Indications for EMR/ESD in cases of early gastric cancer: relationship between histological type, depth of wall invasion, and lymph node metastasis

OSATS scoring confirms ICG enhancement of performance in laparoscopic radical gastrectomy: a post-hoc analysis of a randomized controlled trial

BACKGROUND

Indocyanine green (ICG) fluorescence imaging is effective in increasing the number of lymph node dissections during laparoscopic radical gastrectomy; however, no studies have attempted to explain this phenomenon.

METHODS

This study utilized the data from a previous randomized controlled trial (FUGES-012 study) investigating ICG-guided laparoscopic radical gastrectomy performed between November 2018 and July 2019. The Objective Structured Assessments of Technical Skills (OSATS) scoring system was used to grade videos from the ICG and non-ICG groups. Patients with an OSATS score greater than 29 were classified as the high-OSATS population, while those with an OSATS score less than or equal to 29 were classified as the low-OSATS population.

RESULTS

A total of 258 patients were included in the modified intention-to-treat analysis: 129 in the ICG group and 129 in the non-ICG group. The OSATS score of the ICG group was higher than that of the non-ICG group (29.6±2.6 vs. 26.6±3.6; P <0.001). The ICG group underwent a significantly higher mean total number of lymph node dissections than the non-ICG group (50.5±15.9 vs. 42.0±10.3; adjusted P <0.001). The group assigned to ICG use, better OSATS (high-OSATS) scores were observed, which correlated with greater D2 lymph node retrieval (54.1±15.0 vs. 47.2±8.7; adjusted P =0.039). Finally, the ICG group had a lower rate of lymph node noncompliance than that of the non-ICG group (31.8 vs. 57.4%; P <0.001).

CONCLUSIONS

By applying the ICG fluorescence navigation technique, better OSATS scores were observed, which correlated with greater lymph node retrieval and a lower lymph node noncompliance rate, as recommended for individualized laparoscopic radical gastrectomy.

A nomogram for predicting lymph node metastasis in early gastric signet ring cell carcinoma

At present, the risk factors for lymph node metastasis in early gastric signet ring cell carcinoma (SRCC) remain unclear. However, it is worth noting that the LNM rate and prognosis of early gastric SRCC are superior to those of other undifferentiated cancers. With advancements in endoscopic technology, the 5-year survival rate following endoscopic treatment of early gastric cancer is comparable to traditional surgery while offering a better quality of life. The objective of this study was to develop a nomogram that can predict lymph node status in early gastric SRCC before surgery, aiding clinicians in selecting the optimal treatment strategy. A research cohort was established by retrospectively collecting data from 183 patients with early gastric SRCC who underwent radical gastrectomy with lymph node dissection at our hospital between January 2014 and June 2022. The predictors of early gastric signet ring cell carcinoma lymph node metastasis were identified in the study cohort using the least absolute selection and shrinkage operator (Lasso) and multivariate regression analysis, and a nomogram was developed. The discrimination, accuracy, and clinical practicability of the nomogram were assessed using receiver operating characteristic (ROC) curve analysis, calibration curve analysis, and decision curve analysis. The incidence of lymph node metastasis was 21.9% (40/183) overall. Multivariate logistic regression analysis revealed that tumor size and lymphovascular invasion (LVI) were independent risk factors for lymph node metastasis. Lasso regression analysis demonstrated that tumor size, invasion depth, LVI, E-cadherin expression, dMMR, CA242, NLR, and macroscopic type were associated with lymph node metastasis. The integrated discrimination improvement (IDI) (P = 0.034) and net reclassification index (NRI) (P = 0.023) were significantly improved when dMMR was added to model 1. In addition, the area under curve (AUC) (P = 0.010), IDI (P = 0.001) and NRI (P < 0.001) of the model were significantly improved when type_1 was included. Therefore, we finally included tumor size, invasion depth, dMMR, and macroscopic type to establish a nomogram, which had good discrimination (AUC = 0.757, 95% CI 0.687-0.828) and calibration. Decision curve analysis showed that the nomogram had good clinical performance. We have developed a risk prediction model for early gastric signet ring cell carcinoma that accurately predicts lymph node involvement, providing clinicians with a valuable tool to aid in patient counseling and treatment decision-making.

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.

Nomogram established using risk factors of early gastric cancer for predicting the lymph node metastasis

BACKGROUND

For the prognosis of patients with early gastric cancer (EGC), lymph node metastasis (LNM) plays a crucial role. A thorough and precise evaluation of the patient for LNM is now required.

AIM

To determine the factors influencing LNM and to construct a prediction model of LNM for EGC patients.

METHODS

Clinical information and pathology data of 2217 EGC patients downloaded from the Surveillance, Epidemiology, and End Results database were collected and analyzed. Based on a 7:3 ratio, 1550 people were categorized into training sets and 667 people were assigned to testing sets, randomly. Based on the factors influencing LNM determined by the training sets, the nomogram was drawn and verified.

RESULTS

Based on multivariate analysis, age at diagnosis, histology type, grade, T-stage, and size were risk factors of LNM for EGC. Besides, nomogram was drawn to predict the risk of LNM for EGC patients. Among the categorical variables, the effect of grade (well, moderate, and poor) was the most significant prognosis factor. For training sets and testing sets, respectively, area under the receiver-operating characteristic curve of nomograms were 0.751 [95% confidence interval (CI): 0.721-0.782] and 0.786 (95%CI: 0.742-0.830). In addition, the calibration curves showed that the prediction model of LNM had good consistency.

CONCLUSION

Age at diagnosis, histology type, grade, T-stage, and tumor size were independent variables for LNM in EGC. Based on the above risk factors, prediction model may offer some guiding implications for the choice of subsequent therapeutic approaches for EGC.

Prediction of depth of invasion and lymph node metastasis in superficial pharyngeal cancer by magnifying endoscopy using the Japan Esophageal Society classification

Backgrounds

The pharynx has no muscularis mucosae, so it is unclear whether diagnostic techniques used for the esophagus can be applied to the pharynx. This study investigated the usefulness of magnifying endoscopy with narrowband imaging using the Japan Esophageal Society (JES) classification for predicting the depth of invasion and lymph node metastasis (LNM) in pharyngeal cancer.

Methods

A total of 123 superficial pharyngeal carcinoma lesions that had been observed preoperatively with magnifying endoscopy with narrowband imaging between January 2014 and June 2021 were analyzed. Predictors of subepithelial invasion (SEP) and LNM were sought based on endoscopic findings, including microvascular morphology, using the JES classification.

Results

The lesions were divided into carcinoma in situ (n = 41) and SEP (n = 82). Multivariate analysis identified B2–B3 vessels (odds ratio [OR] 6.54, 95% confidence interval [CI] 1.74–24.61, p = 0.005) and a middle/large avascular area (OR 4.15, 95% CI 1.18–14.62, p = 0.027) as independent predictors of SEP. Significant predictors of LNM were protruding type, B2–B3 vessels, middle/large avascular area, SEP, venous invasion, lymphatic invasion, and tumor thickness > 1000 μm. Median tumor thickness increased significantly in the order of B1 < B2 < B3 vessels (B1, 305 μm; B2, 1045 μm; B3, 4043 μm; p < 0.001). The LNM rates for B1, B2, and B3 vessels were 1.6% (1/63), 4.8% (2/42), and 55.6% (10/18), respectively (p < 0.001).

Conclusions

Magnifying endoscopy with narrowband imaging using the JES classification could predict the depth of invasion in superficial pharyngeal carcinoma. The JES classification may contribute to the prediction of LNM, suggesting that it could serve as an alternative to tumor thickness.

A meta-analysis of the effect of endoscopic submucosal dissection compared with gastrectomy on the wound infection in early stomach cancer subjects

We conducted a meta-analysis to assess the effect of endoscopic submucosal dissection compared with gastrectomy on the wound infection in early stomach cancer subjects. A systematic literature search up to November 2022 was performed and 2765 related studies were evaluated. The chosen studies comprised 7842 early stomach cancer subjects participated in the selected studies' baseline trials; 3308 of them used the endoscopic submucosal dissection, while 4534 used gastrectomy. Odds ratio (OR) with 95% confidence intervals (CIs) were calculated to assess the wound infection in endoscopic submucosal dissection versus gastrectomy for early stomach cancer by the dichotomous methods with a random or fixed effect model. The use of endoscopic submucosal dissection resulted in significantly lower wound infection (OR, 0.45; 95% CI, 0.34-0.60, P < .001) with no heterogeneity (I²  = 8%) compared with the gastrectomy for early stomach cancer. The use of endoscopic submucosal dissection resulted in significantly lower wound infection compared with the gastrectomy for early stomach cancer. The small sample size of some studies in the comparison calls for care when analysing the results.

Establishment and Validation for Predicting the Lymph Node Metastasis in Early Gastric Adenocarcinoma

Lymph node metastasis (LNM) is considered to be one of the important factors in determining the optimal treatment for early gastric cancer (EGC). This study aimed to develop and validate a nomogram to predict LNM in patients with EGC. A total of 842 cases from the Surveillance, Epidemiology, and End Results (SEER) database were divided into training and testing sets with a ratio of 6 : 4 for model development. Clinical data (494 patients) from the hospital were used for external validation. Univariate and multivariate logistic regression analyses were used to identify the predictors using the training set. Logistic regression, LASSO regression, ridge regression, and elastic-net regression methods were used to construct the model. The performance of the model was quantified by calculating the area under the receiver operating characteristic curve (AUC) with 95% confidence intervals (CIs). Results showed that T stage, tumor size, and tumor grade were independent predictors of LNM in EGC patients. The AUC of the logistic regression model was 0.766 (95% CI, 0.709-0.823), which was slightly higher than that of the other models. However, the AUC of the logistic regression model in external validation was 0.625 (95% CI, 0.537-0.678). A nomogram was drawn to predict LNM in EGC patients based on the logistic regression model. Further validation based on gender, age, and grade indicated that the logistic regression predictive model had good adaptability to the population with grade III tumors, with an AUC of 0.803 (95% CI, 0.606-0.999). Our nomogram showed a good predictive ability and may provide a tool for clinicians to predict LNM in EGC patients.

