The significance of endoscopic treatment of early gastric cancer

Gastric endoscopy could be an useful procedure in treating patients with early gastric cancer in certain conditions. We treated 24 patients with gastric cancer for whom no surgery was indicated because of serious complications or patient's refusal. Endoscopic local injection (ELI) with Mitomycin C (MMC), 5-fluorouracil (5-FU), and Picibanil (OK-432) was performed in 16 patients and polypectomy in 8 patients as radical treatment for primary gastric cancer. Of the 16 cases, ELI was effective in 9 cases of early gastric cancers, consisting of 4 cases with complete response (CR), additional 4 with a partial response (PR), but was ineffective in the remaining of all 3 cases of advanced cancers. ELI with MMC + 5FU was performed in 8 cases with an excellent response; 3 cases with CR and 3 cases with PR; 5 patients are alive, with the longest survival period of 54 months, and 2 patients died of other diseases. On the other hand, ELI with OK-432 was carried out in remaining 8 cases with no effective results, showing only 1 case with CR and another case with PR. Polypectomy was effective for 8 protruding type of early gastric cancers with the longest cancer-free period of 31 months. At present, although preoperative evaluation of the depth and range of cancer invasion is difficult, we would like to emphasize that ELI and polypectomy are procedures worthy to be attempted in patients with early gastric cancers with no nodal metastases for surgery is not indicated.     

A feasibility study on the expanded indication for endoscopic submucosal dissection of early gastric cancer

Background  

Endoscopic submucosal dissection (ESD) is the standard treatment for selected cases of early gastric cancer (EGC). Evolution of ESD techniques and accessories has expanded treatment indications. The aim of this study was to compare the therapeutic outcomes for conventional and expanded indications of ESD for EGC.     

Endoscopic and oncologic outcomes according to indication criteria of endoscopic resection for early gastric cancer: a systematic review and meta-analysis

Background

The criteria for endoscopic resection for early gastric cancer (EGC) have been expanded recently, and it has become acceptable to use techniques that are regarded as having equivalent technical and pathological outcomes to absolute indication (AI). However, the long-term oncological outcomes of expanded indication (EI) have yet to be clarified. This meta-analysis aimed to assess the long-term outcome of EI versus AI, to identify the endoscopic feasibility and safety according to the indication, and to provide the appropriate recommendations for each indication.

Methods

Electronic databases including PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and KoreaMed were searched for articles published between January 2000 and October 2014. After screening, the reviewers extracted the information from 12 retrospective cohort studies. A total of 9635 EGC lesions, 4150 lesions in the EI group and 5485 lesions in the AI group, were included in this study.

Results

Meta-analyses showed that the local recurrence rate [risk ratio (RR) 1.34; 95 % CI 0.67–2.70] was not significantly higher in the EI group compared with the AI group, although the metachronous recurrence rate was higher in the EI group than in the AI group (RR 1.60; 95 % CI 1.22–2.10). The rates of en bloc resection [odds ratio (OR) 0.57; 95 % CI 0.41–0.78), complete resection (OR 0.37; 95 % CI 0.25–0.57), and curative resection (OR 0.34; 95 % CI 0.20–0.58) were significantly inferior in the EI group than in the AI group, whereas overall bleeding risk (RR 1.47; 95 % CI 1.19–1.82) and procedure-related perforation rate (OR 2.04; 95 % CI 1.56–2.68) were significantly higher in the EI group than in the AI group.

Conclusions

This meta-analysis suggests that the EI group showed acceptable long-term outcomes with local recurrence rate that was not significantly inferior, although the metachronous recurrence rate was higher compared with that in the AI group.

     

Clinicopathological study of early gastric cancer--indication of conservative surgery and radical endoscopic treatment of early gastric cancer

Clinicopathological factors such as depth of cancer invasion, size, gross type, frequency of metastases to regional lymph nodes, and distant prognosis were evaluated in last consecutive 339 cases with solitary early gastric cancer. The conservative surgery, that is, subtotal gastrectomy with complete dissection of lymph nodes of group 1 and selective celiac group and partial bursectomy, would be indicated for early gastric cancers located in antrum or corpus. But if the metastasis to the group 2 lymph nodes is suspected during the surgery, it is necessary to dissect lymph nodes en bloc more than group 2. The results, concerning the type of early gastric cancer without lymph node metastasis and the indication of endoscopic treatment, were as follows; 1. Intramucosal cancer of elevated type less than 2 cm in diameter. 2. Intramucosal cancer of depressed type less than 1cm in diameter, without peptic ulcer within the lesion, and a differentiated tubular adenocarcinoma histologically. 3. Intramucosal cancer of flat type less than 2 cm in diameter. But it is difficult to detect the depth of cancer invasion and lymph node metastasis preoperatively. We would emphasize that endoscopic treatment should be indicated in the case for which surgical treatment is not indicated.     

