Recurrence in early gastric cancer--presence of micrometastasis in lymph node of node negative early gastric cancer patient with recurrence

BACKGROUND/AIMS: There are cases of recurrence even after curative resection in early gastric cancer. METHODOLOGY: Seven hundred and sixty-five patients with early gastric cancer who underwent curative gastrectomy were analyzed to identify the prognostic factor. Micrometastases within lymph nodes were determined by immunohistochemistry using anti-cytokeratin antibody in node-negative early gastric cancer patients with recurrence. RESULTS: The recurrence was observed in 17 patients. Hematogenous recurrence was observed most frequently (47.1%), followed by peritoneal recurrence (23.5%). Of 17 patients with recurrence, 6 (35.3%) patients died more than 5 years after operation. The prognosis was poorer when the patients were older, and the depth of invasion was greater, lymph node metastasis, lymphatic involvement, and vascular involvement were present, and lymph node dissection was limited. The independent prognostic factors were lymph node metastasis, lymph node dissection, and age by multivariate analysis using Cox proportional hazards. Micrometastases within lymph nodes were confirmed in 3 of 6 node-negative patients with recurrence. CONCLUSIONS: When patients have lymph node metastases or are older, close and long-term follow-up and careful planning of postoperative adjuvant therapy might be necessary to avoid recurrence. The detection of micrometastases by anti-cytokeratin antibody might be useful for predicting the possibility of recurrence in early gastric cancer.     

Prognosis of gastric cancer patients with node-negative metastasis following curative resection: outcomes of the survival and recurrence

BACKGROUND: The purpose of the present study was to provide valuable prognostic information on lymph node-negative gastric cancer patients following curative resection. METHODS: Data from 112 lymph node-negative gastric cancer patients who underwent curative resection were reviewed to identify the independent factors of overall survival and recurrence. RESULTS: The five-year survival rate of lymph node-negative gastric cancer patients was 85.7%, and recurrence was identified in 25 patients after curative surgery. The five-year survival rate of lymph node-negative gastric cancer patients was higher than that of lymph node-positive gastric cancer patients (P<0.001). Recurrence in lymph node-negative gastric cancer patients was less than that of lymph node-positive gastric cancer patients (P=0.001). The median survival after recurrence of lymph node-negative gastric cancer patients was longer than that of lymph node-positive gastric cancer patients (P=0.021). Using multivariate analyses, the following results were determined for lymph node-negative gastric cancer patients: sex, operative type and the presence of serosal involvement were independent factors of overall survival; and lymphadenectomy, number of dissected nodes and the presence of serosal involvement were independent factors of recurrence. CONCLUSIONS: The prognosis of lymph node-negative gastric cancer patients was better than that of lymph node-positive gastric cancer patients. Male sex, subtotal gastrectomy and nonserosal involvement should be considered to be the favourable predictors of postoperative long-term survival of lymph node-negative gastric cancer patients. Conversely, limited lymphadenectomy, few dissected nodes and serosal involvement should be considered to be risk factors of postoperative recurrence of lymph node-negative gastric cancer patients.     

Analysis of the prognostic factors for liver metastasis of gastric cancer after hepatic resection: a multi-institutional study of the indications for resection

