (SM2) (OR 3.44, 95% CI 1.94-6.10, P < 0.001; I² = 0%), positive vertical margin (OR 2.35, 95% CI 1.57-3.53, P < 0.001; I² = 0%), lymphatic invasion (OR 11.06, 95% CI 5.47-22.36, P < 0.001; I² = 0%), and vascular invasion (OR 2.79, 95% CI 1.68-4.64, P < 0.001; I² = 0%) were significantly associated with lymph node metastasis for these patients. However, horizontal margin, tumor size, differentiation type, and ulceration were not identified as risk factors associated with lymph node metastasis.

CONCLUSION

Lymphatic invasion, vascular invasion, deeper submucosal invasion (SM2), and positive vertical margin should be strongly considered in selecting the candidates for additional surgery treatment.

Is Radical Surgery Necessary for All Patients Diagnosed as Having Non-Curative Endoscopic Submucosal Dissection?

If a lesion does not meet the expanded indication criteria for treatment with endoscopic therapy for early gastric cancer or has a positive resection margin, it is regarded as suitable for non-curative resection. Non-curative resection is closely related to the risk of local recurrence, lymph node metastasis, and poor prognosis. If the result is confirmed as non-curative resection, additional treatment should be considered depending on the risks of residual tumor, local recurrence, and lymph node metastasis. As lymphatic invasion is the most important risk factor of recurrence and poor prognosis, surgical treatment should be considered if lymphatic invasion is present. If patients are not suitable for additional surgery owing to old age or coexisting severe disease, close surveillance can be an alternative treatment option.

Long-term outcomes after noncurative endoscopic resection of early gastric cancer: the optimal time for additional endoscopic treatment

BACKGROUND AND AIMS

We aimed to evaluate long-term outcomes with noncurative endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) and surveillance strategies such as the optimal time for additional endoscopic treatment in patients with noncurative ESD.

METHODS

Of 2527 patients who underwent gastric ESD for EGC, 512 (20.3%) patients with noncurative resection were reviewed. Noncurative resection is defined as positive resected margins on histology, lymphovascular infiltration, or beyond the expanded criteria for ESD.

RESULTS

The mean ± standard deviation follow-up duration was 79.0 ± 55.7 months. A total of 264 patients (51.6%) and 50 patients (9.8%) underwent surgery and endoscopic treatment after noncurative resection, respectively, whereas 198 patients (38.7%) were observed. Cancer-specific survival and disease-free survival rates were significantly different among the surgery, other endoscopic treatment, and observation groups (96.7%, 86.8%, and 86.2%, respectively; P =.030; and 92.5%, 73.6%, and 63.0%, respectively; P < .001). When patients who underwent surgery were excluded, the disease-free survival rate of recurrence was not significantly different between the endoscopic treatment and observation groups (73.6% vs 63.0%; P = .548). To exclude the potential for the presence of lymph node metastasis, we further analyzed disease-free survival of local recurrence by comparing the patients with only a positive lateral resection margin. The disease-free survival rate was higher in the endoscopic treatment group than in the observation group (89.2% vs 69.1%; P = .023). Moreover, additional endoscopic treatment within 3 months showed significant associations with lower risk of local recurrence on multivariate analysis (hazard ratio, 0.017; 95% confidence interval, 0.002-0.260; P = .003).

CONCLUSIONS

In patients with noncurative ESD, additional surgery showed a better long-term outcome; moreover, when a positive lateral resection margin was the only noncurative factor, additional endoscopic treatment within 3 months could be considered to improve disease-free survival.

[Treatment Strategies after Non-curative Endoscopic Resection of Early Gastric Cancer]

The cases of non-curative endoscopic resection (NCR) of early gastric cancer have increased due to the widespread use of endoscopic submucosal dissection (ESD). NCR is associated with augmenting chances of local recurrence and lymph node metastasis (LNM). Therefore, some additional treatment strategies after NCR are needed. Treatment strategies for NCR should be determined by considering the risk of residual tumor or local recurrence and LNM. Additional surgical treatment such as gastrectomy and lymph node dissection are recommended in patients who have high-risk of LNM. Close observation without additional treatment is considered for selected patients with a less possibility of local recurrence or LNM. Also it may be suggested if there is no or less benefit from surgery in elderly patients or patients with underlying diseases. Additional endoscopic procedures including ESD, endoscopic mucosal resection or argon coagulation therapy are suggested alternatively for highly selected patients not at risk of LNM based on the absolute or expanded criteria of ESD.

