Endoscopic Resection Versus Surgical Resection for Early Gastric Cancer: A Systematic Review and Meta-Analysis

Assessing the benefits of repeated esophagogastroduodenoscopy at a specialized center before gastric and esophageal cancer surgery

BACKGROUND

The surgical treatment of gastric and esophageal cancer in Denmark is centralized in four specialized esophagogastric cancer (EGC) centers. Patients are referred after an esophagogastroduodenoscopy (EGD) at a secondary healthcare facility. The EGD is repeated at the specialized EGC center before determining a surgical treatment strategy. This multicenter retrospective study aimed to investigate the quality of EGDs performed at a secondary healthcare facility and evaluate the clinical value of repeated EGD at a specialized center when determining the surgical treatment strategy.

METHODS

Patients from three of the four centers, who underwent esophagectomy or gastrectomy with curative intent from 1 June 2016 to 1 May 2021, were included. EGD reports from the referral facilities and EGC centers were compared based on a predefined checklist. Furthermore, endoscopist experience, the time between examinations, and histology were registered. Finally, it was assessed whether the specialized EGD led to any substantial changes in surgical treatment. Baseline characteristics and differences in EGD reports were described and McNemar's chi-square test was performed. A logistic regression analysis was conducted to identify risk factors for a change in surgical strategy.

RESULTS

The study included 953 patients who underwent both an initial EGD and EGD at referral to a specialized center. In 644 cases (68%), the information from the initial EGD was considered insufficient concerning preoperative tumor information. In 113 (12%) cases, the findings in the specialized EGD would lead to a significant alteration in the surgical strategy compared with the primary EGD.

CONCLUSION

The findings suggest that repeated EGD at a specialized center is of clinical value and helps ensure proper surgical treatment for patients undergoing curative surgery for gastroesophageal cancer.

The risk of osteoporotic fractures after gastrectomy: Findings from the Korean national sample cohort database (2002-2019)

Objective

This study used a national sample cohort database to investigate the risk of osteoporotic fractures after gastrectomy is performed for gastric cancer.

Materials and Methods

We used data from the Korea National Health Insurance Service-National Sample Cohort between 2002 and 2019. After performing 1:3 propensity score matching, 28,328 individuals were analysed in the final study (7, 082 cases; 21, 246 controls). Gastrectomy data were extracted from the coded claims data, and osteoporotic fractures were defined as the occurrence of fractures in any of the vertebrae, distal radius, humerus, or hip, according to the 10th version of the International Classification of Diseases. A Cox proportional hazards regression model was generated to investigate the association between gastrectomy and risk of osteoporotic fractures.

Results

Patients with gastric cancer who underwent a gastrectomy had a higher risk of osteoporotic fractures as compared to the general population (men, hazard ratio [HR]: 1.13, 95% confidence interval [CI]: 1.00-1.27; women, HR: 1.18, 95% CI: 1.06-1.30). A significantly higher risk of osteoporotic fractures was observed with surgical resection than with endoscopic resection (men, surgical, HR: 1.28, 95% CI: 1.08-1.52, endoscopic, HR: 1.04, 95% CI: 0.90-1.21; women, surgical, HR: 1.34, 95% CI: 1.11-1.62, endoscopic, HR: 1.13, 95% CI: 1.01-1.27). In men, the risk of hip fracture was the highest among the four fracture sites (HR: 1.18, 95% CI:0.89-1.56), while in women, the risk of vertebral fracture after gastrectomy was the highest (HR: 1.16, 95% CI: 0.99-1.35).

Conclusion

Patients with gastric cancer who underwent gastrectomy had a higher risk of osteoporotic fractures as compared to the general population. This suggests the need for bone metabolism management in patients with gastric cancer to prevent post-gastrectomy complications.

Relationship between HER2 overexpression and long-term outcomes of early gastric cancer: a prospective observational study with a 6-year follow-up

Background

Studies have confirmed the prognostic value of the expression status of human epidermal growth factor receptor 2 (HER2) in advanced gastric cancer. However, its role in early gastric cancer (EGC) remains largely unknown. This study explored the association between HER2 overexpression and clinical outcomes of patients with EGC.

Methods

A total of 211 patients who had undergone endoscopic treatment for pN0 EGC were enrolled. The HER2 expression status was assessed using immunohistochemistry (IHC).