Double contrast-enhanced ultrasonography for the preoperative evaluation of gastric cancer: a comparison to endoscopic ultrasonography with respect to histopathology

Background

This study was designed to compare the accuracy of endoscopic ultrasound (EUS) with double contrast–enhanced ultrasound (DCUS) in the staging of gastric malignancies. DCUS is a transabdominal ultrasound technique using both intravenous and intraluminal contrast to enhance sonographic visualization.

Methods

This retrospective study included 162 patients with biopsy-proven gastric cancer who underwent DCUS and EUS preoperatively with the ultrasound results compared with the pathologic findings of the resected specimens.

Results

The overall accuracy of DCUS and EUS for tumor (T) staging was 77.2% and 74.7%, respectively_. Comparison of ultrasound techniques for T staging revealed that DCUS was superior to EUS only for a tumor depth of T3 (chi-square, P = .025). Lymph nodes were staged correctly with DCUS and EUS in 78.4% and 57.4% of cases, respectively (chi-square, P = .001).

Conclusions

DCUS offers a noninvasive approach for the staging of gastric cancer. DCUS was comparable to EUS in tumor depth evaluation but offered an advantage in lymph node detection.     

Factors related to the curability of early gastric cancer with endoscopic submucosal dissection

Background

Endoscopic submucosal dissection (ESD) yields substantially high rates for curative resection of early gastric cancer (EGC). It is suggested that larger, ulcerative, or upper EGCs may prevent successful ESD. A detailed analysis of factors associated with the curability of ESD was performed.

Methods

Endoscopic submucosal dissection was performed for patients with EGC that fulfilled the expanded criteria, which specified mucosal cancer without ulcer findings irrespective of tumor size, mucosal cancer with ulcers 3 cm in diameter or smaller, and minute submucosal invasive cancer 3 cm or smaller. Resectability (en bloc or by piecemeal resection), curability (curative or non-curative), and complications were assessed, and logistic regression analysis was used to analyze the related factors.

Results

Ulcerative EGCs showed a significantly higher risk associated with ESD on multivariate analysis. When the risk factors (tumor size, location, and ulcer findings) were combined, the larger EGCs (>30 mm) located in the upper third or ulcerative tumors located in the upper and middle portion of the stomach were at significantly higher risk of non-curative resection. Such lesions also were associated with increased risk of procedure-related perforation.

Conclusions

When risk factors including positive ulcer findings and larger size and upper location of tumors are combined, ESD should be performed more carefully.     

Comparison of endoscopic resection and gastrectomy for the treatment of early gastric cancer: a meta-analysis

Background

Endoscopic resection methods, including endoscopic mucosal resection and endoscopic submucosal dissection, have become standard treatment modalities for patients with early gastric cancer (EGC) and absolute indications, with en bloc resection being more frequent with the latter. Endoscopic resection, however, has been associated with higher recurrence and metachronous cancer rates than gastrectomy. This meta-analysis compared the efficacy and safety of endoscopic resection and gastrectomy for EGC.

Methods

PubMed, EMBASE and Web of Science were electronically searched for relevant studies comparing endoscopic resection and gastrectomy for EGC from 1976 through March 2015. The primary endpoints were en bloc resection and histologically complete resection rates. The secondary endpoints were duration of hospital stay and rates of complications, recurrence, metachronous cancer and overall survival.

Results

This meta-analysis enrolled 10 studies with 2070 patients: 993 patients who underwent endoscopic resection and 1077 who underwent gastrectomy. Endoscopic resection was associated with shorter hospital stay (standardized mean difference ?2.02; 95 % confidence interval [CI] ?2.64 to ?1.39) and lower complication rate (relative risk [RR] 0.41; 95 % CI 0.22–0.76) than gastrectomy. However, endoscopic resection was associated with lower rates of en bloc resection (odds ratio [OR] 0.05; 95 % CI 0.02–0.16) and histologically complete resection (OR 0.04; 95 % CI 0.01–0.11) and higher rates of recurrence (RR 5.23; 95 % CI 2.43–11.27) and metachronous cancer (RR 5.22; 95 % CI 2.40–11.34) than gastrectomy. Overall survival rate (OR 1.18; 95 % CI 0.76–1.82) was similar.

Conclusions

Endoscopic resection is minimally invasive and as effective as surgery, suggesting that the former be considered standard treatment for EGC. It should be recommended as standard treatment for EGC with indications. Additional randomized controlled trials from more countries are required.

