eCura评分系统在早期胃癌内镜非治愈性切除后治疗策略选择中的应用价值

目的:评估eCura评分系统在早期胃癌内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）非治愈性切除后治疗策略选择上的辅助作用。方法:2015年1月—2019年6月福建省立医院110例早期胃癌ESD非治愈性切除病例纳入回顾性队列研究,根据eCura评分系统分成低危组79例、中危...     

新型胃癌筛查评分系统在医院就诊人群中的应用

目的探讨新型胃癌筛查评分系统在医院就诊人群中的临床应用价值。 方法采用新型胃癌筛查评分系统对2017年4月至2018年8月间因各种消化道症状在温州市中心医院就诊且符合该筛查流程的患者资料进行回顾性分析,根据新型胃癌筛查评分系统的评分结果将所有患者分为3组,即低危组（0~11分）、中危组（12~16分）及高危组（17~23分）,对3组患者的胃癌及癌前状态的检出情况进行对比分析。 结果共2 674例患者纳入研究,低危组1 694例（63.35%）,中危组833例（31.15%）,高危组147例（5.50%）。共检出胃癌73例,胃癌检出率为2.73%（73/2 674）;3组患者的胃癌检出率分别为1.06%（18/1 694）、4.32%（36/833）及12.93%（19/147）,3组患者间胃癌的检出率两两比较,差异有统计学意义（P均＜0.05）。早期胃癌的检出率中危组[2.04%（17/833）]、高危组[4.08%（6/147）]明显高于低危组[0.35%（6/1 694）, P均＜0.05]。 结论采用新型胃癌筛查评分系统,不仅可以显著提高医院就诊人群的胃癌检出率,而且同时能提高早期胃癌诊断率。     

早期胃癌内镜黏膜下剥离术非治愈性切除的后续治疗策略分析

目的　评价早期胃癌内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）非治愈性切除后追加外科手术的临床意义。方法　2014年1月—2020年12月,在华中科技大学同济医学院附属协和医院行ESD治疗,术后病理结果为非治愈性切除的69例早期胃癌病例纳入回顾性观察,依据真实世界里后续是否追加外科手术分为追加手术组（n=12）和随访组（n=57）。主要观察临床和病理资料的组间差异,追加手术组的外科手术情况,2组三年无复发和肿瘤特异性生存率,影响随访组三年无复发生存率的独立危险因素。结果　与随访组比较,追加手术组的黏膜下层浸润率［66.7%（8/12）比21.1%（12/57）,χ2=7.927,P=0.005］、脉管侵犯率［33.3%（4/12）比1.8%（1/57）,P=0.003］和神经侵犯率［16.7%（2/12）比0.0%（0/57）,P=0.028］更高。追加手术组追加外科手术距ESD手术的间隔时间为18.5 d（7～55 d）,外科手术用时（286.4±85.9）min,清扫淋巴结（25.6±7.4）枚,4例（33.3%）有肿瘤残留,4例（33.3%）发生术后并发症（均经保守治疗好转后出院）,无围手术期死亡病例;有1例于外科手术后17个月发生肝转移,手术后22个月因胃癌肝转移死亡,1例外科手术后22个月因非肿瘤原因死亡,三年无复发生存率和三年肿瘤特异性生存率分别为91.7%（11/12）和91.7%（11/12）。随访组三年无复发生存率和三年肿瘤特异性生存率分别为87.7%（50/57）和100.0%（57/57）。多因素Cox回归分析显示肿瘤长径≥2 cm是影响随访组患者三年无复发生存率的独立危险因素（P=0.037,HR=15.595,95%CI：1.181～205.952）。结论　对于ESD非治愈性切除的早期胃癌患者,追加外科手术或密切随访均是安全可行的后续治疗策略,临床医师应根据患者的内镜手术病理结果,结合患者的身体状况和手术意愿进行合理选择;而对于原发肿瘤长径≥2 cm者,建议积极追加外科手术治疗。     

