Endoscopists' view on superficial spreading type of early gastric cancer – endoscopic resection or surgery?

Abstract

Objective. The superficial spreading type of early gastric cancer (EGC) possesses unique features different from other types of EGC. We aimed to elucidate the clinicopathological features of superficial spreading type of EGC. Material and methods. We analyzed 1455 EGC lesions from 1398 patients who had undergone surgical treatment at Samsung Medical Center from 2000 to 2002. Then the clinicopathological features of 224 superficial-spreading EGC lesions (15.4%) was compared to that of 1231 lesions of a common type of EGC. Results. In the superficial spreading type of EGC, the incidence of undifferentiated type and submucosal invasion were higher than those of common type of EGC (55.4 vs 38.0%, p <?.01 and 58.5 vs 37.8%, p <?.01, respectively). Lymph node metastasis and lymphovascular invasion were more frequent in superficial spreading type than in common type of EGC (19.2 vs 7.6%, p <?.01 and 15.2 vs 7.4%, p <?.01, respectively). There was no difference in recurrence rate or 5-year survival rate between the two groups. Conclusion. Considering higher risk of submucosal invasion and lymph node metastasis in superficial spreading type, a careful consideration should be done before the application of endoscopic resection to the superficial spreading type of EGC.     

Can endoscopic resection be applied for early stage ampulla of Vater cancer?

BACKGROUND: Although endoscopic resection can provide a wide tumor resection with a negative resection margin, it is not yet recommended as a curative therapy for ampulla of Vater cancer. METHODS: To investigate the microinvasion rate and the diagnostic accuracy of endoscopic biopsy to properly judge the safety of endoscopic resection for ampulla of Vater cancer. DESIGN: Single-center, retrospective study. SETTING: Academic medical center. PATIENTS: One hundred fifty-nine patients who were finally diagnosed with ampulla of Vater cancer after curative surgical resection. INTERVENTIONS: We surveyed the pathologic concordance rate of endoscopic biopsy and the surgical pathology. For the 36 early stage (Tis or T1) cancers, we surveyed the presence of microlymphovascular invasion, gross appearance (intra-ampullary type, periampullary type, or mixed type), and pathologic subtype (intestinal type or pancreaticobiliary type). MAIN OUTCOME MEASUREMENTS: Presence of microinvasion in early staged ampulla of Vater cancer. RESULTS: Endoscopic biopsy failed to reveal malignancy in 15.9% of the 126 cases. Microlymphovascular invasion was present in 17 cases (56.7%) of the 30 T1 cancers but was absent in all cases of the 6 Tis cancers (P = .02). Neither the gross appearance (P = .51) nor the pathologic subtype (P = .28) could predict the microinvasion rate. LIMITATIONS: Single-center, retrospective study with small number of patients. CONCLUSIONS: Although endoscopic resection improves the low predictability of endoscopic biopsy, surgical resection should be performed for the T1 stage ampulla of Vater cancer because of the high lymphovascular invasion rate. On the other hand, the safety of endoscopic resection should be evaluated by a large-scale study on Tis cancers to consider the absence of microinvasion.     

Artificial intelligence-assisted endoscopic detection of esophageal neoplasia in early stage: The next step?

Esophageal cancer (EC) is a common malignant tumor of the digestive tract and originates from the epithelium of the esophageal mucosa. It has been confirmed that early EC lesions can be cured by endoscopic therapy, and the curative effect is equivalent to that of surgical operation. Upper gastrointestinal endoscopy is still the gold standard for EC diagnosis. The accuracy of endoscopic examination results largely depends on the professional level of the examiner. Artificial intelligence (AI) has been applied in the screening of early EC and has shown advantages; notably, it is more accurate than less-experienced endoscopists. This paper reviews the application of AI in the field of endoscopic detection of early EC, including squamous cell carcinoma and adenocarcinoma, and describes the relevant progress. Although up to now most of the studies evaluating the clinical application of AI in early EC endoscopic detection are focused on still images, AI-assisted real-time detection based on live-stream video may be the next step.     

Is local resection adequate for T1 stage ampullary cancer?

Background

Concerns for morbidity after a pancreaticoduodenectomy (PD) has led to practitioners adopting endoscopic resection or ampullectomy in the treatment of T1 ampullary cancer (AC). It was hypothesized that survival for patients undergoing local resection of AC was inferior to those undergoing a PD.

Methods

All the data of patients with AC reported in the Surveillance, Epidemiology and End Results (SEER) database between 2004 and 2010 were collected. Five-year survival rates according to nodal disease and histological type were compared.

