A rare case of histologically mixed-type intramucosal gastric cancer accompanied by nodal recurrence and liver metastasis after endoscopic submucosal dissection

A case of early gastric cancer with metastatic recurrence following curative endoscopic submucosal dissection

A 70-year-old man was diagnosed with early gastric cancer with ulcerative findings. Endoscopic submucosal dissection as an absolute indication was performed, and en bloc resection was achieved. Pathological examination revealed a well-differentiated adenocarcinoma, 3 × 2 mm in size, intramucosal, with an ulcerative scar, no lymphovascular invasion, and a tumor-free margin. We diagnosed it as a curative resection and followed up with annual endoscopy. Sixteen months after endoscopic submucosal dissection, esophagogastroduodenoscopy revealed a singular ulcer scar; however, serum carcinoembryonic antigen level was elevated. Computed tomography scan showed wall thickening of the gastric antrum and an irregular mass on the dorsal side. Additionally, 18F-fluorodeoxyglucose positron emission tomography/coomputed tomography showed 18F-fluorodeoxyglucose uptake in the gastric antrum, irregular mass, and liver. Endoscopic ultrasonography revealed an internally heterogeneous mass in the gastric antrum region extending from the submucosal layer to the muscularis propria layer. Using an endoscopic ultrasonography-guided fine needle biopsy with a 22-gauge needle for the mass, we diagnosed local recurrence with the submucosal tumor-like appearance, lymph node metastasis, and liver metastases. Unfortunately, the patient died of gastric cancer 3 months after the diagnosis. Here, we report a rare case of local recurrence in the submucosal layer, lymph node metastasis, and liver metastases 16 months after curative endoscopic submucosal dissection.

Two Cases of Lymph Node Metastasis Found in Differentiated, Small-Sized Gastric Adenocarcinomas: Did Tumor Budding Play a Critical Role?

Background: Endoscopic resection (ER) is a minimally invasive therapeutic approach for early gastric cancer (EGC), particularly for cases with a low risk of lymph node metastasis (LNM). Tumor budding (TB) has gained attention as a potential prognostic indicator for LNM in EGC. Case Presentation: We report two cases-a 73-year-old and an 81-year-old male patient-who presented with gastric adenocarcinoma. Both patients had small-sized, differentiated, and intramucosal adenocarcinomas. However, high-grade TBs per high-power field under ×200 magnification at the invasive front and LNMs were found in both cases. Conclusions: These cases conformed to the post-ER observation guidelines of the current treatment protocol, yet demonstrated LNMs. We found that TB could serve as an effective prognostic marker for LNM compared to traditional risk factors. The aim of this study is to re-examine the ability of TB to predict LNM in EGC, thereby providing an impetus for reconsideration and potential revision of the current treatment guidelines for EGC.

MicroRNA signatures associated with lymph node metastasis in intramucosal gastric cancer

Although a certain proportion of intramucosal carcinomas (IMCs) of the stomach does metastasize, the majority of patients are currently treated with endoscopic resection without lymph node dissection, and this potentially veils any existing metastasis and may put some patients in danger. In this regard, biological markers from the resected IMC that can predict metastasis are warranted. Here, we discovered unique miRNA expression profiles that consist of 21 distinct miRNAs that are specifically upregulated (miR-628-5p, miR-1587, miR-3175, miR-3620-5p, miR-4459, miR-4505, miR-4507, miR-4720-5p, miR-4742-5p, and miR-6779-5p) or downregulated (miR-106b-3p, miR-125a-5p, miR-151b, miR-181d-5p, miR-486-5p, miR-500a-3p, miR-502-3p, miR-1231, miR-3609, and miR-6831-5p) in metastatic (M)-IMC compared to nonmetastatic (N)-IMC, or nonneoplastic gastric mucosa. Intriguingly, most of these selected miRNAs showed stepwise increased or decreased expression from nonneoplastic tissue to N-IMC to M-IMC. This suggests that common oncogenic mechanisms are gradually intensified during the metastatic process. Using a machine-learning algorithm, we demonstrated that such miRNA signatures could distinguish M-IMC from N-IMC. Gene ontology and pathway analysis revealed that TGF-β signaling was enriched from upregulated miRNAs, whereas E2F targets, apoptosis-related, hypoxia-related, and PI3K/AKT/mTOR signaling pathways, were enriched from downregulated miRNAs. Immunohistochemical staining of samples from multiple institutions indicated that PI3K/AKT/mTOR pathway components, MAPK1, phospho-p44/42 MAPK, and pS6 were highly expressed and the expression of SMAD7, a TGF-β pathway component, was decreased in M-IMC, which could aid in distinguishing M-IMC from N-IMC. The miRNA signature discovered in this study is a valuable biological marker for identifying metastatic potential of IMCs, and provides novel insights regarding the metastatic progression of IMC.

