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Lee JH, Oh JY, Kim YI, Lee JY, Kim CG, Choi IJ, Ryu KW, Kim YW, Cho SJ. Endoscopic submucosal dissection for papillary early gastric carcinoma: Insights from a large-scale analysis of post-gastrectomy pathology specimens. Medicine (Baltimore) 2022; 101:e32085. [PMID: 36550814 PMCID: PMC9771273 DOI: 10.1097/md.0000000000032085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Gastric papillary adenocarcinoma is considered a differentiated adenocarcinoma in the current endoscopic submucosal dissection indication guidelines. However, the safety of endoscopic submucosal dissection remains controversial. Currently, data regarding which papillary early gastric cancer should be considered for endoscopic submucosal dissection are unavailable. Thus, the aim of this study was to investigate lymph node metastasis and the safety of endoscopic submucosal dissection in patients with papillary early gastric cancer. This observational study recruited 4264 consecutive patients with early gastric cancer who underwent curative gastrectomy between October 2000 and December 2017 at the National Cancer Center, Korea. Of these, 45 had pathologically confirmed papillary early gastric cancer, 2106 had differentiated non-papillary early gastric cancer, and 2113 had undifferentiated early gastric cancer. Logistic regression analysis was performed to identify risk factors for lymph node metastasis. Mucosal tumors were less common in papillary early gastric cancer (37.9%) than in differentiated non-papillary early gastric cancer (48.8%) and undifferentiated early gastric cancer (60.4%) (both P < .001). Lymph node metastasis was more common in papillary early gastric cancer (20.0%) than in differentiated non-papillary early gastric cancer (9.2%) and undifferentiated early gastric cancer (11.7%; both P < .001). In multivariate analysis, non-mixed-type papillary early gastric cancer showed marginally increased odds of lymph node metastasis than differentiated early gastric cancer (odds ratio [OR]: 2.5, 95% confidence interval [CI]: 1.0-6.3). Rates of lymph node metastasis (1/10, 10%) and angiolymphatic invasion (2/10, 20%) for papillary early gastric cancer meeting expanded criteria were higher than those for other histology types meeting endoscopic submucosal dissection absolute or expanded criteria (P = .03 and P < .001, respectively). Endoscopic submucosal dissection should be considered carefully for papillary early gastric cancer, especially if it meets expanded endoscopic submucosal dissection indications since it is associated with high rates of submucosal invasion and lymph node metastasis.
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Affiliation(s)
- Jung Hwan Lee
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
- Department of Hospital Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Ju Yeon Oh
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Young-Il Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Jong Yeul Lee
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Chan Gyoo Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Il Ju Choi
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Keun Won Ryu
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Young-Woo Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Soo-Jeong Cho
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University, Seoul, Korea
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Choi J, Cho SJ, Na SH, Lee A, Kim JL, Chung H, Kim SG. Use of direct oral anticoagulants does not significantly increase delayed bleeding after endoscopic submucosal dissection for early gastric neoplasms. Sci Rep 2021; 11:9399. [PMID: 33931685 PMCID: PMC8087783 DOI: 10.1038/s41598-021-88656-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 02/17/2021] [Indexed: 11/09/2022] Open
Abstract
Direct oral anticoagulants (DOACs) are widely prescribed for the prevention of stroke in elderly patients with atrial fibrillation and approved indication for DOAC has been expanded. We aimed to evaluate the risk of delayed bleeding in patients who had taken DOAC and underwent endoscopic submucosal dissection (ESD) for gastric neoplasms. We included consecutive patients who underwent ESD between January 2016 and July 2019 in Seoul National University Hospital. Patients were divided into four groups (no med; no medication, DOAC, WFR; warfarin, anti-PLT; anti-platelet agent) according to the medications they had been taken before the procedure. We defined delayed bleeding as obvious post-procedural gastrointestinal bleeding sign including hematemesis or melena combined with hemoglobin drop ≥ 2 g/dL. Among 1634 patients enrolled in this study, 23 (1.4%) patients had taken DOAC and they usually stopped the medication for 2 days before the ESD and resumed within 1 or 2 days. We compared rates of delayed bleeding between groups. Delayed bleeding rates of the groups of no med, DOAC, WFR, and anti-PLT were 2.1% (32/1499) 8.7% (2/23), 14.3% (2/14), 11.2% (11/98), respectively (P < 0.001). However, there was no difference of delayed bleeding rate between no med and DOAC group after propensity score matching (no med vs DOAC, 1.7% vs 10.0%, P = 0.160). Taking DOAC was not associated statistically with post-ESD bleeding when adjusted by age, sex, comorbidities and characteristics of target lesion (Adjusted Odds Ratio: 2.4, 95% Confidence intervals: 0.41-13.73, P = 0.335). Crude rate of bleeding in DOAC users seemed to be higher than no medication group after performing ESD with 2 days of medication cessation. When adjusted by age, sex, and comorbidity, however, this difference seems to be small, which suggests that gastric post-ESD bleeding may be influenced by patients' underlying condition in addition to medication use.
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Affiliation(s)
- Jinju Choi
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, 101, Daehak-ro Jongno-gu, Seoul, 03080, Korea
| | - Soo-Jeong Cho
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, 101, Daehak-ro Jongno-gu, Seoul, 03080, Korea.
| | - Sang-Hoon Na
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ayoung Lee
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, 101, Daehak-ro Jongno-gu, Seoul, 03080, Korea
| | - Jue Lie Kim
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, 101, Daehak-ro Jongno-gu, Seoul, 03080, Korea
| | - Hyunsoo Chung
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, 101, Daehak-ro Jongno-gu, Seoul, 03080, Korea
| | - Sang Gyun Kim
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, 101, Daehak-ro Jongno-gu, Seoul, 03080, Korea
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Huh CW, Kim GJ, Kim BW, Seo M, Kim JS. Long-term Clinical Outcomes and Risk of Peritoneal Seeding after Endoscopic Submucosal Dissection for Early Gastric Cancer: A Focus on Perforation during the Procedure. Gut Liver 2020; 13:515-521. [PMID: 30970443 PMCID: PMC6743801 DOI: 10.5009/gnl18350] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 11/28/2018] [Accepted: 11/30/2018] [Indexed: 12/17/2022] Open
Abstract
Background/Aims The risk of peritoneal seeding following perforation after endoscopic resection in patients with early gastric cancer is unclear. The purpose of this study was to investigate long-term clinical outcomes including peritoneal seeding and overall survival rate following gastric perforation during endoscopic submucosal dissection (ESD). Methods Between January 2002 and March 2015, 556 patients were diagnosed with early gastric cancer and underwent ESD. Among them, 34 patients (6.1%) experienced gastric perforation during ESD. Clinicopathological data of these patients were reviewed to determine the clinical outcome and evidence of peritoneal seeding. Results Among 34 patients with perforation, macroperforations occurred during ESD in 17 cases (50%), and microperforation was identified in the remaining 17 cases (50%). All patients except one who underwent emergency surgery due to severe panperitonitis were managed successfully by endoscopic clipping (n=27) or conservative medical treatment (n=6). No evidence of peritoneal seeding after perforation associated with ESD was found in our cohort. Cumulative survival rates did not differ between the perforation and non-perforation groups (p=0.691). Furthermore, mortality was not associated with perforation. In addition, multivariate analysis showed that tumor size and achievement of curative resection were related to cancer recurrence. Perforation was not associated with cancer recurrence and survival. Conclusions Perforation associated with ESD does not lead to worse clinical outcomes such as peritoneal seeding or cumulative survival rate. Therefore, periodic follow-up might be possible if curative resection was achieved even if perforation occurred during ESD.