Early gastric cancer: A challenge in Western countries

Early gastric cancer (EGC) is an invasive carcinoma involving only the stomach mucosa or submucosa, independently of lymph node status. EGC represents over 50% of cases in Japan and in South Korea, whereas it accounts only for approximately 20% of all newly diagnosed gastric cancers in Western countries. The main classification systems of EGC are the Vienna histopathologic classification and the Paris endoscopic classification of polypoid and non-polypoid lesions. A careful endoscopic assessment is fundamental to establish the best treatment of EGC. Generally, EGCs are curable if the lesion is completely removed by endoscopic resection or surgery. Some types of EGC can be resected endoscopically; for others the most appropriate treatment is surgical resection and D2 lymphadenectomy, especially in Western countries. The favorable oncological prognosis, the extended lymphadenectomy and the reconstruction of the intestinal continuity that excludes the duodenum make the prophylactic cholecystectomy mandatory to avoid the onset of biliary complications.

Lymph node micrometastasis of poorly differentiated node-negative gastric cancer risks a worse-than-expected survival outcome under standard management algorithm

BACKGROUND

Investigation of lymph node micrometastasis (mN) of gastric cancer has been focused on either T1 disease or T1-4N0 disease. Yet, it is unclear whether standard management algorithm toward poorly differentiated gastric cancer (PDGC) is more vulnerable to existence of mN, given its inherently biological aggressiveness, as compared with other histological types.

PATIENTS AND METHODS

A surgical series (n = 3456) of gastric cancer categorized by histological differentiation was enrolled to analyze survival stratification. Of them, a cohort of T1-T4 N0 PDGC (n = 100) were subjected to cytokeratin immunohistochemistry, a surrogate of mN.

RESULTS

Cancer-specific survival by AJCC8 staging system could be nicely differentiated in both well-/moderately differentiated and signet ring cell types, while those between stage IA versus IB (p = 0.105), and stage IB versus IIA (p = 0.141) in PDGC could not. Thirteen (13%) out of 100 node-negative PDGC cases exhibited mN, with 5, 2, 5 and 1 cases occurring in T1, T2, T3, and T4 stage, respectively, without identifiable contributing factors. Prognostic performance of AJCC8 working upon PDGC became more discriminative by incorporating mN, as hazard ratio of stage IIIC referenced to stage IA increased from 43 to 78.

CONCLUSION

Defective discriminative survival of PDGC by standard staging algorithm prompted us to survey mN occurring in T1-T4N0 PDGC. The prognostic performance of AJCC8 working upon PDGC was enhanced by incorporating mN. As so, we recommend documentation of mN exclusively on node-negative PDGC that helps unveil stage migration phenomenon and switch to appropriate adjuvant therapy in need.

A CT-based Radiomics Model for Prediction of Lymph Node Metastasis in Early Stage Gastric Cancer

RATIONALE AND OBJECTIVES

To develop and validate a CT-based radiomics model for preoperative prediction of lymph node metastasis (LNM) in early stage gastric cancer (EGC).

MATERIALS AND METHODS

Four hundred and sixty-three consecutive EGC patients were enrolled in this retrospective study. Radiomics features were extracted from portal venous phase CT scans. A radiomics signature was built based on highly reproducible features using the least absolute shrinkage and selection operator method. The predictive performance of radiomics signature was tested in the training and testing cohorts. Multivariate logistic regression analysis was conducted to build a radiomics-based model combined radiomics signature and lymph node status according to CT. Performance of the model was determined by its discrimination, calibration, and clinical usefulness.

RESULTS

The radiomics signature comprised six robust features showed significant association with LNM in both cohorts. A radiomics model that incorporated radiomics signature and CT-reported lymph node status showed good calibration and discrimination in the training cohort (AUC = 0.91) and testing cohort (AUC = 0.89). Decision curve analysis confirmed the clinical utility of this model.

CONCLUSION

The CT-based radiomics model showed favorable accuracy for prediction of LNM in EGC and may help to improve clinical decision-making.

Assessment of diagnostic value of fluorescent lymphography-guided lymphadenectomy for gastric cancer

BACKGROUND

Indocyanine green fluorescent lymphography helps visualize the lymphatic drainage pattern in gastric cancer; however, it is unknown whether fluorescent lymphography visualizes all metastatic lymph nodes. This study aimed to evaluate the sensitivity of fluorescent lymphography to detect metastatic lymph node stations and lymph nodes and the risk of false-negative findings.

METHODS

Patients with clinical T1-4a gastric cancer were included. Indocyanine green was peritumorally injected the day prior to surgery by endoscopy. Gastrectomy with systematic D1+ or D2 lymphadenectomy was performed. Stations and lymph nodes were retrieved at the back-table using near-infrared imaging and classified as "fluorescent" or "non-fluorescent" and later matched with histopathological findings.

RESULTS

Among 592 patients who underwent minimally invasive gastrectomy from September 2013 until December 2016, lymph node metastases were present in 150. The sensitivity of fluorescent lymphography in detecting all metastatic lymph node stations was 95.3% (143/150 patients), with a false-negative rate of 4.7% (7/150 patients) and the sensitivity in detecting all metastatic lymph nodes was 81.3% (122/150 patients). The negative predictive value was 99.3% for non-fluorescent stations and 99.2% for non-fluorescent LNs. For detecting all metastatic LN stations, subgroup analysis revealed 100% sensitivity for pT1a, 96.8% for pT1b, 100% for pT2, 91.3% for pT3, and 93.6% for pT4a tumors.

CONCLUSIONS

Fluorescent lymphography-guided lymphadenectomy can be a useful method for radical lymphadenectomy by facilitating the complete dissection of all potentially positive LN stations. Fluorescent lymphography-guided lymphadenectomy appears to be a reasonable alternative to conventional systematic lymphadenectomy for gastric cancer.

Clinicopathological features and lymph node metastasis risk in early gastric cancer with WHO criteria in China: 304 cases analysis

AIMS

The aim of this research was to identify the clinicopathological characteristics of early gastric cancer (EGC) based on the WHO criteria, and to analyze predictors for lymph node metastasis (LNM) in EGC in a Chinese study population.

METHODS

We retrospectively collected data of 304 Chinese EGC patients, including 265 patients undergoing radical gastrectomy and 39 patients undergoing endoscopic resection. Histological features were accessed by three experienced pathologists. Univariate analysis and multivariate analysis were used to identify the correlation between clinicopathological features and LNM.

RESULTS

Among the 304 cases with EGC, the rate of well differentiated tubular adenocarcinoma was 11.2%, significantly lower than that of Japanese and South Korean, which was 24.8% and 19.9% respectively (p<0.001 and p = 0.006), but similar to that of a Western result, which was 11.9% (p = 0.860). Among the 265 patients who underwent gastrectomy, 18.5% of the patients had LNM. Univariate analysis showed that macroscopic type, differentiation degree, invasion depth, infiltration pattern (INF), lymphovascular invasion and ulceration were related to LNM. Multivariate analysis revealed that lymphovascular invasion (p < 0.001, OR = 6.549), ulceration (p = 0.035, OR = 2.527) and INF c (p = 0.042, OR = 3.424) were the independent risk factors of LNM in EGC.

CONCLUSIONS

The pathological diagnosis standard of well differentiated tubular adenocarcinoma in China significantly differs from that in Japan and South Korea, but is similar to western countries. LNM is more likely to occur in EGCs with lymphovascular invasion, ulceration and INF c.

Gastric Epithelial Polyps: When to Ponder, When to Panic

This review provides an overview of different types of gastric epithelial polyps. The polyps are classified based on their cell or epithelial compartment of origin. Some of these polyps can be considered reactive or nonneoplastic, whereas others are neoplastic in origin, are sometimes associated with a hereditary polyposis/cancer syndrome, and may have malignant potential. The aim of this review is to provide a pragmatic overview for the practicing pathologist about how to correctly diagnose and deal with gastric epithelial polyps and when (not) to ponder, and when (not) to panic.

A radiomics-based model for prediction of lymph node metastasis in gastric cancer

PURPOSE

To develop and validate a radiomics-based model for preoperative prediction of lymph node metastasis (LNM) in gastric cancer (GC).

METHOD

A total of 768 GC patients were enrolled in this retrospective study. Radiomics features were extracted from portal venous phase computed tomography (CT) scans. A radiomics signature was built with highly reproducible features using the least absolute shrinkage and selection operator (LASSO) method in the training cohort (n = 486). The signature was further validated in internal validation (n = 240) and external testing cohorts (n = 42). Multivariate logistic regression analysis was conducted to build a model that combined radiomics signature, serum biomarkers, and lymph node status according to CT. Performance of the model was determined by its discrimination, calibration, and clinical usefulness. The predictive value of the model was also evaluated in early stage GC (EGC) subgroup.