Results

There were 1916 cases of AC; 421 (22%) had T1 disease. Among those with T1 disease, 217 (51%) received endoscopic surveillance, 21 (5%) underwent local resection/ampullectomy, 20 (5%) underwent ampullectomy with regional lymphadenectomy and 163 (39%) underwent PD. For patients with complete nodal staging (PD, n = 163), 35 (22%) had metastatic disease in the nodes. Grade was significantly associated with node positivity (P = 0.007). In multivariate models, survival was improved with either an ampullectomy with regional lymphadenectomy [hazard ratio (HR) 0.19; 95% confidence interval (CI) 0.05–0.61, P < 0.005] or a PD (HR 0.23; 95% CI 0.15–0.36, P < 0.001).

Conclusion

Patients with T1 AC have a high risk for nodal metastases especially if they are higher-grade lesions. Nodal clearance with a lymphadenectomy or a PD is essential for long-term survival in these patients.     

Metallic or plastic stent for bile duct obstruction in ampullary cancer?

Background and Aims  

Although ampullary cancer is a relatively uncommon malignancy, it is frequently associated with biliary obstruction. Endoscopic biliary drainage is regarded as a palliative treatment of choice for patients with inoperable ampullary cancer. However, there are no data concerning choice of stent in this patient population. The objective of this study was to compare the efficacy of metallic and plastic stents for biliary obstruction in patients with ampullary cancer.     

Radical surgery for early colorectal cancer—anachronism or oncologic necessity?

Background and aims Because of their low morbidity and mortality, limited resection or local excision are accepted therapeutical approaches in early colorectal cancer treatment. Even though, recent publications report recurrence rates after local excision of rectal cancer in up to 30%. This prompted us to evaluate our data for T1N0 colorectal cancer treated by radical surgery regarding recurrence, morbidity, mortality, and survival rates. Materials and methods Clinical, histopathological, and surveillance data from our prospective “colorectal cancer database” from 1979 to 2005 were analyzed to evaluate outcome and prognosis of T1N0 colorectal cancer treated by radical surgery. Only curative resections were included in this study. All patients were followed in an internal surveillance program, which enabled us to prospectively assess morbidity, mortality, and survival. Results A total of 105 T1N0 colon and 69 rectal carcinomas were included in the study. Overall morbidity was 25% (colon) and 34% (rectum). Thirty-day mortality was 1.9% (colon) and 4.3% (rectum). After a median follow-up of 92 and 87 month, no isolated local recurrence occurred. One patient developed both local recurrence and liver metastases. Distant metastases were seen in 4.9% (colon) and 7.5% (rectum). The 5- and 10-year overall survival was 86 and 71% (colon) and 82 and 68% (rectum), respectively. Conclusion Even if radical surgical approaches are associated with a higher rate of morbidity and mortality, our data show that radical surgery for T1N0 colorectal cancer results in excellent tumor control which is of paramount importance for the patients’ prognosis and survival. Combining the data presented with those of the current literature suggests that local approaches to rectal cancer can be recommended for highly selected T1N0 tumors, in palliative situations, or if the patient is unfit for general surgery.     

Pancreatic cancer: Open or minimally invasive surgery?

Pancreatic duct adenocarcinoma is one of the most fatal malignancies, with R0 resection remaining the most important part of treatment of this malignancy. However, pancreatectomy is believed to be one of the most challenging procedures and R0 resection remains the only chance for patients with pancreatic cancer to have a good prognosis. Some surgeons have tried minimally invasive pancreatic surgery, but the shortand long-term outcomes of pancreatic malignancy remain controversial between open and minimally invasive procedures. We collected comparative data about minimally invasive and open pancreatic surgery. The available evidence suggests that minimally invasive pancreaticoduodenectomy(MIPD) is as safe and feasible as open PD(OPD), and shows some benefit, such as less intraoperative blood loss and shorter postoperative hospital stay. Despite the limited evidence for MIPD in pancreatic cancer, most of the available data show that the short-term oncological adequacy is similar between MIPD and OPD. Some surgical techniques, including superior mesenteric artery-first approach and laparoscopic pancreatoduodenectomy with major vein resection, are believed to improve the rate of R0 resection. Laparoscopic distal pancreatectomy is less technically demanding and is accepted in more pancreatic centers. It is technically safe and feasible and has similar short-term oncological prognosis compared with open distal pancreatectomy.     

PET-CT limitations in early stage non-small cell lung cancer: to whom more aggressive approach in radiotherapy and surgery should be directed?