Recurrence after ESD curative resection for early gastric cancer

BACKGROUND

Endoscopic submucosal dissection (ESD) is gaining ground as a minimally invasive treatment for early gastric cancer (EGC) that has a negligible risk of lymph node metastasis. According to the 5th edition of Japanese gastric cancer treatment guidelines, annual or biannual follow-up with endoscopy is recommended, but follow-up with abdominal ultrasonography or computed tomography (CT) for surveillance of metastases is not recommended after the eCuraA resection. However, we experienced a case of lymph node recurrence following ESD resulting in eCuraA.

CASE PRESENTATION

A 76-year-old female received ESD for EGC in a previous hospital 4 years ago. Pathological findings were tub1, 30 mm, T1a (M), UL0, Ly0, V0, pHM-, pVM- (eCuraA) according to the 15th edition of Japanese Classification of Gastric Carcinoma. Follow-up esophagogastroduodenoscopy revealed submucosal tumor, which was suspected as a swollen lymph node by CT and endoscopic ultrasound fine-needle aspiration revealed the recurrence of gastric cancer. We performed total gastrectomy with D2 lymph node dissection. Postoperative pathological examination revealed no local recurrent tumor at the ESD site in the stomach. Swollen lymph node was diagnosed as metastasis and lymph node metastasis was limited near the cardia.

CONCLUSION

This case provides valuable information about tumor with a minimum poorly differentiated adenocarcinoma component may develop lymph node metastasis even satisfying the guidelines criteria for curative resection.

Favorable Long-Term Outcomes of Endoscopic Submucosal Dissection for Differentiated-Type-Predominant Early Gastric Cancer with Histological Heterogeneity

It remains unclear whether endoscopic submucosal dissection (ESD) can be indicated for differentiated-type-predominant early gastric cancer mixed with a minor undifferentiated component (EGC with histological heterogeneity (HH)). Here, we reviewed and compared clinicopathologic characteristics and long-term outcomes of ESD of 257 patients with EGC-HH and those of 2386 patients with pure differentiated-type EGC (PuD-EGC). After ESD, EGC-HH was managed in the same way as PuD-EGC. EGC-HHs were significantly associated with larger tumor size, more frequent submucosal invasion, and lymphovascular invasion compared to PuD-EGCs. Despite these aggressive features of EGC-HH, no local recurrence or gastric cancer-related death occurred during a median of 58 months of follow up after ESD for EGC-HH, if curative resection was achieved. After curative ESD for EGC-HH, six patients had metachronous recurrence (5.0%) and one patient underwent extragastric recurrence in a regional lymph node (0.8%). All these recurrence cases were curatively treated with ESD or gastrectomy. For patients with EGC-HH, five-year overall survival and recurrence-free survival rates after curative ESD were 97.0% and 94.8%, respectively, which were comparable to those of patients with PuD-EGC. In conclusion, ESD showed favorable long-term outcomes after curative resection and may be an acceptable treatment option for EGC-HH meeting curative endoscopic resection criteria.

Endoscopic Submucosal Dissection of Early Gastric Cancer with Mixed-Type Histology: A Systematic Review

BACKGROUND

Endoscopic submucosal dissection (ESD) criteria are histologically categorized by early gastric cancer (EGC) with differentiated- and undifferentiated-type histology. However, EGC is histologically heterogenous and there have been no separate criteria for EGC with mixed-type histology [EGC-MH; differentiated-type predominant EGC mixed with an undifferentiated component (EGC-MD) or undifferentiated-type predominant EGC mixed with a differentiated component (EGC-MU)]. Moreover, therapeutic outcomes of ESD for EGC-MH have not been clearly described.