     

Controversy between endoscopic and surgical treatment against early gastric and colorectal cancer]

Although endoscopic treatment against the patients with early cancer in gastrointestinal tract is an excellent method especially in high aged or poor risk patients, there still exists controversy about the indication for endoscopic treatment because of deeper invasion of the cancer or lymph node metastases. In order to clarify whether the patient has a possibility of nodal involvement or not, we made the clinicopathological analysis concerning 220 cases with early gastric cancers and 118 cases with colorectal cancers. Our retrospective analysis shows that endoscopic resection can be indicated for small polypoid cancer less than 10 mm in size, excluding IIa + IIc type. As to small depressed type, this procedure should be applied for IIc type which is well differentiated adenocarcinoma without ulcer formation (U1 (-)). Regarding early colorectal cancer there has been many discussion how to treat the patients with sm-cancer. Based on our analysis of 39 cases with sm-cancer, we led to the conclusion that the characteristics of sm-cancer with lymph node metastases are i) massive invasion into submucosal layer, ii) positive lymphatic permeation, or iii) "de novo" cancer. As a result, a decision of further surgery should be made even in small lesions less than 10 mm, taking the fact into consideration of the possibility of nodal involvement of sm-cancer.     

早期胃癌行内镜黏膜下剥离术指征及评价

内镜黏膜下剥离术（ESD）是一种内镜下整块切除病变黏膜的治疗方法,已经成为早期胃癌的治疗选择之一。目前ESD治疗早期胃癌较为积极的指征为：（1）分化型黏膜内癌如果表面未形成溃疡,则病变大小不受限制;（2）分化型黏膜内癌如果表面已经形成溃疡,则病变直径≤30mm;（3）分化型sm1癌,病变直径≤30mm;（4）未分化型黏膜内癌,表面未形成溃疡,且病变直径≤20mm。尽管长期随访的资料较少,但目前看来,如果合理地把握ESD治疗指征,早期胃癌的治愈率与手术相当,但可减少并发症,提高病人生活质量,具有安全、可行、有效的特点。     

Follow-up outcomes of endoscopic resection for early gastric cancer with undifferentiated histology

Background

The application of endoscopic resection (ER) for undifferentiated-type early gastric cancer (UD-EGC) remains controversial. The aim was to examine long-term outcomes of ER for UD-EGC. Furthermore, we investigated whether long-term outcomes of ER differed between poorly differentiated adenocarcinoma (PD) and signet ring cell carcinoma (SRC).

Methods

From 2001 to 2011, 209 lesions in 209 patients with UD-EGC (82 PD; 127 SRC) were treated by ER. We retrospectively assessed the clinical outcomes of ER in 209 patients. The survival rate and disease-free survival rates after ER were evaluated as long-term outcomes.

Results

The en bloc resection and curative resection (CR) rates were 91.4 and 55.0 %, respectively. The en bloc and CR rates in PD were 90.2 and 45.1 %, whereas those in SRC were 92.1 and 61.4 %. For patients with PD who underwent non-curative resections, 51.1 % were vertical-cut end-positive and for those with SRC, 63.3 % were lateral-cut end-positive, a statistically significant difference. In those patients where CR was achieved, no case of local recurrence or distant metastasis was observed during the follow-up period (32.7 ± 22.2 months). The 3- and 5-year survival rates were 99.0 and 98.6 %, with no significant difference between CR patients with SRC and PD.

Conclusions

ER may yield good long-term outcomes for UD-EGC if CR is achieved, with no difference between PD and SRC. However, to increase the current CR rate of ER, stricter criteria for performing ER in UD-EGC may be required.     

Clinical implication of endoscopic gross appearance in early gastric cancer: revisited

Background

The macroscopic appearance of early gastric cancer (EGC) is known to reflect its growth patterns. The purpose of this study was to investigate the role of the endoscopic appearance as a predictor of clinical behavior in EGC.

Methods

Between January 2005 and December 2008, 1,845 patients were diagnosed with EGC and underwent surgery. The clinicopathologic characteristics were retrospectively analyzed according to gross appearance. Endoscopic findings were classified by predominant type as elevated, flat, or depressed. Flat and depressed types were categorized together as nonelevated type.

Results

The proportions of elevated, flat, and depressed types were 16.6, 28.6, and 54.8 %. The gross appearance of the elevated type predominantly showed well/moderate differentiation, whereas the flat and depressed types showed signet-ring cells and poor differentiation, respectively. When the elevated and nonelevated types were compared, submucosal invasion, lymphovascular invasion (LVI), and lymph-node metastasis (LNM) were higher in elevated than in nonelevated type. In differentiated EGC, submucosal invasion, LVI, LNM, and multiplicity were significantly higher in the elevated than the nonelevated type. These patterns were significantly common in the order elevated, depressed, and flat types. In undifferentiated EGC, submucosal invasion, LVI, and perineural invasion were significantly higher in elevated than in nonelevated type. These patterns were significantly common in the order elevated, depressed, and flat types. However, LNM was not significantly different based on gross appearance in undifferentiated EGC.