RESULTS

The radiomics signature comprised 7 robust features showed favorable prediction efficacy in all cohorts. A radiomics-based model that incorporated radiomics signature, serum CA72-4, and CT-reported lymph node status had good calibration and discrimination in training cohort [AUC, 0.92; 95% confidence interval (CI), 0.89-0.95] and validation cohort (AUC 0.86; 95% CI, 0.81-0.91). The model also showed a favorable predictive performance for EGC patients with an AUC of 0.85 (95% CI, 0.76-0.94). Decision curve analysis confirmed the clinical utility of this model.

CONCLUSIONS

The radiomics-based model showed favorable accuracy for prediction of LNM in GC. The model may also serve as a noninvasive tool for preoperative evaluation of LNM in EGC.

Endoscopic submucosal dissection versus endoscopic mucosal resection for patients with early gastric cancer: a meta-analysis

OBJECTIVES

To investigate the treatment effects of endoscopic submucosal dissection (ESD) versus endoscopic mucosal resection (EMR) for early gastric cancer (EGC).

DESIGN

Meta-analysis.

METHODS

We systematically searched three electronic databases, including PubMed, EmBase and the Cochrane library for studies published with inception to January 2018. The eligible studies should be evaluated for the efficacy and safety of ESD versus EMR for patients with EGC. The summary ORs and standard mean differences (SMDs) with 95% CIs were employed as effect estimates. Sensitivity analyses were conducted to evaluate the impact of single study on overall analysis. Subgroup analyses were performed for investigated outcomes to evaluate the treatment effects of ESD versus EMR for patients with EGC with specific subsets.

RESULTS

Eighteen studies, with a total of 6723 patients with EGC, were included in final analysis. The summary ORs indicated that patients with EGC who received ESD were associated with an increased incidence of en bloc resection (OR: 9.00; 95% CI: 6.66 to 12.17; p<0.001), complete resection (OR: 8.43; 95% CI: 5.04 to 14.09; p<0.001) and curative resection (OR: 2.92; 95% CI: 1.85 to 4.61; p<0.001) when compared with EMR. Furthermore, ESD was associated with lower risk of local recurrence (OR: 0.18; 95% CI: 0.09 to 0.34; p<0.001). In addition, there was no significant difference between ESD and EMR for the risk of bleeding (OR: 1.26; 95% CI: 0.88 to 1.80; p=0.203). Though, ESD was correlated with greater risk of perforation (OR: 2.55; 95% CI: 1.48 to 4.39; p=0.001), and longer operation time (SMD: 1.12; 95% CI: 0.13 to 2.10; p=0.026) as compared with EMR. Additionally, several different features observed in included studies and patients could bias the effectiveness of ESD versus EMR in patients with EGC.

CONCLUSIONS

ESD is superior than EMR for en bloc resection, complete resection, curative resection and local recurrence, while it increased perforation risk and longer operation time.

Expanding the indication of endoscopic submucosal dissection for undifferentiated early gastric cancer is safe or not?

BACKGROUND

Endoscopic submucosal dissection (ESD) has gained more popularity in the treatment of early gastric cancer (EGC). Although there is a lack of confirmed evidence for the feasibility of ESD for undifferentiated EGC. The aim of the study was to investigate the feasibility of ESD with expanded indications for undifferentiated EGC patients.

METHODS

Data from patients with undifferentiated EGC (including signet-ring cell carcinoma, mucinous adenocarcinoma, mixed adenocarcinoma, and poorly differentiated adenocarcinoma) who underwent radical surgical resection were retrospectively reviewed. The relationship between the clinical parameters and the incidence of lymph node metastasis (LNM) was investigated.

RESULTS

A total of 517 patients were included in this study. The results showed that LNM was significantly associated with ulceration, tumor size, depth of invasion, lymphatic invasion, vascular invasion, and perineural invasion. Multivariate stepwise logistic regression analysis revealed that tumor size (OR = 1.61, 95% CI = 1.03-2.52, P = 0.0367), depth of tumor invasion (OR = 2.77, 95% CI = 1.66-4.63, P = 0.0001), and lymphatic invasion (OR = 14.74, 95% CI = 1.58-137.36, P = 0.0182) were independent risk factors for LNM. In the patients who would be included under the new proposed guidelines for ESD, including men with mucosal tumors ≤2 cm and without ulceration or lymphatic or venous infiltration, LNM was present in 11.9% (14/118).

CONCLUSION

Caution to be exercised in expanding application of ESD should be carefully weighed in undifferentiated EGC.

Endoscopic or Surgical Resection for Gastro-Esophageal Cancer

BACKGROUND

Early gastro-esophageal cancer is staged as m1 to m3 depending on the infiltration of the anatomical layers of the mucosa or, analogously, as sm1 to sm3 depending on the depth of infiltration into the submucosa. The risk of lymph node metastases is low in mucosal carcinoma but increases with the depth of infiltration into the submucosa.

METHODS

This review is based on pertinent publications retrieved by a selective search in MEDLINE, PubMed, the Cochrane Library, and the International Standard Randomised Controlled Trial Number (ISRCTN) registry.

RESULTS

New technologies such as narrow-band imaging have improved the endo- scopic diagnosis and staging of early gastro-esophageal cancer. The development of endoscopic submucosal dissection has led to a higher R0 resection rate, a lower risk of recurrence, and an increase in the number of endoscopic resections that are performed with curative intent. In squamous-cell carcinoma of the esophagus, surgical oncological esophagectomy is indicated if the cancer infiltrates into the third mucosal layer (T1a, m3) or deeper. In esophageal adenocarcinoma, the prevalence of lymph node metastases is low if the cancer is restricted to the mucosa and in- creases only when the submucosa is infiltrated. In the current German S3 guideline, endoscopic resection is recommended for intramucosal adenocarcinoma as long as there are no further histopathological risk factors. Lymph node metastasis in gastric carcinoma begins in the deep mucosal infiltration stage (m3). If certain special con- ditions ("extended criteria") are met, carcinoma expanding into the first submucosal layer (sm1) can be removed endoscopically. All further stages must be treated with total or subtotal gastrectomy with systematic D2 lymphadenectomy.

CONCLUSION

Borderline cases between endoscopic and surgical resection of early carcinoma of the esophagus or stomach must be managed with an interdisciplinary treatment algorithm. If there is a risk of lymph node metastasis, surgical oncological resection is indicated. Such resections of gastroesophageal cancer in the locally advanced stage should always be part of a multimodal treatment approach.

Mucin phenotype of differentiated early gastric cancer: an immunohistochemistry study supporting therapeutic decision making

Introduction: Endoscopic submucosal dissection is widely employed in early gastric cancer (EGC). Foveolar phenotypes should be distinguished from the other differentiated EGC (DEGC) types because of their increased malignant potential. The phenotypic classification could be useful not only for investigating EGC tumorigenesis but also for evaluating the tumor aggressiveness to guide treatment decision making. Methods: On surgical tissue specimens, we studied the mucin phenotype of EGC to distinguish cases with a worse prognosis dictating different therapeutic options or a very close surveillance program. DEGC in our series were classified as mucin foveolar (51%) or mucin intestinal (49%) phenotype. We evaluated correlations among foveolar and intestinal phenotypic markers, tumor patterns, clinicopathologic features and prognostic and therapeutic implications. Immunohistochemistry (IHC) for MUC5AC and CDX2 was performed on 63 EGC patient specimens. MUCA5C was employed as gastric foveolar phenotypic marker and CDX2 as intestinal phenotypic marker. Results: Foveolar DEGC was significantly associated with larger tumor size (p=0.01), high grade (G2-G3) (p=0.001), vessel permeation (p=0.05), lymph node metastasis (p=0.001) and ulceration (p=0.001), whereas intestinal type DEGC was associated with low grade (p=0.001). Conclusion: IHC determination of the mucin phenotype is an easy, inexpensive method that can provide useful, sensitive markers distinguishing the foveolar or intestinal phenotype in DEGC. The precise identification of the foveolar type, featuring a poorer prognosis, should sound a warning bell mandating very close study of the lesion before endoscopic treatment or contraindicating endoscopic resection in favor of the open surgery option.

Endoscopic management of patients with early gastric cancer before and after endoscopic resection: A review

With the wide application of endoscopic resection for early gastric cancer (EGC) by not only Asian endoscopists but also those from Western countries, reviews on standardized treatment processes before and after endoscopic resection are nevertheless lacking. In this article we provide a narrative review of studies on the selection of appropriate EGC for endoscopic resection and the follow-up strategies for those with histologically confirmed EGC after endoscopic resection. EGC should be comprehensively assessed before endoscopic resection, including its exact margin, invasive depth and risk of lymph node metastasis (LNM). While the curative resection status of EGC may be evaluated after endoscopic resection based on the newly developed eCura system, although this needs to be further verified. Surveillance with endoscopy and computed tomography scan is necessary for patients with an EGC level A or B. An additional endoscopic resection is recommended for patients with a level-C1 EGC. For patients with a level-C2 EGC, close follow-up is suggested for low-risk tumors of level C2 and additional surgery for those at high risks. Further postoperative strategy is suggested based on comprehensive assessment of the risk of LNM, patient's quality of life and wishes.

