Early gastric cancer: lymph node metastasis starts with deep mucosal infiltration. Ann Surg. 2009;250:791-797. [PMID: 19809298 DOI: 10.1097/sla.0b013e3181bdd3e4]

[Current S3 guidelines on surgical treatment of gastric carcinoma]

The current S3 guidelines on the diagnosis and treatment of gastric carcinoma including those of the esophagogastric junction describe optimal clinical practice based on a high level of evidence and expert consensus from different medical disciplines. Endoscopy and performance of multiple biopsies is the standard approach to detect malignant tumors in the upper gastrointestinal tract. Further diagnostic procedures are necessary to evaluate the tumor stage. With the exception of mucosal carcinomas, surgical therapy is the cornerstone of curative treatment in all potentially resectable stages. In locally advanced carcinomas perioperative chemotherapy should be carried out and in high-seated tumors preoperative radiochemotherapy might be an alternative option. Palliative surgical resection should be avoided in disseminated asymptomatic stages. In a palliative situation complications of the tumor should primarily be treated by interventional or conservative procedures.

Endoscopic submucosal dissection (ESD) compared with gastrectomy for treatment of early gastric neoplasia: a retrospective cohort study

INTRODUCTION

This study aims to compare perioperative outcomes and oncological clearance of endoscopic submucosal dissection (ESD) versus gastrectomy for treatment of early gastric cancer (EGC).

METHODS

This is a retrospective cohort study including all cases of EGC or severe dysplasia treated at a university-affiliated hospital from 1993 to 2010. Preoperative endoscopic ultrasound and image-enhanced endoscopy were employed to determine depth of invasion. Clinical outcomes including baseline demographics, pathology, postoperative complication, and hospital stay, as well as 3-year survival were compared.

RESULTS

From 1993 to 2010, 114 patients with severe dysplasia or EGC were treated: 40 of them received gastrectomy, while 74 received ESD. There was no difference in age, gender, comorbidity or American Society of Anesthesiologists grade between the two groups. Of patients in the gastrectomy group, 92.5% presented with symptoms as compared with 27.0% of those treated by ESD (p < 0.001). More patients in the ESD group had atrophic gastritis (31.1 vs 10%; p = 0.009) and intestinal metaplasia (68.9 vs 55.0%; p = 0.04). Patients treated by gastrectomy sustained longer operative time [265 (150-360) min] when compared with ESD [89.6 (45-360) min; p < 0.001]. They also had longer median hospital stay [9.9 (6-26) days vs 3.0 (2-10) days; p < 0.001]. There was no perioperative mortality, but the overall complication rate was significantly higher in the gastrectomy group. The 3-year survival rate was 94.6% for ESD and 89.7% for gastrectomy group (log-rank test, p = 0.44).

CONCLUSIONS

ESD achieved similar oncological outcomes when compared with radical gastrectomy for treatment of EGC. Patients receiving ESD had better perioperative outcomes in terms of operative time, complication rate, and hospital stay.

Lymphatic invasion in small differentiated-type mucosal gastric cancer

Endoscopic resection for early gastric cancer is indicated for patients who are at negligible risk of lymph node metastasis. A 71-year-old female underwent endoscopic resection for a 15-mm differentiated-type mucosal gastric tumor, as recommended in the Japanese treatment guidelines. A histological examination revealed lymphatic invasion. Therefore, we performed laparoscopy-assisted distal gastrectomy and D1+ lymph node dissection. A histological examination detected no.3 lymph node metastasis, but no residual cancer cells were observed at the site of the endoscopic resection. This case is rare as lymphatic invasion and lymph node metastasis are highly unusual in small differentiated-type mucosal gastric cancer. Having experienced this case, we consider that en-bloc endoscopic resection of such lesions is extremely important, as it allows precise histological examinations to be performed, which can determine the necessity of additional treatment.

Clinical trials in gastric cancer and the future

Following the first successful gastric resection for gastric cancer by Theodor Billroth in 1881 surgery has made tremendous progress leading to improved surgical mortality and morbidity. However, while treatment of early gastric cancer is frequently curative, 5-year survival rates for advanced gastric cancer remain dismal despite the application of perioperative multimodal treatment concepts. In this article we will outline key clinical trials that have lead to an improvement in treatment of gastric cancer patients with specific emphasis on the last 20 years. We will then outline recent concepts and key clinical trials that are currently being conducted in the field. Finally we will outline open questions that remain to be elucidated in the future.