早期胃癌内镜下非治愈性切除术后追加外科手术患者的临床结果分析

目的　分析早期胃癌内镜下非治愈性切除患者追加外科手术的必要性。方法　回顾分析2009年7月至2023年5月于解放军总医院就诊的内镜下非治愈性切除术后追加外科手术的73例早期胃癌患者资料。主要观察指标包括术后标本病理类型、水平切缘情况、垂直切缘情况、标本浸润深度、是否脉管侵犯、eCura评分、阳性淋巴结例数以及总体生存率。结果　73例被判定为内镜下非治愈性切除的早期胃癌患者均追加了外科手术，其中男58例、女15例，平均年龄61岁（53~67岁）。发病部位方面，37例位于胃上部，24例位于胃下部，11例位于胃中部，1例为多发部位病变。病理类型分型方面，43例为高中分化管状腺癌，16例为黏液/印戒细胞癌，10例为低分化管状腺癌，4例为高级别上皮内瘤变。根据巴黎分型，22例为0‑Ⅱa型，43例为0‑Ⅱb型，8例为0‑Ⅲ型。浸润深度方面，17例为黏膜内癌，23例黏膜下侵犯不足500 μm，33例黏膜下侵犯超过500 μm。脉管浸润方面，8例存在淋巴管侵犯，8例存在静脉侵犯。73例患者中，4例被判断为eCura A，5例为eCura B，4例为eCura C1，60例为eCura C2。在60例被判断为eCura C2的患者中，根据外科术后病理标本评估，仅2例（3.3%）发现存在胃周淋巴结转移。73例内镜下标本中，7例患者水平切缘阳性，21例垂直切缘阳性，2例水平及垂直切缘均为阳性，总计30例患者存在水平或垂直切缘阳性，根据外科术后病理标本评估，9例（30.0%）发现原部位肿瘤残留。73例患者中，5例失访，4例死亡，总体生存率为94.12%（64/68），疾病特异生存率98.53%（67/68），患者随访时间为61.37（10~166）个月。结论　对于内镜下非治愈性切除评估结果为eCura C2的早期胃癌患者，追加手术是可行的，但是实际存在淋巴结转移的患者比例较低。     

中国早期胃癌筛查流程专家共识意见 在广东地区的应用

目的探讨“中国早期胃癌筛查流程专家共识意见”在广东地区胃癌风险人群中的应用价值。方法纳入2018年3月—2019年3月在广东地区进行早期胃癌筛查的居民,采用量化的新型胃癌筛查评分系统进行胃癌初筛,根据初筛结果将患者分为高危组、中危组和低危组,比较各组精查胃镜下早期胃癌、癌前疾病、癌前病变的检出率,统计学分析采用卡方检验。结果完成精查胃镜检查共545例,其中高危组32例,中危组184例,低危组329例。精查胃镜结果显示,早期胃癌检出率方面,高危组(12.5%)>中危组(1.1%)>低危组(0),差异有统计学意义（χ2＝41.85,P<0.01）;癌前疾病检出率方面,高危组(60.9%)>中危组(52.4%)>低危组(34.3%),差异有统计学意义（χ2＝18.00,P<0.01）;癌前病变检出率分别为17.9%、8.8%及8.8%,差异无统计学意义（χ2＝2.58,P＝0.28）。内镜病变检出阳性率组间比较,高危组(71.9%)>中危组(57.1%)>低危组(40.1%),差异有统计学意义（χ2＝21.54,P<0.01）。结论“中国早期胃癌筛查流程专家共识意见”在广东地区胃癌风险人群的早期胃癌及癌前疾病筛查中具有较好的应用价值。     

