Endoscopic submucosal dissection for papillary adenocarcinoma of the stomach: is it really safe?

Abstract

The use of ESD should be more carefully applied in patients with EGC-P meeting the ESD indication criteria, especially the expanded indication criteria, after pretreatment workup compared with other differentiated-type adenocarcinomas, owing to the higher frequencies of submucosal invasion, LNM, and LVI in EGC-P.

Clinicopathologic Features of Submucosal Papillary Gastric Cancer Differ from Those of Other Differentiated-Type Histologies

“…33 In papillary EGC, including mucosal GC and submucosal GC, the reported prevalence of LNM was approximately 18%. 8,9 However, our study found that when invading the SM layer, the LNM rate of papillary EGC increased to 25.6%. Compared with SM invasive WD GC, SM papillary GC showed an approximately four times higher rate of LNM (OR, 3.844; 95% CI, 1.962 to 7.530; p<0.001).…”

“…The invasive pathologic features and high LNM rate of papillary GC have consistently raised a question as to whether the current expanded ESD criteria that are applied to other differentiated EGC could be applied to papillary EGC. 8,9,19,29 When GC reaches the SM layer, the rate of LNM is approximately 15% to 20%, 11,12 which is higher than that of mucosal GC, at 0.4% to 3%. 33 In papillary EGC, including mucosal GC and submucosal GC, the reported prevalence of LNM was approximately 18%.…”

“…Papillary EGC has been found to have high rates of SM invasion and LVI. 8,19,29 Min et al 29 reported that SM papillary GC has a predominant elevated appearance and a higher LVI rate compared to that in other differentiated SM invasive GCs. In line with these observations, our study found that SM papillary GC is larger and has deeper SM invasion depth than that in other differentiated SM invasive GCs.…”

“…18 Papillary EGC has a significantly higher frequency of SM invasion compared to that in other differentiated EGC types. 8,9 The reported SM invasion rates were 41.4% in ESD specimens and 71.4% in surgical specimens, and were higher than those of other differentiated GC (17.1% and 50.8%). 8,19 Thus, detailed analysis of SM invasive features such as a minor poorly differentiated component or SM invasion width may be helpful in predicting the risk of LNM in SM invasive papillary GC.…”

“…1,[4][5][6][7] As a result, although papillary EGC can be treated with endoscopic submucosal dissection (ESD) when lesions meet the expanded criteria, the application of these criteria to papillary EGC is questionable, with concern due to the high rate of LNM in papillary EGC. 8,9 Submucosal (SM) invasion is a risk factor associated with LNM. 10 Compared with mucosal invasion alone, SM invasive EGC has been found to have a higher LNM rate, 11,12 and the expanded ESD criteria consider SM invasion depth as an important factor in deciding whether or not to perform ESD.…”