Comparison on the Long Term Outcome between Endoscopic Submucosal Dissection and Surgical Treatment for Undifferentiated Early Gastric Cancer

Min Woo Chung; Oh Jeong; Young Kyu Park; Kyung Hwa Lee; Jae Hyuk Lee; Wan Sik Lee; Young Eun Joo; Sung Kyu Choi; Sung Bum Cho

doi:10.4166/kjg.2014.63.2.90

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Chung, Jeong, Park, Lee, Lee, Lee, Joo, Choi, and Cho: Comparison on the Long Term Outcome between Endoscopic Submucosal Dissection and Surgical Treatment for Undifferentiated Early Gastric Cancer

Original Article

Korean J Gastroenterol 2014;63(2):90-98.

Published online: 4 October 2014

DOI: https://doi.org/10.4166/kjg.2014.63.2.90

Comparison on the Long Term Outcome between Endoscopic Submucosal Dissection and Surgical Treatment for Undifferentiated Early Gastric Cancer

Min Woo Chung, Oh Jeong¹, Young Kyu Park¹, Kyung Hwa Lee², Jae Hyuk Lee², Wan Sik Lee, Young Eun Joo, Sung Kyu Choi, Sung Bum Cho

Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea

¹Department of General Surgery, Chonnam National University Medical School, Gwangju, Korea

²Department of Pathology, Chonnam National University Medical School, Gwangju, Korea

Correspondence to: Sung Bum Cho, Department of Internal Medicine, Chonnam National University Medical School, 160 Baekseo-ro, Dong-gu, Gwangju 501-757, Korea. Tel: +82-62-220-6296, Fax: +82-62-225-8578, E-mail: portalvein@naver.com

Received 16 December 20137 January 2014 Accepted 8 January 2014

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

There are controversies on the efficacy and safety of endoscopic submucosal dissection (ESD) for undifferentiated early gastric cancer (EGC) despite the expansion of ESD indications. The aim of this study was to evaluate the long term outcome of ESD compared to that of surgical treatment in patients with undifferentiated EGC.

Methods

A total of 76 patients who underwent ESD for undifferentiated EGC and 149 patients who met the ESD indication and received surgical treatment from January 2005 to December 2010 at Chonnam National University Hwasun Hospital were included.

Results

In the ESD group, en bloc resection and complete resection were achieved in 84.2% (64/76) and 76.3% (58/76) of patients, respectively. Among these patients, 58 (76.3%) met the ESD indication (indication group), and the remaining 18 (23.7%) did not meet the ESD indication (above indication group). Complete resection rates for indication group and above indication group were 86.2% (50/58) and 44.4% (8/18), respectively (p<0.05). The mean follow-up period was 42.2±19.2 months. Total recurrence rates in the ESD group and operation group were 14.1% (9/76) and 0.7% (1/149), respectively (p<0.05). The main complication of ESD was bleeding (5.2%, 4/76). In the operation group, 2 (1.3%) patients died from postoperative bleeding and leakage of anastomosis site.

Conclusions

ESD may be a feasible and safe treatment modality compared to that of surgical treatment for undifferentiated EGC when managed according to the expanded criteria. However, close endoscopic surveillance is required in this group because of higher incidence of intragastric recurrence.

Keywords: Endoscopic submucosal dissection, Undifferentiated carcinoma, Early gastric cancer, Gastrectomy

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Fig. 1.

Flow chart of patient inclusion. LN, lymph node; ESD, endoscopic submucosal dissection.

Fig. 2.

Clinical courses after the endoscopic submucosal dissection (ESD) for undifferentiated early gastric cancer.

APC, argon plasma coagulation; Tx, treatment; Op, operation.

Fig. 3.

Kaplan-Meier curve of recurrence rates in patients with undifferentiated early gastric cancer after endoscopic submucosal dissection (ESD) or gastrectomy.

Table 1.

Clinical Characteristics

Parameter	ESD group (n=76)		Operation group (n=149)	p-value
Parameter	Indication group∗ (n=58)	Above indication group (n=18)	Operation group (n=149)	p-value
Age (yr)	60.1±13.2	64.9±9.6	56.7±12.8	0.013
Sex (male/female)	34/24	10/8	72/77	0.174
Location				0.147
Upper third	1 (1.7)	1 (5.6)	12 (8.1)
Mid third	35 (60.3)	12 (66.7)	76 (51.0)
Lower third	22 (37.9)	5 (27.8)	61 (40.9)
Horizontal location				0.536
Anterior wall	12 (20.7)	6 (33.3)	38 (25.5)
Great curvature	15 (25.9)	4 (22.2)	25 (16.8)
Posterior wall	11 (19.0)	3 (16.7)	31 (20.8)
Lesser curvature	20 (34.5)	5 (27.8)	55 (36.9)
Gross type				0.005
Depressed	18 (31.0)	7 (38.9)	89 (59.7)
Flat	20 (34.5)	7 (38.9)	32 (21.5)
Elevated	20 (34.5)	4 (22.2)	28 (18.8)
Size (cm)				0.001
≤1	14 (24.1)	0 (0)	41 (27.5)
>1, ≤2	44 (75.9)	0 (0)	108 (72.5)
>2, ≤4	0 (0)	15 (83.3)	0 (0)
>4	0 (0)	3 (16.7)	0 (0)
Operation method
Laparoscopic	NA	NA	105 (70.5)
Open	NA	NA	44 (29.5)

Values are presented as mean±SD, n only, or n (%).

