Treatment of early gastric cancer in the elderly patient: results of EMR and gastrectomy at a national referral center in Japan

BACKGROUND: The Japanese population is rapidly aging, and the actual number of elderly patients with gastric cancer, including early cancer, has been increasing, even though the standardized incidence of gastric cancer in the population is decreasing. The optimal treatment for these patients remains a challenge to the surgeon. The aim of this retrospective analysis was to describe the results of gastrectomy and EMR for early gastric cancer in elderly patients (80 years of age and over). METHODS: This is a retrospective review of 93 elderly patients who had undergone gastrectomy or EMR at the National Cancer Center Hospital for early gastric cancer. EMR was performed aiming en bloc local resection with a clear curative margin (R0). The clinicopathologic characteristics, comorbidity, postoperative mortality, and outcome were recorded. RESULTS: Gastrectomy was performed in 44 patients (surgery group) and EMR in 49 patients (EMR group). There were significant differences in mean tumor size (p < 0.05), histologic type (p < 0.05), and depth of tumor invasion (p < 0.05) between the two groups. There was no significant difference in comorbidity between the two groups. No operative death was reported in either group. In the EMR group, 7 patients were reported to have recurrence of local disease and two patients died of advanced disease. There were no significant differences in the overall 3-year survival rate or the 5-year survival rate between the surgery group and EMR group (73.5% vs. 82.5% and 55.0% vs. 62.5%, respectively). CONCLUSIONS: EMR (R0) resection was performed safely in the elderly, and the overall results were excellent, the same as the results with gastrectomy. Gastrectomy can still be performed if EMR is unsuccessful.     

A new sinker-assisted endoscopic submucosal dissection for colorectal cancer

BACKGROUND: Endoscopic submucosal dissection (ESD) is accepted as a minimally invasive treatment for early gastric cancer, but it is not widely used to treat the colorectum because of its degree of technical difficulty. Thus, a noninvasive tool that facilitates the direct visualization of the submucosal layer is needed. METHODS: Traction-assisted dissection was performed on 4 superficial lesions. The system consisted of a metallic clip attached by a nylon line to a sinker 6 x 4 x 4 mm in size and weighing 1 g. After partially dissecting the submucosa, the clip was attached to the edge of the exfoliated mucosa and the weight of the sinker pulled down the partly resected lesion. OBSERVATIONS: In all 4 cases, the sinker allowed direct visualization of the cutting line, and en bloc resection was successfully accomplished. CONCLUSIONS: These preliminary results suggest that sinker-assisted ESD is effective for the complete removal of selected superficial early colorectal cancer.     

Differences in tumor core distribution between palpable and nonpalpable prostate tumors in patients diagnosed using extensive transperineal ultrasound-guided template prostate biopsy

BACKGROUND: The authors performed extensive transperineal ultrasound-guided template prostate biopsies to investigate carcinoma core distribution. METHODS: Between August 2000 and May 2004, 371 men underwent template biopsies. Three hundred twelve patients had not undergone a previous biopsy (first group) and 59 had undergone previous transrectal sextant biopsies (repeat group). Of the 312 patients in the first group, 236 had normal digital rectal examination (DRE) findings (DRE- first group) and 76 patients had an abnormal DRE (DRE+ first group). A mean of 20.1 biopsy cores (range, 9-38 cores) was taken from the entire prostate. The region > 2.0 cm from the rectal face of the prostate was defined as the anterior region and the remaining area was defined as the posterior region. RESULTS: In the DRE- first group, the carcinoma core rate (number of tumor cores/number of biopsy cores) in the anterior region (7.2%) did not differ from that of the posterior region (7.3%) (P = 0.9635). However, in the DRE+ first group, the carcinoma core rate in the posterior region (22.0%) was found to be higher than in the anterior region (13.2%) (P < 0.0001). In the repeat group, the carcinoma core rate in the posterior region (3.1%) was significantly (P = 0.0008) lower than that exhibited in the anterior region (7.2%). CONCLUSIONS: The results of the current study suggest that nonpalpable prostate carcinoma is distributed equally within the entire prostate, although palpable carcinoma is distributed mainly in the posterior region and many of the tumor foci in the anterior region may be missed by a transrectal sextant biopsy. The examination of radical prostatectomy specimens is required to prove these results.     

Assistant skill in gastric endoscopic submucosal dissection using a clutch cutter