Results

The prevalence of HER2 overexpression was 14.2%. HER2 overexpression showed a significant correlation with tumor location (P = 0.033). Multivariate analysis showed that HER2 overexpression was significantly associated with an increased risk of tumor recurrence in pN0 EGC (hazard ratio [HR] = 3.97; 95% confidence interval [CI] 1.30–12.14; P = 0.016) but not overall survival (OS) or disease-specific survival (DSS). Of the included patients, age was associated with OS (HR = 1.11; 95% CI 1.04–1.18; P = 0.002], whereas lymphovascular invasion was significantly associated with poor DSS (HR = 33.66; 95% CI 3.05–371.25; P = 0.004).

Conclusion

This study shows that HER2 overexpression is significantly associated with tumor recurrence in pN0 EGC. Hence, Her2 testing at diagnosis is important and differential treatment and/or follow up strategies for patients with Her2 overexpression may merit future study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02309-7.

Updated evaluation of endoscopic submucosal dissection versus surgery for early gastric cancer: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Endoscopic resection (ER) has been a standard treatment modality for early gastric cancer with ignorable risks of lymph node metastasis. As for EGCs within expanded indications, endoscopic submucosal dissection (ESD) has considerable advantages over endoscopic mucosal resection (EMR) regarding higher rate of en bloc resection, complete resection, but lower risk of local recurrence. Previous meta-analyses comparing ESD with surgery for EGC are scarce and not robust to reach definitive conclusions.

METHODS

We searched PubMed, Web of Science, EMBASE, Cochrane Library Databases and Google Scholar through July 2019 to identify studies evaluating ESD vs surgery for EGC. Newcastle-Ottawa Quality Assessment Scale was used to assess the quality of enrolled studies. Patient baseline characteristics, procedure-related and prognosis outcomes, and adverse event data were extracted and pooled for analyses by the Review Manager 5.3 software. Grading of Recommendations Assessment, Development and Evaluation guidelines (GRADE) were used to assess the quality of evidence. Trial Sequential Analysis (TSA) was conducted to weaken random error and enhance the reliability of evidence.

RESULTS

Totally 18 retrospective studies, involving 5993 patients, were included. ESD benefits were 128.38 min shorter operation duration [95%CI: (-204.68, -52.09), P = 0.001], 7.13 days shorter hospital stay [95%CI: (-7.98, -6.28), P < 0.00001], lower risk of procedure-related death [OR = 0.21, 95%CI: (0.07, 0.68), P = 0.009], lower risk of overall complication [OR = 0.47, 95%CI: (0.34, 0.63), P < 0.00001]. ESD was also associated with lower costs and better quality of life. However, ESD had lower rate of en bloc resection [OR = 0.07, 95%CI: (0.03, 0.21), P < 0.00001], histologically complete resection [OR = 0.07, 95%CI: (0.03, 0.14), P < 0.00001], curative resection [OR = 0.06, 95%CI: (0.01, 0.27), P = 0.002], and higher rate of local recurrence [OR = 5.42, 95%CI: (2.91, 10.11), P < 0.00001], metachronous cancer [OR = 10.84, 95%CI: (6.43, 18.26), P < 0.00001], synchronous cancer [OR = 6.59, 95%CI: (1.96, 22.1), P = 0.002]. ESD also led to lower disease-free survival [HR = 4.58, 95%CI: (2.79, 7.52), P < 0.00001] and recurrence-free survival [HR = 1.99, 95%CI: (1.38, 2.87), P = 0.0002]. No significant differences in overall survival (OS) and disease-specific survival (DSS) between ESD and surgery were observed.

CONCLUSIONS

ESD offers a method of less expensive, less trauma, faster recovery and better quality of life compared to surgery for EGC. However, ESD is associated with higher risk of recurrence without compromising OS and DSS. Strict and careful surveillance after ESD is needed. Recurrent EGCs following ESD can usually be detected in early stage and successfully managed by repeated ESD. Accordingly, ESD technique provides an alternative to surgical resection for highly selected EGC patients.

