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Can further gastrectomy be avoided in patients with incomplete endoscopic resection?

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Abstract

Background

Endoscopic resection (ER) is a widely accepted treatment for patients with early gastric cancer (EGC) with no lymph node metastasis. Occasionally, however, additional surgery is needed due to an incomplete resection. The purpose of this study was to detect clinical factors which might identify patients at greater risk of additional surgery after ER and to suggest an alternative treatment strategy for these patients.

Methods

This study retrospectively analyzed 350 patients with gastric cancer who underwent radical gastrectomy and lymphadenectomy after ER in a single institution between July 2004 and July 2014. Risk factors for incomplete resection were identified using binary logistic multiple regression tests and a classification and regression tree analysis.

Results

Residual cancer cells were found in the remnant stomach or lymph node in 96 patients (27.4%). In multivariate analysis, lymphovascular invasion (p < 0.001, odds ratio [OR] 5.619) and depth of invasion greater than the second submucosal layer (SM2) (p < 0.01, OR 3.224) were independent risk factors for lymph node metastasis. Positive resection margin (p < 0.001, OR 7.565), depth of invasion to mucosa (M) and the first submucosal layer (SM1) (p < 0.001, OR 4.219), and size over 3 cm (p < 0.029, OR 2.306) were significant risk factors for residual tumor in the remnant stomach. Of 106 patients who had invasion of the M or SM1 without lymphatic invasion at the time of ER, residual cancer was found in 53 patients. Of these 53 patients, 50 (94.3%) had residual cancer in the mucosal layer and only one had lymph node metastasis.

Conclusion

In patients with EGC with M or SM1 invasion without lymphovascular invasion at the time of ER, who had an incomplete resection, additional endoscopic treatment or close monitoring can be performed instead of additional surgery, especially in patients who are unable to tolerate gastrectomy, for example elderly patients or those with comorbidities.

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References

  1. Japanese Gastric Cancer Association (2011) Japanese classification of gastric carcinoma: 3rd english edition. Gastric Cancer 14:101–112

    Article  Google Scholar 

  2. Itoh H, Oohata Y, Nakamura K et al (1989) Complete ten-year postgastrectomy follow-up of early gastric cancer. Am J Surg 158:14–16

    Article  CAS  PubMed  Google Scholar 

  3. Lee HJ, Kim YH, Kim WH et al (2003) Clinicopathological analysis for recurrence of early gastric cancer. Jpn J Clin Oncol 33:209–214

    Article  PubMed  Google Scholar 

  4. Lee JH, Yom CK, Han HS (2009) Comparison of long-term outcomes of laparoscopy-assisted and open distal gastrectomy for early gastric cancer. Surg Endosc 23:1759–1763

    Article  PubMed  Google Scholar 

  5. Abe S, Ogawa Y, Nagasue N et al (1984) Early gastric cancer: results in a general hospital in Japan. World J Surg 8:308–314

    Article  CAS  PubMed  Google Scholar 

  6. Adachi Y, Shiraishi N, Kitano S (2002) Modern treatment of early gastric cancer: review of the Japanese experience. Dig Surg 19:333–339

    Article  PubMed  Google Scholar 

  7. Ahn JY, Jung HY, Choi KD et al (2011) Endoscopic and oncologic outcomes after endoscopic resection for early gastric cancer: 1370 cases of absolute and extended indications. Gastrointest Endosc 74:485–493

    Article  PubMed  Google Scholar 

  8. Furukawa H, Imamura H, Kodera Y (2002) The role of surgery in the current treatment of gastric carcinoma. Gastric Cancer 5(Suppl 1):13–16

    Article  PubMed  Google Scholar 

  9. Ono H (2005) Endoscopic submucosal dissection for early gastric cancer. Chin J Dig Dis 6:119–121

    Article  PubMed  Google Scholar 

  10. Ono H, Hasuike N, Inui T et al (2008) Usefulness of a novel electrosurgical knife, the insulation-tipped diathermic knife-2, for endoscopic submucosal dissection of early gastric cancer. Gastric Cancer 11:47–52

    Article  PubMed  Google Scholar 

  11. Tsujimoto H, Yaguchi Y, Kumano I et al (2012) Laparoscopic gastrectomy after incomplete endoscopic resection for early gastric cancer. Oncol Rep 28:2205–2210

    PubMed  Google Scholar 

  12. Lee HJ, Jang YJ, Kim JH et al (2011) Clinical outcomes of gastrectomy after incomplete EMR/ESD. J Gastric Cancer 11:162–166

    Article  PubMed  PubMed Central  Google Scholar 

  13. Nagano H, Ohyama S, Fukunaga T et al (2005) Indications for gastrectomy after incomplete EMR for early gastric cancer. Gastric Cancer 8:149–154

    Article  PubMed  Google Scholar 

  14. Ryu KW, Choi IJ, Doh YW et al (2007) Surgical indication for non-curative endoscopic resection in early gastric cancer. Ann Surg Oncol 14:3428–3434

    Article  PubMed  Google Scholar 

  15. Jung H, Bae JM, Choi MG et al (2011) Surgical outcome after incomplete endoscopic submucosal dissection of gastric cancer. Br J Surg 98:73–78

    Article  CAS  PubMed  Google Scholar 

  16. Kawata N, Kakushima N, Tokunaga M et al (2015) Influence of endoscopic submucosal dissection on additional gastric resections. Gastric Cancer 18:339–345

