Journal List > Korean J Gastroenterol > v.63(2) > 1007260

Chung, Jeong, Park, Lee, Lee, Lee, Joo, Choi, and Cho: Comparison on the Long Term Outcome between Endoscopic Submucosal Dissection and Surgical Treatment for Undifferentiated Early Gastric Cancer

Abstract

Background/Aims

There are controversies on the efficacy and safety of endoscopic submucosal dissection (ESD) for undifferentiated early gastric cancer (EGC) despite the expansion of ESD indications. The aim of this study was to evaluate the long term outcome of ESD compared to that of surgical treatment in patients with undifferentiated EGC.

Methods

A total of 76 patients who underwent ESD for undifferentiated EGC and 149 patients who met the ESD indication and received surgical treatment from January 2005 to December 2010 at Chonnam National University Hwasun Hospital were included.

Results

In the ESD group, en bloc resection and complete resection were achieved in 84.2% (64/76) and 76.3% (58/76) of patients, respectively. Among these patients, 58 (76.3%) met the ESD indication (indication group), and the remaining 18 (23.7%) did not meet the ESD indication (above indication group). Complete resection rates for indication group and above indication group were 86.2% (50/58) and 44.4% (8/18), respectively (p<0.05). The mean follow-up period was 42.2±19.2 months. Total recurrence rates in the ESD group and operation group were 14.1% (9/76) and 0.7% (1/149), respectively (p<0.05). The main complication of ESD was bleeding (5.2%, 4/76). In the operation group, 2 (1.3%) patients died from postoperative bleeding and leakage of anastomosis site.

Conclusions

ESD may be a feasible and safe treatment modality compared to that of surgical treatment for undifferentiated EGC when managed according to the expanded criteria. However, close endoscopic surveillance is required in this group because of higher incidence of intragastric recurrence.

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Fig. 1.
Flow chart of patient inclusion. LN, lymph node; ESD, endoscopic submucosal dissection.
kjg-63-90f1.tif
Fig. 2.
Clinical courses after the endoscopic submucosal dissection (ESD) for undifferentiated early gastric cancer.
APC, argon plasma coagulation; Tx, treatment; Op, operation.
kjg-63-90f2.tif
Fig. 3.
Kaplan-Meier curve of recurrence rates in patients with undifferentiated early gastric cancer after endoscopic submucosal dissection (ESD) or gastrectomy.
kjg-63-90f3.tif
Table 1.
Clinical Characteristics
Parameter ESD group (n=76)
Operation group (n=149) p-value
Indication group (n=58) Above indication group (n=18)
Age (yr) 60.1±13.2 64.9±9.6 56.7±12.8 0.013
Sex (male/female) 34/24 10/8 72/77 0.174
Location       0.147
 Upper third 1 (1.7) 1 (5.6) 12 (8.1)  
 Mid third 35 (60.3) 12 (66.7) 76 (51.0)  
 Lower third 22 (37.9) 5 (27.8) 61 (40.9)  
Horizontal location       0.536
 Anterior wall 12 (20.7) 6 (33.3) 38 (25.5)  
 Great curvature 15 (25.9) 4 (22.2) 25 (16.8)  
 Posterior wall 11 (19.0) 3 (16.7) 31 (20.8)  
 Lesser curvature 20 (34.5) 5 (27.8) 55 (36.9)  
Gross type       0.005
 Depressed 18 (31.0) 7 (38.9) 89 (59.7)  
 Flat 20 (34.5) 7 (38.9) 32 (21.5)  
 Elevated 20 (34.5) 4 (22.2) 28 (18.8)  
Size (cm)       0.001
 ≤1 14 (24.1) 0 (0) 41 (27.5)  
 >1, ≤2 44 (75.9) 0 (0) 108 (72.5)  
 >2, ≤4 0 (0) 15 (83.3) 0 (0)  
 >4 0 (0) 3 (16.7) 0 (0)  
Operation method        
 Laparoscopic NA NA 105 (70.5)  
 Open NA NA 44 (29.5)  

Values are presented as mean±SD, n only, or n (%).

NA, not available.

Indication signifies expand indication of endoscopic submucosal dissection (ESD), i.e. tumor size of undifferentiated cancer ≤2 cm without ulcer.