The Mexican consensus on the detection and treatment of early gastric cancer

Gastric cancer is one of the most frequent neoplasias in the digestive tract and is the result of premalignant lesion progression in the majority of cases. Opportune detection of those lesions is relevant, given that timely treatment offers the possibility of cure. There is no consensus in Mexico on the early detection of gastric cancer, and therefore, the Asociación Mexicana de Gastroenterología brought together a group of experts and produced the "Mexican consensus on the detection and treatment of early gastric cancer" to establish useful recommendations for the medical community. The Delphi methodology was employed, and 38 recommendations related to early gastric cancer were formulated. The consensus defines early gastric cancer as that which at diagnosis is limited to the mucosa and submucosa, irrespective of lymph node metástasis. In Mexico, as in other parts of the world, factors associated with early gastric cancer include Helicobacter pylori infection, a family history of the disease, smoking, and diet. Chromoendoscopy, magnification endoscopy, and equipment-based image-enhanced endoscopy are recommended for making the diagnosis, and accurate histopathologic diagnosis is invaluable for making therapeutic decisions. The endoscopic treatment of early gastric cancer, whether dissection or resection of the mucosa, should be preferred to surgical management, when similar oncologic cure results can be obtained. Endoscopic surveillance should be individualized.

Bone metastasis as a recurrence of early papillary adenocarcinoma of the stomach

Papillary adenocarcinomas of the stomach are rare and associated with a high rate of lymphovascular invasion and distant metastasis. However, the association between papillary adenocarcinoma and bone metastasis in gastric cancer remains largely unexplored. We report a rare case of bone metastasis as a recurrence of early papillary adenocarcinoma of the stomach after curative surgery. A 75-year-old man with a pedunculated polyp at the pylorus of the stomach was diagnosed with papillary adenocarcinoma after biopsy of the lesion, and the polyp was surgically resected. Pathohistological examination revealed intramucosal cancer without lymphovascular invasion or lymph node metastasis. Eight months after surgery, imaging studies showed osteolysis in the right sacrum, and the lesion was diagnosed as a bone metastasis after biopsy. The patient received palliative chemotherapy and radiotherapy for the bone metastasis, which resulted in relief of his leg pain. Subsequently, he was provided supportive care when his condition deteriorated, and he died 8 months after the diagnosis of bone metastasis. Our case shows that bone metastasis should not be overlooked, even though it is rare in gastric cancer patients. Papillary adenocarcinoma of the stomach should be carefully followed up through imaging examinations, even after curative resection.

Long-Term Outcomes Comparison of Endoscopic Resection With Gastrectomy for Treatment of Early Gastric Cancer: A Systematic Review and Meta-Analysis

Background: Endoscopic resection (ER) and gastrectomy have been both accepted as curative treatments for early gastric cancer. We intended to compare ER with gastrectomy treatments on safety of patients, disease-free survival and overall survival for early gastric cancer through this systematic review. Methods: A literature search was performed in Pubmed, Embase, and Cochrane Library databases. Studies that have compared ER with gastrectomy for early gastric cancer were included in this meta-analysis. We searched for clinical studies published before March 2019. Stata 12.0 software was used for systematic analysis. Results: Nine studies were included in this systematic review, ER treatment was associated with a shorter length of stay (WMD = -8.53, 95% CI -11.56 to -5.49), fewer postoperative complications (OR = 0.47, 95% CI 0.34-0.65). ER can be performed safely with shorter hospital stay and fewer postoperative complications than gastrectomy. Recurrence rate was higher for ER than for gastrectomy treatment (HR = 3.56, 95% CI 1.86-6.84), mainly because metachronous gastric cancers developed only in the ER treatment. However, most of the metachronous gastric cancers could be curatively treated with ER again, and it didn't affect overall survival of patients with early gastric cancer. There was no difference in overall survival rate between ER and gastrectomy (HR = 0.84, 95% CI 0.63-1.13). Conclusions: ER and gastrectomy are both acceptable for curative treatment of early gastric cancer. However, due to the comparable overall survival and lower postoperative complications and shorter length of stay, ER is better than gastrectomy for early gastric cancer, who met the indication for ER treatment.

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.

Factors Associated with Recurrent Ulcers in Patients with Gastric Surgery after More Than 15 Years: A Cross-Sectional Single-Center Study

Aim

We aimed to establish the independent predictive factors (from Helicobacter pylori infection, biliary reflux, histologic features of the gastric mucosa, drugs, comorbidities, and social habits) for gastric stump ulcer occurrence more than 15 years after surgery.