Diagnosis and treatment of non-metastatic esophagogastric junction adenocarcinoma: what are the current options?

While the prevalence of distal gastric cancer is decreasing in the western world, there has been an alarming rise in the incidence of esophagogastric junction adenocarcinoma (EGJA) during recent decades. Current reports show that the prognosis of EGJA remains poor. Therapy strategies are complex due to the anatomical location of the junction between the esophagus and stomach. Surgery, based on Siewert's classification and associated with regional lymphadenectomy, is the mainstay of treatment. Transthoracic esophagectomy is recommended for type I EGJA, while total gastrectomy is recommended for type III EGJA; both approaches can be considered for type II EGJA. Surgery alone can be indicated only for stage I and IIa tumors. Perioperative chemotherapy should be considered for stage IIb, III and non-metastatic stage IV tumors. Adjuvant chemoradiation can be proposed for tumors with high-risk of recurrence in the absence of neoadjuvant therapy. Neoadjuvant chemoradiation can be proposed for predominantly esophageal EGJA, and might well become a standard treatment for all EGJA tumors in the near future. A multidisciplinary approach is essential for optimal diagnosis and management.

[Endoscopic submucosal dissection: only for expert endoscopists?]

Endoscopic submucosal dissection (ESD) can be applied to early gastrointestinal cancers. This technique was developed to achieve radical curative resection and to reduce unnecessary surgical interventions. ESD was designed in eastern countries and is not widely used in the West. Although ESD represents a major therapeutic advance in endoscopy and is performed with curative intent, the complication rate (hemorrhage, perforation) is higher than reported in other techniques, requiring from endoscopists the acquirement of technical skill and experience through a structured and progressive training program to reduce the morbidity associated with this technique and increase its potential benefits. Although there is substantial published evidence on the applications and results of ESD, there are few publications on training in this technique and a standardized training program is lacking. The current article aims to describe the various proposals for training, as well as the basic principles of the technique, its indications, and the results obtained, since theoretical knowledge that would guide endoscopists during the clinical application of ESD is advisable before training begins. Training in an endoscopic technique has a little value without knowledge of the technique's aims, the situations in which it should be applied, and the results that can be expected.

Prognostic impact of nodal micrometastasis in early esophageal cancer

INTRODUCTION

Nodal micrometastasis is a negative prognosticator for esophageal cancer. There is a trend toward endoscopic resection for early cancer of the esophagus without lymphadenectomy. Frequency and prognostic impact of nodal micrometastasis in early cancer of the esophagus have not been investigated so far.

PATIENTS AND METHODS

This study includes 69 patients with a pT1-stage cancer of the esophagus (SCC: n = 26, AC: n = 43), who underwent transthoracic en-bloc esophagectomy with D2-lympadenectomy between 1996 and 2004. On routine histopathological analysis 48 patients were diagnosed as pN0. Lymph nodes (n = 1344) of these patients were further examined for the presence of isolated tumor cells with the monoclonal anti-epithelial antibody AE1/AE3.

RESULTS

In lymph nodes of 7 (14.6%) out of 48 pN0-patients a positive staining for AE1/AE3 as a sign for nodal micrometastasis was found. In these patients the tumor has infiltrated the submucosal layer. In patients with tumors restricted to mucosal layer (n = 20) no nodal micrometastasis was present. 5-year survival of pN0-patients with nodal micrometastasis was inferior compared to pN0-patients (57% vs. 82%; p = 0.002).

CONCLUSION

Almost 15% of patients with pT1 N0 M0 carcinoma of the esophagus and only those with submucosal infiltration show nodal micrometastasis. It has a significant negative impact on survival already in early esophageal cancer.

Prognostic impact of upper, middle, and lower third mucosal or submucosal infiltration in early esophageal cancer

OBJECTIVE

To identify differences in survival of patients with pT1 esophageal cancer relating to depth of wall infiltration.

BACKGROUND DATA

Histologic analysis of mucosal and submucosal infiltration in thirds has shown an increasing rate of lymph node metastases (LNM) according to the depth of wall infiltration in pT1 esophageal cancer.

METHODS

One hundred seventy-one patients had transthoracic en bloc (n = 161) or transhiatal esophagectomy (n = 10) for pT1 esophageal cancer [121 adenocarcinomas (AC), 50 squamous cell carcinomas (SCC)]. The histologic analysis of the specimen comprised depth of wall penetration of the carcinoma in thirds of pT1a = mucosa (m1, m2, m3) or pT1b = submucosa (sm1, sm2, sm3) and number and infiltration of the resected lymph nodes.