Long-term outcomes of endoscopic submucosal dissection versus surgery in early gastric cancer: a systematic review and meta-analysis

Endoscopic submucosal dissection (ESD) and gastrectomy with lymph node dissection are considered acceptable treatment modalities for early gastric cancer (EGC). In the last decade, ESD has become more favorable than surgery as it offers faster recovery, lower costs, and a superior quality of life when compared to gastrectomy. The aim of this study is to compare the long-term outcome of ESD versus surgery in EGC. We performed a systematic and comprehensive search of major reference databases (Medline, Embase, CINHAL) for all studies that compared the outcome of EGC for patients underwent ESD or surgery in the same cohort. A systematic review was conducted through November 2017, using pooled analysis to calculate 5-year overall survival (OS) rate, disease-specific survival (DSS) rate, disease-free survival (DFS) rate, and recurrence-free survival (RFS) rate of ESD versus gastrectomy. Five-year OS and DSS were similar between ESD and gastrectomy groups 96 versus 96% and 99.4 versus 99.2%, respectively. Likewise, DFS was similar in both groups 95.9 versus 98.5% odds ratio 1.86 (0.57-6.0) P=0.3. However, ESD had a lower RFS compared to surgery 92.4 versus 98.3% odds ratio 0.17 (0.1-4.9) P=0.001. Overall, there was a higher recurrence rate in patients who underwent ESD compared to surgery [40/2943 (1.4%) vs. 12/3116 (0.4) risk ratio (RR) 2.5 (1.3-4.8) P=0.005]. Moreover, synchronous and metachronous cancers were more prevalent in the ESD group compared to the surgery group [1.5 vs. 0.1% RR 5.7 (1.5-21.9) P=0.01] [16/1082 (1.5%) vs. 1/1485 (0.1%) RR 10.1 (5.9-17.1) P=0.0001]. Five-year OS, DSS and DFS were similar between ESD and surgery groups. However, recurrent, synchronous and metachronous cancers were more prevalent in patients treated by ESD compared to patients treated by surgery, resulting in a lower RFS. Adequate surveillance with upper endoscopy is crucial after ESD to detect early recurrence and metachronous lesions.

Increased circulating levels of vascular endothelial growth factor C can predict outcome in resectable gastric cancer patients

Background

Neoangiogenesis has proven to be a relevant pathogenetic mechanism in gastric cancer (GC) and lymphatic spread represents an important well-known prognostic factor. Vascular endothelial growth factor C (VEGF-C) plays a key role in lymphangiogenesis and its blood levels in GC patients are easily measurable. This analysis aimed to investigate the prognostic role of preoperative VEGF-C blood levels.

Methods

VEGF-C serum levels were determined by enzyme-linked immunoadsorbent assay (ELISA) in 186 patients observed at our institution from January 2004 until December 2009 and 82 healthy subjects. Statistical analyses were performed using SPSS 21.0.

Results

VEGF-C levels were significantly higher in GC patients (median: 287.4 pg/mL; range, 76.2-865.2 pg/mL) than in the control group (median VEGF-C: 31 pg/mL; range, 12-97 pg/mL). A significant correlation between VEGF-C levels, T, N and tumor stage has been described. The median overall survival (OS) was statistically significantly higher in pts with low serum VEGF-C levels [median: not reached (NR) vs. 26 months; P<0.0001]. Higher preoperative VEGF-C levels correlated also with earlier disease relapse and poor disease-free survival (DFS) (median NR in each subgroup, P=0.005). Furthermore, high VEGF-C levels [hazard ratio (HR) =2.7; P=0.018] and tumor grading (HR =0.44; P=0.007) were independent prognostic factors for OS at multivariate analysis.

Conclusions

Our study showed that increased VEGF-C levels are significantly associated with advanced regional lymph node involvement and poor OS and DFS in pts with resected GC paving the way to a possible application as prognostic factor in the clinical practice.

Risk Factors of Lymph Node Metastasis in Patients with Early Pure and Mixed Signet Ring Cell Gastric Carcinomas

Background: Early gastric carcinoma (EGC) with pure signet ring cell carcinoma (pSRCC) has been reported to have favourable prognosis and low risk of lymph node metastasis (LNM). However, risk factors of LNM and clinicopathological features for early gastric mixed signet ring cell carcinoma (mSRCC) remain poorly investigated. The aim of this study was to identify risk factors of LNM and compare clinicopathological characteristics and prognosis of early gastric pSRCC with mSRCC.

Methods: This retrospective study was conducted at our center between 2005 and 2015 in 796 patients underwent radical gastrectomies combined with lymph node dissections, A total of 160 patients with early gastric SRCC underwent gastrectomies with lymph node dissections were reviewed, in which 79 cases were pSRCC and 81 cases were mSRCC. Risk factors of LNM and clinicopathologic features of these two groups were statistically compared, including age, gender, tumor location, gross pattern, size, invasion depth, lymphovascular invasion (LVI), helicobacter pylori (Hp) infection, atrophic gastritis, ulcer finding and LNM. Patients were follow-up for post-resection survival. The 5-year survival and disease-specific survival rate were estimated with the Kaplain-Meier method with a log-rank test and compared between the two groups.

Results: Tumor size (P<0.05), invision depth (P<0.05) and LVI (P < 0.0001) were risk factors of LNM, LVI (P < 0.0001) was independent risk factor of LNM in 160 patients. Univariate analysis reviewed LVI (P < 0.0001) as the risk factor in the pSRCC group, and the risk factors of LNM in the mSRCC included LVI (P < 0.0001) and tumor size (P<0.05). Multivariable analysis revealed two independent risk factors in the mSRCC group: 1) tumor size (P < 0.05), and 2) LVI (P < 0.0001). The significant characteristics in two groups included the male gender (P < 0.0001), gross pattern (P < 0.05), LVI (P < 0.01), and Hp infection (P < 0.01). The difference of LNM rate between expanded indication and out of indication in 160 patients was significant (P=0.03). The overall 5-year survival rate for early gastric SRCC was 96.3%. There was no significant difference in the overall survival and disease-specific survival between the two groups.

Conclusions: Although with similar post-resection survival, the independent risk factors of LNM in the early mSRCC group, compared to those in the early pSRCC group, included large tumor size and LVI. Early gastric mSRCC had more aggressive clinicopathological features than pSRCC.

Safety of expanded criteria for endoscopic resection of early gastric cancer in a Western cohort

Background

Endoscopic resection is widely accepted treatment option for early gastric cancer if tumors meet the standard or expanded indications. However, the safety of expanded criteria is still under investigation. Furthermore, discussion, if any additional treatment is necessary for patients who underwent endoscopic resection but exceeded expanded criteria, is rising. This study aimed to evaluate the safety of extended indications for endoscopic resection of early gastric cancer in a Western cohort. Also, we aimed to analyze the lymph node metastasis rate in tumors which exceeds the extended criteria.

Methods

Two hundred eighteen patients who underwent surgery for early gastric cancer at National Cancer Institute, Vilnius, Lithuania between 2005 and 2015 were identified from a prospective database. Lymph node status was examined in 197 patients who met or exceeded extended indications for endoscopic resection.

Results

Lymph node metastasis was detected in 1.7% of cancers who met extended indications and in 30.2% of cancers who exceeded expanded indications. Lymphovascular invasion and deeper tumor invasion is associated with lymph node metastasis in cancers exceeding expanded indications.

Conclusions

Expanded criteria for endoscopic resection of early gastric cancer in Western settings is not entirely safe because these tumors carry the risk of lymph node metastasis.

Young Age and Risk of Lymph Node Metastasis in Differentiated Type Early Gastric Cancer

BACKGROUND

Young patients with gastric cancer reportedly have a worse prognosis than older patients due to delayed diagnosis and more aggressive tumor behavior. However, it is unclear whether this applies to early gastric cancer (EGC), for which endoscopic resection is indicated. We investigated the association between age and lymph node metastasis (LNM).

METHODS

We identified 4055 patients diagnosed with EGC of differentiated histology who underwent surgery. The association between age and LNM was examined using logistic regression for each T stage separately with adjustments for multiple covariates. We compared LNM rates for each of the Japanese Endoscopic Resection Guidelines criteria in younger (< 40 years) and older patients (40 years).

RESULTS

The median number of lymph nodes examined was the same for T1a and T1b stages (n = 34). The median number of lymph nodes examined was not significantly different within T1a stage (P = 0.093), but within T1b stage, the number of lymph nodes examined was significantly different (P = 0.019). The highest number was between 50 and 59 years (median = 37), and the lowest number was in the 20 to 49 years and older than 70 age brackets (median = 34). LNM rate and age were not significantly associated within each stage (P values 0.269, 0.783 for T1a and T1b, respectively). Among patients fulfilling endoscopic resection criteria, the LNM rate in younger patients was lower than in older patients.

CONCLUSIONS

In differentiated-type EGC, young age at diagnosis was not associated with LNM rate. Therefore, endoscopic resection criteria for early gastric cancer can be applied to younger patients.

Endoscopic submucosal dissection versus endoscopic mucosal resection for type 0-II superficial gastric lesions larger than 20 mm

Background:

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are increasingly used for the treatment of superficial gastrointestinal neoplasia. However, the limits and the indications for each technique are still debated. Our retrospective study aimed to compare these techniques in patients with gastric flat lesions larger than 20 mm without the non-lifting sign.

Methods:

Between January 2013 and July 2016, a total of 36 patients with early gastric flat lesions larger than 20 mm and without the non-lifting sign were resected by ESD and were followed up by endoscopy. As a control group, 40 EMR cases from our database were matched. En bloc and curative resection were compared between the two groups according to histological assessment, tumor size, recurrence, complication rate, and procedure time. A Kaplan-Meier comparison was performed for both groups with a log-rank test to compare the survival curves; the chi-square test was employed for other parameters.