    Article  PubMed  Google Scholar 

  17. Breiman L, Friedman J, Stone CJ et al (1984) Classification and regression trees. CRC Press, Boca Raton

    Google Scholar 

  18. Soetikno R, Kaltenbach T, Yeh R et al (2005) Endoscopic mucosal resection for early cancers of the upper gastrointestinal tract. J Clin Oncol 23:4490–4498

    Article  PubMed  Google Scholar 

  19. Gotoda T, Yanagisawa A, Sasako M et al (2000) Incidence of lymph node metastasis from early gastric cancer: estimation with a large number of cases at two large centers. Gastric Cancer 3:219–225

    Article  PubMed  Google Scholar 

  20. Balasubramanian SP (2001) Evaluation of the necessity for gastrectomy with lymph node dissection for patients with submucosal invasive gastric cancer (Br J Surg 2001; 88: 444–9). Br J Surg 88:1133–1134

    CAS  PubMed  Google Scholar 

  21. Kusano C, Iwasaki M, Kaltenbach T et al (2011) Should elderly patients undergo additional surgery after non-curative endoscopic resection for early gastric cancer? Am J Gastroenterol 106:1064–1069

    Article  PubMed  Google Scholar 

  22. Ahn JY, Jung HY, Choi JY et al (2012) Natural course of noncurative endoscopic resection of differentiated early gastric cancer. Endoscopy 44:1114–1120

    Article  CAS  PubMed  Google Scholar 

  23. Kang HJ, Kim DH, Jeon TY et al (2010) Lymph node metastasis from intestinal-type early gastric cancer: experience in a single institution and reassessment of the extended criteria for endoscopic submucosal dissection. Gastrointest Endosc 72:508–515

    Article  PubMed  Google Scholar 

  24. Gotoda T, Iwasaki M, Kusano C et al (2010) Endoscopic resection of early gastric cancer treated by guideline and expanded National Cancer Centre criteria. Br J Surg 97:868–871

    Article  CAS  PubMed  Google Scholar 

  25. Oda I, Gotoda T, Sasako M et al (2008) Treatment strategy after non-curative endoscopic resection of early gastric cancer. Br J Surg 95:1495–1500

    Article  CAS  PubMed  Google Scholar 

  26. Lee JH, Kim JH, Kim DH et al (2010) Is surgical treatment necessary after non-curative endoscopic resection for early gastric cancer? J Gastric Cancer 10:182–187

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Sagawa T, Takayama T, Oku T et al (2003) Argon plasma coagulation for successful treatment of early gastric cancer with intramucosal invasion. Gut 52:334–339

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Lee KM, Kim YB, Sin SJ et al (2009) Argon plasma coagulation with submucosal saline injection for gastric adenoma on outpatient basis. Dig Dis Sci 54:2623–2628

    Article  CAS  PubMed  Google Scholar 

  29. Van Laethem JL, Jagodzinski R, Peny MO et al (2001) Argon plasma coagulation in the treatment of Barrett’s high-grade dysplasia and in situ adenocarcinoma. Endoscopy 33:257–261

    Article  PubMed  Google Scholar 

  30. Kitamura T, Tanabe S, Koizumi W et al (2006) Argon plasma coagulation for early gastric cancer: technique and outcome. Gastrointest Endosc 63:48–54

    Article  PubMed  Google Scholar 

  31. Ahn JY, Choi KD, Na HK et al (2013) Clinical outcomes of argon plasma coagulation for the treatment of gastric neoplasm. Surg Endosc 27:3146–3152

    Article  PubMed  Google Scholar 

  32. Yamanouchi K, Ogata S, Sakata Y et al (2016) Effect of additional surgery after noncurative endoscopic submucosal dissection for early gastric cancer. Endosc Int Open 4:E24–E29

    PubMed  Google Scholar 

  33. Hatta W, Gotoda T, Oyama T et al (2016) Is radical surgery necessary in all patients who do not meet the curative criteria for endoscopic submucosal dissection in early gastric cancer? J Gastroenterol. doi:10.1007/s00535-016-1210-4

    PubMed  Google Scholar 

  34. Hoteya S, Iizuka T, Kikuchi D et al (2016) Clinicopathological outcomes of patients with early gastric cancer after non-curative endoscopic submucosal dissection. Digestion 93:53–58

    Article  CAS  PubMed  Google Scholar 

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Author contributions

Hee Sung Kim, Ji Yong Ahn, and Byung Sik Kim performed the literature search, conception and design, and drafting of the article. Seon Ok Kim performed the analysis and interpretation. All authors were involved in the critical revision and final approval of the article.

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Author notes

  1. Hee Sung Kim and Ji Yong Ahn have contributed equally to this work.

Authors and Affiliations

  1. Department of Gastric Surgery, Ulsan University School of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea

    Hee Sung Kim & Byung Sik Kim

  2. Department of Gastroenterology, Ulsan University School of Medicine, Asan Medical Center, Seoul, Republic of Korea

    Ji Yong Ahn

  3. Department of Clinical Epidemiology and Biostatistics, Ulsan University School of Medicine, Asan Medical Center, Seoul, Republic of Korea

    Seon Ok Kim

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  1. Hee Sung Kim
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Corresponding author

Correspondence to Byung Sik Kim.

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Disclosures

Hee Sung Kim, Ji Yong Ahn, Seon Ok Kim, and Byung Sik Kim have no conflicts of interest or financial ties to disclose.

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Kim, H.S., Ahn, J.Y., Kim, S.O. et al. Can further gastrectomy be avoided in patients with incomplete endoscopic resection?. Surg Endosc 31, 4735–4748 (2017). https://doi.org/10.1007/s00464-017-5550-9

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  • DOI: https://doi.org/10.1007/s00464-017-5550-9

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