Endoscopic submucosal dissection for suspected early gastric cancer: absolute versus expanded criteria in a large Western cohort (with video)

Abstract

Background and Aims: Endoscopic submucosal dissection (ESD) is an effective, minimally invasive, surgerysparing technique for the treatment of early gastric cancer (EGC). It is not well established whether EGC within the Japanese expanded criteria can be safely and effectively treated using ESD in the West. We describe the outcomes of ESD for endoscopically suspected, biopsy specimen-confirmed EGC and its adenomatous precursor lesions (pEGC) using the Vienna classification of dysplasia in a Western cohort. Methods: Prospective data were collected on all pEGCs undergoing ESD at a single expert endoscopy center. Outcomes were compared among pEGC, satisfying the Japanese absolute and expanded criteria, those outside criteria, and those specimens that contained low-grade dysplasia (LGD) only. Specialist GI pathologists reviewed and classified all ESD specimens. Patients were followed up at 6 and 12 months. Results: Over 71 months, 135 pEGCs in 121 patients (mean age, 72.0 years; 61.2% men) underwent ESD. Median pEGC size was 20 mm (interquartile range, 15-30), and 62 (45.9%) satisfied the expanded clinical criteria. Perforation occurred in 1.5% and postprocedural bleeding in 5.2%. Forty-two pEGCs (31.1%) contained LGD only. Rates of en bloc and R0 resection were 94.8% and 86.7%, respectively. One hundred seven pEGCs (79.2%) met the absolute or expanded criteria for endoscopic cure. Two pEGCs recurred during follow-up. Ten of 26 patients with pEGC (38.5%) outside criteria for cure underwent surgery after ESD with residual tumor detected in 3 specimens. Fifteen patients with outside criteria for pEGCs did not undergo surgery because of frailty or their expressed wish. Eleven of 15 patients have so far undergone first surveillance with 1 of 11 experiencing endoscopic and histologic recurrence. Conclusions: ESD is a safe and effective treatment for pEGCs in a Western context. Patients who either decline or are too frail for surgery, with outside criteria resections, may benefit from ESD for local disease control. Large Western studies of ESD for pEGCs are required to define long-term patient outcomes and surveillance guidelines, particularly where pathology shows LGD or high-grade dysplasia only.

Endoscopic submucosal dissection for early gastric cancer in the West: the absolute but not final word

“…However, data originating from Western countries on ESD for EGC remain limited. In this study, Tate and colleagues 8 demonstrate that ESD is highly effective for the en-bloc and R0 resection of gastric neoplasia with an adequate safety profile, comparable with data originating from Asia. 3,4 It is noteworthy to mention that, unlike prior studies reporting ESD outcomes on only histopathologically proven EGC, 9 this study included all ESD cases of gastric neoplasia (dysplastic lesions as well as EGC) in their analysis.…”

“…Perhaps more importantly, the question of whether ESD should be considered in the West for EGCs fulfilling the expanded Japanese criteria remains largely unanswered. From a strictly technique standpoint, as shown by Tate et al 8 and other Western studies, the rates of enbloc and R0 resection for expanded criteria lesions remain lower than those reported in Asia. The cause of this is likely multifactorial, including regional differences in the incidence of EGC, the availability of ESD and training opportunities.…”

“…Nevertheless, in aggregate, studies including both Asian and non-Asian cohorts have demonstrated that certain features, such as an undifferentiated histology and the presence of submucosal invasion, are associated with a higher incidence of LNM and recurrence. 10,11 Unfortunately, the study by Tate et al 8 does not provide any significant additional insight in this matter, given the very few cases of undifferentiated lesions (nZ10) or SM1 (nZ10) included and the short follow-up.…”

“…Studies have suggested differences in tumor characteristics and survival rates between Asian and Western populations, 5 which, coupled with the limited Western data on EGC outcomes after endoscopic resection, have resulted in conflicting recommendations by European guidelines, particularly with regard to the expanded criteria. 6,7 In this issue, Tate et al 8 report their single-center prospective data on ESD for suspected EGC in a Western population. For the purpose of the study, the authors introduced and defined a precursor of early gastric cancer (pEGC) as any demarcated gastric lesion that was suspected on endoscopic imaging (with confirmatory forceps biopsy histologic analysis) to be either EGC of any subtype or adenomatous dysplasia (pre-ESD entity), whereas the term EGC was reserved for histologically proven gastric adenocarcinoma.…”

Clinical outcomes of early gastric cardiac cancer treated with endoscopic submucosal dissection in patients with different indications

“…It may cross the gastroesophageal junction to invade the distal esophagus. Our previous study showed 23.6% of early gastric cancer (EGC) was gastric cardiac carcinoma at our center, which is much higher compared to 7.0% in Japan [2] and 11.9% in western cohort [3]. The incidence of gastric cardiac cancer is rising worldwide for unknown reasons.…”