This editorial comments on the study by Paravati et al., which reported on the incidence of occult regional lymph node metastases in PET-CT T1T2N0 non-small cell lung cancer (NSCLC) patients. A central location and the size of the tumor were shown to be the strongest predictors of the risk of occult nodal disease. Authors comment that in view of limitations of modern imaging, as well as the reported negative predictive value (NPV) of invasive staging methods, the choice of therapeutic options as the extent of surgery (lobectomy or sublobar resection) or radiotherapy [stereotactic body radiation therapy (SBRT) or conformal radiotherapy (RT) with some forms of elective nodal irradiation (ENI)] should consider tumor’s characteristics and not be based only on imaging and invasive staging modalities.     

Role of surgery in colorectal liver metastases: Too early or too late?

As colorectal cancer and colorectal liver metastases become a serious public health problem,new treatment modalities are needed in order to achieve better results. In the last decade there has been very important progress in oncology,with new and more effective chemotherapeutic agents administered alone or in combination improving the resectability rate in up to 40%of patients with colorectal liver metastases.Advances in interventional radiology,in particular,with the use of portal vein embolization and rad...     

Differences in early outcomes after open or laparoscopic surgery: what is the evidence?

Laparoscopic surgery has been widely studied in colorectal cancer and its feasibility and safety have been proven to the extent that in the UK a national laparoscopic colorectal surgery programme has been established. The advantages of laparoscopic surgery have been studied less systematically in diverticular disease. Several prospective uncontrolled studies have demonstrated that laparoscopic surgery for diverticular disease is feasible with low morbidity and mortality rates. A large population study in the USA has demonstrated elective laparoscopic surgery for diverticular disease to have reduced hospital stay by 1 day, and a lower rate of intra-operative and post-operative complications over open surgery. Some of the reported differences may be attributable to selection bias of more complex cases to open surgery. A Cochrane systematic review examining 11 non-randomized and 1 randomized study showed laparoscopic surgery to be feasible in diverticular disease, although there might be a higher minor complications rate in laparoscopic resections. Attention has been focused on surgical techniques as means to reduce complications. There is a belief that preservation of the inferior mesenteric and superior rectal artery protects from anastomotic leak, but a study from the USA looking into that point did not find a difference. The application of hand-assisted laparoscopy seems to help cope with complex diverticular masses and colovesical fistulas. New hybrid techniques incorporating specimen extraction via rectum may reduce complications further. Single incision laparoscopic surgery has recently been shown to be feasible. Although minimally invasive techniques appear superior in terms of early outcomes than open surgery the choice of minimally invasive technique seems to be less relevant to outcomes if accompanied by an appropriate level of surgical experience and expertise. Patient-related factors such as comorbidities or degree of disease complexity are more likely to be related to complication rates.     

Closed chest totally endoscopic coronary artery bypass surgery: Fantasy or reality?

With the introduction of the da Vinci robotic surgical system (Intuitive Surgical, Mountain View, CA) into minimally invasive cardiac surgery, the outlook of performing coronary artery bypass operations “closed chest” became a reality. Between May 1999 and July 2000 this wrist-enhanced instrumentation was used in 143 patients (107 men, 36 women, median age 63 ± 10.3 y). Thirteen patients suffering from coronary artery disease (CAD) were treated as totally endoscopic coronary artery bypass (TECAB), 79 patients underwent a minimally invasive direct coronary artery bypass procedure, and 35 patients were treated using the robotic-enhanced Dresden Technique. Preoperative survival was 100%. All patients in the TECAB group were operated upon via a three- or four-point stab incision using the da Vinci robot for internal mammary artery takedown and for performance of anastomoses. These new robotic-enhanced surgical techniques promote an optimistic way of thinking about the further development of these procedures and its application in patients suffering from CAD.     

Antenatal diagnosis of congenital thoracic malformations: early surgery, late surgery, or no surgery?

Today, congenital thoracic malformations (CTMs), which comprise a spectrum of anomalies rather than separate entities, are frequently detected on routine antenatal ultrasound. However, with similar appearances of different congenital lung and nonpulmonary lesions, a definitive diagnosis cannot usually be established antenatally with absolute certainty. The natural history of CTMs is extremely variable. Large lesions may cause serious complications in the fetus, necessitating treatment in utero. Such prenatal therapy, however, is only required in a small minority of fetuses. Many lesions decrease in size before birth, and some are no longer detectable by ultrasound or chest radiography in the newborn period. All patients with prenatally detected CTMs require thorough postnatal evaluation, including a chest computed tomographic scan. Postnatally, the clinical appearance of CTMs can vary from immediate respiratory distress at birth to an incidental finding on a chest radiograph at any age. A few patients with large lesions require emergency or urgent surgery in the neonatal period. Furthermore, surgery is the accepted standard of care for all symptomatic lesions. Many children, however, will be asymptomatic at birth and in the neonatal period, and there is controversy as to the management of these newborns. Some authors recommend expectant long-term management of asymptomatic lesions, in particular congenital lobar emphysema and extrapulmonary sequestration. Most authors advocate elective resection of all cystic adenomatoid malformations, bronchogenic cysts, and intrapulmonary sequestrations because of the risk of complications, such as infection, hemorrhage, pneumothorax, sudden respiratory compromise, and malignant transformation. Elective lobectomy appears to be very well tolerated and is the most prevalent surgical method. Video-assisted thoracoscopic surgery was reported to be safe and effective. The timing of surgery in asymptomatic patients is not well delineated, with recommendations ranging from 1 month to 2 years of age. Some authors advocate surgery between 6 and 12 months of age because anesthetic and surgical risks decrease within the first months of life. Long-term prospective studies of CTMs are urgently needed to document their natural history.     