NA, not available.

^∗ Indication signifies expand indication of endoscopic submucosal dissection (ESD), i.e. tumor size of undifferentiated cancer ≤2 cm without ulcer.

Table 2.

Clinical Characteristics of Poorly Differentiated Adenocarcinoma and Signet Ring Cell Carcinoma in ESD Patients

Parameter	Total	Poorly differentiated	Signet-ring cell	p-value
Patient	76	51	25
Age (yr)	61.1±12.6	62.5±12.2	58.5±13.4	0.148
Sex (male/female)	44/32	31/20	13/12	0.466
Location				0.202
Upper third	2 (2.6)	2 (3.9)	0 (0)
Mid third	47 (61.8)	34 (66.7)	13 (52.0)
Lower third	27 (35.5)	15 (29.4)	12 (48.0)
Horizontal location				0.933
Anterior wall	18 (23.7)	11 (21.6)	7 (28.0)
Great curvature	19 (25.0)	13 (25.5)	6 (24.0)
Posterior wall	14 (18.4)	10 (19.6)	4 (16.0)
Lesser curvature	25 (32.9)	17 (33.3)	8 (32.0)
Gross type				0.821
Depressed	28 (36.8)	19 (37.3)	9 (36.0)
Flat	27 (35.5)	17 (33.3)	10 (40.0)
Elevated	21 (27.6)	15 (29.4)	6 (24.0)
Size (cm)				0.491
≤1	14 (18.4)	8 (15.7)	6 (24.0)
>1, ≤2	44 (57.9)	29 (56.9)	15 (60.0)
>2	18 (23.7)	14 (27.5)	4 (16.0)
Lauren classification				0.001
Diffuse type	23 (30.3)	9 (17.6)	14 (56.0)
Mixed type	23 (30.3)	12 (23.5)	11 (44.0)
Intestinal type	30 (39.5)	30 (58.8)	0 (0)

Values are presented as mean±SD, n only, or n (%).

ESD, endoscopic submucosal dissection.

Table 3.

Treatment Efficacy of Endoscopic Submucosal Dissection (ESD) for Undifferentiated Early Gastric Cancer

Parameter	Total (n=76)	Indication group (n=58)	Above indication group (n=18)	p-value
Resection method				0.110
En bloc resection	64 (84.2)	51 (87.9)	13 (72.2)
Piecemeal resection	12 (15.8)	7 (12.1)	5 (27.8)
Result of resection				0.001
Complete resection	58 (76.3)	50 (86.2)	8 (44.4)
Incomplete resection	18 (23.7)	8 (13.8)	10 (55.6)
Depth of invasion				0.015
Lamina propria	29 (38.2)	26 (44.8)	3 (16.7)
Muscularis mucosae	31 (40.8)	24 (41.4)	7 (38.9)
Submucosa upper 1/3 (SM1)	10 (13.2)	6 (10.3)	4 (22.2)
Submucosa mid 1/3 (SM2)	4 (5.3)	2 (3.4)	2 (11.1)
Submucosa lower 1/3 (SM3)	2 (2.6)	0 (0)	2 (11.1)
Positive lateral margin invasion	9 (11.8)	3 (5.2)	6 (33.3)	0.001
Positive vertical margin invasion	5 (6.6)	3 (5.2)	2 (11.1)	0.375
Positive lymphovascular invasion	10 (13.2)	6 (10.3)	4 (22.2)	0.193
Complication				0.949
Bleeding	4 (5.3)	3 (5.1)	1 (5.5)
Perforation	0 (0)	0 (0)	0 (0)
Sequential gastrectomy after ESD	12 (15.8)	6 (10.3)	6 (33.3)	0.019

Values are presented as n (%).

Table 4.

Clinical Outcomes after Long Term Follow Up in Endoscopic Submucosal Dissection (ESD) and Operation Group

Parameter	ESD group (n=64)	Operation group (n=149)	p-value
Mean duration of follow up (mo)	41.7±22.6	42.8±17.3	0.703
Total recurrence of cancer after initial treatment	9 (14.1)	1 (0.7)	0.001
Intragastric	8 (12.5)	1 (0.7)
Lymph node	1 (1.6)	0 (0)
Synchronous intragastric lesion (≤12 mo)			0.001
Carcinoma	6 (9.3)	0 (0)
Dysplasia	1 (1.6)	0 (0)
Metachronous intragastric lesion			0.036
Carcinoma	2 (3.1)	1 (0.7)
Dysplasia	1 (1.6)	0 (0)
Site of new lesion (carcinoma+dysplasia)			0.001
ESD scar	1 (1.6)	0 (0)
Other site	9 (14.1)	1 (0.7)
Time of new lesion (mo)			0.224
≤6	4 (6.3)	0 (0)
>6, ≤12	3 (4.7) ^a	0 (0)
>12, ≤24	2 (3.1) ^b	0 (0)
>24, ≤36	0 (0)	1 (0.7)
>36, ≤60	0 (0)	0 (0)
>60	2 (3.1) ^a	0 (0)
Treatment for new lesion			0.261
ESD	6 (9.4)	0 (0)
Operation	5 (7.8)	1 (0.7)
Mortality related initial treatment	0 (0)	2 (1.3)	0.604

Values are presented as mean±SD or n (%).

^a Including one patient with dysplasia;

^b Including one patient with lymph node recurrence.

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