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Affiliation(s)
- Cheal Wung Huh
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Gi Jun Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Byung-Wook Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Myeongsook Seo
- Department of Internal Medicine, Konkuk University Chungju Hospital, Chungju, Korea
| | - Joon Sung Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Kim JW, Lee H, Min YW, Min BH, Lee JH, Sohn TS, Kim JJ, Kim S. Oncologic Safety of Endoscopic Resection Based on Lymph Node Metastasis in Ulcerative Early Gastric Cancer. J Laparoendosc Adv Surg Tech A 2019; 29:1105-1110. [PMID: 31334672 DOI: 10.1089/lap.2019.0311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: There is little evidence regarding appropriate therapeutic modalities for ulcerative-type early gastric cancer (EGC) because the risks and implications of lymph node metastasis are unclear. The indication for endoscopic submucosal dissection (ESD) was investigated for ulcerative-type EGC. Methods: We retrospectively analyzed 192 patients with differentiated ulcerative-type EGC who underwent radical gastrectomy with D2 lymph node dissection. Lymph node metastasis (LNM) risk factors were evaluated using multivariate logistic regression. Results: The LNM rate was 15.1% overall, 0% for mucosa-confined lesions, and 28.2% for submucosa-infiltrating lesions. On multivariate analysis, only lymphovascular invasion (P < .001) was significantly associated with LNM. Among patients with minute submucosal invasion and no lymphovascular invasion, LNM was only observed for tumor sizes ≥2.1 cm. Conclusions: Because LNM risks are negligible, curative ESD could be considered in patients with ulcerative EGC that is confined to the mucosa and histologically differentiated, irrespective of tumor size. In addition, ESD can be attempted for ulcerative EGC with minute submucosal invasion and tumor size <2.1 cm.
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Affiliation(s)
- Ji Won Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyuk Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byung-Hoon Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun Haeng Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Sung Sohn
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae J Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Kim SG, Hwang JH. How to decrease the risk of perforation in endoscopic submucosal dissection (ESD). TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2019. [DOI: 10.1016/j.tgie.2019.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Azari FS, Roses RE. Management of Early Stage Gastric and Gastroesophageal Junction Malignancies. Surg Clin North Am 2019; 99:439-456. [PMID: 31047034 DOI: 10.1016/j.suc.2019.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Esophageal and gastric carcinomas are prevalent malignancies worldwide. In contrast to the poor prognosis associated with advanced stages of disease, early stage disease has a favorable prognosis. Early stage gastric cancer (ESGC) is defined as cancer in which the depth of invasion is limited to the submucosal layer of the stomach on histologic examination, regardless of lymph node status. ESGC that meets standard or expanded criteria can be treated via endoscopic mucosal resection and endoscopic submucosal dissection. Similar indications for endoscopic interventions exist for gastroesophageal junction and esophageal malignancies."
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Affiliation(s)
- Feredun S Azari
- Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein Pavilion, Philadelphia, PA 19104, USA
| | - Robert E Roses
- Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein Pavilion, Philadelphia, PA 19104, USA.
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Clinicopathologic score predicting lymph node metastasis in T1 gastric cancer. Surgery 2018; 163:889-893. [DOI: 10.1016/j.surg.2017.09.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 07/27/2017] [Accepted: 09/12/2017] [Indexed: 02/06/2023]
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Chung CS, Woo HS, Chung JW, Jeong SH, Kwon KA, Kim YJ, Kim KO, Park DK. Risk Factors for Metachronous Recurrence after Endoscopic Submucosal Dissection of Early Gastric Cancer. J Korean Med Sci 2017; 32:421-426. [PMID: 28145644 PMCID: PMC5290100 DOI: 10.3346/jkms.2017.32.3.421] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 11/26/2016] [Indexed: 12/12/2022] Open
Abstract
Although endoscopic submucosal dissection (ESD) is widely accepted as a curative treatment method for early gastric cancer (EGC) worldwide, metachronous recurrence often occurs after ESD for EGC. However, there are insufficient data about the role of Helicobacter pylori (H. pylori) infection and other risk factors for recurrence. We aimed to compare the metachronous lesion in the H. pylori persistent group and the eradicated group, and to identify risk factors for metachronous lesion. We retrospectively analyzed 782 patients who underwent ESD between January 2008 and December 2013. We excluded patients with dysplasia or patients who were not tested for H. pylori infection. One hundred eighty-five patients were enrolled. We studied risk factors for recurrence, and used survival analysis to test. There were 24 patients with metachronous recurrence after ESD for EGC among the group. The incidence of metachronous gastric lesions after ESD for EGC developed more in the over 70-year-old group (P = 0.025) and more in the H. pylori persistent group (P = 0.008). In conclusion, H. pylori infection and old age are independent risk factors for metachronous gastric lesions after ESD in EGC.