Methods

76 patients with previous gastric surgery were included: 21 patients with gastric ulcer (marginal ulcer or ulcer of the rest of the gastric remnant-study group) and 55 controls (nonulcer group).

Results

Helicobacter pylori infection tended to be higher in the control group than in the ulcer group (14.5% vs. 4.8%, p = 0.43), without statistical significance. Alcohol consumption had a significant positive association with ulcer (p = 0.008), while smoking (p = 0.064), low-dose aspirin (p = 0.063), and biliary reflux (p = 0.106) had a tendency toward statistical signification for positive association. On univariate analysis, smoking (p = 0.048, OR = 3.15, 95% CI: 1.01-9.93) and low-dose aspirin consumption (p = 0.067, OR = 2.63, 95% CI: 0.95-7.68) were significantly associated with ulcer. According to the multivariable regression model, alcohol consumption (OR = 6.68, 95% CI: 1.29-41.14) and biliary reflux (OR = 6.12, 95% CI: 1.36-38.26) remained significantly associated with increased odds of stump ulcer.

Conclusion

Biliary reflux and alcohol consumption, but not Helicobacter pylori infection or gastrotoxic drug, seem to be the most important predictors for ulcer recurrence in patients with gastric surgery for peptic ulcer after more than 15 years.

Concomitant stromal tumor and early cancer of the stomach: What should be done?

Concomitant gastric stromal tumor (GST) and gastric cancer (GC) is uncommon; even more uncommon is a concomitant GST and early stage GC (EGC). Tumor resection by endoscopic submucosal dissection (ESD) for concomitant GST and EGC has not been reported. We sought to define the clinical importance of detection of concomitant GST and EGC during the first esophagogastroduodenoscopy (EGD), and compare the clinical outcomes of ESD versus radical surgery for the treatment of concomitant GST and EGC. Our investigation was a retrospective cohort study. Patients with concomitant GST and EGC who underwent ESD or radical surgery were enrolled at the university-affiliated hospital from January 2005 to January 2015. The detection rate of concomitant GST and EGC during the first EGD was 3/25 (12%). Among 25 patients, 14 underwent ESD and 11 underwent surgery. Mean operation time and hospital stay were significantly shorter in the ESD group than the surgery group. There were no significant differences in terms of rates of en bloc resection, complete resection, and early complications. Late complications were more common in the surgery group than in the ESD group. The median follow-up duration was 58.9 months. Three- or 5-year overall survival rates were 100% for both groups and no patient died of EGC and GST. There was no local recurrence in the 2 groups; however, 3 metachronous EGC lesions were found during the follow-up period in the ESD group as follows: the simultaneous occurrence of GST and EGC was uncommon; the detection rate of concomitant GST and EGC was very low at the first EGD; and ESD appeared to be a safe, efficient, and popular treatment option for concomitant GST and EGC, that met the ESD absolute indication, and the outcomes were comparable to those achieved with surgery.

Predictive risk factors associated with synchronous multiple early gastric cancer

The aim of this study was to elucidate the predictive risk factors of synchronous multiple early gastric cancer regardless of the treatment modality.Patients who underwent early gastric cancer treatment between July 2005 and June 2015 were retrospectively reviewed. In total, 1529 patients who were treated for early gastric cancer were included. We analyzed the patient's data to find predictive factors of synchronous multiple early gastric cancer compared to solitary early gastric cancer. Further analysis was performed to verify the difference between endoscopic and surgical treatment groups.Among the 1529 patients, synchronous multiple early gastric cancer was diagnosed in 68 (4.4%) patients. Significant differences in sex (P = .004), gross appearance (P = .038), depth of invasion (P = .007), and lymphovascular invasion (P = .039) were found between patients with solitary early gastric cancer and synchronous multiple early gastric cancer by univariate analysis. In multivariate analysis, male sex (odds ratio, 2.475; P = .011) and submucosal invasion (odds ratio, 1.850; P = .033) were independent predictive risk factors of synchronous multiple early gastric cancer. In addition, in multivariate analysis, significant differences in age, tumor size, longitudinal location, depth of invasion, and histology were found between patients groups depending on the mode of treatment.Male sex and submucosal invasion were predictive risk factors of synchronous multiple early gastric cancer. Patients with these factors should undergo more meticulous endoscopic surveillance.