AIM

This study aimed to evaluate the feasibility of ESD for EGC-MH.

METHODS

We searched core databases for specific inclusion factors: patients with EGC-MH, intervention of ESD, and at least one of the following outcomes: rate of en bloc, complete, curative resection, recurrence, procedure-related adverse event, lymphovascular invasion (LVI), or lymph node metastasis (LNM) that enabled evaluation of feasibility of ESD.

RESULTS

A total of eight (systematic review) and four studies (meta-analysis) were included. There was no robustness in age, location, or morphology of EGC-MH. Moderately differentiated adenocarcinoma was frequent in pre-ESD biopsy. EGC-MH showed larger size, deeper invasion, and higher rates of LVI/LNM than pure-type EGC. Total en bloc, complete resection, and curative resection rates were 94.6% (95% confidence interval 86.6-97.9%), 77.8% (57.9-89.9%), and 55.1% (50.4-59.6%), respectively. There was no LNM or extra-gastric recurrence after ESD if the EGC-MD met the curative resection criteria. However, the EGC-MD itself was a risk factor for non-curative resection. (Margin positivity was the most common reason.) CONCLUSIONS: Although ESD seems to be technically feasible, inaccurate prediction of lateral or vertical margin leads to lower curative resection rate. Application of more strict indication is needed for EGC-MH.

Impact of examining additional deeper sections on the pathological diagnosis of endoscopically resected early gastric cancer

OBJECTIVES

The pathological diagnosis of endoscopically resected early gastric cancer (EGC) is performed by evaluating a few representative sections from the specimen. We aimed to determine whether evaluating twice as many sections as usual by essentially cutting the original sections in half could improve the pathological diagnosis of EGC.

METHODS

We retrospectively investigated 85 EGC in 82 patients who had undergone endoscopic resection at our hospital from August 2008 to October 2012. EGC without indications of curative resection were excluded. We re-examined the original paraffin blocks after shaving away approximately half their original thickness, and evaluated whether the pathological diagnoses were affected. This technique essentially doubled the number of sections examined.

RESULTS

Ten pathological diagnoses of 68 EGC (14.7%) were changed from curative resection to non-curative resection when we evaluated twice as many sections as in the standard method. The median tumor size was 25 mm in the changed diagnosis group versus 14.5 mm in the no change group (P = 0.03). The univariate analysis also showed that tumor size was a significant predictor of changed diagnosis (P = 0.015). Both the changed diagnosis group and no change group had no recurrence during follow up.

CONCLUSIONS

Histological evaluation of twice as many sections as usual changed the initial pathological diagnosis of EGC, although the clinical implication of an additional deeper section was controversial because there was no recurrence. Our analysis also emphasized the importance of detailed histological evaluation to confirm a radical cure in endoscopic resection, especially in the case of larger EGC.

A case of mixed-type early gastric cancer with recurrence following curative endoscopic submucosal dissection for expanded indication

Background and study aims  In Japan, intramucosal gastric adenocarcinoma with ulcerative finding having a predominantly differentiated type with an undifferentiated component, tumor diameter ≤ 3 cm, and no lymphovascular invasion is included in the expanded pathological criteria for curative endoscopic treatment. This indication is based on retrospective examination of surgical resection cases, and is determined to have a negligible risk of lymph node metastasis (LNM). We performed endoscopic submucosal dissection on a 78-year-old man with early gastric cancer in 2011, and pathology revealed a well-differentiated tubular adenocarcinoma (21 × 10 mm in diameter), with poorly differentiated adenocarcinoma components, limited to the mucosa, fibrosis by ulcer scar in the submucosal layer, no lymphovascular invasion, and tumor-free margins. Resection was determined to be curative under expanded indications of the gastric cancer treatment guidelines, 4 ^th edition. However, 55 months after the initial diagnosis, invasive local and distant recurrence was noted. Ultimately, the patient died of gastric cancer 3 months after recurrence.

