Estimation of subepithelial lateral extent in submucosal early gastric cancer: retrospective histological analysis

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

BACKGROUNDS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Individualized proximal margin correlates with outcomes in gastric cancers with radical gastrectomy

The length of proximal margin for gastrectomy remains controversial. The proximal margin and its relationships with clinicopathological variables and overall survival of 922 gastric cancers were retrospectively analyzed. Proximal margin was divided into four groups (0-2.0, 2.1-4.0, 4.1-6.0, and >6.0 cm). It indicated that the overall survival was improved with the increase of proximal margin. The proximal margin of 2.1-4.0 cm was associated with a better overall survival for gastric cancers with solitary-type (T1 and T2 stages, N0 stage, tumor-node-metastasis stages I and II, tumor size <5 cm, histological G1 and G2, and Bormann type I and II). Futhermore, proximal margin of 4.1-6.0 cm was associated with a better overall survival for gastric cancers with infiltrative-type (T3 and T4 stages, N1 stage, tumor-node-metastasis stage III, tumor size ⩾5 cm, histological G3 and G4, and Bormann type III and IV). Univariate analysis revealed that T stage, N stage, tumor-node-metastasis stage, histological grade, Bormann type, carcinoembryonic antigen, carbohydrate antigen 199, extent of gastrectomy, tumor location, and proximal margin were significantly associated with overall survival. Multivariate analysis revealed that tumor-node-metastasis stage, histological grade, Bormann type, carcinoembryonic antigen, carbohydrate antigen 199, extent of gastrectomy, and proximal margin were independent prognostic factors for gastric cancers with radical gastrectomy. In conclusion, the proximal margin was an independent prognostic factor for gastric cancer and should be decided individually. Proximal margin of 2.1-4.0 cm and 4.1-6.0 cm were needed for patients with solitary-type and infiltrative-type, respectively.

Endoscopic Submucosal Dissection (ESD) and Related Techniques as Precursors of "New Notes" Resection Methods for Gastric Neoplasms

Endoscopic full-thickness resection for subepithelial tumors is one of the more attractive proposed methods for less-invasive transluminal surgery but remains challenging in terms of safety and feasibility. Currently, laparoscopic endoscopic cooperative surgery is thought to be a more clinically acceptable approach. In targeting cancers, however, more advanced nonexposure techniques are required to avoid the risk of iatrogenic tumor seeding. By combining these techniques with possible regional lymphadenectomy using sentinel node navigation surgery, an ideal minimally invasive, function-preserving gastric resection can be achieved even in possible node-positive cancers. Further development for this type of advanced endoscopic surgery is expected.