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

Helicobacter pylori Infection following Endoscopic Resection of Early Gastric Cancer

The role of Helicobacter pylori (H. pylori) infection in patients following endoscopic resection of early gastric cancer (EGC) remains unclear. This article presents a review of literature published in the past 15 years. H. pylori-mediated persistent methylation levels are associated with the development of metachronous gastric cancer. The methylation of certain specific genes can be used to identify patients with a high risk of metachronous gastric cancer even after H. pylori eradication. H. pylori eradication after endoscopic resection should be performed as early as possible for eradication success and prevention of metachronous precancerous lesions. Although whether the eradication of H. pylori could prevent the development of metachronous cancer after endoscopic resection is controversial, several meta-analyses concluded that H. pylori eradication could reduce the incidence of metachronous gastric cancer significantly. In addition, H. pylori eradication in gastric cancer survivors after endoscopic resection could reduce healthcare cost and save lives in a cost-effective way. Taken together, H. pylori eradication after endoscopic resection of EGC is recommended as prevention for metachronous precancerous lesions and metachronous gastric cancer.

Additional gastrectomy in early-stage gastric cancer after non-curative endoscopic resection: a meta-analysis

Background and objective

The role of additional gastrectomy after non-curative endoscopic resection remains uncertain. The present meta-analysis aimed to explore the risk factors for early-stage gastric-cancer patients after non-curative endoscopic resection and evaluate the efficacy of additional gastrectomy.

Methods

Relevant studies that reported additional gastrectomy after non-curative endoscopic resection were comprehensively searched in MedLine, Web of Science and EMBASE. We first investigated the risk factors for residual tumor and lymph-node metastasis after non-curative endoscopic resection and then analysed the survival outcome, including 5-year overall survival (OS) and 5-year disease-free survival, of additional gastrectomy.

Results

Twenty-one studies comprising 4870 cases were included in the present study. We found that residual tumor was associated with larger tumor size (>3 cm) (odds ratio [OR] = 2.81, P < 0.001), undifferentiated tumor type (OR = 1.78, P = 0.011) and positive horizontal margin (OR = 9.78, P < 0.001). Lymph-node metastasis was associated with larger tumor size (>3 cm) (OR = 1.73, P < 0.001), elevated tumor type (OR = 1.60, P = 0.035), deeper tumor invasion (>SM1) (OR = 2.68, P < 0.001), lymphatic invasion (OR = 4.65, P < 0.001) and positive vertical margin (OR = 2.30, P < 0.001). Patients who underwent additional gastrectomy had longer 5-year OS (hazard ratio [HR] = 0.34, P < 0.001), 5-year disease-free survival (HR = 0.52, P = 0.001) and 5-year disease-specific survival (HR = 0.50, P < 0.001) than those who did not. Moreover, elderly patients also benefited from additional gastrectomy regarding 5-year OS (HR = 0.41, P = 0.001).

Conclusions

Additional gastrectomy with lymph-node dissection might improve the survival of early-stage gastric-cancer patients after non-curative endoscopic resection. However, risk stratification should be performed to avoid excessive treatment.

New metastatic lymph node classification for early gastric cancer should differ from those for advanced gastric adenocarcinoma: Results based on the SEER database

AIM

To establish an appropriate N classification system for early gastric cancer (EGC).

METHODS

Data from 10714 patients who underwent radical gastrectomy between 1988 and 2011 were retrieved from the National Cancer Institute’s Surveillance, Epidemiology, and End Result database. The overall survival (OS) based on the eighth edition and new tumor lymph node metastasis (TNM) staging systems were compared, and the analysis was repeated in an external validation set from the Fujian Medical University Union Hospital database.

RESULTS

There were no significant differences in OS between N1 and N2 cancers or between N3a and N3b cancers in cases of EGC. The X-tile program identified that the new staging system for EGC consisted of T1N0, T1N1’ [1-6 metastatic lymph nodes (LNs)], and T1N2’ ( ≥ 7 metastatic LNs). Compared with the eighth edition of the TNM staging system, the OS of patients in T1N1’ stage was similar to that of patients with stage IIA disease, whereas the OS of patients in T1N2’ stage was similar to that of patients with stage IIB disease. The new TNM staging system exhibited a slightly lower Akaike Information Criterion value and higher χ² and c-statistic compared with the eighth edition of the TNM classification system. Similar results were found in the external validation dataset from the external validation set.

CONCLUSION

We have developed an optional new TNM staging system with a better predictive ability that can be used to accurately predict the 5-year OS of patients with EGC.

Local or extragastric recurrence after incomplete endoscopic submucosal dissection of early gastric cancer: risk factors and the role of CT

PURPOSE

To investigate the risk factors of local and extragastric recurrence after incomplete endoscopic submucosal dissection (ESD) of early gastric cancer and the role of CT in the surveillance of extragastric recurrence.

METHODS

Institutional review board approval was obtained for this retrospective study with waiver of informed consent. From January 2005 to April 2017, 2086 ESDs were performed. Among them, 202 patients who received incomplete ESDs with positive lateral or deep margins comprised our study population(M:F = 108:94, mean age = 63.3 years). Histopathology, size and depth of the tumor, margin status, and the presence of lymphovascular invasion(LVI) were recorded. The patients were followed-up for a mean period of 38.5 months (range 0.8-139 months). Univariate and multivariate statistical analyses were performed to assess the risk factors of local and extragastric recurrence.

RESULTS

96 patients had (+) lateral margins, 90 had (+) deep margins and 16 had (+) lateral and deep margins. On subsequent surgery and follow-up, local gastric recurrence was found in 54 patients and extragastric recurrence was present in 13 patients. On multivariate analysis, (+) lateral margin [hazard radio (HR) 6.002; P < 0.0001] and tumor size(HR 1.372; P = 0.009) were demonstrated to be significant risk factors for local recurrence and (+) LVI was shown to be the only significant variable for extragastric recurrence(HR 6.798, P = 0.002).

CONCLUSION

A positive lateral margin and tumor size were significant risk factors for local recurrence while positive LVI was shown to be the only significant variable for extragastric recurrence. Therefore, if LVI is positive in patients who received incomplete ESD, subsequent surgery or follow-up with CT is recommended.