Journal List > Korean J Gastroenterol > v.61(4) > 1007071

Choi, Hong, Han, Song, Kim, Seo, Ha, Lee, and Ko: Therapeutic Outcomes of Endoscopic Submucosal Dissection in Undifferentiated-type Early Gastric Cancer

Abstract

Background/Aims

Endoscopic submucosal dissection (ESD) has been accepted as a standard treatment of early gastric cancer (EGC). However, the indication of ESD in undifferentiated-type EGC was controversial. The aim of this study was to evaluate the therapeutic outcomes of ESD in undifferentiated-type EGC according to expanded indication.

Methods

At Soonchunhyang University Bucheon Hospital, a total of 82 lesions in 81 patients with undifferentiated-type EGC were treated with ESD. The therapeutic outcomes of ESD were evaluated by resection method (en bloc resection; piecemeal resection), histologic curative resection, complications and recurrence rates after ESD.

Results

The rate on en bloc resection and complete resection rate were 87.8% (72/82) and 80.5% (66/82), respectively. In signet ring cell carcinoma, the complete resection rate was higher than those in poorly differentiated adenocarcinoma and poorly differentiated adenocarcinoma with signet ring cell features, but there was no statistical significance (89.3% vs.75.0%, 76.7%; p=0.347). The lateral margin positivity rate in poorly differentiated adenocarcinoma, signet ring cell carcinoma and poorly differentiated adenocarcinoma with signet ring cell features were 12.5%, 3.6% and 13.3%, respectively (p=0.395). The vertical margin positivity rate were 12.5%, 3.6% and 10.0%, respectively (p=0.485). The overall recurrence rate was 3.0% during a mean follow-up period of 37.4 months.

Conclusions

ESD may be considered as a feasible treatment for undifferentiated-type EGC according to expanded indication. The therapeutic outcome of ESD in undifferentiated-type EGC is likely to be favorable, though further longer follow-up studies are needed.

References

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Fig. 1.
Clinical courses after ESD in undifferentiated EGC. ESD, endoscopic submucosal dissection; EGC, early gastric cancer; CR, complete resection; ICR, incomplete resection; LVI, lymphovascular invasion; LMI, lateral margin invasion; VMI, vertical margin invasion; OP, operation; APC, argon plasma coagulation; F/U, fo-llow-up; Recur, recurrence.
kjg-61-196f1.tif
Table 1.
Clinical Characteristics of Undifferentiated EGC before ESD
  Total PD SRC PD+ SRC p-value
Patient 81 24 27 30  
Age (yr) 53.5±12.7 58.4±12.8 50.9±11.2 52.0±13.3 0.074
Gender (male/female) 43/38 13/11 14/13 16/14 0.949
Tumor 82 24 28 30  
Location         0.160
Upper 6 (7.3) 2 (8.3) 2 (7.1) 2 (6.7)  
Middle 43 (52.4) 9 (37.5) 13 (46.4) 21 (70.0)  
Lower 33 (40.2) 13 (54.2) 13 (46.4) 7 (23.3)  
Gross type         0.104
Elevated 20 (24.4) 6 (25.0) 5 (17.9) 9 (30.0)  
Flat 24 (29.3) 7 (29.2) 13 (46.4) 4 (13.3)  
Depressed 38 (46.3) 11 (45.8) 10 (35.7) 17 (56.7)  
Size (cm)         0.521
≤1 24 (29.3) 9 (37.5) 8 (28.6) 7 (23.3)  
>1, ≤2 58 (70.7) 15 (62.5) 20 (71.4) 23 (76.7)  

Values are presented as n, mean±SD, or n (%). EGC, early gastric cancer; ESD, endoscopic submucosal dissection; PD, poorly differentiated adenocarcinoma; SRC, signet ring cell carcinoma; PD+SRC, poorly differentiated adenocarcinoma with signet ring cell features.