内镜黏膜下剥离术治疗未分化型早期胃癌的疗效分析

目的 探讨内镜黏膜下剥离术（ESD）治疗未分化型早期胃癌的疗效及预后。方法 回顾性分析2010年1月—2019年4月在南京医科大学第一附属医院行ESD治疗且术后病理证实为早期胃癌的393例患者（400处病灶）的临床病理资料,根据术后病理结果分为未分化癌组（50例,50个病灶）和分化癌组（343例,350个病灶）,收集患者年龄、性别,切除病灶大小及部位、大体分型、浸润深度、有无溃疡及术后随访情况等进行分析。结果 Logistic回归分析表明年龄≤60岁（OR=2.02,95%CI：1.04~3.95,P=0.011）、女性（OR=2.83,95%CI：1.41~5.68,P=0.003）、胃窦部病变（OR=3.92,95%CI：1.65~9.30,P=0.002）、凹陷型病变（OR=5.37,95%CI：2.16~13.38,P<0.001）及浸润至黏膜下层（OR=5.09,95%CI：2.40~10.80,P<0.001）为未分化型早期胃癌发生的独立危险因素。393例患者中,非治愈性切除113例,治愈性切除280例。未分化癌组非治愈性切除率高于分化癌组[90.0%（45/50）比19.8%（68/343）,χ2=104.902,P<0.001]。非治愈性切除患者死亡率高于治愈性切除[4.4%（5/113）比0.7%（2/280）, χ2=5.558,P=0.023]。未分化癌组27例患者追加手术,分化癌组51例追加手术,无一例复发;315例未追加手术患者中,未分化癌组复发率高于分化癌组[26.1%（6/23）比4.1%（12/292）,χ2=5.560,P<0.001]。结论 年龄≤60岁、女性、胃窦部病变、凹陷型病变及浸润至黏膜下层为未分化型早期胃癌发生的独立危险因素。未分化型早期胃癌非治愈性切除率高、ESD术后易复发,建议追加外科手术治疗。     

内镜下黏膜剥离术及外科手术治疗137例早期胃癌的临床分析

[目的]分析我院137例早期胃癌患者的临床表现,肿瘤部位、大小、内镜形态、病理学分型、淋巴结转移等,比较内镜下黏膜剥离术(ESD)与外科手术治疗早期胃癌术后病理特征及疗效的差异,有助于选择合适的治疗方案。[方法]将2005年1月~2015年6月我院进行治疗的137例早期胃癌患者行回顾性分析和总结。应用χ2检验及独立样本t检验进行统计学分析。[结果]2005年1月~2015年6月共诊断新发早期胃癌137例,淋巴结转移率为7.30%(10/137),其中黏膜内癌转移率为2.36%(2/85),黏膜下癌转移率为15.38%(8/52)。经单因素χ2检验提示浸润深度与组织学分型及淋巴结转移相关,ESD术后并发症及住院费用、住院天数显著低于外科手术。[结论]目前经外科治疗的早期胃癌中接近一半的患者可经ESD治愈。早期胃癌患者中仍有部分患者术后病理见淋巴结转移且与肿瘤的黏膜浸润深度相关。胃镜下诊断胃癌需要熟练掌握其特征并善于结合病理活检。ESD早期胃癌治疗存在其优越性,在诊断淋巴结转移方面需要进一步完善。     

新型胃癌筛查评分系统在福建海岛胃癌风险人群的应用

目的　探讨新型胃癌筛查评分系统在福建海岛胃癌风险人群的应用价值。方法　2019年4—6月，对福建省莆田市南日岛人群进行胃癌筛查，前瞻性收集了研究对象的流行病学数据。采用新型胃癌筛查评分系统进行胃癌风险分级后，对所有受试者进行胃镜检查，随后对疑似阳性病例进行放大内镜检查和活检。后续针对阳性人群进行手术治疗（包括内镜及外科手术）。比较胃癌风险分级的各组人群中胃癌及癌前病变的检出率，采用卡方检验等统计学分析。结果　共纳入研究对象1 423例，检出胃癌19例（1.34%）。胃癌风险分级的低危组、中危组和高危组胃癌检出率分别为0.88%（9/1 025）、1.76%（6/341）和7.02%（4/57）。对胃癌检出率进行配对比较显示，低危组和高危组差异有统计学意义（χ2=12.364，P=0.003）。低危组与中危组、中危组与高危组之间差异无统计学意义（P>0.05）。所有患者共检出胃癌前病变87例（6.11%）。对胃癌前病变检出率进行配对比较显示，低危组、中危组和高危组的检出率分别为6.24%（64/1 025）、5.87%（20/341）和5.26%（3/57），3组间差异无统计学意义（P>0.05）。结论　在胃癌筛查过程中，新型胃癌筛查评分系统有助于对福建海岛胃癌风险人群进一步风险分层，为内镜精查提供依据。     