Does the interval of screening endoscopy affect survival in gastric cancer patients?: A cross-sectional study

Gastric cancer remains the second most common cancer in Korea; however, its mortality has decreased due to earlier diagnosis. In Korea, screening endoscopy has been performed nationwide since 1999. The aim of this study was to elucidate the benefit of screening endoscopy on actual survival in gastric cancer patients and to determine the optimal interval of screening endoscopy.We analyzed 1651 patients diagnosed with gastric adenocarcinoma who underwent surgical treatment between June 2008 and December 2014. Patients were divided into 4 groups according to the interval of screening endoscopy prior to their gastric cancer diagnosis. (Group I = within 1 year, Group II = >1 but <2 years, Group III = more than 2 years, Group IV = no prior endoscopic examination). Patient demographics, clinicopathologic characteristics, and postoperative surgical outcomes including overall survival were compared.The 5-year gastric cancer-specific survival rates of groups I and II were significantly higher than groups III and IV (90.9% vs 85.4%, P = 0.002, respectively). Multivariate analysis showed that screening interval was an independent factor for the diagnosis of advanced gastric cancer. The risk of advanced gastric cancer decreased in group I (odds ratio: 0.515, 95% confidence interval [CI] 0.369-0.719; P < 0.001) and group II (odds ratio: 0.678, 95% CI 0.517-0.889, P = 0.005).Screening endoscopy was helpful in increasing the survival of gastric cancer patients. A 2-year endoscopic screening interval is suitable to detect early-stage gastric cancer.

Recent insights in the therapeutic management of patients with gastric cancer

Gastric cancer remains frequent and one of the most lethal malignancies worldwide. In this article, we aimed to comprehensively review recent insights in the therapeutic management of gastric cancer, with focus on the surgical and perioperative management of resectable forms, and the latest advances regarding advanced diseases. Surgical improvements comprise the use of laparoscopic surgery including staging laparoscopy, a better definition of nodal dissection, and the development of hyperthermic intraperitoneal chemotherapy. The best individualized perioperative management should be assessed before curative-intent surgery for all patients and can consists in perioperative chemotherapy, adjuvant chemo-radiation therapy or adjuvant chemotherapy alone. The optimal timing and sequence of chemotherapy and radiation therapy with respect to surgery should be further explored. Patients with advanced gastric cancer have a poor prognosis. Nevertheless, they can benefit from doublet or triplet chemotherapy combination, including trastuzumab in HER2-positive patients. Upon progression, second-line therapy can be considered in patients with good performance status. Although anti-HER2 (trastuzumab) and anti-VEGFR (ramucirumab) may yield survival benefit, anti-EGFR and anti-HGFR therapies have failed to improve outcomes. Nevertheless, combination regimens containing cytotoxic drugs and targeted therapies should be further evaluated; keeping in mind that gastric cancer biology is different between Asia and the Western countries.

Impact on long-term survival of the number of lymph nodes resected in patients with pT1N0 gastric cancer after R0 resection: A multicenter study in China

Although studies on the association between the number of lymph nodes resected and prognosis in patients with pT2-4N0 stages of gastric cancer have reported consistent results, there is no consensus on the optimal number of lymph nodes to be examined for pT1N0 stage gastric cancer. The aim of this study was to evaluate the long-term effect of the number of lymph nodes removed on the outcomes of patients with pT1N0 stage gastric cancer after R0 resection.From December 2009 to December 2011, 227 patients undergoing R0 resection of pT1N0 stage gastric cancer at 4 Chinese centers were enrolled in this study. Patients were assigned to 2 groups according to the number of lymph nodes dissected (≤15 or > 15). Standard survival methods and restricted multivariable Cox regression models were applied.More women (P = 0.031) were in the ≤15 group than in the >15 group. The mean number of lymph nodes removed from women was greater than that from men (P = 0.007). The 5-year survival rate was significantly higher in the >15 lymph nodes resected group than the ≤15 group. The number of lymph nodes resected was identified as an independent prognostic factor and was significantly correlated with overall survival (OS).A lymphadenectomy with dissection of more than 15 lymph nodes improved the long-term survival of patients with pT1N0 gastric cancer after R0 resection. Therefore, it is necessary to consider removing more than 15 lymph nodes among such patients.