Results:

En bloc resection rate and curative resection rate were significantly higher in the ESD group than in the EMR group. Procedure time was significantly longer in the ESD group. No significant differences were found in the recurrence and complication rates, although the former were higher in the EMR group and the latter in the ESD group. Survival curves were similar for both groups.

Conclusions:

Our retrospective analysis seems to confirm a clear advantage for ESD over EMR in removing early superficial gastric neoplasm. Although ESD has expanded the endoscopic resectability of endoscopic gastric lesions, EMR may still be considered one of the therapeutic options for flat gastric lesions without the non-lifting sign.

The incidence of lymph node metastasis in early gastric cancer according to the expanded criteria in comparison with the absolute criteria of the Japanese Gastric Cancer Association: a systematic review of the literature and meta-analysis

BACKGROUND AND AIMS

Japanese criteria for curative endoscopic resection of early gastric cancer initially included nonulcerated, well-differentiated mucosal lesions ≤2 cm in diameter, known as the absolute criteria. Subsequently, these indications were expanded to include larger, ulcerated, and undifferentiated mucosal lesions as well as differentiated lesions with slight submucosal invasion. Whether patients meeting the expanded criteria can be managed safely without gastrectomy and lymph node dissection has been controversial. The risk of lymph node metastasis (LNM) in patients who met the expanded criteria is a critical factor in determining the best course of management for these patients.

METHODS

We comprehensively searched main reference databases for studies that included patients who underwent gastrectomy and lymph node dissection for early gastric cancer. A meta-analysis was conducted by using the random effects model. Relative risk reduction was used to compare the incidence of LNM in patients meeting the absolute criteria as compared with those meeting the expanded criteria.

RESULTS

Twelve studies met the inclusion criteria, providing a total of 9798 patients. The incidence of LNM was 0.2% for patients who met the absolute criteria as compared with 0.7% for patients who met the expanded criteria. Analysis of the various components of the expanded criteria was conducted, revealing that the incidence of LNM for differentiated mucosal lesions ≤3 cm with ulceration and for differentiated mucosal lesions without ulceration, irrespective of size, was 16 of 2814 (0.57%), reference range (RR) 3.01; P = .02 and 8 of 3004 (0.27%), RR 1.69; P = .37, respectively, only marginally higher than the risk of LNM associated with the absolute criteria. In contrast, undifferentiated mucosal lesions ≤2 cm and differentiated lesions <3 cm with slight submucosal invasion had a significantly higher incidence of LNM in comparison with the absolute criteria (25/972 [2.6%], RR 6.79; P = .0004 and 8/315 [2.5%], RR 6.30; P = .004, respectively).

CONCLUSION

Overall, expanding the indication for endoscopic resection to include mucosal nonulcerated differentiated lesions irrespective of size and differentiated mucosal ulcerated lesions <3 cm is justified with minimal increased risk in comparison to the absolute criteria. However, expanding the indication for undifferentiated lesions ≤2 cm and differentiated lesions with slight submucosal invasion (T1b) should be balanced with the risks of surgery, given the increased risk of LNM in these patients.

Construction and external validation of a nomogram that predicts lymph node metastasis in early gastric cancer patients using preoperative parameters

Objective

To create a nomogram to predict the incidence of lymph node metastasis (LNM) in early gastric cancer (EGC) patients and to externally validate the nomogram.

Methods

To construct the nomogram, we retrospectively analyzed a primary cohort of 272 EGC patients. Univariate analysis and a binary logistic regression were performed. A nomogram predicting the incidence of LNM in EGC patients was created. The discrimination ability of the nomogram was measured using the concordance index (c-index), and the nomogram was also calibrated. Then, another prospective cohort of 81 patients was analyzed to validate the nomogram.

Results

In the primary cohort, LNM was pathologically confirmed in 37 (13.6%) patients. In multivariate analysis, the presence of an ulcer, the maximum lesion diameter observed via gastroscopy, the thickness of the lesion observed via endoscopic ultrasonography, and the presence of enlarged lymph nodes on computed tomography (CT) were independent risk factors for LNM. A nomogram was then created based on the regression model with the c-index of 0.905, and the calibration curve of the nomogram fell approximately on the ideal 45-degree line. The cut-off score of the nomogram was 110, and the sensitivity, specificity, positive predictive and negative predictive values of the nomogram in the primary cohort were 81.1%, 86.0%, 47.6% and 96.7%, respectively, and in the prospective validation cohort were 75.0%, 91.0%, 60.0% and 95.5%, respectively. The calibration curve of the external validation cohort was almost on the 45-degree line.

Conclusions

We developed an effective nomogram predicting the incidence of LNM for EGC patients.

Tumour infiltrating lymphocytes are predictors of lymph node metastasis in early gastric cancers

Lymph node metastasis (LNM) is an important factor for predicting prognosis and selecting appropriate treatment in early gastric cancers (EGCs). We investigated the histopathological and microenvironmental predictors of LNM in EGCs. We retrieved 43 cases of EGC without LNM and 59 cases with LNM. Clinicopathological variables and tumour-infiltrating lymphocytes (TILs), Crohn's-like lymphoid reaction (CLR), tumour stromal percentage (TSP), and FOXA1 expression were evaluated and correlated with LNM. Among the 102 cases, 68 cases (66.7%) had low TILs and 34 cases (33.3%) had high TILs. High TILs were significantly correlated with the absence of LNM (p<0.001), less extent of invasion (p=0.004), absence of LVI (p=0.035), conspicuous CLR (p<0.001), and the absence of TSP (p=0.009). Conspicuous CLR was observed in 47 cases (46.1%) and TSP was present in 17 cases (16.7%) and neither was correlated with LNM. High FOXA1 expression was significantly associated with presence of LNM, low TILs, and submucosal invasion. In multivariate analysis, low TILs (p=0.023), LVI (p=0.008), and submucosal invasion (p=0.001) were independent predictive factors for LNM in EGCs. Evaluation of TILs in biopsied or endoscopically resected EGC specimens may help to predict LNM and select subsequent proper treatment modalities and follow-up.

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.

A Risk-prediction Model Based on Lymph-node Metastasis for Incorporation Into a Treatment Algorithm for Signet Ring Cell-type Intramucosal Gastric Cancer

OBJECTIVE

The aim of the study was to develop a reliable and easy-to-use risk-scoring system (RSS) to predict lymph-node metastasis (LNM) and determine the feasibility of endoscopic submucosal dissection for mucosa-confined signet ring cell carcinomas (SRCs).

BACKGROUND

Fewer LNM and better survival rates have been reported for early gastric SRCs compared with other undifferentiated early gastric cancers (EGCs).

METHODS

Data from 1544 patients with mucosa-confined SRCs were reviewed. Stepwise logistic regression analysis determined the independent predictors of LNM. Risk scores were based on the final predictive factors for LNM, and performance was internally validated using a split-sample approach. External validation was also performed in an independent dataset (n = 208) to assess the discriminatory power of the RSS.

RESULTS

The overall LNM incidence was 3.8% (57/1544). Three risk factors (tumor size ≥1.7 cm, tumors of elevated type, and lymphatic-vascular involvement) were significantly associated with LNM. These factors were incorporated into the RSS, and were assigned scores ranging from 0 to 4. The area under the receiver-operating characteristic curve for predicting LNM after internal and external validation was 0.68 (95% confidence interval, 0.0793-0.2865) and 0.686 (95% confidence interval, 0.618-0.748), respectively. A score of 2 points was the optimal cut-off value for LNM prediction, and the overall diagnostic accuracy was 96%. LNM were found in 2.9% and 23.8% of the low and high-risk groups of the RSS, respectively.

CONCLUSIONS

A RSS may help to predict LNM and evaluate endoscopic submucosal dissection feasibility in patients with intramucosal SRC.

One-dimensional and 2-dimensional tumor size measurement for prediction of lymph node metastasis in differentiated early gastric cancer with minute submucosal invasion

BACKGROUND AND AIMS

Differentiated minute submucosal cancers measuring ≤3 cm that exhibit no lymphovascular invasion are considered eligible for endoscopic resection; however, the ≤3-cm criterion remains debatable. The aim of this study was to verify the optimal tumor size cutoff for endoscopic resection eligibility, and to determine whether 2-dimensional tumor size measurement would be more accurate for this purpose.

METHODS

The clinicopathologic data for 574 patients undergoing curative surgery for differentiated minute submucosal cancer were reviewed retrospectively. A receiver operating curve analysis and bootstrapped samples were used to identify the optimal cutoff values for predicting lymph node (LN) metastasis.

RESULTS

Four hundred fourteen patients were eligible for the study. LN metastasis accompanied 2.5% of differentiated minute submucosal cancers that were ≤3 cm in size and lacked lymphovascular invasion. There was no lymph node metastasis in the tumors with 1-dimensional sizes ≤1.0 cm and 2-dimensional sizes ≤1.0 cm². When 10,000 bootstrapped data were used, optimal cutoff values were 2.9 cm (LN metastasis: 2.1%) and 8.3 cm² (LN metastasis: 2.5% incidence) for 1- and 2-dimensional tumor size, respectively. Although the area under the curve was 0.611 (P = .046) for 2-dimensional size, specificity and accuracy were greater for the dichotomized 2-dimensional measure than for the dichotomized 1-dimensional measure (P < .001, McNemar test). In addition, 2-dimensional tumor size was the only significant risk factor for LN metastasis (odds ratio, 1.09; 95% confidence interval, 1.01-1.20).