早期胃癌内镜下非治愈性切除后胃内再发的危险因素分析

目的 探讨早期胃癌（EGC）非治愈性切除后胃内再发的危险因素。方法 收集2008年10月到2018年6月,于上海仁济医院消化内镜中心行早期胃癌内镜下治疗结果为非治愈性切除,并选择继续随访的59例患者相关资料,运用单因素Logistic回归分析胃内再发危险因素。结果 随访4~77个月,中位时长40个月,出现胃内再发11例,单因素Logistic回归分析显示淋巴脉管侵犯（OR=8.63,95%CI：1.24~60.04,P=0.030）和eCura高危分级（OR=7.31,95%CI：1.05~51.10,P=0.045）是胃内再发的危险因素。结论 非治愈性切除后可考虑常规行eCura分级评估,存在淋巴脉管侵犯或eCura分级高危者不建议继续随访;eCura分级低危者可继续行内镜随访,并注意观察原病灶周围是否存在异常。     

急性上消化道出血Rockall评分系统的应用及与预后的关系

[目的]探讨急性上消化道出血（AUGIB）患者Rockatl危险性积分的应用及其与预后的关系。[方法]114例于2011年2月至2013年2月间接诊的AUGIB患者进行Rockall危险性积分评分,并分为低危组（≤2分）、中危组（3～4分）和高危组（≥5分）,比较住院期间及电话随访出院30天内各组患者输血、再出血和死亡事件发生率差异。[结果]114例患者中,列入低危组29例（25．44％）、中危组45例（37．47％）、高危组40例（35．09％）;低危组、中危组、高危组输血率分别为3．45％、24．44％、42．50Yoo（组间比较X2=13．56,P〈0．01）,再出血率分别为6．89％、15．56％、30．00％（组间比较X2=6．38,P〈O．05）,病死率分别为0％、2．22％、15．00％（组间比较X2=25．67,P〈0．001）,组间比较均差异有统计学意义。[结论]Rockall危险性积分对AUGIB患者预后有较强预测价值,适合作为判断AUGIB预后和制定治疗措施的依据。     

History and future perspectives in Japanese guidelines for endoscopic resection of early gastric cancer

Japanese guidelines for gastric cancer treatment were first published in 2001 for the purpose of showing the appropriate indication for each treatment method, thereby reducing differences in the therapeutic approach among institutions, and so on. With the accumulation of evidence and the development and prevalence of endoscopic submucosal dissection (ESD), the criteria for the indication and curability of endoscopic resection (ER) for early gastric cancer (EGC) have expanded. However, several problems still remain. Although a risk-scoring system (eCura system) for predicting lymph node metastasis (LNM) may help treatment decision in patients who do not meet the curative criteria for ER of EGC, which is referred to as eCura C-2 in the latest guidelines, additional gastrectomy with lymphadenectomy may be excessive for many patients, even those at high risk for LNM. Less-invasive function-preserving surgery, such as non-exposed endoscopic wall-inversion surgery with laparoscopic sentinel node sampling, may overcome this problem. In addition, further less-invasive treatment, such as ER with chemotherapy, should be established for patients who prefer not to undergo additional gastrectomy.     

早期胃癌内镜下切除日本指南的历史和未来展望

日本胃癌治疗指南首次发表于2001年,其目的是为了明确不同治疗方案的适应证,从而减少不同医疗机构间治疗方式的差异。随着病例的积累及内镜黏膜下剥离术(ESD)的发展,早期胃癌(EGC)内镜下切除(ER)的适应证和治愈性范围有所扩大,但是,仍有部分问题亟待解决。使用风险评分系统(eCura system)评估淋巴结转移(LNM)的情况,可能有助于确定不符合内镜切除标准的EGC患者的治疗方案。对于不符合内镜切除标准的EGC患者,即最新指南中的eCura C-2分期的患者,尽管他们的LNM风险较高,但对于很多患者来说,追加胃切除联合淋巴结清扫术仍然是过度的治疗。而保留功能的低侵入性手术,如内镜下非开放式胃壁反转切除术联合腹腔镜前哨淋巴结活检,有可能会解决该问题。此外,对于拒绝追加胃切除术的患者,可采取更多的低侵入性治疗方式,如ER联合化疗。     