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Affiliation(s)
- Chang Su Chung
- Division of Gastroenterology, Department of Internal Medicine, Gachon University, Gil Medical Center, Incheon, Korea
| | - Hyun Sun Woo
- Division of Gastroenterology, Department of Internal Medicine, Gachon University, Gil Medical Center, Incheon, Korea
| | - Jun Won Chung
- Division of Gastroenterology, Department of Internal Medicine, Gachon University, Gil Medical Center, Incheon, Korea.
| | - Seok Hoo Jeong
- Division of Gastroenterology, Department of Internal Medicine, Catholic Kwandong University International St. Mary's Hospital, Incheon, Korea
| | - Kwang An Kwon
- Division of Gastroenterology, Department of Internal Medicine, Gachon University, Gil Medical Center, Incheon, Korea
| | - Yoon Jae Kim
- Division of Gastroenterology, Department of Internal Medicine, Gachon University, Gil Medical Center, Incheon, Korea
| | - Kyoung Oh Kim
- Division of Gastroenterology, Department of Internal Medicine, Gachon University, Gil Medical Center, Incheon, Korea
| | - Dong Kyun Park
- Division of Gastroenterology, Department of Internal Medicine, Gachon University, Gil Medical Center, Incheon, Korea
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Kim SB, Lee SH, Bae SI, Jeong YH, Sohn SH, Kim KO, Jang BI, Kim TN. Association between Helicobacter pylori status and metachronous gastric cancer after endoscopic resection. World J Gastroenterol 2016; 22:9794-9802. [PMID: 27956803 PMCID: PMC5124984 DOI: 10.3748/wjg.v22.i44.9794] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 09/24/2016] [Accepted: 10/27/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the effect of Helicobacter pylori (H. pylori) status test and H. pylori eradication on the occurrence of metachronous gastric cancer (MGC) after endoscopic submucosal dissection (ESD) of early gastric cancer (EGC) and risk factors of MGC.
METHODS The authors retrospectively reviewed the medical records of 433 patients (441 lesions) who underwent ESD for EGC from January 2005 to January 2015 in Yeungnam University Hospital. Patients were categorized into two groups; the H. pylori tested group (n = 257) and the H. pylori non-tested group (n = 176) based on performance of H. pylori status test after ESD of EGC. The H. pylori tested group was further categorized into three subgroups based on H. pylori status; the H. pylori-eradicated subgroup (n = 120), the H. pylori-persistent subgroup (n = 42), and the H. pylori-negative subgroup (n = 95). Incidences of MGC and risk factors of MGC were identified.
RESULTS Median follow-up duration after ESD was 30.00 mo (range, 6-107 mo). Total 15 patients developed MGC during follow-up. MGC developed in 11 patients of the H. pylori tested group (7 in the H. pylori-negative subgroup, 3 in the H. pylori-eradicated subgroup, and 1 in the H. pylori-persistent subgroup) and 4 patients of the H. pylori non-tested group (P > 0.05). The risk factors of MGC were endoscopic mucosal atrophy in the H. pylori tested group and intestinal metaplasia in all patients.
CONCLUSION H. pylori eradication and H. pylori status test seems to have no preventive effect on the development of MGC after ESD for EGC. The risk factors of MGC development were endoscopic mucosal atrophy in the H. pylori tested group alone and intestinal metaplasia in all patients.
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Huh CW, Youn YH, Jung DH, Park JJ, Kim JH, Park H. Early Attempts to Eradicate Helicobacter pylori after Endoscopic Resection of Gastric Neoplasm Significantly Improve Eradication Success Rates. PLoS One 2016; 11:e0162258. [PMID: 27588679 PMCID: PMC5010208 DOI: 10.1371/journal.pone.0162258] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 08/21/2016] [Indexed: 12/22/2022] Open
Abstract
PURPOSE After endoscopic resection (ER) of gastric tumors, eradication of Helicobacter pylori (H. pylori) infection is advised to reduce metachronous recurrence. Optimal timing of such therapy (yet to be established) was investigated herein, examining early active and late scarring stages of post-ER iatrogenic ulcers. MATERIALS AND METHODS Analysis included 514 patients who received proton-pump inhibitor (PPI)-based triple therapy for H. pylori eradication after ER for gastric neoplasms between January 2008 and June 2015. Clinicopathologic characteristics, particularly the timing of triple therapy, were used to compare eradication rates, assigning patients to early- (≤2 weeks), intermediate- (2-8 weeks), and late-phase (≥8 weeks) treatment groups. RESULTS H. pylori eradication rates differed significantly by timing of triple therapy after ER (early, 90.0%; intermediate, 76.2%, late, 72.4%; p <.001). However, eradication success rates were not significantly affected by age, smoking, alcohol consumption, preexisting comorbidity, method of ER, size and location of iatrogenic ulcer, and duration of therapeutic regimen. Early initiation of H. pylori eradication was also identified as a significant independent predictor of eradication success in multivariate analysis (Odds ratio = 3.67, 95% CI 2.18-6.16; p <.001). CONCLUSION In patients undergoing ER of gastric tumors, early post-ER attempts at eradication of H. pylori offer the best chance of eradication success.
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Affiliation(s)
- Cheal Wung Huh
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Hoon Youn
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- * E-mail:
| | - Da Hyun Jung
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Jun Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jie-Hyun Kim
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyojin Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Abstract
Gastric cancer (GC) is third leading cause of cancer-related death. Only 28.3% of new GC cases survive more than 5 years. Although incidence has declined in the United States, an increase is estimated for 2016. Risk factors include sex (risk is higher in men), Helicobacter pylori infection, heredity, and lifestyle. GC is usually diagnosed between the ages of 60-80 years. Prognosis of GC is largely dependent on the tumor stage at diagnosis and classification as intestinal or diffuse type; diffuse-type GC has worse prognosis. Chemoprevention has been shown to decrease risk, but is currently not used clinically.
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Affiliation(s)
- Juan M Marqués-Lespier
- Division of Gastroenterology, Department of Medicine, University of Puerto Rico School of Medicine, San Juan, PR 00935, USA
| | - María González-Pons
- University of Puerto Rico Comprehensive Cancer Center, San Juan, PR 00935, USA
| | - Marcia Cruz-Correa
- Departments of Medicine, Surgery, and Biochemistry, University of Puerto Rico, Medical Sciences Campus, San Juan, PR 00935, USA.