Table 2.
Clinical Results after ESD in Undifferentiated EGC
  Total PD SRC PD+ SRC p-value
Resection method         0.541
En bloc resection 72 (87.8) 21 (87.5) 26 (92.9) 25 (83.3)  
Piecemeal resection 10 (12.2) 3 (12.5) 2 (7.1) 5 (16.7)  
Curative resection         0.347
Complete resection 66 (80.5) 18 (75.0) 25 (89.3) 23 (76.7)  
Incomplete resection 16 (19.5) 6 (25.0) 3 (10.7) 7 (23.3)  
Tumor size (cm)         0.862
≤1 22 (26.8) 7 (29.2) 8 (28.6) 7 (23.3)  
>1, ≤2 60 (73.2) 17 (70.8) 20 (71.4) 23 (76.7)  
Depth of invasion         0.953
Mucosa 72 (87.8) 21 (87.5) 25 (89.3) 26 (86.7)  
Submucosa 10 (11.2) 3 (12.5) 3 (10.7) 4 (13.3)  
Marginal residual tumor          
Lymphovascular invasion (+) 4 (4.9) 1 (4.2) 1 (3.6) 2 (6.7) 0.845
Lateral margin invasion (+) 8 (9.8) 3 (12.5) 1 (3.6) 4 (13.3) 0.395
Vertical margin invasion (+) 7 (8.5) 3 (12.5) 1 (3.6) 3 (10.0) 0.485
Treatment after ICR         0.123
APC 4 (25.0) 0 (0.0) 1 (33.3) 3 (42.9)  
Operation 9 (56.2) 3 (50.0) 2 (66.7) 4 (57.1)  
Follow-up 3 (18.8) 3 (50.0) 0 (0.0) 0 (0.0)  
Recurrence, n (%) 3 (3.7) 2 (8.3) 0 (0.0) 1 (3.3) 0.347
In complete resection 2 (3.0) 1 (5.6) 0 (0.0) 1 (4.3) 0.437
In incomplete resection 1 (6.3) 1 (16.7) 0 (0.0) 0 (0.0) 0.746
Recurrence type         <0.001
Local metastasis 3 (100.0) 2 (100.0) 0 (0.0) 1 (100.0)  
Distant metastasis 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)  
Treatment after reccurence         0.223
APC 1 (33.3) 0 (0.0) 0 (0.0) 1 (100.0)  
Re-ESD 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)  
Operation 1 (33.3) 1 (50.0) 0 (0.0) 0 (0.0)  
Follow-up loss 1 (33.3) 1 (50.0) 0 (0.0) 0 (0.0)  

Values are presented n (%). ESD, endoscopic submucosal dissection; EGC, early gastric cancer; PD, poorly differentiated adenocarcinoma; SRC, signet ring cel carcinoma; PD+SRC, poorly differentiated adenocarcinoma with signet ring cell features; ICR, incomplete resection; CR, complete resection APC, argon plasma coagulation.

Table 3.
Relationship between Clinicopathologic Factors and Histologically Complete Resection
  CR ICR p-value
Gender     0.828
Male 35 (53.8) 8 (50.0)  
Female 30 (46.2) 8 (50.0)  
Location     0.009
Upper 2 (3.0) 4 (25.0)  
Middle 37 (56.1) 6 (37.5)  
Lower 27 (40.9) 6 (37.5)  
Gross type     0.395
Elevated 14 (21.2) 6 (37.5)  
Flat 20 (30.3) 6 (37.5)  
Depressed 32 (48.5) 4 (25.0)  
Size (cm)     0.149
≤1 20 (30.3) 2 (12.5)  
>1, ≤2 46 (69.7) 14 (87.5)  
Histology     0.347
PD 18 (27.3) 6 (37.5)  
SRC 25 (37.9) 3 (18.8)  
PD+ SRC 23 (34.8) 7 (43.8)  
Resection type     0.967
En bloc 58 (87.9) 14 (87.5)  
Piecemeal 8 (12.1) 2 (12.5)  
Depth of invasiion     <0.001
Mucosa 64 (97.0) 8 (50.0)  
Submucosa 2 (3.0) 8 (50.0)  

Values are presented as n (%). CR, complete resection; ICR, incomplete resection; PD, poorly differentiated adenocarcinoma; SRC, signet ring cell carcinoma; PD+ SRC, poorly differentiated adenocarcinoma with signet ring cell features.

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