Feasibility of further expansion of the indications for endoscopic submucosal dissection in undifferentiated-type early gastric cancer
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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.
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.
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%).
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.
KeywordsGastric cancer Endoscopic submucosal resection Gastric carcinoma Lymph node metastasis
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 to be included in the study, or the equivalent, was obtained from all patients.
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