Therapeutic Outcomes of Endoscopic Submucosal Dissection in Undifferentiated-type Early Gastric Cancer

Moon Han Choi; Su Jin Hong; Jae Pil Han; Jeong-Yeop Song; Dae Yong Kim; Sung Woo Seo; Ji Su Ha; Yun Nah Lee; Bong Min Ko

doi:10.4166/kjg.2013.61.4.196

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

Original Article

Korean J Gastroenterol 2013;61(4):196-202.

Published online: 4 October 2013

DOI: https://doi.org/10.4166/kjg.2013.61.4.196

Therapeutic Outcomes of Endoscopic Submucosal Dissection in Undifferentiated-type Early Gastric Cancer

Moon Han Choi, Su Jin Hong, Jae Pil Han, Jeong-Yeop Song, Dae Yong Kim, Sung Woo Seo, Ji Su Ha, Yun Nah Lee, Bong Min Ko

Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea

Correspondence to: Su Jin Hong, Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University College of Medicine, 170 Jomaru-ro, Wonmi-gu, Bucheon 420-767, Korea. Tel: +82-32-621-5087, Fax: +82-32-621-5080, E-mail: sjhong@ schmc.ac.kr

Received 13 December 201229 January 2013 Accepted 29 January 2013

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

Keywords: Undifferentiated carcinoma, Early gastric cancer, Endoscopic submucosal dissection, Complete resection

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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.

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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