Survival Benefit of Additional Surgery After Non-curative Endoscopic Submucosal Dissection for Early Gastric Cancer: A Propensity Score Matching Analysis

BACKGROUND AND PURPOSE

Previous studies comparing survival outcomes between patients who did and did not undergo additional surgery after non-curative endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) were limited in that the baseline characteristics differed significantly between the groups. We aimed to address this limitation and compared survival outcomes between these two groups using propensity score matching analysis.

METHODS

The study enrolled 1969 consecutive patients who underwent non-curative ESD for EGC between 2000 and 2011 at any of 19 institutions across Japan. Using propensity score matching analysis, patients who underwent additional surgery (n = 1064) were compared with patients who did not (n = 905). Overall survival (OS) and disease-specific survival (DSS) after ESD were compared between both groups.

RESULTS

Propensity score matching analysis yielded 553 matched pairs and well-balanced baseline characteristics between the two groups. The 5-year OS rates were 91.0% in the additional surgery group and 75.5% in the no additional surgery group, and the 5-year DSS rates were 99.0 and 96.8%, respectively. OS and DSS in the additional surgery group were significantly higher than in the no additional surgery group (OS, p < 0.001; DSS, p = 0.013). In Cox proportional hazard analysis, additional surgery significantly reduced gastric cancer-related death after non-curative ESD for EGC (hazard ratio 0.33, 95% confidence interval 0.12-0.79, p = 0.012).

CONCLUSIONS

Our findings suggest that additional surgery reduces mortality after non-curative ESD for EGC. We recommend additional surgery for patients after non-curative ESD for EGC.

Clinical outcomes of early gastric cancer patients after noncurative endoscopic submucosal dissection in a large consecutive patient series

BACKGROUND

Clinical outcomes of early gastric cancer (EGC) patients after noncurative endoscopic submucosal dissection (ESD) have not been fully elucidated; we therefore aimed to clarify these outcomes.

METHODS

A total of 3058 consecutive patients with 3474 clinically diagnosed EGCs at initial onset underwent ESD with curative intent at our hospital between 1999 and 2010. We retrospectively assessed the following clinical outcomes of noncurative gastric ESD patients with a possible risk of lymph node (LN) metastasis by dividing patients into two groups with different treatment strategies (additional gastrectomy and simple follow-up): presence of LN metastasis at the time of gastrectomy, incidence of LN and distant metastases during the follow-up period, clinicopathological factors associated with metastasis, and 5-year disease-specific survival (DSS).

RESULTS

After exclusion of 75 noncurative ESD patients with only a positive horizontal margin, 569 noncurative ESD patients with a possible risk of LN metastasis were identified. Among the 356 patients undergoing additional gastrectomy, LN metastasis was identified in 18 patients. A positive vertical margin with submucosal invasion (odds ratio 3.6) and lymphovascular invasion (odds ratio 3.5) were significantly associated with LN metastasis. The 5-year DSS rate was 98.8 %. Among the 212 patients who underwent simple follow-up, LN and/or distant metastases were found in eight patients. In this group, lymphovascular invasion (hazard ratio 6.6) was significantly associated with metastasis with a 5-year DSS rate of 96.8 %.

CONCLUSIONS

Additional gastrectomy should be performed particularly in noncurative gastric ESD patients with lymphovascular invasion or a positive vertical margin with submucosal invasion.

Comparison of Long-Term Outcomes After Non-curative Endoscopic Resection in Older Patients with Early Gastric Cancer

BACKGROUND

Limited data exist that describe the long-term outcomes from additional surgery following non-curative endoscopic resection (ER) of early gastric cancer (EGC) in older people. This study aimed to determine the appropriate treatment strategy for these patients.

METHODS

We analyzed data from 2895 patients who underwent ER for EGC, of whom 451 (15.6%) had non-curative resections followed by curative surgery or surveillance only. Of these patients, 138 were older (aged ≥70 years). We compared the long-term outcomes of the different treatment strategies in the older patients with non-curative resections for EGC, and the outcomes of each treatment strategy, with those in younger patients.

