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Feasibility of further expansion of the indications for endoscopic submucosal dissection in undifferentiated-type early gastric cancer

  • Yusuke HoriuchiEmail author
  • Satoshi Ida
  • Noriko Yamamoto
  • Souya Nunobe
  • Naoki Ishizuka
  • Shoichi Yoshimizu
  • Akiyoshi Ishiyama
  • Toshiyuki Yoshio
  • Toshiaki Hirasawa
  • Tomohiro Tsuchida
  • Koshi Kumagai
  • Manabu Ohashi
  • Takeshi Sano
  • Junko Fujisaki
Original Article
  • 92 Downloads

Abstract

Background

Based on Japanese guidelines for endoscopic submucosal dissection (ESD) in undifferentiated-type early gastric cancer (UD-EGC), UD-predominant mixed-type (M-UD) EGC is considered high risk for lymph node metastasis (LNM). However, differences in LNM risk between pure UD (P-UD) and M-UD remain unclear. This study assessed risk factors for LNM considering differences between P-UD and M-UD and identified pathological features related to the lowest LNM risk.

Methods

This single-center, retrospective study included 1425 patients with UD-EGC treated with surgical resection between April 2005 and May 2017. We divided patients into those with and without LNM and compared background characteristics and post-operative pathological results between groups. Patients were further stratified based on depth, tumor diameter, ulcerative findings, lymphatic invasion, vascular invasion, and histological type to clarify post-operative pathological features associated with the lowest LNM risk.

Results

When comparing background characteristics and post-operative pathological results, multivariate analysis showed that, in patients with LNM, tumor diameters were significantly larger, and there were higher rates of submucosal invasion, lymphatic invasion, and M-UD histological type. In patients with absence of ulcerative findings, absence of lymphatic invasion, and absence of vascular invasion, no LNM occurred among those with intramucosal P-UD tumor diameters of 1–40 mm (1–20 mm: 95% confidence interval [CI], 0–5.5%; 21–40 mm: 95% CI, 0–6.1%).

Conclusions

Intramucosal P-UD EGC patients with absence of ulcerative findings, absence of lymphatic invasion, absence of vascular invasion, and tumor diameters of ≤ 40 mm did not show LNM. We suggest expanding indications for ESD to include these patients.

Keywords

Gastric cancer Endoscopic submucosal resection Gastric carcinoma Lymph node metastasis 

Notes

Author contributions

Conceptualization: YH, SI, SN, NY, JF; methodology: YH, SI, NI; formal analysis and investigation: YH, NI; writing—original draft preparation: YH; writing—review and editing: YH, TY, KK, NI, SN; funding acquisition: YH; resources: YH, SI, SN, SY, AI, TY, TH, TT, KK, MO, TS, JF; supervision: YH, JF.

Compliance with ethical standards

Conflict of interest

There is no conflict of interest associated with this study.

Human rights statement

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later versions.

Informed consent

Informed consent to be included in the study, or the equivalent, was obtained from all patients.