BACKGROUND/AIMS: The number of reports of hepatic resection for metastatic gastric cancer is very small. The outcome and indications of hepatic resection for metastatic gastric cancer remains unknown. METHODOLOGY: A multi-institutional study was made. Thirty-six patients who underwent a hepatic resection for liver metastasis of gastric cancer with no residual tumor were included in this study. The clinicopathological factors were examined as prognostic factors by multivariate analyses. Thirty patients had recurrence and the recurrence pattern and risk factors for extrahepatic recurrence was examined. RESULTS: The overall survival rate was 64% at 1 year, 43% at 2 years, 26% at 3 years 26% at 5 years, and 26% at 10 years after hepatectomy. Multivariate analysis showed that lymphatic invasion, venous invasion of cancer cells of primary gastric cancer and the number of the liver metastasis (> 3) were independent poor prognostic factors after hepatic resection. The most common recurrence pattern was intrahepatic recurrence in 22 patients (73%). The risk factors for extrahepatic recurrence was serosal invasion, lymph node metastasis of primary gastric cancer, stage, and curability of operation. CONCLUSIONS: Hepatic resection for liver metastasis should be attempted in case primary gastric cancer has neither lymphatic invasion nor venous invasion. The most common recurrent site was the liver. In patients with advanced gastric cancer, having neither serosal invasion nor lymph node metastasis, who underwent a less curative operation, the intra-hepatic recurrence would be expected. Thus, aggressive adjuvant chemotherapy through the hepatic artery may improve the survival after hepatectomy in these patients.     

Prediction of survival period for patients with postoperative recurrence after curative resection for advanced gastric carcinoma

BACKGROUND/AIMS: Although many studies have attempted to clarify the prognostic indicators for gastric carcinoma, there have been few studies regarding the factors that correlate with the survival period of patients with postoperative recurrence. METHODOLOGY: Among 504 advanced gastric adenocarcinoma patients who had undergone curative gastrectomy, 188 patients who had died of recurrence were used in this study. RESULTS: Univariate analysis indicated that age, the presence of lymph node metastasis and blood vessel invasion, the number of positive lymph nodes, and gastrectomy significantly correlated with the survival period. Multivariate analysis indicated that the length of the survival period was independently influenced by the number of positive lymph nodes and blood vessel invasion. The survival time of patients with less than 3 positive lymph nodes and no accompanying blood vessel invasion was significantly longer than that of other patients. CONCLUSIONS: The number of positive lymph nodes and the presence of blood vessel invasion are the most important factors predicting the survival period of patients with postoperative recurrence after curative resection for advanced gastric carcinoma.     

Peritoneal recurrence of gastric adenocarcinoma after curative resection

BACKGROUND/AIMS: Death from gastric carcinoma after curative resection is mostly due to recurrence. The most common recurrence is peritoneal dissemination, which represents 33 to 50% of total recurrence after curative gastrectomy. Since survival after peritoneal dissemination is very poor, selection of high-risk patients for further management after resection may contribute to better survival. METHODOLOGY: Based on a prospective database, a total of 1,092 patients with gastric carcinoma who underwent curative resection were included in this study. The incidence of peritoneal recurrence, disease-free interval and survival after peritoneal recurrence were determined. The clinicopathological factors including sex, age, tumor location, size, gross appearance, histological findings, depth of tumor invasion, lymph node status, tumor cell infiltration pattern were analyzed to see if there is any relationship with peritoneal dissemination. RESULTS: The incidence of peritoneal recurrence after curative resection was 13.46%. The mean disease-free interval was 14.2 months and the survival after peritoneal recurrence was 4.9 months in average. Almost all the clinicopathological factors were related with peritoneal recurrence, but only depth of tumor invasion, gross appearance and tumor infiltration pattern are closely associated with peritoneal tumor dissemination after multivariate analyses. CONCLUSIONS: Since the prognosis after peritoneal recurrence is so poor, selection of high-risk patients for further management after gastrectomy may be based on these three factors.     

Prognostic value of number of examined lymph nodes in patients with node-negative gastric cancer