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Lee SH, Choi CW, Kim SJ, Choi CI, Kim DH, Jeon TY, Kim DH, Lee HJ, Kim KH, Hwang SH. Risk factors for lymph node metastasis in mucosal gastric cancer and re-evaluation of endoscopic submucosal dissection. Ann Surg Treat Res 2016; 91:118-26. [PMID: 27617252 PMCID: PMC5016601 DOI: 10.4174/astr.2016.91.3.118] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 05/19/2016] [Accepted: 05/19/2016] [Indexed: 12/29/2022] Open
Abstract
Purpose The selection of the appropriate treatment strategy for patients with mucosal gastric cancer (MGC) remains controversial. In the present study, we aimed to determine the risk factors for lymph node (LN) metastasis in MGC and reassess the role of endoscopic submucosal dissection (ESD). Methods We examined 1,191 MGC patients who underwent curative gastrectomy between January 2005 and December 2014. We determined the clinicopathologic risk factors for LN metastasis among the MGC patients. Results Among 1,191 patients with MGC, 42 patients (3.5%) had LN metastasis. Univariate analysis indicated that age ≤ 50 years (P = 0.045), tumor invasion to the muscularis mucosa (P < 0.001), tumor size > 2 cm (P = 0.014), presence of ulceration (P = 0.01), diffuse type as per Lauren classification (P = 0.005), and undifferentiated-type histology (P = 0.001) were associated with LN metastasis. Moreover, multivariate analysis indicated that tumor invasion to the muscularis mucosa (P = 0.001; odds ratio [OR], 4.909), presence of ulceration (P = 0.036; OR, 1.982), and undifferentiated-type histology (P = 0.025; OR, 4.233) were independent risk factors for LN metastasis. In particular, LN metastasis was observed in some MGC cases with indications for ESD, including absolute indications (1 of 179, 0.6%) and expanded indications (9 of 493, 1.8%). Conclusion Although MGC patients can be treated via ESD, we recommend that they undergo a more aggressive treatment strategy if they have tumor invasion to the muscularis mucosa, ulceration, or undifferentiated-type histology in the final pathology report.
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Affiliation(s)
- Si-Hak Lee
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea.; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Cheol Woong Choi
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Su Jin Kim
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Chang In Choi
- Department of Surgery, Pusan National University School of Medicine, Yangsan, Korea
| | - Dae-Hwan Kim
- Department of Surgery, Pusan National University School of Medicine, Yangsan, Korea
| | - Tae-Yong Jeon
- Department of Surgery, Pusan National University School of Medicine, Yangsan, Korea
| | - Dong-Heon Kim
- Department of Surgery, Pusan National University School of Medicine, Yangsan, Korea
| | - Hyun Jung Lee
- Department of Pathology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Ki-Hyun Kim
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sun-Hwi Hwang
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea.; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
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Long-Term Outcome of Endoscopic Resection vs. Surgery for Early Gastric Cancer: A Non-inferiority-Matched Cohort Study. Am J Gastroenterol 2016; 111:240-9. [PMID: 26782817 DOI: 10.1038/ajg.2015.427] [Citation(s) in RCA: 138] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 12/01/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Few studies have compared the long-term outcomes of endoscopic resection and surgery. The aim of this study was to compare the long-term outcomes of endoscopic resection with those of surgery for early gastric cancer (EGC). METHODS We reviewed prospectively collected data of patients who had undergone endoscopic resection (1,290 patients) or surgery (1,273 patients) for EGC. To reduce the effect of selection bias, we performed a propensity score-matching analysis between the two groups. The primary outcome was overall survival (OS). The secondary outcomes were disease-specific survival, disease-free survival (DFS), recurrence-free survival (RFS), occurrence of metachronous gastric cancer, treatment-related complications, length of hospital stay, and 30-day outcomes. The study was designed as a non-inferiority study and tested in an intention-to-treat analysis. RESULTS In a propensity-matched analysis of 611 pairs, the 10-year OS proportion was 96.7% in the endoscopic resection group and 94.9% in the surgery group (P=0.120) (risk difference -1.8%, 95% confidence interval (CI) -4.04-0.44, Pnon-inferiority=0.014), which met the non-inferiority criterion. In contrast, the 10-year RFS proportion was 93.5% in the endoscopic resection group and 98.2% in the surgery group (P<0.001) (risk difference 4.7%, 95% CI 2.50-6.97, Pnon-inferiority=0.820), which did not meet the non-inferiority criterion, mainly because of metachronous recurrence in the endoscopic resection group. The rate of early complications was higher in the endoscopic resection group than in the surgery group (9.0 vs. 6.6%, P=0.024), whereas the rate of late complications was higher in the surgery group than in the endoscopic resection group (0.5 vs. 2.9%, P<0.001). In the multiple Cox regression analysis, patient's age, the comorbidity index, the performance index, sex, tumor morphology, and depth of invasion were predictors of OS in patients with EGC. CONCLUSIONS Endoscopic resection might not be inferior to surgery with respect to OS in patients with EGC lesions that meet the absolute or expanded criteria. However, DFS, RFS, and metachronous RFS might be lower after endoscopic resection than after surgery.
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Mukhija D, Nagpal SJS, Tsai C, Raja S, Sanaka MR. Successful Curative Resection of Early Gastric Cancer by Endoscopic Submucosal Dissection in a High-Risk Cirrhotic Patient. J Gastrointest Cancer 2016; 48:74-75. [PMID: 26780901 DOI: 10.1007/s12029-016-9800-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Dhruvika Mukhija
- Department of Gastroenterology, Desk Q3, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44185, USA
| | - Sajan Jiv Singh Nagpal
- Department of Gastroenterology, Desk Q3, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44185, USA
| | - Chung Tsai
- Department of Gastroenterology, Desk Q3, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44185, USA
| | - Siva Raja
- Department of Gastroenterology, Desk Q3, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44185, USA
| | - Madhusudhan R Sanaka
- Department of Gastroenterology, Desk Q3, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44185, USA.
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Kim Y, Kim YW, Choi IJ, Cho JY, Kim JH, Kwon JW, Lee JY, Lee NR, Seol SY. Cost comparison between surgical treatments and endoscopic submucosal dissection in patients with early gastric cancer in Korea. Gut Liver 2015; 9:174-80. [PMID: 25167804 PMCID: PMC4351023 DOI: 10.5009/gnl13299] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND/AIMS This study was conducted to evaluate whether medical costs can be reduced using endoscopic submucosal dissection (ESD) instead of conventional surger-ies in patients with early gastric cancer (EGC). METHODS Pa-tients who underwent open gastrectomy (OG), laparoscopy-assisted gastrectomy (LAG), and ESD for EGC were recruited from three medical institutions in 2009. For macro-costing, the medical costs for each patient were derived from the ex-penses incurred during the patient's hospital stay and 1-year follow-up. The overall costs in micro-costing were determined by multiplying the unit cost with the resources used during the patients' hospitalization. RESULTS A total of 194 patients were included in this study. The hospital stay for ESD was 5 to 8 days and was significantly shorter than the 12-day hospital stay for OG or the 11- to 17-day stay for LAG. Using macro-costing, the average medical costs for ESD during the hospital stay ranged from 2.1 to 3.4 million Korean Won (KRW) per patient, and the medical costs for conventional surgeries were estimated to be between 5.1 million and 8.2 million KRW. There were no significant differences in the 1-year follow-up costs between ESD and conventional surger-ies. CONCLUSIONS ESD patients had lower medical costs than those patients who had conventional surgeries for EGC with conservative indications. (Gut Liver, 2015;9174-180).