A Rare Case of Local Recurrence Following Curative Endoscopic Submucosal Dissection of Intramucosal Differentiated-Type Gastric Cancer

A 78-year-old man underwent endoscopic submucosal dissection (ESD) of early gastric cancer (EGC) (type 0-IIa) in the anterior wall of the antrum. En bloc resection was achieved. The histopathological examination revealed very well-differentiated tubular adenocarcinoma (tub1) of 30 × 22 mm in size, confined to the mucosa. No lymphovascular invasion or ulceration was observed, and there was no undifferentiated-type component and the margins were tumor-free. Therefore, this lesion fulfilled the eCuraA criteria. Two years after ESD, esophagogastroduodenoscopy revealed an irregular, slightly-depressed lesion within the post-ESD scar. Tubular adenocarcinoma was suspected based on histopathological examination of a biopsy specimen. The tumor was resected by ESD. A histopathological examination revealed well-differentiated tubular adenocarcinoma (tub1) of 6 × 4 mm in size, confined to the mucosa. No lymphovascular invasion was detected and the margins were tumor-free. These findings indicated a curative resection. Recurrence following a curative ESD of an intramucosal differentiated-type EGC which fulfilled the eCuraA criteria is rare. Careful endoscopic observation using magnifying narrow band imaging (NBI) is needed after ESD, even when curative resection is achieved.

A primary tumor of mixed histological type is a novel poor prognostic factor for patients undergoing resection of liver metastasis from gastric cancer

BACKGROUND

Surgical resection can be an option for the treatment of metastatic liver tumors originating from gastric cancer; however, its prognostic impact is controversial. The aim of this study was to identify prognostic factors in patients with surgical resection of liver metastasis from gastric cancer.

METHODS

We retrospectively analyzed the clinicopathological features of 38 consecutive patients undergoing hepatectomy for metastatic tumors from gastric cancer in our institution between 1990 and 2014.

RESULTS

The median overall survival of the patients was 28 months. The 5-year survival rate was 33.9%. Primary tumors of a mixed histological type, and residual tumors during the course of treatment were identified as significant independent poor prognostic factors.

CONCLUSIONS

Histological evaluation of primary tumors may aid to identify patients suitable for undergoing surgical resection of liver metastasis from gastric cancer.

Lymph node metastasis in differentiated-type early gastric cancer: a single-center retrospective analysis of surgically resected cases

BACKGROUND

Lymph node metastasis (LNM) from early gastric cancer (EGC) is rare, especially for differentiated-type EGC. However, LNM has been reported in a few cases after endoscopic curative resection of differentiated-type EGC. This study aimed to evaluate LNM risk factors to identify those that should be considered during the preoperative evaluation of differentiated-type EGC.

PATIENTS AND METHODS

A total of 976 EGC patients who underwent radical gastrectomy were reviewed in this study. Univariate and multivariate analyses were used to analyze the predictive factors for LNM based on the histology of the differentiated-type EGC cases.

RESULTS

Differentiated-type EGC was observed in 59% of the cases. The rate of LNM was 6.6% (38/576 patients) in the differentiated-type EGC cases. Macroscopic shape, ulcers, tumor size, deeper invasion and lymphovascular invasion were shown to be related to LNM in differentiated-type EGC. Multivariate analysis revealed that size, depth, ulceration and lymphovascular invasion were independent predictors of LNM in differentiated-type EGC. When lymphovascular invasion was absent, the presence of one or more of the risk factors of ulcer lesions, tumor size >30 mm and submucosal invasion increased the rate of LNM. Thirteen patients who underwent radical gastrectomy were shown to have differentiated-type EGC with LNM that met the standard and expanded criteria of endoscopic submucosal dissection.

CONCLUSIONS

As endoscopic resection is widely used, it is important to clarify the clinical significance of LNM in differentiated-type EGC and to screen for LNM with this incidence in mind and to follow the clinical courses of such cases, especially in China.

Outcomes of endoscopic submucosal dissection for differentiated-type early gastric cancer with histological heterogeneity

BACKGROUND

Long-term clinical outcomes after endoscopic submucosal dissection (ESD) is unclear for differentiated-type-predominant early gastric cancer (EGC) mixed with undifferentiated component (MUC-EGC). Therefore, the role and appropriate indication of ESD for MUC-EGC remain to be evaluated.

METHODS

Between 2007 and 2011, 1,577 differentiated-type EGC lesions [1,408 pure differentiated-type (PuD)-EGCs and 169 MUC-EGCs] in 1,527 consecutive patients were treated by ESD. After ESD, MUC-EGC was managed in the same way as PuD-EGC. The clinicopathological features and long-term outcomes after ESD of MUC-EGC were compared with those of PuD-EGC.

