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Numata N, Oka S, Tanaka S, Kagemoto K, Sanomura Y, Yoshida S, Arihiro K, Shimamoto F, Chayama K. Risk factors and management of positive horizontal margin in early gastric cancer resected by en bloc endoscopic submucosal dissection. Gastric Cancer 2015; 18:332-8. [PMID: 24737447 DOI: 10.1007/s10120-014-0368-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 03/09/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although endoscopic submucosal dissection (ESD) is a widely accepted treatment for early gastric cancer (EGC), there is no consensus regarding the management of positive horizontal margin (HM) despite en bloc ESD. The aim of the current study was to identify the risk factors and optimal management of positive HM in EGCs resected by en bloc ESD. METHODS A total of 890 consecutive patients with 1,053 intramucosal EGCs resected by en bloc ESD between April 2005 and June 2011. Clinicopathological data were retrieved retrospectively to assess the positive HM rate, local recurrence rate, risk factors for positive HM, and outcomes of treatment for local recurrent tumor. Positive HM was defined as a margin with direct tumor invasion (type A), the presence of cancerous cells on either end of 2-mm-thick cut sections (type B), or an unclear tumor margin resulting from crush or burn damage (type C). RESULTS The positive HM rate was 2.0% (21/1,053). The local recurrence rate was 0.3% (3/1,053). All local recurrent tumors were intramucosal carcinomas, and were resected curatively by re-ESD. Multivariate analysis with logistic regression showed tumor location in the upper third of the stomach and lesions not matching the absolute indication to be independent risk factors for positive HM. CONCLUSION The risk factors for HM positivity in cases of EGC resected by en bloc ESD are tumor location in the upper third of the stomach and dissatisfaction of the absolute indication for curative ESD.
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Affiliation(s)
- Norifumi Numata
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan,
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Gotoda T, Ho KY, Soetikno R, Kaltenbach T, Draganov P. Gastric ESD: current status and future directions of devices and training. Gastrointest Endosc Clin N Am 2014; 24:213-33. [PMID: 24679233 DOI: 10.1016/j.giec.2013.11.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopic mucosal resection (EMR) of early gastric cancer, which has been proved to be safe and effective and is the established standard of care in Japan, has become increasingly established worldwide in the past decade. Endoscopic submucosal dissection (ESD) is superior to EMR, as it is designed to provide precise pathologic staging and long-term curative therapy based on an en bloc R0 specimen irrespective of the size and/or location of the tumor. However, ESD requires highly skilled and experienced endoscopists. The introduction of ESD to the Western world necessitates collaborations between Eastern and Western endoscopists, pathologists, and surgeons.
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Affiliation(s)
- Takuji Gotoda
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan.
| | - Khek-Yu Ho
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228
| | - Roy Soetikno
- Department of Gastroenterology and Hepatology, Veterans Affairs Palo Alto, Stanford University, 3801 Miranda Avenue, GI-111, Palo Alto, CA 94304, USA
| | - Tonya Kaltenbach
- Department of Gastroenterology and Hepatology, Veterans Affairs Palo Alto, Stanford University, 3801 Miranda Avenue, GI-111, Palo Alto, CA 94304, USA
| | - Peter Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, 1600 SW Archer Road, Room HD 602, PO Box 100214, Gainesville, FL 32610, USA
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Gotoda T, Jung HY. Endoscopic resection (endoscopic mucosal resection/ endoscopic submucosal dissection) for early gastric cancer. Dig Endosc 2013; 25 Suppl 1:55-63. [PMID: 23362925 DOI: 10.1111/den.12003] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Accepted: 10/04/2012] [Indexed: 12/12/2022]
Abstract
Endoscopic resection of early gastric cancer is a well-established standard therapy in Japan and Korea, and is increasingly used in other countries. Endoscopic resection should be curative for patients, and safe, easy and effective not only for patients, but also for endoscopists. Endoscopic submucosal dissection (ESD) is superior to standard endoscopic mucosal resection (EMR) as it is designed to provide en bloc R0 resection regardless of size and/or location. Correct pathological assessment of en bloc resected specimens is crucial for accurate diagnosis and patient stratification for the risk of metastasis. Outcome studies in Japan and Korea, countries with the highest incidence of gastric cancer, have shown that ESD is efficacious in leading to a good long-term outcome; however, ESD requires an experienced endoscopist with a high skill level. Expanded indications for endoscopic resection have been proposed, especially after large en bloc resection have been accomplished using ESD. The use of ESD could be of huge benefit for the management of gastrointestinal superficial neoplasms. However, for ESD to become a viable therapeutic option, it requires close and supportive working relationships between endoscopists, pathologists and surgeons.
