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Journal of Gastroenterology

, Volume 52, Issue 2, pp 175–184 | Cite as

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

  • Waku HattaEmail author
  • Takuji Gotoda
  • Tsuneo Oyama
  • Noboru Kawata
  • Akiko Takahashi
  • Yoshikazu Yoshifuku
  • Shu Hoteya
  • Koki Nakamura
  • Masaaki Hirano
  • Mitsuru Esaki
  • Mitsuru Matsuda
  • Ken Ohnita
  • Ryo Shimoda
  • Motoyuki Yoshida
  • Osamu Dohi
  • Jun Takada
  • Keiko Tanaka
  • Shinya Yamada
  • Tsuyotoshi Tsuji
  • Hirotaka Ito
  • Yoshiaki Hayashi
  • Tomohiro Nakamura
  • Tooru Shimosegawa
Original Article—Alimentary Tract

Abstract

Background

Although radical surgery is routinely performed for patients who do not meet the curative criteria for endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) due to the risk of lymph node metastasis (LNM), this standard therapeutic option may be excessive given the lower number of patients with LNM. Therefore, we aimed to investigate long-term outcomes and validate risk factors predicting recurrence after ESD.

Methods

Of 15,785 patients who underwent ESD for EGC at 19 institutions between 2000 and 2011, 1969 patients not meeting the curative criteria were included in this multi-center study. Based on the treatment strategy after ESD, patients were divided into radical surgery (n = 1064) and follow-up (no additional treatment, n = 905) groups.

Results

Overall survival (OS) and disease-specific survival (DSS) were significantly higher in the radical surgery group than in the follow-up group (p < 0.001 and p = 0.012, respectively). However, the difference in 3-year DSS between the groups (99.4 vs. 98.7 %) was rather small compared with the difference in 3-year OS (96.7 vs. 84.0 %). LNM was found in 89 patients (8.4 %) in the radical surgery group. Lymphatic invasion was found to be an independent risk factor for recurrence in the follow-up group (hazard ratio 5.23; 95 % confidence interval 2.01–13.6; p = 0.001).

Conclusions

This multi-center study, representing the largest cohort to date, revealed a large discrepancy between OS and DSS in the two groups. Since follow-up with no additional treatment after ESD may be an acceptable option for patients at low risk, further risk stratification is needed for appropriate individualized treatment strategies.

Keywords

Endoscopic submucosal dissection Early gastric cancer Radical surgery Follow-up Lymphatic invasion 

Notes

Acknowledgments

We thank Naoki Nakaya (Department of Preventive Medicine and Epidemiology, Tohoku Medical Megabank Organization) for his insightful comments and advice regarding statistical analysis in this study. We also thank Hiroyuki Ono (Division of Endoscopy, Shizuoka Cancer Center), Masahiro Nakagawa (Department of Internal Medicine, Hiroshima City Hospital), Naohiko Harada (Department of Gastroenterology, National Hospital Organization Kyushu Medical Center), Yasumasa Hara (Department of Internal Medicine, Toyama Prefectural Central Hospital), and Kohei Yamanouchi (Department of Internal Medicine and Gastrointestinal Endoscopy, Saga Medical School) for their assistance with patient enrollment and data collection. Finally, we thank Tomoyuki Koike (Department of Gastroenterology, Tohoku University Graduate School of Medicine) and Katsunori Iijima (Department of Gastroenterology, Akita University Graduate School of Medicine) for their insightful comments.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