AIM:To elucidate the potential impact of examined lymph nodes(eLNs)on long-term survival of nodenegative gastric cancer patients after curative surgery.METHODS:A total of 497 node-negative gastric cancer patients who underwent curative gastrectomy between January 2000 and December 2008 in our center were enrolled in this study.Patients were divided into4 groups according to eLNs through cut-point analysis.Clinicopathological features were compared between≤15 eLNs group and>15 eLNs group and potential prognostic factors were analyzed.The Log-rank test was used to assess statistical differences between the groups.Independent prognostic factors were identifiedusing the Cox proportional hazards regression model.Stratified analysis was performed to investigate the impact of eLNs on patient survival in each stage.Overall survival was also compared among the four groups.Finally,we explored the recurrent sites associated with eLNs.RESULTS:Patients with eLNs>15 had a better survival compared with those with eLNs≤15 for the entire cohort.By the multivariate survival analysis,we found that the depth of invasion and the number of eLNs were the independent predictors of overall survival(OS)of patients with node-negative gastric cancer.According to the cut-point analysis,T2-T4 patients with 11-15 eLNs had a significantly longer mean OS than those with 4-10 eLNs or 1-3 eLNs.Patients with≤15 eLNs were more likely to experience locoregional and peritoneal recurrence than those with>15eLNs.CONCLUSION:Number of eLNs could predict the prognosis of node-negative gastric cancer,and dissection of>15 eLNs is recommended during lymphadenectomy so as to improve the long-term survival.     

Feasibility of endoscopic papillectomy in early stage ampulla of Vater cancer

Background and Aim:  Although endoscopic papillectomy has been attempted in early stage ampullary cancer (pTis, T1), its curative role and indications remain uncertain. The present study was designed to assess the factors that predict malignancy and lymph node metastasis and to suggest potential indications for endoscopic papillectomy by analyzing clinicopathological data.
Methods:  We performed a retrospective analysis of clinical and histopathological data of 216 patients with ampullary cancer between 1991 and 2006.
Results:  No tumor in pTis stage had metastasized to lymph nodes and only 9% of tumors in pT1 had metastasized. Tumor size ( P  = 0.018), depth of invasion ( P  = 0.021) and venous invasion ( P  = 0.014) were found to be significantly related to lymph node metastasis. Cases with early stage ampullary cancer of less than 2 cm with a well-differentiated histology and no angiolymphatic invasion ( n  = 13) showed no lymph node metastasis and no recurrence during a median follow up of 35.9 months.
Conclusion:  Endoscopic papillectomy can be adopted as a viable alternative to surgery in patients with early stage ampullary cancer of less than 2 cm in size and with a well-differentiated histology. When a resected specimen has a well-differentiated histology, and there is no resection margin involvement and no angiolymphatic invasion, our findings indicate that subsequent radical surgery is unnecessary.     

Survival predictors in patients with node-negative gastric carcinoma

BACKGROUND: Presence or absence of nodal metastasis influences outcome of gastric cancer patients. This study gives insight into survival predictors and clinicopathological features of node-negative gastric adenocarcinoma. METHODS: Between 1988 and 1999, 689 gastric cancer patients without other cancer or gastrectomy for benign disease who underwent curative resection were enrolled in this study. Clinicopathological data in patients with node metastasis were compared with those without. RESULTS: The survival rate at 5 and 10 years for node-negative cases was 91.7% and 89.7%, respectively. On univariate analysis, node-negative patients were characterized by frequent location in the lower two-thirds of the stomach (84.9%), tumor size less than 4 cm (63.5%), grossly superficial type (71.6%), more medullary stromal reaction (50.5%) and intestinal type (67.7%), tumor invasion confined to serosa (78.4%), less poorly differentiated cell type (43.2%), and less lymphovascular invasion (33.4%). Multivariate analysis demonstrated that lymphovascular invasion (relative risk: 5.036) and depth of cancer invasion (relative risk: 4.404) were independent poor prognostic factors. However, lymphovascular invasion and serosal invasion were also correlated (P < 0.001). CONCLUSION: Patients with node-negative gastric adenocarcinoma had less disease progression and a favorable survival. Lymphovascular invasion and depth of cancer invasion were two independent but correlated survival predictors.     

