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Endoscopic Submucosal Dissection of Early Gastric Cancer with Mixed-Type Histology: A Systematic Review

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Abstract

Background

Endoscopic submucosal dissection (ESD) criteria are histologically categorized by early gastric cancer (EGC) with differentiated- and undifferentiated-type histology. However, EGC is histologically heterogenous and there have been no separate criteria for EGC with mixed-type histology [EGC-MH; differentiated-type predominant EGC mixed with an undifferentiated component (EGC-MD) or undifferentiated-type predominant EGC mixed with a differentiated component (EGC-MU)]. Moreover, therapeutic outcomes of ESD for EGC-MH have not been clearly described.

Aim

This study aimed to evaluate the feasibility of ESD for EGC-MH.

Methods

We searched core databases for specific inclusion factors: patients with EGC-MH, intervention of ESD, and at least one of the following outcomes: rate of en bloc, complete, curative resection, recurrence, procedure-related adverse event, lymphovascular invasion (LVI), or lymph node metastasis (LNM) that enabled evaluation of feasibility of ESD.

Results

A total of eight (systematic review) and four studies (meta-analysis) were included. There was no robustness in age, location, or morphology of EGC-MH. Moderately differentiated adenocarcinoma was frequent in pre-ESD biopsy. EGC-MH showed larger size, deeper invasion, and higher rates of LVI/LNM than pure-type EGC. Total en bloc, complete resection, and curative resection rates were 94.6% (95% confidence interval 86.6–97.9%), 77.8% (57.9–89.9%), and 55.1% (50.4–59.6%), respectively. There was no LNM or extra-gastric recurrence after ESD if the EGC-MD met the curative resection criteria. However, the EGC-MD itself was a risk factor for non-curative resection. (Margin positivity was the most common reason.)

Conclusions

Although ESD seems to be technically feasible, inaccurate prediction of lateral or vertical margin leads to lower curative resection rate. Application of more strict indication is needed for EGC-MH.

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Abbreviations

ESD:

Endoscopic submucosal dissection

EGC:

Early gastric cancer

EGC-MH:

EGC with mixed-type histology

EGC-MD:

Differentiated-type predominant EGC mixed with an undifferentiated component

EGC-MU:

Undifferentiated-type predominant EGC mixed with a differentiated component

LNM:

Lymph node metastasis

LVI:

Lymphovascular invasion

SM1:

Submucosal section 1

ROBINS-I:

Risk of bias in non-randomized studies of interventions

CI:

Confidence interval

OR:

Odds ratio

SRC:

Signet ring cell carcinoma

OS:

Overall survival

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Acknowledgment

This research was supported by the Bio & Medical Technology Development Program of the National Research Foundation (NRF) & by the Korean government, Ministry of Science and ICT (MSIT) (Grant Number NRF2017M3A9E8033253).

Funding

English editing was done by the editing company (www.editage.co.kr). There was no funding source relevant to this editing of article.

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Authors and Affiliations

  1. Department of Internal Medicine, Hallym University College of Medicine, Sakju-ro 77, Chuncheon, Gangwon-do, 24253, Korea

    Chang Seok Bang, Young Joo Yang & Gwang Ho Baik

  2. Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, Korea

    Chang Seok Bang, Young Joo Yang & Gwang Ho Baik

  3. Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, Korea

    Chang Seok Bang & Jae Jun Lee

  4. Department of Anesthesiology and Pain Medicine, Hallym University College of Medicine, Chuncheon, Korea

    Jae Jun Lee

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Contributions

CSB. contributed to the conceptualization, funding acquisition, methodology, project administration, writing of the original draft, and writing of the review and editing. CSB, YJY, JJL, and GHB. contributed to the data curation, formal analysis, investigation, and resources.

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Correspondence to Chang Seok Bang.

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Bang, C.S., Yang, Y.J., Lee, J.J. et al. Endoscopic Submucosal Dissection of Early Gastric Cancer with Mixed-Type Histology: A Systematic Review. Dig Dis Sci 65, 276–291 (2020). https://doi.org/10.1007/s10620-019-05761-w

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