Abstract
Background
The necessity of additional gastrectomy for patients not meeting the inclusion criteria after endoscopic submu cosal dissection (ESD) is controversial. The aim of this study was to elucidate the risk factors for lymph node metastasis (LNM) and residual cancer (RC) in patients not meeting the inclusion criteria after ESD and to determine additional treatment strategies.
Methods
Of 1443 gastric cancer patients who underwent ESD between 2004 and 2013, 167 patients diagnosed as having a lesion not meeting the inclusion criteria after ESD were retrospectively analyzed. Of the 167 cases, 100 cases underwent additional gastrectomy, and 67 cases were observed without surgery.
Results
Overall, 9.0 % (9/100) and 9.0 % (9/100) of patients not meeting the inclusion criteria after ESD presented with LNM and RC, respectively, but neither was observed in 83 patients (83.0 %). Multivariate analysis revealed that lymphovascular involvement (LVI) (OR 38.38; 95 % CI 1.94–761.43, p = 0.017) and undifferentiated type (OR 45.58; 95 % CI 2.88–720.94, p = 0.007) were independent risk factors for LNM, and positive horizontal margin was an independent risk factor for RC (OR 9.48; 95 % CI 1.72–52.13, p = 0.010). In differentiated types without LVI, no cases had LNM (0/38) in the additional gastrectomy group, and there was no lymph node or distant recurrence (0/39) in the observation group.
Conclusions
Additional treatment is necessary for patients with LVI, undifferentiated type, and positive horizontal margin. Careful follow-up may be acceptable for patients with the differentiated type without LVI, especially for the elderly or patients with severe comorbidities.
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References
Gotoda T (2007) Endoscopic resection of early gastric cancer. Gastric Cancer 10(1):1–11
Chiu PW, Teoh AY, To KF, Wong SK, Liu SY, Lam CC, Yung MY, Chan FK, Lau JY, Ng EK (2012) Endoscopic submucosal dissection (ESD) compared with gastrectomy for treatment of early gastric neoplasia: a retrospective cohort study. Surg Endosc 26(12):3584–3591
Oda I, Gotoda T, Hamanaka H, Eguchi T, Saito Y, Matsuda T, Bhandari P, Emura F, Saito D, Ono H (2005) Endoscopic submucosal dissection for early gastric cancer: technical feasibility, operation time and complications from a large consecutive series. Dig Endosc 17(1):54–58
Imagawa A, Okada H, Kawahara Y, Takenaka R, Kato J, Kawamoto H, Fujiki S, Takata R, Yoshino T, Shiratori Y (2006) Endoscopic submucosal dissection for early gastric cancer: results and degrees of technical difficulty as well as success. Endoscopy 38(10):987–990
Oda I, Saito D, Tada M, Iishi H, Tanabe S, Oyama T, Doi T, Otani Y, Fujisaki J, Ajioka Y, Hamada T, Inoue H, Gotoda T, Yoshida S (2006) A multicenter retrospective study of endoscopic resection for early gastric cancer. Gastric Cancer 9(4):262–270
Park JC, Lee SK, Seo JH, Kim YJ, Chung H, Shin SK, Lee YC (2010) Predictive factors for local recurrence after endoscopic resection for early gastric cancer: long-term clinical outcome in a single-center experience. Surg Endosc 24(11):2842–2849
Park YM, Cho E, Kang HY, Kim JM (2011) The effectiveness and safety of endoscopic submucosal dissection compared with endoscopic mucosal resection for early gastric cancer: a systematic review and metaanalysis. Surg Endosc 25(8):2666–2677