Efficacy of prophylactic extended lymphadenectomy with gastrectomy for patients with node-negative advanced gastric carcinoma

BACKGROUND/AIMS: Extended lymphadenectomy with gastrectomy is widely performed for patients with advanced gastric carcinoma. However, the therapeutic value of prophylactic extensive lymphadenectomy in patients with node-negative advanced gastric cancer is controversial. METHODOLOGY: We retrospectively analyzed 221 patients who underwent curative gastrectomy for advanced gastric carcinoma without lymph node metastasis to evaluate the effect of prophylactic extended lymphadenectomy on postoperative survival. The postoperative survival rate of patients who underwent extended lymphadenectomy was compared with that of patients who underwent limited lymphadenectomy. Predictive risk factors for tumor recurrence and recurrent patterns also were analyzed. RESULTS: Extended lymphadenectomy improved the postoperative survival rate of patients with advanced tumors even when lymph node spread was absent. Whether or not prophylactic extended lymphadenectomy was performed significantly affected tumor recurrence in patients with node-negative advanced gastric carcinoma. CONCLUSIONS: Extensive lymphadenectomy with gastrectomy prolongs survival of patients with node-negative advanced tumors.     

Intraoperative chemohyperthermic peritoneal perfusion as an adjuvant to gastric cancer: final results of a randomized controlled study

BACKGROUND/AIMS: Although the most frequent cause of death after curative resection of advanced gastric cancer is peritoneal recurrence, there was no effective therapy for the prevention of peritoneal recurrence. This randomized trial sought to determine whether intraoperative chemohyperthermic peritoneal perfusion could eliminate microscopic residual disease and thereby improve survival of patients with advanced gastric cancer. METHODOLOGY: One-hundred and thirty-nine patients with T2-4 gastric cancer underwent curative gastrectomy with extended lymphadenectomy. These patients were randomly allocated into the following three groups. Patients in the CHPP group received surgery + chemohyperthermic peritoneal perfusion, and those in the CNPP group underwent surgery + chemonormothermic peritoneal perfusion. The third group was surgery alone group. In the CHPP and CNPP groups, peritoneal cavity was perfused with 6-8 liters of heated saline at, respectively, 42-43 degrees C and 37 degrees C with 30 mg of mitomycin C and 300 mg of cisplatin by a extracorporeal circulation machine. RESULTS: Major operative complication occurred in 19% (9/48), 14% (6/44) and 19% (9/47) of the CHPP, CNPP and surgery alone group, respectively. Complication which uniquely developed after chemohyperthermic peritoneal perfusion was bowel perforation. Mortality rates of each group were 4% (2/48), 0% (0/44) and 4% (2/47) in the CHPP, CNPP and surgery alone group, respectively. Overall 5-year survival rates of CHPP, CNPP and surgery alone groups were 61%, 43% and 42%, respectively. In a subset analysis, patients with gastric cancer having serosal invasion or lymph node metastasis have shown a statistically significant improvement in survival when treated with chemohyperthermic peritoneal perfusion. However, chemonormothermic peritoneal perfusion had no survival benefit. By analyzing with Cox proportional hazard model, chemohyperthermic peritoneal perfusion emerged as an independent prognostic factor for good survival. Surgery alone had three-fold higher risk of death than chemohyperthermic peritoneal perfusion. CONCLUSIONS: Chemohyperthermic peritoneal perfusion had an efficiency for the prophylaxis of recurrence after curative resection of advanced gastric cancer, and is indicated for patients with tumor infiltrating beyond serosal layer and node positive tumor.     