RESULTS

The rate of LNM was 0% for 70 mucosal carcinomas and 34% for 101 submucosal carcinomas (P = 0.001). For sm1, this rate was 13%, for sm2 19% and for sm3 56%. The 5-year survival rate (5Y-SR) was 82% for pN0 and 45% for pN+ patients (P < 0.001). There was no significant prognostic difference between AC and SCC (5Y-SR: 74% vs 71%). The 5Y-SR of the pT1a group was 87% compared with 66% for pT1b (P = 0.046). The 5-year survival rate for sm1 and sm2 were similar; sm1 + sm2 were together significantly better (80%) than sm3 (46%) (P = 0.008). In multivariate analysis, only sm3 was an independent prognostic factor (P = 0.01).

CONCLUSIONS

After esophagectomy, the prognosis of patients with sm1/sm2 infiltration is as good as for patients with mucosal carcinoma. Sm3 infiltration is the worst prognostic factor in pT1 esophageal cancer.

Endoskopische Submukosadissektion: Aktuelle Indikationen und Grenzen

<b><i>Hintergrund: </i></b>Die Technik der endoskopischen Submukosadissektion (ESD) erlaubt eine En-bloc-Resektion auch großflächiger gastrointestinaler Läsionen. Vorteile sind eine verbesserte histopathologische Beurteilbarkeit der Resektate, eine gestiegene Anzahl von R0-Resektionen und eine verminderte Rezidivrate. Das Verfahren ist allerdings technisch anspruchsvoll und erfordert eine Lernkurve. Unabhängig vom Resektionsverfahren sind onkologische Kriterien bei der Resektion gastrointestinaler Frühkarzinome streng zu beachten. <b><i>Methode: </i></b>Literaturübersicht. <b><i>Ergebnisse: </i></b>Neben großen Publikationen aus Asien liegen mittlerweile auch aus Europa erste Daten mit vielversprechenden R0-Resektionsraten vor. Für das Magenfrühkarzinom kann die ESD auch außerhalb Asiens als endoskopisches Resektionsverfahren der Wahl betrachtet werden. Die deutsche Leitlinie erlaubt eine endoskopische Resektion von Magenfrühkarzinomen derzeit nur bei ausgewählten kleinen Läsionen (entsprechend den japanischen «guideline resection criteria»). Gegenüber der ESD im Magen ist die ESD im Kolon und im Ösophagus technisch schwieriger und komplikationsträchtiger; hier sollte die Methode aktuell nur in Zentren mit ESD-Erfahrung im Magen angewandt werden. <b><i>Schlussfolgerung: </i></b>Studien zur Klärung der Frage, ob eine Ausweitung der Resektionskriterien auch für europäische Magenfrühkarzinome (entsprechend den japanischen «expanded resection criteria») zumindest teilweise möglich ist, sind dringend erforderlich. Der definitive Stellenwert der kolorektalen ESD (insbesondere für Läsionen oberhalb des Rektums, das bezüglich technischer Schwierigkeiten und Komplikationen eine Sonderstellung einnimmt) ist derzeit unklar und muss in den nächsten Jahren evaluiert und definiert werden.

Additive lymph node dissection may be necessary in minute submucosal cancer of the stomach after endoscopic resection

PURPOSE

In early gastric cancer (EGC), minute submucosal (SM1) invasion of the stomach has been regarded as an expanded indication for endoscopic resection (ER). The exact prediction of SM1 invasion before ER may be difficult. Thus, SM1 invasion may be important to decide additive treatment after ER. This study was designed to investigate the incidence of lymph node metastasis (LNM) in SM1-EGC based on surgical specimens and to evaluate the factors that indicate additional treatment after ER.

METHODS

From May 2005 to December 2008, 1,676 patients with EGC underwent surgery at Severance and Gangnam Severance Hospital, Seoul, Korea. Among them, 126 patients were diagnosed with differentiated SM1-EGC. The clinicopathologic characteristics were analyzed with respect to LNM and lymphovascular invasion (LVI), which is a known independent risk factor for LNM. Intratumoral marker immunohistochemistry was examined as a predictor of LVI.