BACKGROUND A clutch cutter is a scissor-type knife used in endoscopic submucosal dissection(ESD) for gastrointestinal tract tumors. The assistant during the ESD using a clutch cutter(ESD-C) needs to rotate the device and grasp the target tissue appropriately; therefore, the assistant's skill may affect the technical outcomes of ESD-C.AIM To determine how assistant skill level affected the technical outcomes of gastric ESD-C using an ex vivo porcine training model.METHODS In this pilot study, mock lesions of 15-30 mm in diameter were created in the middle or lower third of the porcine stomach. A total of 32 ESD-C procedures were performed by 16 trainees. Each trainee operator performed two ESD-C procedures; one ESD-C was assisted by an expert(ESD-C-E), and the other was assisted by a non-expert(ESD-C-NE). The total procedure time of the ESD was set as the primary outcome, and en bloc resection rate, complete procedure rate, perforation rate, and each procedure time/speed for mucosal incision or submucosal dissection were set as the secondary outcomes. In addition, we investigated factors associated with the difficulty of ESD including incompletion of ESD procedure, a long procedure time(≥ 20 min) or intraoperative perforation.RESULTS The median total procedure time of the ESD-C-E was significantly shorter than that of the ESD-C-NE(12.9 min vs 21.9 min, P = 0.001). The en bloc resection rate was 100% in both groups. Complete resection rates of the ESD-C-E and ESD-C-NE groups were 100% and 93.8%, respectively. No intraoperative perforation was observed in both groups. In the multivariate analysis, assistant skill was significantly associated with the difficulty of ESD, with the highest odds ratio of 16.5.CONCLUSION Assistance by an expert is an important factor when trainees perform ESD-C procedures.     

Endoscopic biopsies from gastrointestinal carcinomas and their suitability for molecular analysis: a review of the literature and recommendations for clinical practice and research

Endoscopic biopsies (EBs) are the gold standard for diagnosing gastrointestinal carcinoma yet no guidelines address EB use for prognostic and predictive molecular testing. This review summarizes the reported quantity and quality of EBs, their relationship with molecular test failure rates and the resultant concordance between EB and resection specimen. Studies reporting molecular testing on gastrointestinal carcinoma EBs published between 2002 and 2014 were identified. Details regarding EB quantity, quality, tumour content, molecular test failure rates as well as causes and concordance with resection specimens were reviewed. Seventy‐five studies were identified. Eighteen (24%) reported the mean EB number per patient (median: 2.1, range: 1–6.6 EBs). Sixty‐one (81%) reported the frequency of test failure (median: 0%, range: 0–100%). Twenty‐two (29%) investigated EB and resection specimen concordance (range: 0–100%). EB quantity and quality affected neither concordance nor failure rate. In summary, few studies currently report EB quantity, EB quality or EB and resection specimen concordance. Reliable molecular testing in EBs appears achievable, and can be representative of resection specimens. Concordance depends upon the testing methodology and biomarker heterogeneity within the tumour. To improve patient care, EB sampling, processing and reporting requires standardization and needs optimization for each biomarker individually.     

No prognostic significance of p53 expression in esophageal squamous cell carcinoma.

BACKGROUND AND OBJECTIVES: It is generally accepted that the overexpression of p53 protein is associated with poor prognosis in breast, colorectal, and other types of cancer. However, the prognostic significance of p53 aberrations in esophageal squamous cell carcinoma has yet to be determined. We attempted to analyze the relationship between p53 expression and the clinicopathologic features of esophageal squamous cell carcinoma by reviewing the medical records of a large patient population. Our study of esophageal squamous cell carcinoma involves the largest patient population to date. METHODS: p53 expression in formalin-fixed, paraffin-embedded samples of 239 patients with primary esophageal squamous cell carcinoma (TNM stage I:79 cases, stage II: 82 cases, stage III: 78 cases), who underwent esophageal resection without additional treatment, were analyzed by immunohistochemical staining using a polyclonal antibody, RSP53. The relationships between p53 immunoreactivity and prognostic factors were determined by the chi(2) test, and the prognostic impact of p53 protein expression was analyzed by univariate and multivariate survival analyses. RESULTS: In 115 (48.1%) of 239 esophageal tumors, nuclear immunoreactivity for the p53 protein was detected. The expression of the p53 protein did not correlate with sex, age, histological grading, lymph node metastasis, vascular invasion, or TNM stage. Similarly, p53 expression did not correlate with prognosis in univariate and multivariate survival analysis. CONCLUSIONS: The expression of the p53 gene product had no impact on the prognosis of esophageal squamous cell carcinoma.     

Meta-analysis and systematic review of colorectal endoscopic mucosal resection

AIM： To evaluate the proportion of successful complete cure en-bloc resections of large colorectal polyps achieved by endoscopic mucosal resection （EMR）. METHODS： Studies using the EMR technique to resect large colorectal polyps were selected. Successful complete cure en-bloc resection was defined as one piece margin-free polyp resection. Articles were searched for in Medline, Pubmed, and the Cochrane Control Trial Registry, among other sources. RESULTS： An initial search identified 2620 reference articles, from which 429 relevant articles were selected and reviewed. Data was extracted from 25 studies （n = 5221） which met the inclusion criteria. All the studies used snares to perform EMR. Pooled proportion of en-bloc resections using a random effect model was 62.85% （95% CI： 51.50-73.52）. The pooled proportion for complete cure en-bloc resections using a random effect model was 58.66% （95% CI： 47.14-69.71）. With higher patient load （〉 200 patients）, this complete cure en-bloc resection rate improves from 44.19% （95% CI： 24.31-65.09） to 69.17% （95% CI： 51.11-84.61）. CONCLUSION： EMR is an effective technique for the resection of large colorectal polyps and offers an alternative to surgery.