Conclusions

Clinical behavior differs according to endoscopic appearance in EGC. The endoscopic appearance of EGC may facilitate prediction of clinical behavior, particularly in differentiated EGC.     

Surgical treatment of early gastric cancer

Around half the cases of gastric cancer are found in the early stage in Japan. With an expected good prognosis, many treatment options have been developed to maintain a good quality of life of the patients after the treatment. Gastric cancer is diagnosed with endoscopy, and the depth of invasion is diagnosed with endoscopy and endoscopic ultrasound. One of the new treatments is endoscopic submucosal dissection. Improvements in surgical treatment are minimizing lymph node dissection, reconstruction methods, laparoscopy-assisted surgery, and sentinel node navigation surgery. Minimizing lymph node dissection for early gastric cancer is well described in the Guidelines for Gastric Cancer Treatments. Pylorus-preserving gastrectomy, jejunal interposition, pouch reconstruction, and Roux-en-Y reconstruction after distal gastrectomy are improvements in reconstruction after gastrectomy. More and more surgeons start laparoscopy-assisted gastrectomy with lymph node dissection. Even with these improvements, the 5-year survival of early gastric cancer is more than 90% in Japan. Further improvements would be possible in the future.     

Lymph node metastasis as a significant prognostic factor in early gastric cancer: Analysis of 1,136 early gastric cancers

Background: Gastric cancer is the most frquent cancer and the leading cause of death from cancer in Korea. Early gastric cancer has been defined as a gastric carcinoma confined to mucosa or submucosa, regardless of lymph node status, and has an excellent prognosis with a >90% 5-year survival rate. From 1974 to 1992, we encountered 7,606 cases of gastric cancer and performed 6,928 gastric resections. Among them, 1,136 cases were early gastric cancer (14.9% of all gastric cancer cases and 16.4% of resected gastric cancer cases). Methods: A retrospective analysis of 1,136 cases of early gastric cancer was performed to evaluate the prognostic significance of clinicopathologic features (sex, age, tumor location, gross type, histologic type, depth of invasion, status of lymph node metastasis, resection type). Lymph node metastasis was classified into three groups: N(n=0) for no lymph node metastasis; N(n=1–3) for one to three lymph node metastases; and N(n>3) for more than three lymph node metastases. All patients received radical total or subtotal gastrectomy with lymph node dissection. Results: In univariate and multivariate analysis of these nine factors, the only statistically significant prognostic factor was regional lymph node metastasis (p<0.001). The others had no statistically significant association with prognosis. Lymph node metastasis was present in 178 cases (15.7%). The factors associated with the lymph node metastasis were depth of invasion and gross type [protruding type (e.g., types I, IIa)]. One hundred twenty-five of these patients had one to three lymph node metastases, and 53 cases had more than three lymph node metastases. The difference in 5-year survival rates among these groups was statistically significant: 94.5% for N(n=0), 88.3% for N(n=1–3), and 77.3% for N(n>3). Conclusion: We propose that for early gastric cancer, lymph node dissection is necessary in addition to gastric resection, at least in patients with a high risk of lymph node metastasis.     

老年人早期胃癌的外科治疗

目的探讨老年人早期胃癌的特点及外科治疗适宜手术方式及预后. 方法回顾性分析1977年8月～1997年12月平均年龄为68岁的74例早期胃癌患者共施行78次手术,术后通过临床和胃镜随诊,随诊率为100 %.用SAS软件对早期胃癌术后生存概率分析. 结果本组手术切除率100%,手术死亡率0,腹腔及切口感染0,无吻合口漏.5年生存率98.59% ±0.14%(95%可信区间);10年生存率91.61%±0.04%(95%可信区间).淋巴结转移率5.4%.本组早期胃癌无淋巴结转移者5年生存率为100%.4例有淋巴结转移或淋巴管癌栓,5年生存率为75%. 结论纤维胃镜普查使老年人早期胃癌发现率增加,年龄不是早期胃癌根治切除的禁忌证,由于早期胃癌多癌灶病例占 18.92%,即使病变较小,亦应作3/4胃切除,癌灶相距远者应行全胃切除.本组胃癌诊断早,手术根治及时,选择术式适当.本组5、10年生存率高,且术后生活质量优良.