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Affiliation(s)
- Younhee Kim
- National Evidence-Based Healthcare Collaborating Agency, Seoul and Institute of Health and Environment, Seoul National University, Seoul, Korea
| | - Young Woo Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Il Ju Choi
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Joo Young Cho
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Jong Hee Kim
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Jin Won Kwon
- Institute of Health and Environment, Seoul National University, Seoul and College of Pharmacy, Kyungpook National University, Daegu, Korea
| | - Ja Youn Lee
- Institute of Health and Environment, Seoul National University, Seoul, Korea
| | - Na Rae Lee
- Institute of Health and Environment, Seoul National University, Seoul, Korea
| | - Sang Yong Seol
- Department of Internal Medicine, Inje University Busan Paik Hospital, Busan, Korea
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Sun W, Han X, Wu S, Yang C. Endoscopic Resection Versus Surgical Resection for Early Gastric Cancer: A Systematic Review and Meta-Analysis. Medicine (Baltimore) 2015; 94:e1649. [PMID: 26512558 PMCID: PMC4985372 DOI: 10.1097/md.0000000000001649] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Endoscopic resection (ER) has been widely accepted to treat early gastric cancer (EGC) in place of surgical resection (SR). The aim of this meta-analysis was to conduct a comprehensive comparison between the two methods.Four literature databases, including PubMed, Web of Science, the Cochrane Library, and EMBASE, were searched for studies that compared ER with SR to treat EGC. In this meta-analysis, primary and secondary endpoints were compared between the two groups. Primary endpoints included overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), and recurrence-free survival (RFS). Secondary endpoints included operation-related death, local recurrence, metachronous lesions, procedure-related complication, bleeding, hospital stay, operation time, and cost.Nineteen studies consisting of a total of 6118 patients were identified and selected for evaluation. Meta-analysis showed that long-term outcomes of ER versus SR for EGC were comparable in terms of 5-year OS (risk ratio [RR] 1.00, 95% confidence interval [CI] 0.98-1.02), DSS (RR 0.98, 95% CI 0.89-1.08), DFS (RR 0.95, 95% CI 0.86-1.05), and RFS (RR 0.98, 95% CI 0.94-1.01). However, ER had shorter operation time (standardized mean difference [SMD] -3.39, 95% CI -3.58 to 3.20), hospital stay (SMD -2.86, 95% CI -4.02 to -1.69), lower costs (SMD -5.30, 95% CI -10.37 to -0.22), and fewer procedure-related complications (RR 0.43, 95% CI 0.28-0.65) compared to SR. Nevertheless, ER had higher incidences of local recurrence (risk difference 0.01, 95% CI 0.00-0.02) and metachronous lesions (RR 6.81, 95% CI 3.80-12.19).Endoscopic resection was associated with similar long-term outcomes and considerable advantages concerning operation time, hospital stay, costs, and complications, compared with SR, and was also associated with disadvantages such as higher incidence of local recurrence and metachronous lesions. Further high-quality studies from more countries are required to confirm these results.
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Affiliation(s)
- Weili Sun
- From the Division of Gastroenterology and Hepatology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
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Evans JA, Chandrasekhara V, Chathadi KV, Decker GA, Early DS, Fisher DA, Foley K, Hwang JH, Jue TL, Lightdale JR, Pasha SF, Sharaf R, Shergill AK, Cash BD, DeWitt JM. The role of endoscopy in the management of premalignant and malignant conditions of the stomach. Gastrointest Endosc 2015; 82:1-8. [PMID: 25935705 DOI: 10.1016/j.gie.2015.03.1967] [Citation(s) in RCA: 184] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 03/19/2015] [Indexed: 02/07/2023]
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18
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Choi JM, Kim SG, Yang HJ, Lim JH, Choi J, Im JP, Kim JS, Kim WH, Jung HC. Clinical outcomes of no residual disease in the specimen after endoscopic resection for gastric neoplasms. Surg Endosc 2015; 30:610-618. [PMID: 26091988 DOI: 10.1007/s00464-015-4248-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 05/08/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND No residual disease (NRD) can be found in the specimen after endoscopic resection (ER) of biopsy-proven gastric neoplasm. This study aimed to evaluate the endoscopic and pathologic characteristics of patients with NRD and identify the cause and long-term prognosis. METHODS Medical records of patients who underwent ER for biopsy-proven gastric neoplasms at a single tertiary hospital between January 2005 and November 2014 were retrospectively reviewed. Patients whose post-ER histology was revealed as NRD were included. Overall incidence, clinicopathologic characteristics, cause, and long-term prognosis were analyzed. RESULTS NRD was detected in 143 (3.2%) of 4401 cases of gastric neoplasms treated with ER. Mean endoscopic size of the initial lesion was 8.15 ± 6.64 mm; in 93 cases (65.0%), the lesion was located in the lower third of the stomach. Initial pathologic diagnosis was as follows: adenoma (n = 110), carcinoma (n = 29), and atypical gland (n = 4). The causes of NRD were minute lesions removed by biopsy in 140 patients, pathologic misdiagnoses in two, and localization error in one. Local recurrence was detected in five patients (3.6%) with minute lesions during follow-up and treated with argon plasma coagulation (n = 4) or re-ER (n = 1). Synchronous (n = 5, 3.6%) and metachronous gastric lesions (n = 6, 4.3%) were also detected during follow-up. CONCLUSIONS The main cause of NRD was minute lesions which might be completely removed by initial diagnostic biopsy. These cases showed a minimal rate of local recurrence and synchronous or metachronous gastric neoplasms. Careful follow-up is also mandatory for detection of residual disease.