CONCLUSIONS

One- and 2-dimensional cutoff values of 2.9 cm and 8.3 cm² might be suitable for patients at high risk of postoperative morbidity and mortality. Two-dimensional tumor size is an acceptable measurement method for estimating the risk of LN metastasis.

Predictive Factors for Lymph Node Metastasis in Undifferentiated Early Gastric Cancer: a Systematic Review and Meta-analysis

OBJECTIVES

Less invasive surgery is gaining popularity for the treatment of early gastric cancer (EGC), but there are no definitive guidelines for the use of less invasive surgery for the treatment of undifferentiated EGC. The aims of this meta-analysis were to identify potential predictive factors for lymph node metastasis (LNM) in undifferentiated EGC and to guide the personalized therapeutic modality for patients with undifferentiated EGC.

METHODS

An extensive search of the PubMed, Embase, and Cochrane Library databases was performed to identify relevant articles involving undifferentiated EGC and LNM. Eligible data were systematically reviewed through a meta-analysis using Review Manager 5.3.

RESULTS

In total, 23 studies were included in this analysis. The meta-analysis found that the variables sex (female), age (greater than 60 years), tumor size (greater than 20 mm), depth of invasion (submucosal invasion), presence of lymphovascular involvement, presence of ulcer findings, histology type (non-signet ring carcinoma), and tumor location (not in the middle part of the stomach) were significantly associated with LNM.

CONCLUSIONS

Eight variables were identified as predictive factors for LNM in undifferentiated EGC. The significance of these variables should be further confirmed during the process of LNM in undifferentiated EGC patients for future clinical application.

Clinicopathological characteristics of patients who underwent additional gastrectomy after incomplete endoscopic resection for early gastric cancer

To evaluate the clinicopathological characteristics and factors that lead to residual tumors in patients who underwent additional gastrectomy for incomplete endoscopic resection (ER) for early gastric cancer (EGC).Between 2003 and 2013, the medical records of patients underwent additional gastrectomy after incomplete ER were retrospectively reviewed. Those diagnosed with the presence of histologic residual tumor in specimens obtained by gastrectomy were assigned to the residual tumor (RT) group (n = 47); those diagnosed with the absence of histologic residual tumor were assigned to the nonresidual tumor (NRT) group (n = 33).In the multivariate analysis, endoscopic piecemeal resection, Helicobacter pylori infection, large tumor size (>2 cm), and both (lateral and vertical) marginal involvement were independent factors of the presence of residual tumor in additional gastrectomy after incomplete resection ER for EGC and the rates of independent factors were significantly higher in the RT group than in the NRT group (P < 0.05).Before ER, preexamination to accurately determine the GC invasion depth and the presence of LN metastasis is very important. During ER, surgeons should attempt to perform en bloc resection and to resect the mucous membrane with adequate safety margins to prevent tumor invasion into the lateral and vertical margins.

A nomogram composed of clinicopathologic features and preoperative serum tumor markers to predict lymph node metastasis in early gastric cancer patients

Predicting lymph node metastasis (LNM) accurately is of great importance to formulate optimal treatment strategies preoperatively for patients with early gastric cancer (EGC). This study aimed to explore risk factors that predict the presence of LNM in EGC. A total of 697 patients underwent gastrectomy enrolled in this study, were divided into training and validation set, and the relationship between LNM and other clinicopathologic features, preoperative serum combined tumor markers (CEA, CA19-9, CA125) were evaluated. Risk factors for LNM were identified using logistic regression analysis, and a nomogram was created by R program to predict the possibility of LNM in training set, while receiver operating characteristic (ROC) analysis was applied to assess the predictive value of the nomogram model in validation set. Consequently, LNM was significantly associated with tumor size, macroscopic type, differentiation type, ulcerative findings, lymphovascular invasion, depth of invasion and combined tumor marker. In multivariate logistic regression analysis, factors including of tumor size, differentiation type, ulcerative findings, lymphovascular invasion, depth of invasion and combined tumor marker were demonstrated to be independent risk factors for LNM. Moreover, a predictive nomogram with these independent factors for LNM in EGC patients was constructed, and ROC curve demonstrated a good discrimination ability with the AUC of 0.847 (95% CI: 0.789-0.923), which was significantly larger than those produced in previous studies. Therefore, including of these tumor markers which could be convenient and feasible to obtain from the serum preoperatively, the nomogram could effectively predict the incidence of LNM for EGC patients.

Feasibility study on expanded indication for endoscopic submucosal dissection of intramucosal poorly differentiated early gastric cancer

AIM: To identify clinicopathological factors predictive of lymph node metastasis (LNM) in intramucosal poorly differentiated early gastric cancer (EGC), and further to expand the possibility of using endoscopic submucosal dissection (ESD) for the treatment of intramucosal poorly differentiated EGC.

METHODS: Data for 81 surgically treated patients with intramucosal poorly differentiated EGC were collected, and the association between the clinicopathological factors and the presence of LNM was retrospectively analyzed by univariate and multivariate logistic regression analyses. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Several clinicopathologic factors were investigated to identify predictive factors for lymph nodes metastasis, including gender, age, family history of gastric cancer, number of tumors, tumor location, ulceration, tumor size, macroscopic type, lymphatic vessel involvement, and signet-ring-cell component.

RESULTS: Tumor size (OR = 7.273, 95%CI: 1.246-29.918, P = 0.042), lymphatic vessel involvement (OR = 42.219, 95%CI: 1.923-97.052, P = 0.018) and signet-ring-cell component (OR = 17.513, 95%CI: 1.647-77.469, P = 0.034) that were significantly associated with LNM by univariate analysis, were found to be significant and independent risk factors for LNM by multivariate analysis. However, gender, age, family history of gastric cancer, number, location, ulceration and macroscopic type of tumor were found not to be associated with LNM. Of these 81 patients diagnosed with intramucosal poorly differentiated EGC, 7 (8.6%) had LNM. The LNM rates were 9.1%, 22.2% and 57.1%, respectively, in cases with one, two and three of the risk factors. There was no LNM in 54 patients without the three risk clinicopathological factors.

CONCLUSION: Tumor size, lymphatic vessel involvement and signet-ring-cell component are independently associated with the presence of LNM in intramucosal poorly differentiated EGC. Thus, these three risk factors may be used as a simple criterion to expand the possibility of using ESD for the treatment of intramucosal poorly differentiated EGC.

A Risk Prediction Model Based on Lymph-Node Metastasis in Poorly Differentiated-Type Intramucosal Gastric Cancer

Background and Aim

Endoscopic submucosal dissection (ESD) for undifferentiated type early gastric cancer is regarded as an investigational treatment. Few studies have tried to identify the risk factors that predict lymph-node metastasis (LNM) in intramucosal poorly differentiated adenocarcinomas (PDC). This study was designed to develop a risk scoring system (RSS) for predicting LNM in intramucosal PDC.

Methods

From January 2002 to July 2015, patients diagnosed with mucosa-confined PDC, among those who underwent curative gastrectomy with lymph node dissection were reviewed. A risk model based on independent predicting factors of LNM was developed, and its performance was internally validated using a split sample approach.

Results

Overall, LNM was observed in 5.2% (61) of 1169 patients. Four risk factors [Female sex, tumor size ≥ 3.2 cm, muscularis mucosa (M3) invasion, and lymphatic-vascular involvement] were significantly associated with LNM, which were incorporated into the RSS. The area under the receiver operating characteristic curve for predicting LNM after internal validation was 0.69 [95% confidence interval (CI), 0.59–0.79]. A total score of 2 points corresponded to the optimal RSS threshold with a discrimination of 0.75 (95% CI 0.69–0.81). The LNM rates were 1.6% for low risk (<2 points) and 8.9% for high-risk (≥2 points) patients, with a negative predictive value of 98.6% (95% CI 0.98–1.00).

Conclusions

A RSS could be useful in clinical practice to determine which patients with intramucosal PDC have low risk of LNM.

Predictors of Lymph Node Metastasis in Western Early Gastric Cancer

BACKGROUND

The application of endoscopic and local resection for early gastric cancer (EGC) is limited by the risk of regional lymph node (LN) metastasis. We sought to determine the incidence and predictors of LN metastasis in a contemporary cohort of Western patients with early gastric cancer.

METHODS

Sixty-seven patients with pT1 gastric adenocarcinoma underwent radical surgery without neoadjuvant therapy at our institution between 1995 and 2011, and clinicopathologic factors predicting LN metastasis were analyzed.

RESULTS

LN metastases were present in 15/67 (22 %) pT1 tumors, including 1/23 (4 %) T1a tumors and 14/44 (32 %) T1b tumors. Tumor size, site, degree of differentiation, macroscopic tumor sub-classification, perineural invasion status, and depth of submucosal tumor penetration did not predict LN metastasis. The presence of lymphovascular invasion (LVI) and positive nodal status by endoscopic ultrasound (EUS) were the only factors that predicted LN metastasis on multivariate analysis. T1a tumors without LVI had a 0 % rate of positive LN, whereas T1b tumors with LVI had a 64.3 % rate of positive LN.

CONCLUSIONS

EGC limited to the mucosa, without evidence of LVI, and N0 on EUS, may be considered for limited resection. However, any EGC with submucosal invasion, LVI, or positive nodes on EUS should undergo radical resection with lymphadenectomy.

