Clinical outcomes of early gastric cancer patients after noncurative endoscopic submucosal dissection in a large consecutive patient series

Abstract

Background Clinical outcomes of early gastric cancer (EGC) patients after noncurative endoscopic submucosal dissection (ESD) have not been fully elucidated; we therefore aimed to clarify these outcomes. Methods A total of 3058 consecutive patients with 3474 clinically diagnosed EGCs at initial onset underwent ESD with curative intent at our hospital between 1999 and 2010. We retrospectively assessed the following clinical outcomes of noncurative gastric ESD patients with a possible risk of lymph node (LN) metastasis by dividing patients into two groups with different treatment strategies (additional gastrectomy and simple follow-up): presence of LN metastasis at the time of gastrectomy, incidence of LN and distant metastases during the follow-up period, clinicopathological factors associated with metastasis, and 5-year disease-specific survival (DSS). Results After exclusion of 75 noncurative ESD patients with only a positive horizontal margin, 569 noncurative ESD patients with a possible risk of LN metastasis were identified. Among the 356 patients undergoing additional gastrectomy, LN metastasis was identified in 18 patients. A positive vertical margin with submucosal invasion (odds ratio 3.6) and lymphovascular invasion (odds ratio 3.5) were significantly associated with LN metastasis. The 5-year DSS rate was 98.8 %. Among the 212 patients who underwent simple follow-up, LN and/or distant metastases were found in eight patients. In this group, lymphovascular invasion (hazard ratio 6.6) was significantly associated with metastasis with a 5-year DSS rate of 96.8 %.Conclusions Additional gastrectomy should be performed particularly in noncurative gastric ESD patients with lymphovascular invasion or a positive vertical margin with submucosal invasion.

Pattern of extragastric recurrence and the role of abdominal computed tomography in surveillance after endoscopic resection of early gastric cancer: Korean experiences

“…With a curative operation, a greater than 96% 5-year survival rate can be achieved in EGC with lymph node metastasis at stages such as T1N1 [25]. Even after noncurative endoscopic resection of EGC, additional radical gastrectomy with lymph node dissection showed a 5-year overall AGC advanced gastric cancer, CR curative resection, CTx chemotherapy, EGC early gastric cancer, LN lymph node, NCR noncurative resection, STG subtotal gastrectomy, TG total gastrectomy Pattern of extragastric recurrence and the role of abdominal computed tomography in… 849 survival rate of 94.3-94.7%, which is significantly greater (by about 10 percentage points) than that seen after no treatment [26][27][28]. For extragastric recurrences involving only regional lymph nodes, some case reports and studies showed good prognosis after curative surgery [8,19].…”

“…Recent reports from Korea and Japan included large populations of EGC patients and longer follow-up periods [8,9,19,28]. In terms of extragastric recurrence, all of the studies to date have reported a low incidence and a common pattern.…”

Management of non-curative endoscopic submucosal dissection for early gastric cancer: do we have enough data to support this?

“…Additional gastrectomy should be performed particularly in noncurative gastric ESD patients with lymphovascular invasion even in the elderly cohort without comorbidities (4,5). Nevertheless, we have not had enough data to support the real feasibility of gastric ESD linked to the survival benefits for elderly patients with comorbidities.…”

“…It is possible that lymphatic invasion and subsequent LNM may be a primary route for recurrence in non-curative ESD in the simple followup patients. And, lymphovascular invasion was identified as an independent predictor of gastric cancer-related death in non-curative gastric ESD patients in the simple followup group (4,5). Additional surgical intervention could be determined based on a comprehensive review of the resected specimen including lymphovascular tumor emboli, tumor size, histological type and depth of invasion.…”

“…One possible reason is that the patients in the follow-up patients were significantly older than those in the additional gastrectomy. However, both studies did not investigate life-threating concomitant diseases in detail or the causes of non-gastric cancer deaths in the non-curative ESD setting (4,5). Prognostic predictors of the healthy status can be useful for decision making in cases of the non-curative gastric ESD.…”