References

  1. 1.
    Ferlay J, Shin HR, Bray F, et al. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer. 2010;127:2893–917.CrossRefPubMedGoogle Scholar
  2. 2.
    Ono H, Yao K, Fujishiro M, et al. Guidelines for endoscopic submucosal dissection and endoscopic mucosal resection for early gastric cancer. Dig Endosc; 2015 PMID: 26234303.Google Scholar
  3. 3.
    Nishida T, Kato M, Yoshio T, et al. Endoscopic submucosal dissection in early gastric cancer in elderly patients and comorbid conditions. World J Gastrointest Endosc. 2015;7:524–31.PubMedPubMedCentralGoogle Scholar
  4. 4.
    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;3:219–25.CrossRefPubMedGoogle Scholar
  5. 5.
    Hirasawa T, Gotoda T, Miyata S, 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.CrossRefPubMedGoogle Scholar
  6. 6.
    Association Japanese Gastric Cancer. Japanese gastric cancer treatment guidelines 2010 (ver. 3). Gastric Cancer. 2011;14:113–23.CrossRefGoogle Scholar
  7. 7.
    Ryu KW, Choi IJ, Doh YW, et al. Surgical indication for non-curative endoscopic resection in early gastric cancer. Ann Surg Oncol. 2007;14:3428–34.CrossRefPubMedGoogle Scholar
  8. 8.
    Oda I, Gotoda T, Sasako M, et al. Treatment strategy after non-curative endoscopic resection of early gastric cancer. Br J Surg. 2008;95:1495–500.CrossRefPubMedGoogle Scholar
  9. 9.
    Ito H, Inoue H, Ikeda H, et al. Surgical outcomes and clinicopathological characteristics of patients who underwent potentially noncurative endoscopic resection for gastric cancer: a report of a single-center experience. Gastroenterol Res Pract. 2013;2013:427405.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Son SY, Park JY, Ryu KW, et al. The risk factors for lymph node metastasis in early gastric cancer patients who underwent endoscopic resection: is the minimal lymph node dissection applicable? A retrospective study. Surg Endosc. 2013;27:3247–53.CrossRefPubMedGoogle Scholar
  11. 11.
    Yang HJ, Kim SG, Lim JH, et al. Predictors of lymph node metastasis in patients with non-curative endoscopic resection of early gastric cancer. Surg Endosc. 2015;29:1145–55.CrossRefPubMedGoogle Scholar
  12. 12.
    Kim ER, Lee H, Min BH, et al. Effect of rescue surgery after non-curative endoscopic resection of early gastric cancer. Br J Surg. 2015;102:1394–401.CrossRefPubMedGoogle Scholar
  13. 13.
    Kusano C, Iwasaki M, Kaltenbach T, et al. Should elderly patients undergo additional surgery after non-curative endoscopic resection for early gastric cancer? Long-term comparative outcomes. Am J Gastroenterol. 2011;106:1064–9.CrossRefPubMedGoogle Scholar
  14. 14.
    Katsube T, Murayama M, Yamaguchi K, et al. Additional surgery after non-curative resection of ESD for early gastric cancer. Anticancer Res. 2015;35:2969–74.PubMedGoogle Scholar
  15. 15.
    Saka M, Katai H, Fukagawa T, et al. Recurrence in early gastric cancer with lymph node metastasis. Gastric Cancer. 2008;11:214–8.CrossRefPubMedGoogle Scholar
  16. 16.
    Youn HG, An JY, Choi MG, et al. Recurrence after curative resection of early gastric cancer. Ann Surg Oncol. 2010;17:448–54.CrossRefPubMedGoogle Scholar
  17. 17.
    Association Japanese Gastric Cancer. Japanese classification of gastric carcinoma: 3rd English edition. Gastric Cancer. 2011;14:101–12.CrossRefGoogle Scholar
  18. 18.
    Choi J, Kim SG, Im JP, et al. Comparison of endoscopic ultrasonography and conventional endoscopy for prediction of depth of tumor invasion in early gastric cancer. Endoscopy. 2010;42:705–13.CrossRefPubMedGoogle Scholar
  19. 19.
    Nakamura K, Ueyama T, Yao T, et al. Pathology and prognosis of gastric carcinoma. Findings in 10,000 patients who underwent primary gastrectomy. Cancer. 1992;70:1030–7.CrossRefPubMedGoogle Scholar
  20. 20.
    Sasako M, Kinoshita T, Maruyama K. Prognosis of early gastric cancer. Stom Intest. 1993;28:139–46.Google Scholar
  21. 21.
    Shimizu S, Tada M, Kawai K. Early gastric cancer: its surveillance and natural course. Endoscopy. 1995;27:27–31.CrossRefPubMedGoogle Scholar
  22. 22.
    Kitano S, Shiraishi N, Uyama I, et al. A multicenter study on oncologic outcome of laparoscopic gastrectomy for early cancer in Japan. Ann Surg. 2007;245:68–72.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Fujimoto A, Ishikawa Y, Akishima-Fukasawa Y, et al. Significance of lymphatic invasion on regional lymph node metastasis in early gastric cancer using LYVE-1 immunohistochemical analysis. Am J Clin Pathol. 2007;127:82–8.CrossRefPubMedGoogle Scholar
  24. 24.
    Ishida M, Morita S, Saka M, et al. Metachronous liver metastasis from early gastric cancer. J Gastrointest Surg. 2012;16:837–41.CrossRefPubMedGoogle Scholar
  25. 25.
    Kumagai K, Tanaka T, Yamagata K, Yokoyama N, Shimizu K. Liver metastasis in gastric cancer with particular reference to lymphatic advancement. Gastric Cancer. 2001;4:150–5.CrossRefPubMedGoogle Scholar
  26. 26.
    Sano T, Sasako M, Kinoshita T, et al. Recurrence of early gastric cancer. Follow-up of 1475 patients and review of the Japanese literature. Cancer. 1993;72:3174–8.CrossRefPubMedGoogle Scholar
  27. 27.
    Yoshikawa T, Tsuburaya A, Kobayashi O, et al. Is D2 lymph node dissection necessary for early gastric cancer? Ann Surg Oncol. 2002;9:401–5.CrossRefPubMedGoogle Scholar
  28. 28.
    Yamagata K, Kumagai K. Experimental study of lymphogenous peritoneal cancer dissemination: migration of fluorescent-labelled tumor cells in a rat model of mesenteric lymph vessel obstruction. J Exp Clin Cancer Res. 2000;19:211–7.PubMedGoogle Scholar
  29. 29.
    Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83.CrossRefPubMedGoogle Scholar
  30. 30.
    Choi JH, Kim ES, Lee YJ, et al. Comparison of quality of life and worry of cancer recurrence between endoscopic and surgical treatment for early gastric cancer. Gastrointest Endosc. 2015;82:299–307.CrossRefPubMedGoogle Scholar
  31. 31.
    Songun I, Putter H, Kranenbarg EM, et al. Surgical treatment of gastric cancer: 15-year follow-up results of the randomised nationwide Dutch D1D2 trial. Lancet Oncol. 2010;11:439–49.CrossRefPubMedGoogle Scholar
  32. 32.
    Kawabata H, Oda I, Suzuki H, et al. Bone metastasis from early gastric cancer following non-curative endoscopic submucosal dissection. World J Gastroenterol. 2013;19:5016–20.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Japanese Society of Gastroenterology 2016