RESULTS

The older patients underwent curative resections, non-curative resections with surgery, or non-curative resections with surveillance, and the 5-year disease-specific survival (DSS) rates were 100, 100, and 73%, respectively. There was a trend toward significance for DSS in favor of the non-curative resections with surgery group compared with the non-curative resections with surveillance-only group (p = 0.069). Among those who did not undergo additional surgery, the older patients had worse DSS than the younger patients, and patients who underwent additional surgery had better DSS, irrespective of their ages. Multivariable analysis adjusted for other-cause mortality generated similar results. Overall survival and recurrence-free survival did not differ according to treatment strategy, and perioperative morbidity and mortality did not differ significantly according to age.

CONCLUSIONS

In older patients with non-curatively resected EGC, additional surgery demonstrated a trend toward better DSS, and perioperative complications did not increase significantly.

Long-Term Outcomes of Gastric Endoscopic Submucosal Dissection: Focus on Metachronous and Non-Curative Resection Management

Introduction

Endoscopic submucosal dissection (ESD) is an effective treatment for gastric superficial neoplasms and curative in 80-85% of the patients. The aims of this study were to identify risk factors for non-curative resection and metachronous development, and to evaluate patient management and outcome after non-curative resection.

Methods

In this single-centre study, the outcome of consecutive patients submitted to gastric ESD was assessed during a minimum follow-up of 18 months. Univariate analysis and multivariate logistic regression were performed to identify risk factors.

Results

ESD was performed in 194 lesions (164 patients) between 2005 and 2014. The median follow-up was 40 months. En bloc and complete resection rates were 95.3 and 93.8%, respectively. Male sex, larger tumor size, longer procedural time, and more advanced histology were associated with a non-curative resection (p < 0.05), but only carcinoma detected in biopsies before resection was identified as a significant risk factor on multivariate analysis. Metachronous lesions occurred in 18.4%, and the incidence rate was 4.7 lesions/100 person-years. Older age at diagnosis was identified as the only predictor of metachronous development in logistic regression. In the non-curative resection group, survival did not differ between patients allocated to surveillance and those submitted to gastrectomy; 75% of gastrectomy specimens showed no residual lesion.

Conclusions

The risk factors identified for non-curative resection help to improve patient selection and patient information. Older patients had an increased risk for the development of metachronous lesions. In patients with non-curative resections, individualized patient management and surveillance seems to be an adequate option in selected cases.

Recent developments and innovations in gastric cancer

Gastric cancer has an important place in the worldwide incidence of cancer and cancer-related deaths. It can metastasize to the lymph nodes in the early stages, and lymph node metastasis is an important prognostic factor. Surgery is a very important part of gastric cancer treatment. A D2 lymphadenectomy is the standard surgical treatment for cT1N+ and T2-T4 cancers, which are potentially curable. Recently, the TNM classification system was reorganized, and the margins for gastrectomy and lymphadenectomy were revised. Endoscopic, laparoscopic and robotic treatments of gastric cancer have progressed rapidly with development of surgical instruments and techniques, especially in Eastern countries. Different endoscopic resection techniques have been identified, and these can be divided into two main categories: endoscopic mucosal resection and endoscopic submucosal dissection. Minimally invasive surgery has been reported to be safe and effective for early gastric cancer, and it can be successfully applied to advanced gastric cancer with increasing experience. Cytoreductive surgery and hyperthermıc intraperıtoneal chemotherapy were developed as a combined treatment modality from the results of experimental and clinical studies. Also, hyperthermia increases the antitumor activity and penetration of chemotherapeutics. Trastuzumab which is a monoclonal antibody interacts with human epidermal growth factor (HER) 2 and is related to gastric carcinoma. The anti-tumor mechanism of trastuzumab is not clearly known, but mechanisms such as interruption of the HER2-mediated cell signaling pathways and cell cycle progression have been reported previously. H. pylori is involved in 90% of all gastric malignancies and Japanese guidelines strongly recommend that all H. pylori infections should be eradicated regardless of the associated disease. In this review, we present innovations discussed in recent studies.