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Affiliation(s)
- Ji Min Choi
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Daehangno 101, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Sang Gyun Kim
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Daehangno 101, Jongno-gu, Seoul, 110-744, Republic of Korea.
| | - Hyo-Joon Yang
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joo Hyun Lim
- Department of Internal Medicine, Healthcare Research Institute, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Republic of Korea
| | - Jeongmin Choi
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Daehangno 101, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Jong Pil Im
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Daehangno 101, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Joo Sung Kim
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Daehangno 101, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Woo Ho Kim
- Department of Pathology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyun Chae Jung
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Daehangno 101, Jongno-gu, Seoul, 110-744, Republic of Korea
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Long-term outcome comparison of endoscopic resection and surgery in early gastric cancer meeting the absolute indication for endoscopic resection. Gastrointest Endosc 2015; 81:333-41.e1. [PMID: 25281498 DOI: 10.1016/j.gie.2014.07.047] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 07/17/2014] [Indexed: 01/01/2023]
Abstract
BACKGROUND Endoscopic resection (ER) of early gastric cancer (EGC) meeting the absolute indication has excellent long-term outcomes. OBJECTIVE To compare long-term outcomes of ER with those of surgery in patients with EGC who met the absolute indication for ER. DESIGN Retrospective cohort study. SETTING A specialized center for the treatment of cancer. PATIENTS AND INTERVENTIONS We retrospectively reviewed data from patients who underwent gastrectomy or ER for EGC between 2002 and 2007. Gastric cancers were differentiated-type adenocarcinoma without ulceration confined to the mucosal layer and 2 cm or smaller in size. MAIN OUTCOME MEASUREMENTS The primary outcome was overall survival (OS). Metachronous cancer rates and adverse event rates were compared. Kaplan-Meier plots and Cox proportional hazard regression analyses were applied for comparisons. Differences in baseline characteristics were adjusted by propensity score. RESULTS Among 375 patients, 261 underwent ER and 114 underwent surgery. The median follow-up duration was 76.4 months. The 5-year OS rates did not significantly differ between the ER and surgery groups (95.7% vs 93.6%, respectively; P = .725 by log-rank test). There were no gastric cancer-related deaths in either group. Metachronous gastric cancer developed more frequently in the ER group (6.1%, 16/261) than in the surgery group (0.9%, 1/114) (P = .024). However, most patients (93.8%, 15/16) in the ER group were curatively treated with repeat ER. Adverse event rates were higher in the surgery group than those in the ER group (7.9% vs 2.7%, P = .028). LIMITATIONS Retrospective, single-center study. CONCLUSIONS The OS rate after ER for mucosal gastric cancer that met the absolute indication was comparable to that achieved with surgery. Although metachronous cancers were more common after ER, they were usually treatable and did not affect survival.
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20
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Jung S, Park CH, Kim EH, Shin SJ, Chung H, Lee H, Park JC, Shin SK, Lee YC, Lee SK. Preventing metachronous gastric lesions after endoscopic submucosal dissection through Helicobacter pylori eradication. J Gastroenterol Hepatol 2015; 30:75-81. [PMID: 25088761 DOI: 10.1111/jgh.12687] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Metachronous recurrence often occurs after endoscopic submucosal dissection for early gastric cancer, and a method for preventing recurrence is unknown. We aimed to identify risk factors for metachronous lesions, and the effects of aspirin use and Helicobacter pylori eradication on preventing recurrence. METHODS A total of 1041 consecutive patients who underwent endoscopic submucosal dissection for early gastric cancer between January 2007 and December 2011 were retrospectively analyzed. Every patient was examined endoscopically at 2, 6, and 12 months after endoscopic submucosal dissection, and then annually. Patients were classified into the metachronous group or non-metachronous group according to the existence of metachronous lesions and subdivided by Helicobacter pylori status into three groups: not infected, eradicated after infection, and not eradicated. RESULTS At 39 months' median follow-up, metachronous gastric lesions had developed in 35 patients (3.4%), including 16 with dysplasia and 19 cancers. Metachronous group were significantly older than non-metachronous group (P = 0.02). Although non-metachronous group took aspirin more frequently than metachronous group (15.5% vs 5.7%), the difference was statistically insignificant (P = 0.11). In the not eradicated group, the odds ratio of metachronous lesion was 7.762 compared with the not infected group (95% confidence interval, 1.483-60.854; P = 0.02). In the eradicated group, the odd ratio of metachronous lesion was 8.120 compared with not infected group (95% confidence interval, 1.950-58.985; P = 0.01). CONCLUSION Helicobacter pylori infection was an independent risk factor for metachronous gastric lesions. However, eradication of Helicobacter pylori alone does not prevent all metachronous lesions in an inflamed stomach.
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Affiliation(s)
- Sungmo Jung
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, South Korea
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21
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Park SY, Lim SO, Ki HS, Jun CH, Park CH, Kim HS, Choi SK, Rew JS. Low pepsinogen I level predicts multiple gastric epithelial neoplasias for endoscopic resection. Gut Liver 2014; 8:277-81. [PMID: 24827624 PMCID: PMC4026645 DOI: 10.5009/gnl.2014.8.3.277] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background/Aims Synchronous/metachronous gastric epithelial neoplasias (GENs) in the remaining lesion can develop at sites other than the site of endoscopic resection. In the present study, we aimed to investigate the predictive value of serum pepsinogen for detecting multiple GENs in patients who underwent endoscopic resection. Methods In total, 228 patients with GEN who underwent endoscopic resection and blood collection for pepsinogen I and II determination were evaluated retrospectively. Results The mean period of endoscopic follow-up was 748.8±34.7 days. Synchronous GENs developed in 46 of 228 (20.1%) and metachronous GENs in 27 of 228 (10.6%) patients during the follow-up period. Multiple GENs were associated with the presence of pepsinogen I <30 ng/mL (p<0.001). Synchronous GENs were associated with the presence of pepsinogen I <30 ng/mL (p<0.001). Conclusions Low pepsinogen I levels predict multiple GENs after endoscopic resection, especially synchronous GENs. Cautious endoscopic examination prior to endoscopic resection to detect multiple GENs should be performed for these patients.