RESULTS

The mean SM1 invasion depth was 621.3 ± 745.6 μm. The LNM rates did not differ significantly between differentiated SM1-EGC (6.3%) and SM1-EGC (4.1%) meeting the expanded indication for ER. Female gender, moderate differentiation, LVI, and LVI grade were positively correlated with LNM. Female gender and elevated lesion morphology were associated with LVI. The expression levels of VEGF-C and OPHN1 were higher in LVI-positive tissues.

CONCLUSIONS

The LNM rate in differentiated SM1-EGC meeting the expanded ER criteria was 4.1% in the present study, indicating that additional lymph node dissection may be necessary after ER in some cases of SM1-EGC.

VEGF-D correlates with metastatic disease in gastric cancer patients undergoing surgery

BACKGROUND

The present study was designed to evaluate the impact of the tyrosine kinase ligands VEGF-A/C/D, PDGF-A/B on tumor dissemination and survival in gastric cancer. This is the first study analyzing all these parameters in a homogeneous patient population undergoing surgery.

METHODS

The expression pattern of VEGF-A/C/D and PDGF-A/B was analyzed by reverse transcriptase polymerase chain reaction (RT-PCR) in 69 samples of human gastric adenocarcinoma and correlated with tumor stage and survival.

RESULTS

Expression of the ligand VEGF-D significantly correlated with distant metastatic disease (P=0.00001) but not with patient survival. However, VEGF-A inversely correlated with M1 and grading, PDGF-A inversely correlated with pT and pN category. In contrast, VEGF-C and PDGF-B did not have an impact on clinicopathological parameters.

CONCLUSIONS

The ligand VEGF-D, rather than the other ligands or tyrosine kinase receptors analyzed, is associated with progressive disease in gastric cancer patients undergoing surgery. The VEGF-D ligand might be a helpful marker indicating disseminated disease, and targeting VEGF-D may be a potential therapeutic strategy, although limitations imposed by the selected sample population have to be considered critically.

Comparison between endoscopic and surgical resection of mucosal esophageal adenocarcinoma in Barrett's esophagus at two high-volume centers

BACKGROUND AND OBJECTIVE

Esophagectomy has previously been the gold standard for patients with mucosal adenocarcinoma in Barrett's esophagus (Barrett's carcinoma, BC). Because of the minimal invasiveness and excellent results obtained with endoscopic resection (ER), the latter has become an accepted alternative. However, few data have so far been published comparing the 2 treatment methods.

METHODS

A total of 114 patients with mucosal BC who were treated surgically or endoscopically in 2 high-volume centers were included in this study. Between 1996 and 2009, 38 patients with mucosal BC received transthoracic esophageal resection with 2-field lymphadenectomy (median 29 lymph nodes removed; all pN0) in the Department of Surgery at the University of Cologne. Seventy-six patients with BC treated with ER followed by argon-plasma-coagulation of the remaining non-dysplastic Barrett's esophagus in the Department of Gastroenterology in Wiesbaden were matched according to the following criteria: age, gender, infiltration depth (pT1m1-3), differentiation grade (G1/2 vs. 3) and follow-up period.

RESULTS

There were no significant differences between the 2 groups with regard to epidemiologic and tumor criteria. Complete remission (CR) was achieved in all patients in the surgery group and all but 1 patient in the ER group (98.7%; the patient died of other causes before CR was achieved). Major complications after surgery occurred in 32% of the patients, significantly more often than in the ER group (0% major complications, P < 0.001). The 90-day mortality rates were 0% in the ER group and 2.6% in the surgical group (1 of 38; P = 0.333). The median follow-up periods were 4.1 years in the ER group and 3.7 years in the surgical group. During this period, 1 patient in the ER group had a local recurrence and 4 had metachronous neoplasia (overall recurrence rate 6.6%). However, repeat endoscopic treatment was possible in all of the patients, and the long-term CR rates in the surgical and ER groups were 100% and 98.7%, respectively. No tumor-related mortality was observed in either group.

CONCLUSIONS

For patients with mucosal BC, both surgery and ER are effective treatment modalities. Surgery is associated with a higher morbidity rate and shows a risk for procedure-related mortality. However, the recurrence rate is higher in patients treated with ER, so that thorough follow-up procedures are mandatory.

The effect of the expression of vascular endothelial growth factor (VEGF)-C and VEGF receptor-3 on the clinical outcome in patients with gastric carcinoma

AIMS

We aimed to investigate the relationship among VEGF-C/VEGFR-3 expression, lymphatic metastasis and patient prognosis in gastric carcinoma.