RESULTS

En bloc resection and en bloc with R0 resection rates in MUC-EGC cases were 94.1 % and 81.7 %, respectively. MUC-EGC was significantly associated with larger tumor size, more frequent submucosal invasion, and lymphovascular invasion compared to PuD-EGC. Despite these aggressive features of MUC-EGC, no lymph node metastasis or extragastric recurrence occurred during follow-up after ESD if MUC-EGC met the curative endoscopic resection (ER) criteria for tumors of absolute or expanded indications. Four MUC-EGC cases meeting the curative ER criteria underwent additional radical gastrectomy after ESD, and no case showed lymph node metastasis. During a median 48 months of follow-up, overall survival rates for MUC-EGC meeting the curative ER criteria for tumors of absolute or expanded indications (3-year survival rates, 100 % and 100 %) were comparable to those of PuD-EGC.

CONCLUSIONS

Long-term outcomes after ESD were favorable for MUC-EGCs meeting the curative ER criteria for tumors of absolute or expanded indications. Therefore, ESD may be used as a promising treatment option for these cases.

MET-Amplified Intramucosal Gastric Cancer Widely Metastatic after Complete Endoscopic Submucosal Dissection

Intramucosal gastric cancer (IGC) is associated with a very low risk of lymph node metastasis; thus it is the main candidate for minimally invasive surgical procedures, such as endoscopic submucosal dissection (ESD). Herein, we document an extraordinary case of IGC, which showed a very aggressive clinical course. A 66-year-old female underwent ESD for early gastric cancer. Histologically, the tumor consisted mainly of moderately differentiated adenocarcinoma measuring 1.6 cm in diameter, and the tumor was confined to the mucosa. Despite annual esophagogastroduodenoscopic follow-up, the tumor recurred, with wide metastasis to multiple lymph nodes and bones throughout the body after three years. Fluorescence in situ hybridization study demonstrated MET gene amplification as well as low grade polysomy 7 in both original and recurrent tumors. The clinical characteristics of metastatic IGCs and the implication of MET amplification are discussed.

A case of single lymph node metastasis near the common hepatic artery following a curative endoscopic resection for gastric mucosal cancer

Although the absolute indication for endoscopic resection (ER) in gastric cancer is widely accepted, expanded indication for endoscopic submucosal dissection (ESD) is still regarded as investigational because of the risk of concomitant lymph node (LN) metastasis or recurrence following ESD. However, LN metastasis in early gastric cancer confined to absolute indication for ER cannot be negligible. Herein we report a 72-year-old man who underwent laparoscopic distal gastrectomy for LN metastasis around the common hepatic artery following curative ESD to the lesion that had met as an absolute indication for ER 1 year ago. There was only one metastatic LN near the common hepatic artery (LN 8), without malignancy at the ESD site or other harvested LNs.

Preliminary results of multicenter questionnaire study on long-term outcomes of curative endoscopic submucosal dissection for early gastric cancer

BACKGROUND AND AIM

There are a number of published reports on long-term outcomes of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC), but most reports are from single centers with median follow-up periods shorter than 5 years. This questionnaire study investigated long-term outcomes of curative ESD for EGC at six Japanese institutions with follow-up rates of at least 90% over a minimum 5-year period.

METHODS

All consecutive patients with initial-onset EGC who underwent ESD through December 2006 at the six institutions were included in our study. The questionnaire covered pathological curability and long-term outcomes of patients with curative resections or curative resections for expanded indications over follow-up periods of at least 5 years.

RESULTS

There were 3788 patients with initial-onset EGC including 1710 (45.1%) patients with curative resections and 1289 (34.0%) patients with curative resections for expanded indications. The remaining 789 (20.8%) patients had non-curativeresections. Altogether, 1601 (93.6%) patients with curative resections and 1205 (93.5%) patients with curative resections for expanded indications were successfully followed up for at least 5 years. No recurrences were reported in any of the 1601 patients with curative resections whereas three recurrences (0.2%) were reported in the 1205 patients with curative resections for expanded indications. Gastric cancer-related deaths occurred in seven (0.2%) of the 2806 patients with curative resections or curative resections for expanded indications including six patients with metachronous gastric cancer-related deaths.