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Affiliation(s)
- Seon Young Park
- Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Sung Ook Lim
- Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Ho Seok Ki
- Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Chung Hwan Jun
- Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Chang Hwan Park
- Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Hyun Soo Kim
- Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Sung Kyu Choi
- Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Jong Sun Rew
- Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
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Lee JH, Nam BH, Ryu KW, Ryu SY, Kim YW, Kim S, Park YK. Tumor differentiation is not a risk factor for lymph node metastasis in elderly patients with early gastric cancer. Eur J Surg Oncol 2014; 40:1771-6. [PMID: 25245539 DOI: 10.1016/j.ejso.2014.07.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 07/16/2014] [Accepted: 07/29/2014] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The aim of this study was to identify risk factors for lymph node metastasis in elderly patients (70 years or more) with early gastric cancer. METHODS We reviewed the prospectively collected database of 6893 patients with early gastric cancer who had undergone curative gastrectomy in 3 tertiary cancer centers between January 2003 and December 2009 in Korea. Patients were sorted into 4 groups according to age: less than 50, fifties, sixties, and 70 years or more. Risk factors for lymph node metastasis in early gastric cancer were analyzed. RESULTS One thousand and thirty five patients (15.0%) were 70 years or more. As age increased, the frequency of large differentiated tumor, lymphatic and submucosa invasion increased. Old age was associated with a lower risk for lymph node metastasis in patients with early gastric cancer (Odds ratio [OR], OR, 0.622; 95% CI, 0.5466-0.830, P = 0.010). Ulceration or differentiation of tumor was not associated with lymph node metastasis in elderly patients with early gastric cancer. CONCLUSIONS Elderly patients with undifferentiated type histology early gastric cancer without other risk factors for lymph node metastasis may be candidates for endoscopic resection.
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Affiliation(s)
- J H Lee
- Department of Surgery, Sungkyunkwan University School of Medicine, South Korea
| | - B-H Nam
- Center for Clinical Trial, National Cancer Center, South Korea
| | - K W Ryu
- Center for Gastric Cancer, National Cancer Center, South Korea
| | - S Y Ryu
- Department of Surgery, Chonnam National University Hwasoon Hospital, South Korea
| | - Y W Kim
- Center for Gastric Cancer, National Cancer Center, South Korea
| | - S Kim
- Department of Surgery, Sungkyunkwan University School of Medicine, South Korea
| | - Y K Park
- Department of Surgery, Chonnam National University Hwasoon Hospital, South Korea.
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Matsukuma S, Takeo H, Sato K. Nuclear artifacts in gastric endoscopic submucosal dissection specimens: A clinicopathological study. Mol Clin Oncol 2014; 2:882-886. [PMID: 25054062 DOI: 10.3892/mco.2014.322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 05/29/2014] [Indexed: 11/05/2022] Open
Abstract
To delineate the characteristics of nuclear artifacts associated with endoscopic submucosal dissection (ESD), we examined 97 gastric ESD specimens from 79 patients. In 69 of the specimens (71%), multinucleated figures and/or atypical mitotic-like figures, including tripolar-like and bizarre spindles, were found in the peripheral portions close to the marking areas. These nuclear figures were mostly recognizable as artifacts, but were infrequently (13 specimens) accompanied by other nuclear alterations and/or architectural abnormalities, mimicking dysplasia. However, in the deep cut sections, the dysplastic characteristics tended to disappear and coagulative or degenerative findings became more prominent. These nuclear artifacts were not found in 69 age- and gender-matched control gastrectomy specimens without ESD. Multinucleated artifacts were associated with the size of the ESD specimens (P=0.003), frequency of marking (P<0.001) and a history of 'previous' marking 1-6 days prior to ESD (P<0.001); however, they were not associated with age, ESD procedure time, or 'fresh' marking on the day of the ESD. Atypical mitosis-like characteristics were associated with a history of 'fresh' (P=0.007) as well as 'previous' (P=0.002) marking, but not with other variables. Dysplasia-like artifacts were associated with older age only (P=0.031). Follow-up data of all the patients with nuclear artifacts showed no aggressive behavior. Therefore, we concluded that these nuclear changes were ESD-related artifacts. Particularly in older patients, these changes may simulate dysplasia and must be distinguished from true dysplasia or neoplasia.
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Affiliation(s)
- Susumu Matsukuma
- Health Care Center, Japan Self-Defense Forces Central Hospital, Tokyo 154-0001, Japan ; Department of Pathology, Japan Self-Defense Forces Central Hospital, Tokyo 154-0001, Japan
| | - Hiroaki Takeo
- Department of Pathology, Japan Self-Defense Forces Central Hospital, Tokyo 154-0001, Japan
| | - Kimiya Sato
- Department of Pathology, Japan Self-Defense Forces Central Hospital, Tokyo 154-0001, Japan
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Kim YI, Choi IJ, Kook MC, Cho SJ, Lee JY, Kim CG, Ryu KW, Kim YW. The association between Helicobacter pylori status and incidence of metachronous gastric cancer after endoscopic resection of early gastric cancer. Helicobacter 2014; 19:194-201. [PMID: 24612125 DOI: 10.1111/hel.12116] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The long-term effect of Helicobacter pylori eradication in preventing metachronous gastric cancer (GC) development after endoscopic resection (ER) of early gastric cancer (EGC) remains controversial. The aim of this study was to investigate the effect of H. pylori status on the incidence of metachronous GC after ER during long-term follow-up. PATIENTS AND METHODS We retrospectively reviewed the medical records of 374 patients who underwent ER for EGC. Helicobacter pylori status was assessed by histology, rapid urease test, and serology. According to the H. pylori status after ER, included patients were classified into H. pylori-negative group (n = 218), H. pylori-eradicated group (n = 49), and H. pylori-persistent group (n = 107). Metachronous GC incidence and risk factors according to H. pylori status were analyzed. RESULTS Median follow-up duration after ER was 4.3 years (range 1.0-11.3 years). During the follow-up period, metachronous GC had developed in 13 patients (6.0% [13/218]) in the H. pylori-negative group, 2 patients (4.1% [2/49]) in the H. pylori-eradicated group, and 16 patients (15.0% [16/107]) in the H. pylori-persistent group. Cumulative incidence of metachronous GC was significantly higher in patients with H. pylori-persistent group than in those with H. pylori-negative (p = .011, log-rank test) and H. pylori-eradicated group (p = .006, log-rank test). In a multivariate Cox proportional hazard model, age ≥65 years (hazard ratio [HR] 2.29, p = .038), family history of GC (HR 2.60, p = .014), and H. pylori-persistent status (HR 2.42, p = .019) were associated with metachronous GC development. CONCLUSIONS Persistent H. pylori infection after ER may increase risk of metachronous GC development.