References

  1. 1.
    Ono H, Kondo H, Gotoda T, Shirao K, Yamaguchi H, Saito D, et al. Endoscopic mucosal resection for treatment of early gastric cancer. Gut. 2001;48:225–9.CrossRefGoogle Scholar
  2. 2.
    Oda I, Gotoda T, Hamanaka H, Eguchi T, Saito Y, Matsuda T, et al. Endoscopic submucosal dissection for early gastric cancer: technical feasibility, operation time and complications from a large consecutive series. Dig Endosc. 2005;17:54–8.CrossRefGoogle Scholar
  3. 3.
    Ono H, Hasuike N, Inui T, Takizawa K, Ikehara H, Yamaguchi Y, et al. Usefulness of a novel electrosurgical knife, the insulation-tipped diathermic knife-2, for endoscopic submucosal dissection of early gastric cancer. Gastric Cancer. 2008;11:47–52.CrossRefGoogle Scholar
  4. 4.
    Gotoda T, Kondo H, Ono H, Saito Y, Yamaguchi H, Saito D, et al. A new endoscopic mucosal resection procedure using an insulation-tipped electrosurgical knife for rectal flat lesions: report of two cases. Gastrointest Endosc. 1999;50:560–3.CrossRefGoogle Scholar
  5. 5.
    Ohkuwa M, Hosokawa K, Boku N, Ohtu A, Tajiri H, Yoshida S. New endoscopic treatment for intramucosal gastric tumors using an insulated-tip diathermic knife. Endoscopy. 2001;33:221–6.CrossRefGoogle Scholar
  6. 6.
    Yamamoto H, Kawata H, Sunada K, Satoh K, Kaneko Y, Ido K, et al. Success rate of curative endoscopic mucosal resection with circumferential mucosal incision assisted by submucosal injection of sodium hyaluronate. Gastrointest Endosc. 2002;56:507–12.CrossRefGoogle Scholar
  7. 7.
    Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2014 (ver. 4). Gastric Cancer. 2017;20:1–19.CrossRefGoogle Scholar
  8. 8.
    Hirasawa T, Gotoda T, Miyata S, Kato Y, Shimoda T, Taniguchi H, et al. Incidence of lymph node metastasis and the feasibility of endoscopic resection for undifferentiated-type early gastric cancer. Gastric Cancer. 2009;12:148–52.CrossRefGoogle Scholar
  9. 9.
    Okada K, Fujisaki J, Yoshida T, Ishikawa H, Suganuma T, Kasuga A, et al. Long-term outcomes of endoscopic submucosal dissection for undifferentiated-type early gastric cancer. Endoscopy. 2012;44:122–7.CrossRefGoogle Scholar
  10. 10.
    Abe S, Oda I, Suzuki H, Nonaka S, Yoshinaga S, Odagaki T, et al. Short- and long-term outcomes of endoscopic submucosal dissection for undifferentiated early gastric cancer. Endoscopy. 2013;45:703–7.CrossRefGoogle Scholar
  11. 11.
    Lee S, Choi KD, Han M, Na HK, Ahn JY, Jung KW, et al. Long-term outcomes of endoscopic submucosal dissection versus surgery in early gastric cancer meeting expanded indication including undifferentiated-type tumors: a criteria-based analysis. Gastric Cancer. 2018;21:490–9.CrossRefGoogle Scholar
  12. 12.
    Takizawa K, Takashima A, Kimura A, Mizusawa J, Hasuike N, Ono H, et al. A phase II clinical trial of endoscopic submucosal dissection for early gastric cancer of undifferentiated type: Japan Clinical Oncology Group study JCOG1009/1010. Jpn J Clin Oncol. 2013;43:87–91.CrossRefGoogle Scholar
  13. 13.
    Takizawa K, Ono H, Kakushima N, Tanaka M, Hasuike N, Matsubayashi H, et al. Risk of lymph node metastases from intramucosal gastric cancer in relation to histological types: how to manage the mixed histological type for endoscopic submucosal dissection. Gastric Cancer. 2013;16:531–6.CrossRefGoogle Scholar
  14. 14.
    Hanaoka N, Tanabe S, Mikami T, Okayasu I, Saigenji K. Mixed-histologic-type submucosal invasive gastric cancer as a risk factor for lymph node metastasis: feasibility of endoscopic submucosal dissection. Endoscopy. 2009;41:427–32.CrossRefGoogle Scholar
  15. 15.
    Gotoda T, Sasako M, Ono H, Katai H, Sano T, Shimoda T. Evaluation of the necessity for gastrectomy with lymph node dissection for patients with submucosal invasive gastric cancer. Br J Surg. 2001;88:444–9.CrossRefGoogle Scholar
  16. 16.
    Gotoda T, Yanagisawa A, Sasako M, Ono H, Nakanishi Y, Shimoda T, et al. Incidence of lymph node metastasis from early gastric cancer: estimation with a large number of cases at two large centers. Gastric Cancer. 2000;3:219–25.CrossRefGoogle Scholar
  17. 17.
    Hatta W, Gotoda T, Oyama T, Kawata N, Takahashi A, Yoshifuku Y, et al. 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. J Gastroenterol. 2017;52:175–84.CrossRefGoogle Scholar
  18. 18.
    Hatta W, Gotoda T, Oyama T, Kawata N, Takahashi A, Yoshifuku Y, et al. A scoring system to stratify curability after endoscopic submucosal dissection for early gastric cancer. Am J Gastroenterol. 2017;112:874–81.CrossRefGoogle Scholar
  19. 19.
    Sekiguchi M, Oda I, Taniguchi H, Suzuki H, Morita S, Fukagawa T, et al. Risk stratification and predictive risk-scoring model for lymph node metastasis in early gastric cancer. J Gastroenterol. 2016;51:961–70.CrossRefGoogle Scholar
  20. 20.
    Watanabe M, Miyata H, Gotoh M, Baba H, Kimura W, Tomita N, et al. Total gastrectomy risk model: data from 20,011 Japanese patients in a nationwide internet-based database. Ann Surg. 2014;260:1034–9.CrossRefGoogle Scholar
  21. 21.
    Kurita N, Miyata H, Gotoh M, Shimada M, Imura S, Kimura W, et al. Risk model for distal gastrectomy when treating gastric cancer on the basis of data from 33,917 Japanese patients collected using a nationwide web-based data entry system. Ann Surg. 2015;262:295–303.CrossRefGoogle Scholar
  22. 22.
    Yang JY, Lee HJ, Kim TH, Huh YJ, Son YG, Park JH, et al. Short- and long-term outcomes after gastrectomy in elderly gastric cancer patients. Ann Surg Oncol. 2017;24:469–77.CrossRefGoogle Scholar

Copyright information

© The International Gastric Cancer Association and The Japanese Gastric Cancer Association 2019

Authors and Affiliations

  • Yusuke Horiuchi
    • 1
    Email author
  • Satoshi Ida
    • 2
  • Noriko Yamamoto
    • 3
  • Souya Nunobe
    • 2
  • Naoki Ishizuka
    • 4
  • Shoichi Yoshimizu
    • 1
  • Akiyoshi Ishiyama
    • 1
  • Toshiyuki Yoshio
    • 1
  • Toshiaki Hirasawa
    • 1
  • Tomohiro Tsuchida
    • 1
  • Koshi Kumagai
    • 2
  • Manabu Ohashi
    • 2
  • Takeshi Sano
    • 2
  • Junko Fujisaki
    • 1
  1. 1.Department of GastroenterologyCancer Institute HospitalTokyoJapan
  2. 2.Department of Gastric SurgeryCancer Institute HospitalTokyoJapan
  3. 3.Department of PathologyCancer Institute HospitalTokyoJapan
  4. 4.Department of Clinical Trial Planning and ManagementCancer Institute HospitalTokyoJapan

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