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Affiliation(s)
- Takuji Gotoda
- Department of Gastroenterology and Hepatology, Tokyo Medical University Hospital, Tokyo, Japan.
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Higashimaya M, Oka S, Tanaka S, Numata N, Sanomura Y, Yoshida S, Arihiro K, Chayama K. Endoscopic submucosal dissection for residual early gastric cancer after endoscopic submucosal dissection. Gastrointest Endosc 2013. [PMID: 23206812 DOI: 10.1016/j.gie.2012.09.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Makoto Higashimaya
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
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Gotoda T. Endoscopic resection for premalignant and malignant lesions of the gastrointestinal tract from the esophagus to the colon. Gastrointest Endosc Clin N Am 2008; 18:435-50, viii. [PMID: 18674695 DOI: 10.1016/j.giec.2008.05.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The endoscopic mucosal resection and endoscopic submucosal dissection techniques, if performed with the right indications and with expertise, should be considered even in the West as elective treatment modalities for early gastrointestinal neoplasia. Because the experience is still limited, more should be done to strengthen the performance capacity and foster cooperation among skilled endoscopists.
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Affiliation(s)
- Takuji Gotoda
- Endoscopy Division, Department of Endoscopy, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan.
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Ryu KW, Choi IJ, Doh YW, Kook MC, Kim CG, Park HJ, Lee JH, Lee JS, Lee JY, Kim YW, Bae JM. Surgical indication for non-curative endoscopic resection in early gastric cancer. Ann Surg Oncol 2007; 14:3428-34. [PMID: 17899290 DOI: 10.1245/s10434-007-9536-z] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2007] [Revised: 06/22/2007] [Accepted: 06/28/2007] [Indexed: 12/25/2022]
Abstract
BACKGROUND Endoscopic resection (ER) is an effective treatment for early gastric cancer (EGC) without lymph node metastasis. However, after ER additional surgery may be needed to manage the risks presented by residual cancer or lymph node metastasis. METHODS ER was performed on 344 gastric adenocarcinomas between November 2001 and April 2006 at the Korean National Cancer Center under the strict pre-procedural indication. The authors performed operations in 43 patients due to: residual mucosal cancer, a mucosal cancer larger than 3 cm, or a submucosal cancer regardless of size or margin involvement. ER and surgical specimens were reviewed and analyzed for residual cancer and lymph node metastasis. RESULTS Based on examinations of ER specimens, cancer was confined to the mucosal layer in 15 patients (34.9%) and invaded the submucosal layer in 28 patients (65.1%). Surgical specimens showed residual cancer in 17 patients (39.5%) and lymph node metastasis in four (9.3%). Neither residual cancer nor lymph node metastasis was found in patients with less than 500 microm submucosal invasion without margin involvement in ER specimens. In three of four patients with lymph node metastasis, the depth of submucosal invasion was 500 microm or more; the remaining patient had a 4-cm-sized differentiated mucosal cancer. CONCLUSIONS When a pathologic evaluation of an ER specimen reveals more than 500 microm of submucosal invasion or a mucosal cancer of larger than 3 cm, surgery should be considered due to the risk of lymph node metastasis.
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Affiliation(s)
- Keun Won Ryu
- Gastric Cancer Branch, Research Institute and Hospital, National Cancer Center, 809 Madu1-dong, Ilsandong-gu, Goyang-si, Gyeonggi-do, 410-769, Korea
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Abstract
The purpose of this review is to examine recent advances in the techniques and technologies of endoscopic resection of early gastric cancer (EGC). Endoscopic mucosal resection (EMR) of EGC, with negligible risk of lymph node metastasis, is a standard technique in Japan and is increasingly becoming accepted and regularly used in Western countries. EMR is a minimally invasive technique which is safe, convenient, and efficacious; however, it is insufficient when treating larger lesions. The evidence suggests that difficulties with the correct assessment of depth of tumor invasion lead to an increase in local recurrence with standard EMR when lesions are larger than 15 mm. A major factor contributing to this increase in local recurrence relates to lesions being excised piecemeal due to the technical limitations of standard EMR. A new development in endoscopic techniques is to dissect directly along the submucosal layer -- a procedure called endoscopic submucosal dissection (ESD). This allows the en-bloc resection of larger lesions. ESD is not necessarily limited by lesion size and it is predicted to replace conventional surgery in dealing with certain stages of ECG. However, it still has a higher complication rate when compared to standard EMR, and it requires high levels of endoscopic skill and experience. Endoscopic techniques, indications, pathological assessment, and methods of endoscopic resection of EGC need to be established for carrying out appropriate treatment and for the collation of long-term outcome data.