Authors and Affiliations

  • Waku Hatta
    • 1
    Email author
  • Takuji Gotoda
    • 2
  • Tsuneo Oyama
    • 3
  • Noboru Kawata
    • 4
  • Akiko Takahashi
    • 3
  • Yoshikazu Yoshifuku
    • 5
  • Shu Hoteya
    • 6
  • Koki Nakamura
    • 7
  • Masaaki Hirano
    • 8
  • Mitsuru Esaki
    • 9
  • Mitsuru Matsuda
    • 10
  • Ken Ohnita
    • 11
  • Ryo Shimoda
    • 12
  • Motoyuki Yoshida
    • 13
  • Osamu Dohi
    • 14
  • Jun Takada
    • 15
  • Keiko Tanaka
    • 16
  • Shinya Yamada
    • 17
  • Tsuyotoshi Tsuji
    • 18
  • Hirotaka Ito
    • 19
  • Yoshiaki Hayashi
    • 20
  • Tomohiro Nakamura
    • 21
  • Tooru Shimosegawa
    • 1
  1. 1.Department of GastroenterologyTohoku University Graduate School of MedicineSendaiJapan
  2. 2.Division of Gastroenterology and Hepatology, Department of MedicineNihon University School of MedicineTokyoJapan
  3. 3.Division of EndoscopySaku Central Hospital Advanced Care CenterSakuJapan
  4. 4.Division of EndoscopyShizuoka Cancer CenterShizuokaJapan
  5. 5.Department of Gastroenterology and Metabolism, Graduate School of Biomedical SciencesHiroshima UniversityHiroshimaJapan
  6. 6.Department of GastroenterologyToranomon HospitalTokyoJapan
  7. 7.Department of Internal MedicineHiroshima City HospitalHiroshimaJapan
  8. 8.Department of Internal MedicineNiigata Prefectural Central HospitalJoetsuJapan
  9. 9.Department of GastroenterologyKitakyushu Municipal Medical CenterKitakyushuJapan
  10. 10.Department of Internal MedicineToyama Prefectural Central HospitalToyamaJapan
  11. 11.Department of Gastroenterology and HepatologyNagasaki University HospitalNagasakiJapan
  12. 12.Department of Internal Medicine and Gastrointestinal EndoscopySaga Medical SchoolSagaJapan
  13. 13.Department of Gastroenterology and Endocrinology and MetabolismNara Medical UniversityKashiharaJapan
  14. 14.Department of Gastroenterology and HepatologyKyoto Prefectural University of MedicineKyotoJapan
  15. 15.Department of GastroenterologyGifu University Graduate School of MedicineGifuJapan
  16. 16.Department of GastroenterologyShinshu University School of MedicineMatsumotoJapan
  17. 17.Department of Gastroenterology and HepatologyJapanese Red Cross Society Kyoto Daiichi HospitalKyotoJapan
  18. 18.Department of GastroenterologyAkita City HospitalAkitaJapan
  19. 19.Department of GastroenterologyOsaki Citizen HospitalOsakiJapan
  20. 20.Division of GastroenterologyFukui Prefectural HospitalFukuiJapan
  21. 21.Department of Preventive Medicine and EpidemiologyTohoku Medical Megabank OrganizationSendaiJapan

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