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Affiliation(s)
- Young-Il Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
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El-Sedfy A, Brar SS, Coburn NG. Current role of minimally invasive approaches in the treatment of early gastric cancer. World J Gastroenterol 2014; 20:3880-3888. [PMID: 24833843 PMCID: PMC3983444 DOI: 10.3748/wjg.v20.i14.3880] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 12/29/2013] [Accepted: 02/27/2014] [Indexed: 02/06/2023] Open
Abstract
Despite declining incidence, gastric cancer remains one of the most common cancers worldwide. Early detection in population-based screening programs has increased the number of cases of early gastric cancer, representing approximately 50% of newly detected gastric cancer cases in Asian countries. Endoscopic mucosal resection and endoscopic submucosal dissection have become the preferred therapeutic techniques in Japan and Korea for the treatment of early gastric cancer patients with a very low risk of lymph node metastasis. Laparoscopic and robotic resections for early gastric cancer, including function-preserving resections, have propagated through advances in technology and surgeon experience. The aim of this paper is to discuss the recent advances in minimally invasive approaches in the treatment of early gastric cancer.
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Differences in the treatment of young gastric cancer patients: patients under 50 years have better 5-year survival than older patients. Adv Med Sci 2013; 57:259-65. [PMID: 23314560 DOI: 10.2478/v10039-012-0052-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE In the literature, the manifestations of gastric cancer have been described based on all patients. In recent times, interest has focused on the subgroup of young patients. In the following analysis, the subgroup of young patients (< 50y) is compared with an older reference group (≥ 50y). MATERIAL AND METHODS Between 01.01.1995 and 31.12.2005, 482 patients with a previously untreated gastric cancer underwent surgery. Fifty-six patients in this group were under 50 years of age, and the remaining 367 patients constituted the reference group. All data were recorded prospectively and analyzed retrospectively from the clinical cancer registry of the University of Erlangen. RESULTS The analysis showed that the young patients had a similar tumor stage distribution. Diffuse tumor stages in the Laurén classification occurred significantly more often. The postoperative complication rate was similar, but the hospital mortality rate was significantly lower. The young patients had an obvious, but not significant, 5-year survival advantage in all tumor stages. CONCLUSIONS Younger patients can be operated on with greater confidence as they have a significantly lower hospital mortality rate. They exhibit markedly better 5-year survival at all tumor stages. According to our data, there is nothing to support the general belief that young patients have a poorer disease course. Further clinical and experimental studies are necessary to investigate this group more precisely.
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Pham DV, Shah A, Borao FJ, Gorcey S. Endoscopic submucosal dissection training with ex vivo human gastric remnants. Surg Endosc 2013; 28:222-6. [PMID: 23996336 DOI: 10.1007/s00464-013-3164-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Accepted: 07/31/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) offers en bloc resection of early cancer or precancerous lesions, potentially saving patients from major organ resection, such as gastrectomy, colectomy, and esophagectomy. Japan now leads the world in ESD due to its high rate of gastric cancer. Western countries, with their lower gastric cancer rates, do not get as much experience with the technique. Training in ESD utilizing both in vivo and ex vivo porcine stomach has been shown to decrease rates of perforation and operative time. Both models can be prohibitively expensive or not generally available to the majority of endoscopists on a regular basis. This study describes the framework for using human gastric remnants from sleeve gastrectomy patients for ESD training. METHODS Patients undergoing sleeve gastrectomy for morbid obesity were consented for use of their gastric specimen before surgery. The specimen was weighed and measured by the pathologist and then used for ESD training. The specimen was mounted to a 15-mm laparoscopic port and secured using a pursestring suture. ESD was then performed through this port. RESULTS We were able to successfully use this model to resect multiple marked out lesions in an en bloc fashion. Training using this model has improved our dissection times from approximately 2 h to 30 min for a 2-cm simulated lesion. CONCLUSIONS ESD requires the endoscopist to perform a surgical dissection. Until now, development of these skills required intensive training on porcine models that are not widely available. We were able to create a method using the excised portion from sleeve gastrectomy patients, providing a more accessible and cost-effective model for ESD training and potentially other endoscopic therapeutic modalities.
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Affiliation(s)
- David V Pham
- Department of Surgery, Monmouth Medical Center, 300 Second Avenue, Long Branch, NJ, 07740, USA,
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Miyaki R, Yoshida S, Tanaka S, Kominami Y, Sanomura Y, Matsuo T, Oka S, Raytchev B, Tamaki T, Koide T, Kaneda K, Yoshihara M, Chayama K. Quantitative identification of mucosal gastric cancer under magnifying endoscopy with flexible spectral imaging color enhancement. J Gastroenterol Hepatol 2013; 28:841-7. [PMID: 23424994 DOI: 10.1111/jgh.12149] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Magnifying endoscopy with flexible spectral imaging color enhancement (FICE) is clinically useful in diagnosing gastric cancer and determining treatment options; however, there is a learning curve. Accurate FICE-based diagnosis requires training and experience. In addition, objectivity is necessary. Thus, a software program that can identify gastric cancer quantitatively was developed. METHODS A bag-of-features framework with densely sampled scale-invariant feature transform descriptors to magnifying endoscopy images of 46 mucosal gastric cancers was applied. Computer-based findings were compared with histologic findings. The probability of gastric cancer was calculated by means of logistic regression, and sensitivity and specificity of the system were determined. RESULTS The average probability was 0.78 ± 0.25 for the images of cancer and 0.31 ± 0.25 for the images of noncancer tissue, with a significant difference between the two groups. An optimal cut-off point of 0.59 was determined on the basis of the receiver operating characteristic curves. The computer-aided diagnosis system yielded a detection accuracy of 85.9% (79/92), sensitivity for a diagnosis of cancer of 84.8% (39/46), and specificity of 87.0% (40/46). CONCLUSION Further development of this system will allow for quantitative evaluation of mucosal gastric cancers on magnifying gastrointestinal endoscopy images obtained with FICE.
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Affiliation(s)
- Rie Miyaki
- Departments of Gastroenterology and Metabolism, Hiroshima University, Hiroshima, Japan
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Abstract
PURPOSE OF REVIEW The review focuses on the latest endoscopic techniques that are emerging in the management of early gastric cancer. RECENT FINDINGS Improved sensitivity and specificity in the diagnosis of early gastric cancers has been demonstrated in a number of studies by narrow band imaging (92.7 and 94.5%), confocal laser endomicroscopy (90.2 and 98.5%), and magnification chromoendoscopy (88.6 and 93.2%), respectively. In early gastric cancer, endoscopic submucosal dissection (ESD) has been shown to be superior to endoscopic mucosal resection (EMR) with curative resection rate at 79.5% for ESD vs. 59% for EMR, and a lower local recurrence rate at 0.82% for ESD vs. 5.03% for EMR. SUMMARY Advanced diagnostic and therapeutic endoscopic techniques are changing the paradigm of care in patients with early gastric cancers.
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