A nomogram for predicting the likelihood of lymph node metastasis in early gastric patients

Background

Early gastric cancer is defined as a lesion confined to the mucosa or submucosa, regardless of the size or lymph node metastasis. Treatment methods include endoscopic mucosal resection or endoscopic submucosal dissection, wedge resection, laparoscopically assisted gastrectomy and open gastrectomy. Lymph node metastasis is strong related with survival and recurrence. Therefore, the likelihood of lymph node metastasis is one of the most important factors when determining the most appropriate treatment.

Methods

We retrospectively analyzed 597 patients who underwent D2 gastrectomy for early gastric cancer. The relationship between lymph node metastasis and clinicopathological features was analyzed. Using multivariate logistic regression analyses, we created a nomogram to predict the lymph node metastasis probability for early gastric cancer. Receiver operating characteristic analyses was performed to assess the predictive value of the model.

Results

In the present study, 58 (9.7 %) early gastric cancer patients were histologically shown to have lymph node metastasis. The multivariate logistic regression analysis demonstrated that the age at diagnosis, differentiation status, the presence of ulcers, lymphovascular invasion and depth of invasion were independent risk factors for lymph node metastasis in early gastric cancer. Additionally, the tumor macroscopic type, size and histology type significantly correlated with these important independent factors. We constructed a predictive nomogram with these factors for lymph node metastasis in early gastric cancer patients, and the discrimination was good with the AUC of 0.860 (95 % CI: 0.809–0.912).

Conclusions

We developed an effective nomogram to predict the incidence of lymph node metastasis for early gastric cancer patients.

Upgrading the definition of early gastric cancer: better staging means more appropriate treatment

Since Murakami defined early gastric cancer (EGC) as a "carcinoma limited to the gastric mucosa and/or submucosa regardless of the lymph node status", several authors have focused on the most influential histopathological parameters for predicting the development of lymph node metastases by considering the lymph node status as an important prognostic factor. A few authors have also considered the depth of invasion as one of the keys to explaining the existence of subgroups of patients affected by EGC with poor prognoses. In any case, EGC is still considered an initial phase of tumor progression with good prognosis. The introduction of modern endoscopic devices has allowed a precise diagnosis of early lesions, which can lead to improved definitions of tumors that can be radically treated with endoscopic mucosal resection or endoscopic submucosal dissection (ESD). Given the widespread use of these techniques, the Japanese Gastric Cancer Association (JGCA) identified in 2011 the standard criteria that should exclude the presence of lymph node metastases. At that time, EGCs with nodal involvement should have been asserted as no longer fitting the definition of an early tumor. Some authors have also demonstrated that the morphological growth pattern of a tumor, according to Kodama's classification, is one of the most important prognostic factors, thereby suggesting the need to report it in histopathological drafts. Notwithstanding the acquired knowledge regarding the clinical behavior of EGC, Murakami's definition is still being used. This definition needs to be upgraded according to the modern staging of the disease so that the appropriate treatment would be selected.

Nomogram for predicting lymph node metastasis rate of submucosal gastric cancer by analyzing clinicopathological characteristics associated with lymph node metastasis

BACKGROUND

To combine clinicopathological characteristics associated with lymph node metastasis for submucosal gastric cancer into a nomogram.

METHODS

We retrospectively analyzed 262 patients with submucosal gastric cancer who underwent D2 gastrectomy between 1996 and 2012. The relationship between lymph node metastasis and clinicopathological features was statistically analyzed. With multivariate logistic regression analysis, we made a nomogram to predict the possibility of lymph node metastasis. Receiver operating characteristic (ROC) analysis was also performed to assess the predictive value of the model. Discrimination and calibration were performed using internal validation.

RESULTS

A total number of 48 (18.3%) patients with submucosal gastric cancer have pathologically lymph node metastasis. For submucosal gastric carcinoma, lymph node metastasis was associated with age, tumor location, macroscopic type, size, differentiation, histology, the existence of ulcer and lymphovascular invasion in univariate analysis (all P<0.05). The multivariate logistic regression analysis identified that age ≤50 years old, macroscopic type III or mixed, undifferentiated type, and presence of lymphovascular invasion were independent risk factors of lymph node metastasis in submucosal gastric cancer (all P<0.05). We constructed a predicting nomogram with all these factors for lymph node metastasis in submucosal gastric cancer with good discrimination [area under the curve (AUC) =0.844]. Internal validation demonstrated a good discrimination power that the actual probability corresponds closely with the predicted probability.

CONCLUSIONS

We developed a nomogram to predict the rate of lymph node metastasis for submucosal gastric cancer. With good discrimination and internal validation, the nomogram improved individualized predictions for assisting clinicians to make appropriated treatment decision for submucosal gastric cancer patients.

Defining a Subgroup Treatable for Laparoscopic and Endoscopic Cooperative Surgery in Undifferentiated Early Gastric Cancer: the Role of Lymph Node Metastasis

BACKGROUND

Recently, the use of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) and the development of laparoscopic and endoscopic cooperative surgery (LECS) have enabled either the preservation of the stomach or the minimization of the extent of partial resection. ESD has recently been practiced on a differentiated type of EGC. However, there is no clear evidence for endoscopic treatments of undifferentiated EGC. The purposes of this study are to investigate predictive factors of lymph node metastasis (LNM) in undifferentiated EGC and expand the possibility of using LECS for the treatment of undifferentiated EGC.

METHODS

Data from 116 patients with undifferentiated EGC and surgically treated were collected, and 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.

RESULTS

The tumor size (OR = 11.748, 95 % CI 2.034-62.213, P = 0.008), depth of invasion (OR = 13.928, 95 % CI 1.971-92.434, P = 0.016), and lymphatic vessel involvement (OR = 11.522, 95 % CI 2.645-59.172, P = 0.021) that were significantly associated with LNM by univariate analysis were found to be significant and independent risk factors for LNM by multivariate analysis. The LNM rate was 5.9 % (4/68) and 29.2 % (14/48) with intramucosal and submucosal undifferentiated EGC, respectively. LNM was observed in 66.7 % (2/3) of patients with both risk factors (tumor larger than or equal to 2.0 cm and the presence of lymphatic vessel involvement (LVI)), but in none of 36 patients without the two risk factors in intramucosal undifferentiated EGC. The 5-year survival rates were 88.9, 72.4, and 33.3 %, respectively, in cases with none, one, and two of the risk factors, respectively, in intramucosal undifferentiated EGC (P < 0.05).

CONCLUSIONS

ESD alone may be a sufficient treatment for intramucosal undifferentiated EGC if the tumor is less than 2.0 cm in size and when LVI is absent upon postoperative histological examination. LECS is feasible and safe for patients with undifferentiated EGC.

Endoscopic and oncologic outcomes according to indication criteria of endoscopic resection for early gastric cancer: a systematic review and meta-analysis

BACKGROUND

The criteria for endoscopic resection for early gastric cancer (EGC) have been expanded recently, and it has become acceptable to use techniques that are regarded as having equivalent technical and pathological outcomes to absolute indication (AI). However, the long-term oncological outcomes of expanded indication (EI) have yet to be clarified. This meta-analysis aimed to assess the long-term outcome of EI versus AI, to identify the endoscopic feasibility and safety according to the indication, and to provide the appropriate recommendations for each indication.

METHODS

Electronic databases including PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and KoreaMed were searched for articles published between January 2000 and October 2014. After screening, the reviewers extracted the information from 12 retrospective cohort studies. A total of 9635 EGC lesions, 4150 lesions in the EI group and 5485 lesions in the AI group, were included in this study.

RESULTS

Meta-analyses showed that the local recurrence rate [risk ratio (RR) 1.34; 95% CI 0.67-2.70] was not significantly higher in the EI group compared with the AI group, although the metachronous recurrence rate was higher in the EI group than in the AI group (RR 1.60; 95% CI 1.22-2.10). The rates of en bloc resection [odds ratio (OR) 0.57; 95% CI 0.41-0.78), complete resection (OR 0.37; 95% CI 0.25-0.57), and curative resection (OR 0.34; 95% CI 0.20-0.58) were significantly inferior in the EI group than in the AI group, whereas overall bleeding risk (RR 1.47; 95% CI 1.19-1.82) and procedure-related perforation rate (OR 2.04; 95% CI 1.56-2.68) were significantly higher in the EI group than in the AI group.

CONCLUSIONS

This meta-analysis suggests that the EI group showed acceptable long-term outcomes with local recurrence rate that was not significantly inferior, although the metachronous recurrence rate was higher compared with that in the AI group.

Risk of lymph node metastases from early gastric cancer in relation to depth of invasion: experience in a single institution

BACKGROUND

An accurate assessment of potential lymph node metastasis is important for the appropriate treatment of early gastric cancers. Therefore, this study analyzed predictive factors associated with lymph node metastasis and identified differences between mucosal and submucosal gastric cancers.

MATERIALS AND METHODS

A total of 518 early gastric cancer patients who underwent radical gastrectomy were reviewed in this study. Clinicopathological features were analyzed to identify predictive factors for lymph node metastasis.

RESULTS

The rate of lymph node metastasis in early gastric cancer was 15.3% overall, 3.3% for mucosal cancer, and 23.5% for submucosal cancer. Using univariate analysis, risk factors for lymph node metastasis were identified as tumor location, tumor size, depth of tumor invasion, histological type and lymphovascular invasion. Multivariate analysis revealed that tumor size >2 cm, submucosal invasion, undifferentiated tumors and lymphovascular invasion were independent risk factors for lymph node metastasis. When the carcinomas were confined to the mucosal layer, tumor size showed a significant correlation with lymph node metastasis. On the other hand, histological type and lymphovascular invasion were associated with lymph node metastasis in submucosal carcinomas.