CONCLUSION

This questionnaire study's results indicated favorable long-term outcomes for patients with curative resections or curative resections for expanded indications.

Long-term outcomes of endoscopic submucosal dissection for early gastric cancer: a retrospective comparison with conventional endoscopic resection in a single center

BACKGROUND

Few studies have compared the outcomes of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) in patients with early gastric cancer.

METHODS

We studied 780 lesions for which endoscopic treatment was indicated according to the Japanese Gastric Cancer Association (JGCA) criteria or the extended National Cancer Center (NCC) criteria from April 1995 to December 2007. A total of 359 lesions were treated by endoscopic aspiration mucosectomy (EAM) between April 1995 and March 2003 (EAM group), and 421 lesions were treated by ESD between April 2003 and December 2007 (ESD group). Long-term outcomes (local recurrence rate, overall survival) were compared between the groups.

RESULTS

The median follow-up was 73 months in the EAM group and 65 months in the ESD group. Overall, the local recurrence rate was significantly lower in the ESD group (0.2 %, 1/421) than in the EAM group (4.2 %, 15/359) (p < 0.05). For lesions meeting the JGCA criteria, the local recurrence rate was 2.9 % in the EAM group and 0 % in the ESD group (p < 0.05). For lesions meeting the NCC criteria, the local recurrence rate was 12.5 % in the EAM group and 0.6 % in the ESD group (p < 0.05). There was no significant difference between the groups in overall survival.

CONCLUSIONS

On long-term follow-up, ESD was associated with a lower rate of local recurrence than EAM for lesions that met the JGCA or the NCC criteria. From the point of view of radical curability, ESD can be recommended for the management of lesions that meet either set of criteria.

A case of lymph node metastasis following a curative endoscopic submucosal dissection of an early gastric cancer

Currently in Japan, differentiated gastric submucosal invasive cancers <500 μm (SM1) with negative lymphovascular involvement are included in expanded pathological criteria for curative endoscopic treatment. This is based on a retrospective examination of surgical resection cases in which patients suitable for such expanded criteria were determined to have a negligible risk of lymph node metastasis. We performed endoscopic submucosal dissection on a 65-year-old male with early gastric cancer in April 2005, and pathology revealed a well-differentiated adenocarcinoma, 21 × 10 mm in size, SM1 invasion depth and negative lymphovascular invasion as well as tumor-free margins, so the case was diagnosed as a curative resection. This case, however, resulted in lymph node metastasis that was diagnosed by endoscopic ultrasonography with fine-needle aspiration biopsy in May 2009. Distal gastrectomy with D2 lymph node dissection was then performed, confirming lymph node metastasis from the original gastric cancer.

Early detection of recurrence after endoscopic treatment for early gastric cancer

OBJECTIVE

Although there have been many reports regarding clinical outcomes of endoscopic treatment for early gastric cancer (EGC), little is known about detection of recurrence after endoscopic submucosal dissection (ESD). This study aims to clarify the clinical value of serological marker or imaging tools, including conventional CT and PET-CT scans, in detecting recurrent gastric cancer after ESD in Korea.

MATERIAL AND METHODS

From July 2004 to March 2008, 212 patients who had received ESD for EGC were enrolled in the study. For preoperative staging, conventional CT and PET-CT scans were performed in 141 patients, and for detection of recurrence of cancer, conventional CT, PET-CT scans and tumour marker; CEA, CA19-9, AFP were checked in 165 patients.

RESULTS

The local recurrence rate was 4.7% (10/212) during the study period. At 9 months after endoscopic treatment, 3 cases recurred. Four showed recurrence at 12 months, 2 at 18 months and 1 at 24 months. The positive rate was 7.1% (10/141) in conventional CT and 0% (0/24) in PET-CT scans for preoperative staging. Conventional CT and PET-CT scans could not detect local recurrence of cancer during the follow-up period. Tumour markers did not show any significant correlation with recurrence of cancer.

CONCLUSIONS

The study suggests that conventional CT, PET-CT scans and tumour marker have no role in the primary surveillance of early gastric cancer and/or in detecting recurrence after endoscopic treatment. For early diagnosis of recurrence after endoscopic treatment, a biopsy specimen from the endoscopic examination has to be obtained at regular intervals.