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
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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.
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.
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).
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.
KeywordsEndoscopic submucosal dissection Early gastric cancer Radical surgery Follow-up Lymphatic invasion
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.
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