Gotoda T, Yanagisawa A, Sasako M, Ono H, Nakanishi Y, Shimoda T, Kato Y (2000) Incidence of lymph node metastasis from early gastric cancer: estimation with a large number of cases at two large centers. Gastric Cancer 3(4):219–225
Korenaga D, Orita H, Maekawa S, Maruoka A, Sakai K, Ikeda T, Sugimachi K (1997) Pathological appearance of the stomach after endoscopic mucosal resection for early gastric cancer. Br J Surg 84(11):1563–1566
Nagano H, Ohyama S, Fukunaga T, Seto Y, Fujisaki J, Yamaguchi T, Yamamoto N, Kato Y, Yamaguchi A (2005) Indications for gastrectomy after incomplete EMR for early gastric cancer. Gastric Cancer 8(3):149–154
Oda I, Gotoda T, Sasako M, Sano T, Katai H, Fukagawa T, Shimoda T, Emura F, Saito D (2008) Treatment strategy after non-curative endoscopic resection of early gastric cancer. Br J Surg 95(12):1495–1500
Yokoi C, Gotoda T, Hamanaka H, Oda I (2006) Endoscopic submucosal dissection allows curative resection of locally recurrent early gastric cancer after prior endoscopic mucosal resection. Gastrointest Endosc 64(2):212–218
Oka S, Tanaka S, Kaneko I, Mouri R, Hirata M, Kanao H, Kawamura T, Yoshida S, Yoshihara M, Chayama K (2006) Endoscopic submucosal dissection for residual/local recurrence of early gastric cancer after endoscopic mucosal resection. Endoscopy 38(10):996–1000
Bae SY, Jang TH, Min BH, Lee JH, Rhee PL, Rhee JC, Kim JJ (2012) Early additional endoscopic submucosal dissection in patients with positive lateral resection margins after initial endoscopic submucosal dissection for early gastric cancer. Gastrointest Endosc 75(2):432–436
Kikuchi D, Iizuka T, Hoteya S, Yamada A, Furuhata T, Yamashita S, Domon K, Nakamura M, Matsui A, Mitani T, Ogawa O, Watanabe S, Yahagi N, Kaise M (2012) Safety and efficacy of secondary endoscopic submucosal dissection for residual gastric carcinoma after primary endoscopic submucosal dissection. Digestion 86(4):288–293
Japanese Gastric Cancer Association (2011) Japanese gastric cancer treatment guidelines 2010 (ver. 3). Gastric Cancer 14(2):113–123
Park WY, Shin N, Kim JY, Jeon TY, Kim GH, Kim H, do Park Y (2013) Pathologic definition and number of lymphovascular emboli: impact on lymph node metastasis in endoscopically resected early gastric cancer. Hum Pathol 44(10):2132–2138
Japanese Gastric Cancer Association (1998) Japanese classification of gastric carcinoma, 2nd English edition. Gastric Cancer 1(1):10–24
Kwee RM, Kwee TC (2008) Predicting lymph node status in early gastric cancer. Gastric Cancer 11(3):134–148
Ryu KW, Choi IJ, Doh YW, Kook MC, Kim CG, Park HJ, Lee JH, Lee JS, Lee JY, Kim YW, Bae JM (2007) Surgical indication for non-curative endoscopic resection in early gastric cancer. Ann Surg Oncol 14(12):3428–3434
Son SY, Park JY, Ryu KW, Eom BW, Yoon HM, Cho SJ, Lee JY, Kim CG, Lee JH, Kook MC, Choi IJ, Kim YW (2013) The risk factors for lymph node metastasis in early gastric cancer patients who underwent endoscopic resection: is the minimal lymph node dissection applicable? A retrospective study. Surg Endosc 27(9):3247–3253
Kim H, Kim JH, Park JC, Lee YC, Noh SH, Kim H (2011) Lymphovascular invasion is an important predictor of lymph node metastasis in endoscopically resected early gastric cancers. Oncol Rep 25(6):1589–1595
Kusano C, Iwasaki M, Kaltenbach T, Conlin A, Oda I, Gotoda T (2011) Should elderly patients undergo additional surgery after non-curative endoscopic resection for early gastric cancer? Long-term comparative outcomes. Am J Gastroenterol 106(6):1064–1069