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Affiliation(s)
- Takuji Gotoda
- National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
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Tonouchi H, Mohri Y, Kobayashi M, Tanaka K, Ohi M, Kusunoki M. Laparoscopy-assisted distal gastrectomy with laparoscopic sentinel lymph node biopsy after endoscopic mucosal resection for early gastric cancer. Surg Endosc 2007; 21:1289-93. [PMID: 17278041 DOI: 10.1007/s00464-007-9221-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2006] [Revised: 08/28/2006] [Accepted: 10/09/2006] [Indexed: 01/15/2023]
Abstract
BACKGROUND There has been a trend toward minimally invasive treatment of early gastric cancer. We report the preliminary results of laparoscopy-assisted distal gastrectomy with laparoscopic sentinel lymph node biopsy after endoscopic mucosal resection. METHODS Six patients underwent laparoscopy-assisted distal gastrectomy after endoscopic mucosal resection between February 2002 and October 2005 at Mie University Hospital. These patients first underwent laparoscopic sentinel lymph node biopsy and then laparoscopy-assisted distal gastrectomy with lymphadenectomy. RESULTS No patient underwent conversion to open surgery during the operation. None of the patients had any postoperative complications. The mean length of postoperative hospital stay was 11.3 days. Sentinel lymph nodes were identified laparoscopically in five patients. There were 20 sentinel and 85 nonsentinel lymph nodes in the six patients. Postoperatively, tissue sections showed that none of the lymph nodes were metastasized. Immunohistochemistry with D2-40 antibody showed that there were normal lymphatics in the submucosal layer with mucosal defects at the endoscopic mucosal resection site. No patients had any tumor recurrence during followup. CONCLUSIONS Laparoscopy-assisted distal gastrectomy after endoscopic mucosal resection was a safe and curative procedure. Endoscopic mucosal resection before sentinel lymph node biopsy was acceptable for early gastric cancer.
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Affiliation(s)
- Hitoshi Tonouchi
- Department of Innovative Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu-City, Mie, 514-8507, Japan.
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Chung YS, Park DJ, Lee HJ, Kim SG, Jung HC, Song IS, Kim WH, Lee KU, Choe KJ, Yang HK. The role of surgery after incomplete endoscopic mucosal resection for early gastric cancer. Surg Today 2007; 37:114-7. [PMID: 17243028 DOI: 10.1007/s00595-006-3328-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2006] [Accepted: 06/02/2006] [Indexed: 02/07/2023]
Abstract
PURPOSE Endoscopic mucosal resection (EMR) is a relatively new treatment option for early gastric cancer (EGC). However, cases of incomplete EMR resulting in a positive lateral margin or submucosal invasion (positive vertical margin) have been reported. We conducted this study to evaluate the role of surgery after incomplete EMR for EGC. METHODS We analyzed 19 patients who underwent gastrectomy as a result of an incomplete EMR. The patients were divided into three groups according to the type of incomplete EMR: a positive lateral margin (LM) group (n = 9), a positive vertical margin (VM) group (n = 4), and a positive lateral and vertical margin (LM + VM) group (n = 6). RESULTS The positive residual tumor rate and the positive lymph node rate were 44.4% (4/9) and 0% (0/9) in the LM group, 50.0% (2/4) and 25.0% (1/4) in the VM group, and 83.3% (5/6) and 16.7% (1/6), LM + VM group, respectively. Curative resection was performed in all patients and there was no recurrence in 30.8 months of follow-up. CONCLUSION Radical surgery is recommended for patients with a positive lateral resection margin or submucosal invasion, or both, after EMR for EGC, because of the possibility of residual tumor or lymph node metastasis.
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Affiliation(s)
- Yoo Seung Chung
- Department of Surgery, Seoul National University College of Medicine, 28 Yongon-dong, Chongno-gu, Seoul, 100-744, South Korea
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Shiraishi N, Yasuda K, Kitano S. Laparoscopic gastrectomy with lymph node dissection for gastric cancer. Gastric Cancer 2007; 9:167-76. [PMID: 16952034 DOI: 10.1007/s10120-006-0380-9] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2006] [Accepted: 04/19/2006] [Indexed: 02/07/2023]
Abstract
Since 1991, laparoscopic surgery has been adopted for the treatment of gastric cancer, and it has been performed worldwide, especially in Japan and Korea. We reviewed the English-language literature to clarify the current status of and problems associated with laparoscopic gastrectomy with lymph node dissection as treatment for gastric cancer. In Japan, early-stage gastric cancer (T1/T2, N0) is considered the only indication for laparoscopic gastrectomy. As yet, there is little high-level evidence based on long-term outcome supporting laparoscopic gastrectomy for cancer, but reports have provided level 3 evidence that the procedure is technically safe, and that it yields better short-term outcomes than open surgery; that is, recovery is faster, hospital stay is shorter, there is less pain, and cosmesis is better. However, investigation into the oncological outcome of laparoscopic gastrectomy as treatment for cancer is lacking. To establish laparoscopic surgery as a standard treatment for gastric cancer, multicenter randomized controlled trials to compare the short- and long-term outcomes of laparoscopic surgery versus open surgery are necessary.