Table 2.
Clinical Characteristics of Poorly Differentiated Adenocarcinoma and Signet Ring Cell Carcinoma in ESD Patients
Parameter Total Poorly differentiated Signet-ring cell p-value
Patient 76 51 25  
Age (yr) 61.1±12.6 62.5±12.2 58.5±13.4 0.148
Sex (male/female) 44/32 31/20 13/12 0.466
Location       0.202
 Upper third 2 (2.6) 2 (3.9) 0 (0)  
 Mid third 47 (61.8) 34 (66.7) 13 (52.0)  
 Lower third 27 (35.5) 15 (29.4) 12 (48.0)  
Horizontal location       0.933
 Anterior wall 18 (23.7) 11 (21.6) 7 (28.0)  
 Great curvature 19 (25.0) 13 (25.5) 6 (24.0)  
 Posterior wall 14 (18.4) 10 (19.6) 4 (16.0)  
 Lesser curvature 25 (32.9) 17 (33.3) 8 (32.0)  
Gross type       0.821
 Depressed 28 (36.8) 19 (37.3) 9 (36.0)  
 Flat 27 (35.5) 17 (33.3) 10 (40.0)  
 Elevated 21 (27.6) 15 (29.4) 6 (24.0)  
Size (cm)       0.491
 ≤1 14 (18.4) 8 (15.7) 6 (24.0)  
 >1, ≤2 44 (57.9) 29 (56.9) 15 (60.0)  
 >2 18 (23.7) 14 (27.5) 4 (16.0)  
Lauren classification       0.001
 Diffuse type 23 (30.3) 9 (17.6) 14 (56.0)  
 Mixed type 23 (30.3) 12 (23.5) 11 (44.0)  
 Intestinal type 30 (39.5) 30 (58.8) 0 (0)  

Values are presented as mean±SD, n only, or n (%).

ESD, endoscopic submucosal dissection.

Table 3.
Treatment Efficacy of Endoscopic Submucosal Dissection (ESD) for Undifferentiated Early Gastric Cancer
Parameter Total (n=76) Indication group (n=58) Above indication group (n=18) p-value
Resection method       0.110
En bloc resection 64 (84.2) 51 (87.9) 13 (72.2)  
 Piecemeal resection 12 (15.8) 7 (12.1) 5 (27.8)  
Result of resection       0.001
 Complete resection 58 (76.3) 50 (86.2) 8 (44.4)  
 Incomplete resection 18 (23.7) 8 (13.8) 10 (55.6)  
Depth of invasion       0.015
 Lamina propria 29 (38.2) 26 (44.8) 3 (16.7)  
 Muscularis mucosae 31 (40.8) 24 (41.4) 7 (38.9)  
 Submucosa upper 1/3 (SM1) 10 (13.2) 6 (10.3) 4 (22.2)  
 Submucosa mid 1/3 (SM2) 4 (5.3) 2 (3.4) 2 (11.1)  
 Submucosa lower 1/3 (SM3) 2 (2.6) 0 (0) 2 (11.1)  
Positive lateral margin invasion 9 (11.8) 3 (5.2) 6 (33.3) 0.001
Positive vertical margin invasion 5 (6.6) 3 (5.2) 2 (11.1) 0.375
Positive lymphovascular invasion 10 (13.2) 6 (10.3) 4 (22.2) 0.193
Complication       0.949
 Bleeding 4 (5.3) 3 (5.1) 1 (5.5)  
 Perforation 0 (0) 0 (0) 0 (0)  
Sequential gastrectomy after ESD 12 (15.8) 6 (10.3) 6 (33.3) 0.019

Values are presented as n (%).

Table 4.
Clinical Outcomes after Long Term Follow Up in Endoscopic Submucosal Dissection (ESD) and Operation Group
Parameter ESD group (n=64) Operation group (n=149) p-value
Mean duration of follow up (mo) 41.7±22.6 42.8±17.3 0.703
Total recurrence of cancer after initial treatment 9 (14.1) 1 (0.7) 0.001
 Intragastric 8 (12.5) 1 (0.7)  
 Lymph node 1 (1.6) 0 (0)  
Synchronous intragastric lesion (≤12 mo)     0.001
 Carcinoma 6 (9.3) 0 (0)  
 Dysplasia 1 (1.6) 0 (0)  
Metachronous intragastric lesion     0.036
 Carcinoma 2 (3.1) 1 (0.7)  
 Dysplasia 1 (1.6) 0 (0)  
Site of new lesion (carcinoma+dysplasia)     0.001
 ESD scar 1 (1.6) 0 (0)  
 Other site 9 (14.1) 1 (0.7)  
Time of new lesion (mo)     0.224
 ≤6 4 (6.3) 0 (0)  
 >6, ≤12 3 (4.7) a 0 (0)  
 >12, ≤24 2 (3.1) b 0 (0)  
 >24, ≤36 0 (0) 1 (0.7)  
 >36, ≤60 0 (0) 0 (0)  
 >60 2 (3.1) a 0 (0)  
Treatment for new lesion     0.261
 ESD 6 (9.4) 0 (0)  
 Operation 5 (7.8) 1 (0.7)  
Mortality related initial treatment 0 (0) 2 (1.3) 0.604

Values are presented as mean±SD or n (%).

a Including one patient with dysplasia;

b Including one patient with lymph node recurrence.

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