Prognostic factors in patients with node-negative gastric carcinoma： A comparison with node-positive gastric carcinoma

AIM: To identify the clinicopathological characteristics of lymph node-negative gastric carcinoma, and also to evaluate outcome indicators in the lymph node-negative patients. METHODS: Of 2848 gastric carcinoma patients, 1524 (53.5%) were lymph node-negative. A statistical analysis was performed using the Cox model to estimate outcome indicators. RESULTS: There was a significant difference in the recurrence rate between lymph node-negative and lymph node-positive patients (14.4% vs 41.0%, P<0.001). The 5-year survival rate was significantly lower in lymph node-positive than in lymph node-negative patients (31.1% vs 77.4%, P<0.001). Univariate analysis revealed that the following factors influenced the 5-year survival rate: patient age, tumor size, depth of invasion, tumor location, operative type, and tumor stage at initial diagnosis. The Cox proportional hazard regression model revealed that tumor size, serosal invasion, and curability were independent, statistically significant, prognostic indicators of lymph node-negative gastric carcinoma. CONCLUSION: Lymph node-negative patients have a favorable outcome attributable to high curability, but the patients with relatively large tumors and serosal invasion have a poor prognosis. Curability is one of the most reliable predictors of long-term survival for lymph node-negative gastric carcinoma patients.     

The rates and CT patterns of locoregional recurrence after resection surgery of lung cancer: correlation with histopathology and tumor staging

The purpose of our study was to assess the rates and CT patterns of locoregional recurrence after resection surgery of lung cancers according to histopathology and tumor staging. Three hundred and seventy nine patients who underwent lung resection surgery due to lung cancer in a recent 6 year period were followed up with CT (at 3, 6, 12, 18, 24 months, and then annually after surgery) for evaluation of locoregional tumor recurrence (analysis of hilar or mediastinal lymph nodes and surgical margin including bronchial stump, pleura, and chest wall). The recurrence rates and CT patterns were compared in terms of underlying histopathology and tumor staging. Of 379 patients, 75 (20%) patients had locoregional recurrences. The recurrence rates were higher in squamous cell carcinoma (39/190, 21%) than adenocarcinoma (24/140, 17%) (P = 0.012). The patterns of recurrence in 75 patients were hilar-mediastinal lymph node enlargement (n = 39, 52%), ipsilateral pleural lesion (n = 24, 32%), chest wall lesion (n = 13, 17%), bronchial stump lesion (n = 8, 11%), and bronchial extension including the trachea (n = 3, 4%). Bronchial stump recurrence was seen only in squamous cell carcinoma. Bronchioloalveolar carcinoma did not show any evidence of locoregional recurrence. Pleural (P = 0.0016) and mediastinal nodal (P = 0.001) recurrence, respectively, were more common in N2 than N0 cancers. Chest wall recurrence rates were higher with higher T staging (P < 0.001). The locoregional recurrence of lung cancer occurs in about one fifth of patients who undergo curative resection and is more common in squamous cell carcinoma than in adenocarcinoma. Recurrent patterns are diverse and different according to histopathologic type and pathologic staging of lung cancer.     

Clinical prognostic factors for ovarian metastasis in women with gastric cancer

BACKGROUND/AIMS: Krukenberg's tumor is considered to be a metastatic carcinoma to the ovary derived from a primary malignancy, usually from the gastrointestinal tract. This retrospective study tries to evaluate the clinicopathologic characteristics of ovarian metastasis in female gastric cancer and to define the prognostic factors. METHODOLOGY: Of 1,890 female patients with gastric cancers, 37 patients with metastatic ovarian carcinomas were analyzed. RESULTS: Patients with ovarian metastasis were younger in age, higher in primary tumor location, and far advanced in depth of invasion and lymph node metastases. Ovarian metastasis was largely related to the peritoneal seeding, which was statistically significant on survival time. A multivariate analysis of prognostic factors indicated that the presence of peritoneal seeding was the only significant independent factor. The young female patients with far advanced gastric cancer were vulnerable to recurrence of ovarian metastasis and were considered to undergo prophylactic oophorectomy with gastrectomy. The prognosis of ovarian metastasis is dismal, because this is frequently associated with the peritoneal disseminations. CONCLUSIONS: It is essential to treat the peritoneal disseminations in order to improve the survival rate of female gastric cancer patients with ovarian metastasis.     

