Is endoscopic submucosal dissection an effective treatment for operable patients with clinical submucosal invasive early gastric cancer?

Background and study aims: Gastrectomy with lymph node dissection is the gold standard curative treatment for clinical submucosal invasive early gastric cancer (cSM EGC), but a relatively small number of operable patients with cSM EGC have undergone endoscopic submucosal dissection (ESD) instead because they refused surgery. The aim of this study was to determine the effectiveness of ESD in these operable patients.

Methods: The therapeutic outcomes of ESD were retrospectively assessed for 38 patients with 38 operable cSM EGC lesions who initially refused surgery at the National Cancer Center Hospital, Tokyo, from January 1999 to December 2008.

Results: The en bloc resection rate was 84.2 % (32 lesions) and the complete (R0) resection rate was 63.2 % (24 lesions). A total of 33 lesions (86.8 %) involved submucosal invasion on pathology. Resection was non-curative in 34 patients (89.5 %), 22 of whom (64.7 %) underwent subsequent gastrectomy after the need for such surgery was carefully explained to them again. The median follow-up period was 73.2 months (range 3 – 115 months). Local recurrence was detected in one patient, distant metastasis in two patients, and both local recurrence and distant metastasis were detected in one patient. None of these four patients with recurrence (10.5 %) had undergone surgery when their recurrent disease was detected and all of them died from gastric cancer. The 5-year cause-specific survival rate for all patients was 91.8 %.

Conclusion: The 5-year cause-specific survival rate for all patients was lower than the previously reported rate of 96.7 % for pathologically submucosal invasive EGC patients after gastrectomy; therefore, ESD appears to have been an ineffective treatment for operable patients with cSM EGC.

• References

• 1 Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2010 (ver. 3). Gastric Cancer 2011; 14: 113-123
• 2 Gotoda T, Yanagisawa A, Sasako M 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: 219-225
• 3 Ono H, Kondo H, Gotoda T et al. Endoscopic mucosal resection for treatment of early gastric cancer. Gut 2001; 48: 225-229
• 4 Gotoda T, Kondo H, Ono H et al. A new endoscopic mucosal resection procedure using an insulation-tipped electrosurgical knife for rectal flat lesions. Gastrointest Endosc 1999; 50: 560-563
• 5 Oda I, Gotoda T, Hamanaka H et al. Endoscopic submucosal dissection for early gastric cancer: technical feasibility, operation time and complications from a large consecutive series. Dig Endosc 2005; 17: 54-58
• 6 Yamamoto H, Kawata H, Sunada K et al. Successful one-piece resection of large superficial tumors in the stomach and colon using sodium hyaluronate and small-caliber-tip transparent hood. Endoscopy 2003; 35: 690-694
• 7 Oyama T, Kikuchi Y. Aggressive endoscopic mucosal resection in the upper GI tract – Hook knife EMR method. Minim Invas Ther Allied Technol 2002; 11: 291-295
• 8 Gotoda T, Iwasaki M, Kusano C et al. Endoscopic resection of early gastric cancer treated by guideline and expanded National Cancer Centre criteria. Br J Surg 2010; 97: 868-871
• 9 Ono H, Yoshida S. Endoscopic diagnosis of the depth of cancer invasion for gastric cancer. Stomach and Intestine (abstract in English) 2001; 36: 334-340
• 10 Sano T, Okuyama Y, Kobori O et al. Early gastric cancer endoscopic diagnosis of depth of invasion. Dig Dis Sci 1990; 35: 1340-1344
• 11 Gotoda T, Sasako M, Ono H et al. Evaluation of the necessity for gastrectomy with lymph node dissection for patients with submucosal invasive gastric cancer. Br J Surg 2001; 88: 444-449
• 12 Okamura T, Tsujitani S, Korenaga D et al. Lymphadenectomy for cure in patients with early gastric cancer and lymph node metastasis. Am J Surg 1988; 155: 476-480
• 13 Korenaga D, Haraguchi M, Tsujitani S et al. Clinicopathological features of mucosal carcinoma of the stomach with lymph node metastasis in eleven patients. Br J Surg 1986; 73: 431-433
• 14 Iriyama K, Asakawa T, Koike H et al. Is extensive lymphadenectomy necessary for surgical treatment of intramucosal carcinoma of the stomach?. Arch Surg 1989; 124: 309-311
• 15 Inoue K, Tobe T, Kan N et al. Problems in the definition and treatment of early gastric cancer. Br J Surg 1991; 78: 818-821
• 16 Maehara Y, Orita H, Okuyama T et al. Predictors of lymph node metastasis in early gastric cancer. Br J Surg 1992; 79: 245-247
• 17 Sano T, Kobori O, Muto T. Lymph node metastasis from early gastric cancer: endoscopic resection of tumour. Br J Surg 1992; 79: 241-244
• 18 Tsuchiya A, Kikuchi Y, Ando Y et al. Lymph node metastases in gastric cancer invading the submucosal layer. Eur J Surg Oncol 1995; 21: 248-250
• 19 Hanazaki K, Wakabayashi M, Sodeyama H et al. Clinicopathologic features of submucosal carcinoma of the stomach. J Clin Gastroenterol 1997; 24: 150-155
• 20 Kitamura K, Yamaguchi T, Taniguchi H et al. Analysis of lymph node metastasis in early gastric cancer: rationale of limited surgery. J Surg Oncol 1997; 64: 42-47
• 21 Nakamura K, Ueyama T, Yao T et al. Pathology and prognosis of gastric carcinoma. Findings in 10000 patients who underwent primary gastrectomy. Cancer 1992; 70: 1030-1037
• 22 Shimizu S, Tada M, Kawai K. Early gastric cancer: its surveillance and natural course. Endoscopy 1995; 27: 27-31
• 23 Sue-Ling HM, Johnston D, Martin IG et al. Gastric cancer: a curable disease in Britain. BMJ 1993; 307: 591-596
• 24 Sasako M, Kinoshita T, Maruyama K. Prognosis of early gastric cancer. Stomach and Intestine (abstract in English) 1993; 28: 139-146
• 25 Maruyama K, Sasako M, Kinoshita T et al. Effectiveness of systematic lymph node dissection in gastric cancer surgery. In: Nishi M, Ichikawa H, Nakajima T, et al. eds. Gastric cancer. Berlin: Springer; 1993
• 26 Yano H, Monden T, Kinuta M et al. The usefulness of laparoscopy-assisted distal gastrectomy in comparison with that of open distal gastrectomy for early gastric cancer. Gastric Cancer 2001; 4: 93-97
• 27 Kitano S, Shiraishi N, Uyama I. Japanese Laparoscopic Surgery Study Group et al. A multicenter study on oncologic outcome of laparoscopic gastrectomy for early cancer in Japan. Ann Surg 2007; 245: 68-72