Are we doing too much?: local excision before radical surgery in early rectal cancer

Purpose

In early rectal cancer cases, the use of local excision is increasing. The general indication for local excision is based on the preoperative stage, but there is often a discrepancy between pre and postoperative stages. We sought to determine the indications for local excision in T1 rectal adenocarcinoma patients by comparing the preoperative clinical and postoperative pathological stages. A second aim was to compare the oncologic outcomes between local excision and radical resection.

Methods

Between 2004 and 2014, 152 T1 rectal adenocarcinoma patients were enrolled. We divided the subjects into two groups, local excision and radical resection, depending on the modality of treatment the patients initially received. The group of patients who underwent radical resection was subsequently subdivided into “excisable” and “non-excisable” groups based on the postoperative pathology.

Results

Of 152 patients, 28 patients (18.4%) underwent local excision, while 124 patients (81.6%) underwent radical resection. Of 124 patients, in clinically suspected T2 or less and N0 (93) cases, 50 patients (53.8%) needed treatment beyond local excision, and local excision was sufficient for 43 patients (46.2%). The 3-year overall survival (p?=?0.393) and 3-year disease-free survival (p?=?0.076) between the local excision and radical resection groups showed no significant difference.

Conclusions

The clinical T stage was overestimated in more than half of the cases. Therefore, if cT1/2 tumors with cN0 are suspected preoperatively, local excision is initially recommended and will allow for determination of underlying pathology. The clinician can then decide whether to monitor or intervene with radical resection.

     

Molecular analysis of diminutive,flat, depressed colorectal lesions: are they precursors of polypoid adenoma or early stage carcinoma?

BACKGROUND: The diminutive, flat depressed colorectal lesion is a possible precursor of early stage carcinoma. However, the significance of this lesion in colon carcinogenesis remains unclear. METHODS: Eighty-one diminutive flat lesions (<5 mm diameter) with a central depression (DPdep) were resected colonoscopically and their molecular characteristics were investigated. In parallel, 68 diminutive polyps (<5 mm diameter) with a polypoid growth pattern but no depression (DPpo) were analyzed as controls. After histopathologic diagnosis, only neoplastic tissues were stained by immunohistochemistry for p53 gene and cyclooxygenase 2 (COX-2) and the proliferation marker, Ki-67. Mutation of the K-ras gene was analyzed with the polymerase chain reaction-restriction fragment length polymorphism method by using DNA from microdissected tissue in paraffin sections. RESULTS: Seventy-nine of 81 DPdep and 35 of 68 DPpo were diagnosed as neoplastic. Mild, moderate, and severe dysplasia were found in, respectively, 56, 15, and 8 DPdep polyps, and in 34, 1, and 0 DPpo polyps. Thus, DPdep were more likely to be neoplastic and to exhibit moderate and severe dysplasia compared with DPpo (p < 0.0001). No DPdep or DPpo was positive for the p53 protein. The proportion of specimens with K-ras codon 12 mutation was 13.4% in diminutive polyps (DP), and tended to be lower in DPdep (8.6%) than in DPpo (25.0%) (p = 0.073). The median (interquartile range) of the Ki-67 index of DPdep tended to be lower than that of DPpo (respectively, 0.0 [0.0-5.9] vs. 4.5 [0.0-17.1]; p = 0.0281). COX-2 overexpression was observed in 12 of 77 (15.6%) DP and there was no significant difference between DPdep (3 of 23, 13.0%) and DPpo (9 of 54, 16.7%). CONCLUSION: Diminutive, flat, depressed lesions in this study had low rates of the genetic alterations associated with malignant progression. This indicates that either a different neoplastic mechanism is operative or that these lesions have a lower malignant potential than indicated by their histopathologic features.