Analysis of 300 consecutive cases of pancreatic adenocarcinoma in a single-center in China

BACKGROUND: Most of the reports on the prognostic indi-cators of patients with pancreatic adenocarcinoma are from developed countries. The present study focused on the prog-nostic indicators of Chinese patients with pancreatic adeno-carcinoma.
METHODS: A total of 300 patients with pancreatic adenocar-cinoma who had undergone curative resection were included. The resection and R0/R1 resection rates for adenocarcinomas from different parts of the pancreas were calculated and clini-cal characteristics were analyzed.
RESULTS: In 3427 patients diagnosed with pancreatic adeno-carcinomas, only 300 (8.8%) were eligible for radical resection. The total median survival of these patients was 19 months, and their 1-, 3-, and 5-year survival rates were 72.5%, 28.0%and 23.4%, respectively. The prognostic factors included so-cioeconomic status, smoking history, symptoms, high blood glucose, and various tumor characteristics, including perineu-ral and vascular invasion, lymph node metastases, and CA19-9 levels before and after operation. Operation-associated prog-nostic indicators included operation time, blood loss and transfusions, pancreatic ifstula, and complications. Indepen-dent predictors of mortality included poor socioeconomic sta-tus, smoking history, symptoms, CA19-9, perineural invasion and lymph node metastasis, grade of ifstula and complications. Patient survival was not correlated with either resection mar-gin or adjuvant chemotherapy in multivariate analysis.
CONCLUSIONS: The survival rates of patients with curative resection for pancreatic adenocarcinoma in China are close to those in developed countries, but curative resection rate is far below. Socioeconomic status, symptoms, and CA19-9 are the three most prominent prognostic factors, which are helpful in patient selection and perioperative care.     

The preoperative positivity for serum hepatitis B e antigen did not affect overall survival after curative resection of hepatitis B virus-related hepatocellular carcinoma

Background and Aim:  Previous studies have reported different risk factors for early and late intrahepatic recurrence after resection of hepatocellular carcinoma (HCC). However, the prognostic significance of the risk factors for early and late recurrence has not been clarified.
Methods:  A total of 190 Hepatitis B surface antigen-positive patients who received curative resection for HCC were reviewed. We investigated prognostic factors for disease-free and overall survival after resection, and further analyzed the relationship between significant prognostic factors and risk factors for early (≤14 months) and late (>14 months) intrahepatic recurrence.
Results:  The 5-year disease-free and overall survival rates were 43.9% and 71.5%, respectively. In multivariate analysis, adverse prognostic factors for disease-free survival were presence of serum HBeAg, perioperative transfusion, and the presence of portal vein invasion (PVI) and/or intrahepatic metastasis (IM). Multivariate analysis revealed that overall survival was associated with ICG R15, serum albumin, Edmondson–Steiner grade, and the presence of PVI and/or IM. Independent risk factors for early intrahepatic recurrence were perioperative transfusion and PVI and/or IM, whereas positivity for HBeAg was the only risk factor for late recurrence. In addition, post-recurrence survival in patients with late intrahepatic recurrence was completely comparable to that of patients who never experienced recurrence.
Conclusions:  The presence of serum HBeAg, the risk factor for late intrahepatic recurrence did not affect overall survival after resection because late recurrence was relatively well controlled by current available treatments. To further improve long-term surgical outcomes, effective treatment and preventive methods for early intrahepatic recurrence should be investigated.     

