Endoscopic resection of early gastric cancer

Abstract

The purpose of this review is to examine recent advances in the techniques and technologies of endoscopic resection of early gastric cancer (EGC). Endoscopic mucosal resection (EMR) of EGC, with negligible risk of lymph node metastasis, is a standard technique in Japan and is increasingly becoming accepted and regularly used in Western countries. EMR is a minimally invasive technique which is safe, convenient, and effi cacious; however, it is insuffi cient when treating larger lesions. The evidence suggests that diffi culties with the correct assessment of depth of tumor invasion lead to an increase in local recurrence with standard EMR when lesions are larger than 15 mm. A major factor contributing to this increase in local recurrence relates to lesions being excised piecemeal due to the technical limitations of standard EMR. A new development in endoscopic techniques is to dissect directly along the submucosal layer -a procedure called endoscopic submucosal dissection (ESD). This allows the en-bloc resection of larger lesions. ESD is not necessarily limited by lesion size and it is predicted to replace conventional surgery in dealing with certain stages of ECG. However, it still has a higher complication rate when compared to standard EMR, and it requires high levels of endoscopic skill and experience. Endoscopic techniques, indications, pathological assessment, and methods of endoscopic resection of EGC need to be established for carrying out appropriate treatment and for the collation of long-term outcome data.

Multicenter study of the long-term outcomes of endoscopic submucosal dissection for early gastric cancer in patients 80 years of age or older

“…When histological evaluation was difficult, or, revealed that a lesion was outside the indication criteria and/or that it had a positive margin, the curability was defined as noncurative hospital stay (on post-ESD day 10). The complication rate (bleeding and perforation) was similar to those in other reports [2][3][4][5][6][7][8][9][10], showing that ESD was mostly safely performed even in the elderly. Curative ESD was achieved in 366 of 470 lesions (77.9%).…”

“…Endoscopic submucosal dissection (ESD) is widely recognized as a safe and effective treatment of EGC [2][3][4][5], even in aged or high-risk patients [6][7][8][9][10]. However, little information is available on the long-term outcomes of ESD in a large number of elderly patients.…”

Preventive effects of etodolac, a selective cyclooxygenase‐2 inhibitor, on cancer development in extensive metaplastic gastritis, a Helicobacter pylori‐negative precancerous lesion

“…[21][22][23][24][25][26] All patients were inhabitants from around the Wakayama area. In Japan, where the incidence of gastric cancer is high, treatment of mucosal gastric cancer without lymph node metastasis is usually achieved with endoscopic resection, preserving the stomach.…”

“…Although institutional differences in indications for endoscopic resection exist, lesions with preoperative endoscopic diagnoses of intestinal-type intramucosal cancer without ulcer findings, intestinal-type intramucosal cancer 3 cm in diameter with ulcer findings and intestinal-type minute invasive submucosal (<500 lm below muscularis mucosa) cancer 3 cm in diameter are considered to be indicated for endoscopic resection. 25,26 In these 267 patients, the extent of coexisting CAG was evaluated endoscopically and by the results of 2 serum tests, pepsinogen (PG) and H. pylori antibody level, as described in the following section.…”

Lymph node metastasis from undifferentiated-type mucosal gastric cancer satisfying the expanded criteria for endoscopic resection based on routine histological examination

“…ER is indicated for tumors with a negligible risk of lymph node (LN) metastasis [6]. Although the indications for ER specifi ed by the Japanese treatment guidelines are strictly limited to small mucosal tumors with differentiated histology (D-type), expanded indications for some D-type lesions (intramucosal cancers either ≤3 cm in size with no lymphatic-vascular capillary involvement regardless of ulceration fi ndings or with no ulceration regardless of tumor size) have been proposed and accepted by high-volume ER centers [2,6,7].It remains in dispute, however, as to which undifferentiated-type (UD-type) EGC lesions involve a negligible risk of LN metastasis. We recently published a study in which 3843 cases of surgically resected UD-type EGCs were examined, with particular emphasis placed on investigating the existence of LN metastasis [8].…”