预测老年早期胃癌患者内镜黏膜下剥离术后复发风险的列线图模型

目的探讨个体化预测老年早期胃癌(EGC)患者内镜黏膜下剥离术(ESD)后复发风险的列线图模型构建。方法回顾性队列研究。我院消化科2000年1月至2016年12月共收治行ESD治疗的老年EGC患者3987例,选择临床病理资料和随访资料完整的28例复发患者作为复发组,276例未复发患者作为对照组。调取所有患者一般资料,Logistic回归分析筛选影响EGC患者ESD后复发的独立危险因素,利用R软件建立相应的列线图风险预测模型。结果3987例老年EGC患者,平均随访2.7年,29例复发,复发率为0.73%(29/3987)。复发组和对照组患者的年龄≥75岁[11例(39.3%)比171例(62.0%)]、病变≥3 mm[19例(67.9%)比111例(40.0%)]、T分期黏膜层[9例(32.1%)比153例(55.4%)]和淋巴结转移[19例(67.9%)比102例(39.0%)]比较,差异有统计学意义(均P<0.05)。Logistic回归分析结果显示,年龄≥75岁(OR=2.128,95%CI:1.373~3.624)、T分期(OR=1.763,95%CI:1.079~2.934)、病变≥3 mm(OR=2.604,95%CI:1.363~4.217)、淋巴浸润(OR=2.871,95%CI:1.425~5.639)是EGC患者ESD术后复发的独立危险因素(均P<0.05)。基于以上危险因素建立的列线图模型,验证结果显示预测值与实测值基本一致,具有较好的预测性能;内部验证结果显示,一致性指数为0.817(95%CI:0.722~0.941),提示该模型具有较高的精准度和区分度。结论对老年EGC患者行ESD术前,应充分考虑年龄、肿瘤大小、T分期和淋巴浸润等因素,综合评估EGC患者ESD术后的复发率。本预测模型能提高术后复发的诊断效能,具有较高的临床价值。     

Is endoscopic submucosal dissection safe for papillary adenocarcinoma of the stomach?

AIM: To identify the clinicopathological predictors of lymph node(LN) metastasis and evaluate the outcomes of endoscopic submucosal dissection(ESD) in papillary adenocarcinoma-type early gastric cancers(EGCs).METHODS: From January 2005 to May 2013, 49 patients who underwent surgical operation and 24 patients who underwent ESD for papillary adenocarcinomatype EGC were enrolled to identify clinicopathological characteristics and predictive factors of LN metastasis and to evaluate the outcomes of ESD for papillary adenocarcinoma-type EGC.RESULTS: Most papillary adenocarcinoma-type EGCs were located in the lower third of the stomach and had an elevated macroscopic shape. The overall prevalence of LN metastasis was 18.3%(9/49). The presence of lymphovascular invasion was found to be a predictor of LN metastasis(P = 0.016). According to current indication criteria of ESD, 6 and 11 of the 49 patients had absolute and expanded indications for ESD, respectively. Two patients(11.8%) with expanded indication for ESD had LN metastasis. Of the 24 patients who underwent ESD, 13(54%) achieved out-of-ESD indication, with 9 of those 13 patients undergoing surgical operation due to non-curative resection. CONCLUSION: The use of ESD should be carefully considered for papillary adenocarcinoma-type EGC with suspected ESD indication after pre-treatment work-up because of the higher frequency of LN metastasis and additional surgeries.     

Bone metastasis from early gastric cancer following non-curative endoscopic submucosal dissection

A 67-year-old male underwent endoscopic submucosal dissection(ESD)to treat early gastric cancer(EGC)in 2001.The lesion(50 mm × 25 mm diameter)was histologically diagnosed as poorly differentiated adenocarcinoma,with an ulcer finding.Although the tumor was confined to the mucosa with no evidence of lymphovascular involvement,the ESD was regarded as a noncurative resection due to the histological type,tumor size,and existence of an ulcer finding(as indicated by the 2010 Japanese gastric cancer treatment guidelines,ver.3).Despite strong recommendation for subsequent gastrectomy,the patient refused surgery.An alternative follow-up routine was designed,which included five years of biannual clinical examinations to detect and measure serum tumor markers and perform visual assessment of recurrence by endoscopy and computed tomography scan after which the examinations were performed annually.The patient’s condition remained stable for eight years,until a complaint of back pain in 2010 prompted further clinical investigation.Bone scintigraphy indicated increased uptake.Histological examination of biopsy specimens taken from the lumbar spine revealed adenocarcinoma resembling the carcinoma cells from the EGC that had been treated previously by ESD,and which was consistent with immunohistochemical findings of gastrointestinal tract cancer.Thus,the diagnosis of bone metastasis from EGC was made.The reported rates of EGC recurrence in surgically resected cases range 1.4%-3.4%,but among these bone metastasis is very rare.To our knowledge,this is the first reported case of bone metastasis from EGC following a non-curative ESD and occurring after an eight-year disease-free interval.     