Prognostic and clinical evaluation of patients with T2 gastric cancer

BACKGROUND/AIMS: Little is known about the clinicopathological features of intermediate-stage T2 gastric cancer, defined as tumors invading the muscularis propria or subserosa. METHODOLOGY: Of 808 patients with gastric cancer, 210 patients (25.9%) who underwent gastrectomy for T2 gastric cancer were selected for this retrospective study. The clinicopathologic findings of these patients were analyzed retrospectively from their hospital records. RESULTS: Of all 808 patients with gastric cancer, 73 patients (9.0%) had tumors invading the muscularis propria (mp). The remaining 137 patients (16.9%) had tumors invading the subserosa (ss). Compared with ss gastric cancer, mp gastric cancer was associated with smaller tumor size, an absence of lymphatic spreading, and hematogenous and late recurrence [disease-free interval: 654.5 days (mp) vs. 365.5 days (ss)]. Univariate analysis of cases with curative operations showed that lymphatic invasion, and lymph node metastasis were significant prognostic factors in patients with T2 gastric cancer. Further examination by multivariate analysis demonstrated that pN2 or higher as classified by both the JCGC (Japanese Classification of Gastric Cancer) and the TNM lymph node staging systems was a predictor of poor prognosis. CONCLUSIONS: JCGC and TNM lymph node staging systems were the most reliable prognostic factors for T2 gastric cancer. Close follow-up should be required for patients with stage pN2 or higher gastric cancer. Long-term follow-up should be required for mp cancers, in particular.     

Palliative surgery for advanced stage (stage IV) gastric adenocarcinoma

BACKGROUND/AIMS: The factors that effect resectability, major morbidity, early mortality, and survival in advanced stage gastric adenocarcinoma patients are evaluated. METHODOLOGY: Records of 74 patients that underwent surgery for stage IV gastric adenocarcinoma in the Third Surgical Clinic of Izmir Atatürk Training Hospital between January 1997 and January 2004 were reviewed retrospectively. Two groups (the patients with resectable disease and those with unresectable disease) were compared with regard to age, gender, primary complaint, symptoms, site of the tumor, involvement of adjacent organs, lymph node involvement, distant metastases, differentiation of tumor, surgical procedure, perioperative blood transfusions, and postoperative hospital stay. RESULTS: Mean age of the 74 patients was 58.4 years. Forty-five cases (60.8%) were considered as unresectable and 29 (39.2%) patients underwent a palliative resection. There was a significant relation between resectability and site of the tumor, and severity of invasion. As the number of perioperative blood transfusions increased, morbidity and mortality increased significantly. Although early mortality was high in the palliative resection group, survival (mean 10.4 months, longest 25 months) was better compared to that of the unresectable gastric cancer group (mean 3.5 months, longest eight months). CONCLUSIONS: A palliative gastric surgery may be applied to improve prognosis of advanced gastric cancer patients, even at the presence of peritoneal dissemination, hepatic metastases, N3 lymph node involvement, adjacent organ invasion, or poor differentiation of the tumor.     

Benefits of endoscopic submucosal dissection according to size and location of gastric neoplasm, compared with conventional mucosal resection

Background and Aims:  To clarify optimal therapeutic strategies for early gastric cancers without vestigial remnant or recurrence, we evaluated the benefits of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) according to tumor size and location.
Methods:  From January 2000 to December 2007, a total of 328 gastric lesions were treated using conventional EMR, while 572 lesions were treated by ESD. Patients who underwent surgery on the upper gastrointestinal tract before EMR or ESD were excluded from the study. We compared tumor size, location and rates of complete resection, curative resection, postoperative bleeding, perforation and local recurrence between EMR and ESD according to tumor situation.
Results:  Overall local complete resection rate (EMR, 64.2%; ESD, 95.1%) and overall curative resection rate (EMR, 59.5%; ESD, 82.7%) were significantly higher in ESD than in EMR. No significant differences were seen in complication rates between EMR and ESD. Local recurrence was detected in 13 lesions (4.0%) of the EMR group during follow up. In contrast, no local recurrence was detected in the ESD group. For lesions 5 mm or less in diameter, complete resection rate in the EMR group was not significantly inferior to that in the ESD group at any location. However, rates were overwhelmingly better in the ESD group than in the EMR group for lesions more than 5 mm in diameter, regardless of location.
Conclusion:  We concluded that lesions exceeding 5 mm in diameter should be treated by ESD, although a high resection rate is obtained also with EMR for lesions of 5 mm or less in diameter.