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Affiliation(s)
- Norio Shiraishi
- Department of Surgery I, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Oita, 879-5593, Japan
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Abstract
The purpose of this review is to examine recent advances in the techniques and technologies of endoscopic resection of early gastric cancer (EGC). Endoscopic mucosal resection (EMR) of EGC, with negligible risk of lymph node metastasis, is a standard technique in Japan and is increasingly becoming accepted and regularly used in Western countries. EMR is a minimally invasive technique which is safe, convenient, and efficacious; however, it is insufficient when treating larger lesions. The evidence suggests that difficulties with the correct assessment of depth of tumor invasion lead to an increase in local recurrence with standard EMR when lesions are larger than 15 mm. A major factor contributing to this increase in local recurrence relates to lesions being excised piecemeal due to the technical limitations of standard EMR. A new development in endoscopic techniques is to dissect directly along the submucosal layer -- a procedure called endoscopic submucosal dissection (ESD). This allows the en-bloc resection of larger lesions. ESD is not necessarily limited by lesion size and it is predicted to replace conventional surgery in dealing with certain stages of ECG. However, it still has a higher complication rate when compared to standard EMR, and it requires high levels of endoscopic skill and experience. Endoscopic techniques, indications, pathological assessment, and methods of endoscopic resection of EGC need to be established for carrying out appropriate treatment and for the collation of long-term outcome data.
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Affiliation(s)
- Takuji Gotoda
- National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
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Gotoda T, Yamamoto H, Soetikno RM. Endoscopic submucosal dissection of early gastric cancer. J Gastroenterol 2006; 41:929-42. [PMID: 17096062 DOI: 10.1007/s00535-006-1954-3] [Citation(s) in RCA: 489] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2006] [Accepted: 09/12/2006] [Indexed: 02/07/2023]
Abstract
The purpose of this review was to examine a remarkable technical advance regarding the indications for and the technique of endoscopic resection of early gastric cancer. Endoscopic mucosal resection (EMR) of early gastric cancer with no risk of lymph node metastasis has been a standard technique in Japan, probably owing to the high incidence of gastric cancer in Japan and the fact that more than half of Japanese gastric cancer cases are diagnosed at an early stage. Very recently, several EMR techniques have become increasingly accepted and regularly used in Western countries. Although these minimally invasive techniques are safe, convenient, and efficacious, they are unsuitable for large lesions in particular. Difficulty in correctly assessing the depth of tumor invasion and an increase in local recurrence when standard EMR procedures are used have been reported in cases of large lesions, because such lesions are often resected piecemeal owing to the technical limitations of standard EMR. A new development in therapeutic endoscopy, called endoscopic submucosal dissection (ESD), allows the direct dissection of the submucosa, and large lesions can be resected en bloc. ESD is not limited by resection size and is expected to replace surgical resection. However, it is still associated with a higher incidence of complications than standard EMR procedures and requires a high level of endoscopic skill. The endoscopic indications, techniques, and management of complications of ESD for early gastric cancer for properly carrying out established therapeutic endoscopy are described.
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Affiliation(s)
- Takuji Gotoda
- Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Tokyo, Japan
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Abstract
PURPOSE OF REVIEW To examine recent advances in the techniques and technologies of endoscopic resection of early gastric cancer. RECENT FINDINGS Endoscopic mucosal resection of early gastric cancer with no risk of lymph node metastasis has been a standard technique in Japan and is increasingly becoming accepted and regularly used in Western countries. Though this minimally invasive technique is a safe, convenient and efficacious method, it is insufficient for larger lesions. Difficulties in correctly assessing the depth of tumour invasion and increases in local recurrence by standard endoscopic mucosal resection have been reported in lesions larger than 15 mm. This is because such lesions are often resected piecemeal due to the technical limitation of standard endoscopic mucosal resection. New developments in endoscopic resection techniques to dissect the submucosa directly, called endoscopic submucosal dissection, allows resections of larger lesions en bloc. There are no limitations in resection size in endoscopic submucosal dissection, which is expected to replace surgery. This technique, however, still has higher complications rates than standard endoscopic mucosal resection and requires highly skilled endoscopists. SUMMARY The techniques, indications, and pathological assessment methods of endoscopic resection of early gastric cancer are described so that proper treatment guidelines can be established and long-term outcome data can be assessed.
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Affiliation(s)
- Takuji Gotoda
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan.
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