Epstein-Barr virus-associated lymphoepithelioma-like early gastric carcinomas and endoscopic submucosal dissection: Case series

Epstein-Barr virus(EBV)-associated lymphoepitheliomalike gastric carcinoma(LELC) is characterized by a lower lymph node(LN) metastasis rate and a higher survival rate than other forms of gastric cancer. Although current prognosis for LELC is favorable, the most common approach is radical gastrectomy involving an extensive D2 lymph node dissection. Here, we report four cases of EBV-associated early LELC that were treated by an alternative approach, endoscopic submucosal dissection(ESD). The long-term outcome of this procedure is discussed. All patients were treated by ESD en bloc, and all ESD specimens showed tumor-free lateral resection margins. None of the lesions showed lymphovascular invasion. A pathological examination of ESD specimens revealed submucosal invasion of more than 500 μm in all four cases. One patient underwent additional radical surgery post-ESD; no residual tumor or LN metastasis was noted in the surgical specimen. The other three patients did not undergo additional surgery, either because of severe comorbidity or their refusal to undergo operation, but were subjected to medical follow-up. None of the ESD-treated patients reported local recurrence or distant metastases during the 27-32 mo of follow-up after ESD.     

Endoscopic management of patients with early gastric cancer before and after endoscopic resection: A review

With the wide application of endoscopic resection for early gastric cancer (EGC) by not only Asian endoscopists but also those from Western countries, reviews on standardized treatment processes before and after endoscopic resection are nevertheless lacking. In this article we provide a narrative review of studies on the selection of appropriate EGC for endoscopic resection and the follow‐up strategies for those with histologically confirmed EGC after endoscopic resection. EGC should be comprehensively assessed before endoscopic resection, including its exact margin, invasive depth and risk of lymph node metastasis (LNM). While the curative resection status of EGC may be evaluated after endoscopic resection based on the newly developed eCura system, although this needs to be further verified. Surveillance with endoscopy and computed tomography scan is necessary for patients with an EGC level A or B. An additional endoscopic resection is recommended for patients with a level‐C1 EGC. For patients with a level‐C2 EGC, close follow‐up is suggested for low‐risk tumors of level C2 and additional surgery for those at high risks. Further postoperative strategy is suggested based on comprehensive assessment of the risk of LNM, patient's quality of life and wishes.     

内镜黏膜下剥离术治疗早期胃印戒细胞癌的疗效及非治愈性切除的危险因素分析

目的探讨内镜黏膜下剥离术(ESD)治疗早期胃印戒细胞癌(SRCC)的疗效及预后,并探讨非治愈性切除的危险因素。方法回顾性分析2012年10月至2020年10月在南京大学医学院附属鼓楼医院、南京医科大学附属无锡人民医院、泰州市人民医院、南京市高淳人民医院行ESD治疗的62例早期胃SRCC患者的临床病理资料,根据术后病理结果分为治愈性切除组34例和非治愈性切除组28例,收集患者性别、年龄、肿瘤大小及部位、大体分型、浸润深度、切缘、溃疡及术后随访情况等进行分析。结果整块切除率为100%(n=62),完全切除率为83.9%(n=52),治愈性切除率为54.8%(n=34)。术中穿孔率为1.6%(n=1),迟发出血率为1.6%(n=1)。28例非治愈性切除的患者中,20例追加了外科手术,死亡2例,其中1例在外科手术后死于术后出血,另1例在外科手术后死于术后感染。8例非治愈性切除的患者没有追加外科手术,其中2例患者死于淋巴结转移。ESD治愈性切除组的5年生存率明显高于ESD非治愈性切除组,组间差异有统计学意义(P=0.023)。肿瘤直径>20 mm(OR=59.73,95%CI=9.94~358.87,P<0.001)及溃疡是(OR=24.49,95%CI=2.11~284.72,P=0.011)是早期胃SRCC非治愈性切除的独立危险因素。结论达到内镜下治愈性切除标准的早期胃SRCC患者,预后明显好于非治愈性切除的患者。肿瘤直径>20 mm和溃疡为早期胃SRCC非治愈性切除的独立危险因素。     