MATERIAL AND METHODS

VEGF-C and VEGFR-3 expression in gastric carcinoma tissues obtained from 204 patients who underwent curative gastrectomy (105 cases presented with lymph node metastasis and 99 cases without metastasis) was examined immunohistochemically. There was no significant difference in the other clinicopathologic variables except for postoperative pathological tumor stage (pT) and TNM stage between the two groups. The results were statistically processed.

RESULTS

The results showed that VEGF-C was located mainly in the cytoplasm of tumor cells and VEGFR-3 was found predominantly in the endothelium of lymphatic vessels. VEGF-C and VEGFR-3 expression was more frequent in gastric carcinoma tissues than that in normal gastric tissues, 54.90% and 35.29% respectively, which revealed that the expression of VEGF-C and VEGFR-3 was significantly stronger in patients with lymph node metastasis than in those without metastasis. Patients who had positive staining for VEGF-C showed significantly less favorable survival rates compared with patients who had negative staining for VEGF-C. The survival rates of patients who had positive staining for VEGFR-3 also were significantly lower compared with patients who had negative staining for VEGFR-3. Patients who had positive staining for both VEGF-C and VEGFR-3 exhibited the most unfavorable prognosis. Multivariate analysis demonstrated that the expression of VEGF-C and VEGFR-3 was an independent prognostic determinant. In addition, faint to moderate VEGF-C expression was detected in normal gastric epithelial cells (18/204, 8.9%).

CONCLUSIONS

VEGF-C and VEGFR-3 expression could serve as a prognostic biomarker in patients with gastric carcinoma.

Oesophagogastric junction adenocarcinoma: which therapeutic approach?

Gastric and oesophageal cancers are among the leading causes of cancer-related death worldwide. By contrast with the decreasing prevalence of gastric cancer, incidence and prevalence of oesophagogastric junction adenocarcinoma (OGJA) are rising rapidly in developed countries. We provide an update about treatment strategies for resectable OGJA. Here we review findings from the latest randomised trials and meta-analyses, and propose guidelines regarding endoscopic, surgical, and perioperative treatments. Through a team approach, members from all diagnostic and therapeutic disciplines, such as gastroenterologists, surgeons, oncologists, radiologists, and radiotherapists, can effectively administer a range of treatment modalities.

Predictive factors for lymph node metastasis in early gastric cancer

AIM

To analyze the predictive factors for lymph node metastasis (LNM) in early gastric cancer (EGC).

METHODS

Data from patients surgically treated for gastric cancers between January 1994 and December 2007 were retrospectively collected. Clinicopathological factors were analyzed to identify predictive factors for LNM.

RESULTS

Of the 2936 patients who underwent gastrectomy and lymph node dissection, 556 were diagnosed with EGC and included in this study. Among these, 4.1% of patients had mucosal tumors (T1a) with LNM while 24.3% of patients had submucosal tumors with LNM. Univariate analysis found that female gender, tumors ≥ 2 cm, tumor invasion to the submucosa, vascular and lymphatic involvement were significantly associated with a higher rate of LNM. On multivariate analysis, tumor size, lymphatic involvement, and tumor with submucosal invasion were associated with LNM.

CONCLUSION

Tumor with submucosal invasion, size ≥ 2 cm, and presence of lymphatic involvement are predictive factors for LNM in EGC.

Nano-imaging of the lymph network structure with quantum dots

Sentinel lymph node diagnosis contributes to operative strategy in cancer surgery. During lymph node metastasis, cancer cells first reach the sentinel lymph node (SLN) via lymph flow. To perform SLN biopsy effectively, it is important that cancer cells are detected with high sensitivity in SLN connected to the tumor site. Here we present a method to visualize a high-risk area in the SLN for lymph node metastasis with a high degree of accuracy. Quantum dots (QDs), bright fluorescent nanoparticles, were endoscopically injected into the gastrointestinal wall of pigs, and their signal was specifically detected in the SLN with a laparoscopic device. Single-particle imaging under a confocal microscope showed that the QDs were distributed heterogeneously in the SLN and that their distribution marked the inflow locus of afferent lymphatic vessels where lymph node metastasis begins. Moreover, we developed a method using cellular marker conjugated QDs that visualizes specific cells in SLNs, suggesting that this method can be applied for the detection of cancer cells in sentinel lymph nodes using tumor-specific-molecular conjugated QDs. These results show that our method might significantly increase the detection rate of cancer metastasis in SLNs.