Ahn JY, Jung HY, Choi JY, Kim MY, Lee JH, Choi KS, Kim DH, Choi KD, Song HJ, Lee GH, Kim JH, Park YS (2012) Natural course of noncurative endoscopic resection of differentiated early gastric cancer. Endoscopy 44(12):1114–1120
Hanaoka N, Tanabe S, Mikami T, Okayasu I, Saigenji K (2009) Mixed-histologic-type submucosal invasive gastric cancer as a risk factor for lymph node metastasis: feasibility of endoscopic submucosal dissection. Endoscopy 41(5):427–432
Takizawa K, Ono H, Kakushima N, Tanaka M, Hasuike N, Matsubayashi H, Yamagichi Y, Bando E, Terashima M, Kusafuka K, Nakajima T (2013) Risk of lymph node metastases from intramucosal gastric cancer in relation to histological types: how to manage the mixed histological type for endoscopic submucosal dissection. Gastric Cancer 16(4):531–536
Lee JH, Choi IJ, Han HS, Kim YW, Ryu KW, Yoon HM, Eom BW, Kim CG, Lee JY, Cho SJ, Kim YI, Nam BH, Kook MC (2015) Risk of lymph node metastasis in differentiated type mucosal early gastric cancer mixed with minor undifferentiated type histology. Ann Surg Oncol 22(6):1813–1819
Lee IS, Yook JH, Park YS, Kim KC, Oh ST, Kim BS (2013) Suitability of endoscopic submucosal dissection for treatment of submucosal gastric cancers. Br J Surg 100(5):668–673
Jung H, Bae JM, Choi MG, Noh JH, Sohn TS, Kim S (2011) Surgical outcome after incomplete endoscopic submucosal dissection of gastric cancer. Br J Surg 98(1):73–78
Yoon H, Kim SG, Choi J, Im JP, Kim JS, Kim WH, Jung HC (2013) Risk factors of residual or recurrent tumor in patients with a tumor-positive resection margin after endoscopic resection of early gastric cancer. Surg Endosc 27(5):1561–1568
Isomoto H, Shikuwa S, Yamaguchi N, Fukuda E, Ikeda K, Nishiyama H, Ohnita K, Mizuta Y, Shiozawa J, Kohno S (2009) Endoscopic submucosal dissection for early gastric cancer: a large-scale feasibility study. Gut 58(3):311–316
Lee H, Yun WK, Min BH, Lee JH, Rhee PL, Kim KM, Rhee JC, Kim JJ (2011) A feasibility study on the expanded indication for endoscopic submucosal dissection of early gastric cancer. Surg Endosc 25(6):1985–1993
Nishida T, Tsujii M, Kato M, Hayashi Y, Akasaka T, Iijima H, Takehara T (2013) Endoscopic surveillance strategy after endoscopic resection for early gastric cancer. World J Gastrointest Pathophysiol 5(2):100–106
Kato M, Nishida T, Yamamoto K, Hayashi S, Kitamura S, Yabuta T, Yoshio T, Nakamura T, Komori M, Kawai N, Nishihara A, Nakanishi F, Nakahara M, Ogiyama H, Kinoshita K, Yamada T, Iijima H, Tsujii M, Takehara T (2013) Scheduled endoscopic surveillance controls secondary cancer after curative endoscopic resection for early gastric cancer: a multicentre retrospective cohort study by Osaka University ESD study group. Gut 62(10):1425–1432
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Takahiro Toyokawa, Masaichi Ohira, Hiroaki Tanaka, Hiroaki Minamino, Katsunobu Sakurai, Yasuaki Nagami, Naoshi Kubo, Atsushi Yamamoto, Koji Sano, Kazuya Muguruma, Kazunari Tominaga, Hiroko Nebiki, Yoshito Yamashita, Tetsuo Arakawa, Kosei Hirakawa have no conflicts of interest or financial ties to disclose.
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Toyokawa, T., Ohira, M., Tanaka, H. et al. Optimal management for patients not meeting the inclusion criteria after endoscopic submucosal dissection for gastric cancer. Surg Endosc 30, 2404–2414 (2016). https://doi.org/10.1007/s00464-015-4491-4
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DOI: https://doi.org/10.1007/s00464-015-4491-4