Is radical surgery necessary in all patients who do not meet the curative criteria for endoscopic submucosal dissection in early gastric cancer? A multi-center retrospective study in Japan

Background

Although radical surgery is routinely performed for patients who do not meet the curative criteria for endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) due to the risk of lymph node metastasis (LNM), this standard therapeutic option may be excessive given the lower number of patients with LNM. Therefore, we aimed to investigate long-term outcomes and validate risk factors predicting recurrence after ESD.

Methods

Of 15,785 patients who underwent ESD for EGC at 19 institutions between 2000 and 2011, 1969 patients not meeting the curative criteria were included in this multi-center study. Based on the treatment strategy after ESD, patients were divided into radical surgery (n = 1064) and follow-up (no additional treatment, n = 905) groups.

Results

Overall survival (OS) and disease-specific survival (DSS) were significantly higher in the radical surgery group than in the follow-up group (p < 0.001 and p = 0.012, respectively). However, the difference in 3-year DSS between the groups (99.4 vs. 98.7 %) was rather small compared with the difference in 3-year OS (96.7 vs. 84.0 %). LNM was found in 89 patients (8.4 %) in the radical surgery group. Lymphatic invasion was found to be an independent risk factor for recurrence in the follow-up group (hazard ratio 5.23; 95 % confidence interval 2.01–13.6; p = 0.001).

Conclusions

This multi-center study, representing the largest cohort to date, revealed a large discrepancy between OS and DSS in the two groups. Since follow-up with no additional treatment after ESD may be an acceptable option for patients at low risk, further risk stratification is needed for appropriate individualized treatment strategies.

     

Endoscopic Therapy of Early Colorectal Cancer (pT1) - A Prospective Study

INTRODUCTION: In a prospective study initiated in 1982, we have been investigating the question as to whether - and if so, which - pT1 carcinomas of the colorectum can be treated exclusively via the endoscope. METHOD: In the period between February 1, 1982 and April 30, 2001, a total of 5,470 polyps were removed endoscopically at the Medical Department I of the Klinikum Ludwigsburg. Among these lesions, a total of 144 (2.6 %) pT1 carcinomas were found in 141 patients. We were able to follow 120 patients with 123 pT1 carcinomas over a mean follow-up period of 46 months (range: 1-60). In low-risk situations (definitive removal in healthy tissue, G1-G2, no lymphatic involvement), endoscopic treatment alone usually represented sufficient treatment. In high-risk cases (removal in healthy tissue uncertain or negative, and/or lymphatic vessel involvement, and/or G3/G4), subsequent surgical resection was carried out. RESULTS: 64 cases were classified as high-risk, 59 as low-risk. Nevertheless, 9 patients with 10 low-risk carcinomas were submitted to surgery (young age, patient's own request). In none of these 10 cases was residual tumour or lymph node metastasis detected in the surgical specimen. 47 patients with 49 low-risk carcinomas were treated solely by endoscopic polypectomy using the diathermy snare, and 45 patients with 47 carcinomas remained recurrence-free during the follow-up period. In a single case, a local recurrence was detected 2 months after polypectomy and underwent curative resection. In another case, peritoneal carcinosis with tumour infiltrating into the colon developed 8 months after initial treatment; this, however, was most probably a recurrence of a previously operated carcinoma of the uterus. Among the high-risk cases, 10 were not submitted to surgery on account of advanced age and/or rejection of an operation by the patient; all remained recurrence-free. Among the surgically treated high-risk carcinomas, 3 surgical specimens contained residual tumour, while 2 revealed a lymph node metastasis. In our group of patients, no tumour-related mortality was seen among endoscopically treated patients. DISCUSSION: In the light of the fact that the reported mortality rate associated with open surgery for colorectal carcinoma is 3 % as compared with about 1 % risk of lymph node metastasis and 0,1 % mortality rate for the endoscopic modality, endoscopic removal of a pT1 tumour in a low-risk situation followed by appropriate surveillance can be considered as adequate treatment.