Digestive Endoscopy
Long-term outcome of early gastric cancer after endoscopic submucosal dissection: Expanded indication is comparable to absolute indication

https://doi.org/10.1016/j.dld.2013.01.014Get rights and content

Abstract

Background

Endoscopic submucosal dissection has become widely used for early gastric cancer with an expanded indication, although there is no strong consensus. We aimed to compare the clinical and long-term oncological outcome after endoscopic submucosal dissection according to indication.

Methods

Retrospective review of 1152 patients with 1175 lesions who had undergone endoscopic submucosal dissection for early gastric cancer at tertiary educational hospital in Korea, between March 2005 and November 2011. Of these, 366 and 565 lesions were included in the absolute and expanded indication groups, respectively.

Results

En bloc resection rates were not significantly different between the absolute and expanded indication groups. The complete resection rate was higher in the absolute indication group versus the expanded indication group (94.8% vs. 89.9%, respectively; P = 0.008). In the expanded indication group, complete resection rate was higher in the differentiated versus undifferentiated tumour subgroups (92.9% vs. 78.4%, respectively; P < 0.001). Recurrence rates were 7.7% in the absolute indication group vs. 9.3% in the expanded indication group (P = 0.524). Disease-free survival was not significantly different between the two indication groups (P = 0.634).

Conclusions

Endoscopic submucosal dissection for early gastric cancer with expanded indication is a feasible approach to disease management. Periodic endoscopic follow-up is necessary to detect cancer recurrence.

Introduction

Since the introduction of endoscopic mucosal resection (EMR) in the early 1990s, endoscopic resection has been a preferential treatment instead of gastrectomy for early gastric cancer (EGC) confined to the mucosa without lymph node metastasis because of minimal invasiveness [1], [2], [3], [4], [5], [6]. However, EMR, the first developed method of endoscopic resection, is limited in that it is inadequate for en bloc resection of gastric lesions larger than 2 cm in diameter [7]. Endoscopic submucosal dissection (ESD) was developed for the purpose of en bloc resection, regardless of tumour size and location [8]. According to current guidelines, the absolute indication (AI) for endoscopic resection is a differentiated-type adenocarcinoma without ulcerative findings that is 2 cm or less in diameter, with tumour invasion confined to the mucosa [9]. These criteria, however, are so strict that unnecessary surgeries are likely performed [10]. A study by Gotoda et al. on 5265 patients who had undergone gastrectomy with lymph node dissection for EGC proposed criteria suggesting a low risk of lymph node metastasis [11]. Based on these observations, expanded indication (EI) for ESD was suggested [9]. Although ESD has become widely used according to EI [12], [13], [14], [15], [16], [17], [18], there is no strong consensus regarding EI due to concerns of increasing risk of lymph node metastasis [19], [20], [21], [22]. To evaluate the practicality of ESD following the expanded criteria, we analyzed the clinical and long-term oncological outcome after ESD for EGC, comparing AI versus EI.

Section snippets

Patients

Consecutive clinical data of 1152 patients with 1175 lesions who had undergone ESD for EGC between March 2005 and November 2011 were prospectively collected at our tertiary educational hospital in Seoul, Korea. ESD for EGC was performed based on EI. Although all lesions were considered to meet the expanded indication through endoscopy and biopsy before ESD, 241 were revealed to be outside of EI after histopathological examination. These 241 lesions that did not satisfy AI or EI were excluded

Clinicopathological characteristics

Table 1 shows patient and tumour characteristics according to the ESD indication. Mean age was higher in the AI versus the EI group (64 vs. 62 years, respectively; P = 0.004). The percentage of males was also higher in AI group than in EI group (78.2% vs. 69.9%, respectively, P = 0.006). Tumour locations were not different between the two groups. Due to differences of indication criteria between the AI and EI groups, tumour characteristics including macroscopic appearance, size, presence of ulcer,

Discussion

Endoscopic resection is an alternative treatment option for selected patients with EGC [9], [10]. The popularity of endoscopic resection is growing because of its minimal invasiveness [10]. In particular, ESD has special merit in that it enables the lesion to be resected in one piece regardless of tumour size [8]. Japanese Gastric Cancer Treatment Guidelines 2010 reported that a differentiated-type adenocarcinoma without ulcerative findings, with an invasion depth clinically diagnosed as T1a,

Conflict of interest statement

None declared.

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