CONCLUSIONS

Tumor size >2 cm, submucosal tumor, undifferentiated tumor and lymphovascular invasion are predictive factors for lymph node metastasis in early gastric cancer. Risk factors are quite different depending on depth of tumor invasion. Endoscopic treatment might be possible in highly selective cases.

Redefining early gastric cancer

BACKGROUND

The problem is that current definitions of early gastric cancer allow the inclusion of regional lymph node metastases. The increasing use of endoscopic submucosal dissection to treat early gastric cancer is a concern because regional lymph nodes are not addressed. The aim of the study was thus to critically evaluate current evidence with regard to tumour-specific factors associated with lymph node metastases in "early gastric cancer" to develop a more precise definition and improve clinical management.

METHODS

A systematic and comprehensive search of major reference databases (MEDLINE, EMBASE, PubMed and the Cochrane Library) was undertaken using a combination of text words "early gastric cancer", "lymph node metastasis", "factors", "endoscopy", "surgery", "lymphadenectomy" "mucosa", "submucosa", "lymphovascular invasion", "differentiated", "undifferentiated" and "ulcer". All available publications that described tumour-related factors associated with lymph node metastases in early gastric cancer were included.

RESULTS

The initial search yielded 1494 studies, of which 42 studies were included in the final analysis. Over time, the definition of early gastric cancer has broadened and the indications for endoscopic treatment have widened. The mean frequency of lymph node metastases increased on the basis of depth of infiltration (mucosa 6% vs. submucosa 28%), presence of lymphovascular invasion (absence 9% vs. presence 53%), tumour differentiation (differentiated 13% vs. undifferentiated 34%) and macroscopic type (elevated 13% vs. flat 26%) and tumour diameter (≤2 cm 8% vs. >2 cm 25%).

CONCLUSION

There is a need to re-examine the diagnosis and staging of early gastric cancer to ensure that patients with one or more identifiable risk factor for lymph node metastases are not denied appropriate chemotherapy and surgical resection.

Intramucosal gastric cancer: the rate of lymph node metastasis in signet ring cell carcinoma is as low as that in well-differentiated adenocarcinoma

OBJECTIVE

Endoscopic resection (ER) plays a major role in the management of early gastric cancer. Less lymph node metastasis (LNM) and better survival rates were reported in early gastric signet ring cell carcinoma (SRC) than adenocarcinoma. We investigated and compared the clinicopathologic characteristics of endoscopic and surgical features in early gastric SRC and adenocarcinoma in accordance with histologic differentiation to examine the feasibility of ER in early gastric SRC.

PATIENTS AND METHODS

From January 2003 to September 2011, patients diagnosed with early gastric cancer among patients who had undergone a curative gastrectomy with lymph node dissection were enrolled. Patients' age, sex, tumor size, location, macroscopic type, depth of invasion, lymphovascular invasion (LVI), and LNM were determined.

RESULTS

A total of 696 patients were enrolled. SRC was more frequent in women and more common at the mid-body than differentiated adenocarcinoma. SRC was more common in patients younger than 50 years of age (P < 0.001) and the elevated type was less common in SRC than other adenocarcinomas (P < 0.001). The incidence of submucosal invasion, LVI, and LNM in SRC were similar to well-differentiated adenocarcinoma. Moderately and poorly differentiated group, tumor size greater than 20 mm, submucosal invasion, and LVI were independent risk factors predicting LNM. Intramucosal SRC less than 20 mm had no LNM.

CONCLUSION

Rate of LNM and submucosal invasion in early SRC was as low as those in early well-differentiated adenocarcinoma. ER for early gastric SRC may be an alternative to surgical gastrectomy under certain conditions.

Laparoscopic distal, subtotal gastrectomy for advanced gastric cancer

The objective of this study was to show laparoscopic subtotal, distal gastrectomy with D2 lymphadenectomy as a safe and appropriate method for the resection of advanced gastric cancer. This study was conducted at a designated NCI Cancer Center. Subjects of the study were patients with advanced gastric malignancy, including transmural penetration of the tumor and/or nodal disease, requiring subtotal, distal gastrectomy. The main outcome measure is a description of the technique of a laparoscopic subtotal, distal gastrectomy for antral and distal body tumors. In conclusion, the laparoscopic approach to advanced gastric malignancy with a subtotal, distal gastrectomy and D2 lymphadenectomy is a safe, oncologically appropriate procedure which provides excellent outcomes.

Prognostic analysis of submucosa-invasive gastric cancer with lymph node metastasis

BACKGROUND

The aims of this study were to identify prognostic factors of patients with submucosa-invasive (T1b) gastric cancer and to verify the validity of adjuvant chemotherapy for this disease.

METHODS

We retrospectively examined the cases of 1,236 consecutive patients in our prospectively maintained database with T1b gastric cancer who underwent gastrectomy in 1995-2012. We used 11 clinicopathologic characteristics to identify prognostic factors by univariate and multivariate analyses. We compared the survival of the 160 node-positive T1b gastric cancer patients with that of 133 patients in the same database who had node-positive muscularis propria-invasive (T2) gastric cancer and had undergone gastrectomy without adjuvant chemotherapy during the same period, as a reference cohort.

RESULTS

The 5-year overall survival rate was 91.4% for all 1,236 patients. Advanced age (hazard ratio [HR] 4.51; 95% confidence interval [CI] 3.26-6.24; P < .01), male sex (HR 2.26; 95% CI 1.56-3.26; P < .01), and the presence of lymph node metastasis (HR 1.89; 95% CI 1.33-2.70; P < .01) were independent prognostic factors. The 5-year overall survival rates were 92.5% in node-negative patients, 84.5% in patients with 1 or 2 metastatic nodes, and 80.1% in patients with 3 or more metastatic nodes (P < .01). The 5-year overall survival rates of the node-positive T1b and T2 gastric cancer patients were 83.6% and 81.2%, respectively (P = .73).

CONCLUSION

The prognosis of node-positive T1b gastric cancer patients after curative gastrectomy was unsatisfactory. Adjuvant chemotherapy should be considered for these patients, especially those with 3 or more metastatic nodes.

Is endoscopic resection an alternative to surgery for early low-risk submucosal gastric cancers: analysis of a large surgical database

BACKGROUND

Although endoscopic resection (ER) for early gastric cancers (EGCs) has become popular with the development of endoscopic instruments and skillful endoscopists, the risk of lymph node metastasis (LNM) is still an obstacle in performing ER. In this study, we aimed to identify the risk factors of LNM and validated the expanded criteria, with the goal of suggesting modified criteria for ER in submucosal EGCs.

METHODS

Of patients who underwent gastrectomy with LN dissection and were diagnosed as EGCs with depth of invasion such as sm1, sm2 or ≤ 500 μm from 1999 to 2008, 318 EGCs with submucosal invasion ≤ 500 μm were enrolled through pathologic evaluations. To identify the risk factors of LNM, a multivariate analysis of clinicopathologic factors was performed. By combining the independent risk factors of LNM, the risk of LNM was analyzed.

RESULT

LNM were detected in 35 cases (11.0 %). Tumors >30 mm in size and with lymphatic invasion were identified as an independent risk factor for LNM in EGCs with depth of invasion ≤ 500 μm. Among 94 cases meeting the expanded criteria, two cases (2.1 %) were found to have LNM. Based on the submucosal invasion <300 μm, there was no LNM in EGCs with a size ≤ 30 mm and no lymphovascular invasion, regardless of differentiation grade.

CONCLUSION

To exclude the possibility of LNM, applying the modified criteria based on the submucosal invasion <300 μm in performing ER might be worthwhile.

Non-curative endoscopic resection does not always lead to grave outcomes in submucosal invasive early gastric cancer

BACKGROUND

Endoscopic submucosal dissection (ESD) has been widely performed for the treatment of early gastric cancer (EGC). The aim of this study is to examine the effectiveness of ESD in submucosal invasive gastric cancers (SM-GC), with a special focus on patients who underwent non-curative resection.

METHODS

Data for 1,246 patients who underwent ESD for treatment of EGC at six medical centers in Daegu-Gyeongbuk, Korea, between February 2003 and May 2010 were collected. After retrospective analysis of ESD databases, 118 patients were enrolled and classified into three groups: (1) EGC with submucosal invasion less than 500 μm (SM1-GC) that met the expanded criteria (EC) (SM1 EC, n = 42); (2) SM1-GC that did not meet the EC (SM1 non-EC, n = 38); and (3) EGC with submucosal invasion greater than 500 μm (SM2-GC, n = 38).

RESULTS

The en bloc and complete resection rates did not differ significantly among the three groups. However, the curative resection rate was significantly better in the SM1 EC group (69.0%) compared to that in SM1 non-EC and SM2-GC groups (0% in both cases). Out of a total of 118 patients, 89 (75.4%) underwent non-curative resection, and cancer recurrence was observed in 9 (9/89, 10.1%). We analyzed the survival rate in these non-curative patients and the overall survival and disease-free survival did not differ significantly between patients that were treated with additional surgical resection and those that were simply followed up after ESD.

CONCLUSIONS

Non-curative resection in SM-GC does not always lead to cancer recurrence. Thus, if additional surgery cannot be performed because of the patient's unsuitable condition or refusal, a close follow-up with endoscopy can be considered as an alternative for carefully selected patients. Moreover, as the ESD technology continues to evolve, it might be possible to expand the criteria for curative ESD in patients with SM-GC.