Endoscopic Resection of Gastric Cancer

Endoscopic Submucosal Dissection for Early Gastric Cancer Exceeding Expanded Criteria-Long-Term Outcomes from the German ESD Registry

Background and aims: Endoscopic submucosal dissection (ESD) has become a standard treatment for early gastric cancer (EGC), often fulfilling guideline criteria (GC) or expanded criteria (EC). When lesions exceed the EC, surgical resection is recommended. However, a subgroup of these patients are not treated surgically. The aim of this study was to investigate the long-term follow-up of patients after ESD for EGC outside the EC (out of indication; OI). Methods: Patients who were included in the prospective German ESD registry were analyzed when ESD was performed for EGC. Patients were stratified in three groups according to histopathological features (GC, EC and OI). The results were evaluated in terms of patient characteristics, procedure characteristics and follow-up data. Results: Over a 48-month period, 195 patients from 14 German centers were included. In total, 71 lesions (36.4%) met the guideline criteria, 70 lesions (35.9%) corresponded to the expanded criteria and 54 lesions (27.7%) turned out to be OI. The R0 resection rate was significantly higher for the GC and EC groups than for the OI group (94.4% vs. 84.3% vs. 55.6%, p < 0.001). Additional surgery was not performed in 72% (39/54) of patients in the OI group. During a mean follow-up of 37 months, overall survival showed no significant difference between the EC and OI groups when endoscopic follow-up was performed without additional surgery (p = 0.064). Conclusions: The results show that a good long-term survival can be achieved after ESD for patients with OI lesions without additional surgery. The treatment decision has to be made on an individual basis, taking the patient's comorbidities and the risk of surgical resection into account.

Feasibility and Efficacy of Gastric Underwater Endoscopic Mucosal Resection

Gastric cancer, a leading cause of cancer-related deaths globally, necessitates effective and early detection and treatment strategies. Endoscopic resection techniques, particularly endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), have evolved significantly, enhancing the treatment of gastric neoplasms. Underwater endoscopic mucosal resection (UEMR) is a widely used technique for the resection of duodenal and colorectal neoplasms. However, the feasibility and efficacy of UEMR in the stomach are not well established. This retrospective observational study, conducted at a tertiary medical center, evaluated the efficacy and safety of UEMR in 81 patients with gastric neoplasms. Thus, it indicates that UEMR is a highly effective and safe technique for managing small to medium-sized gastric neoplasms, achieving 100% en bloc and 93.8% R0 resection rates with a low incidence of complications. Moreover, the procedure time was found to be significantly shorter for UEMR compared to ESD, thus highlighting its efficiency. While UEMR demonstrates high safety and efficacy, it is not suitable for all patients, with some requiring conversion to ESD as a treatment option. Despite the promising results, broader validation through extensive and randomized trials is recommended to establish UEMR as a standard approach in gastric cancer management.

Risk of tuberculosis after endoscopic resection and gastrectomy in gastric cancer: nationwide population-based matched cohort study

BACKGROUND

This study aimed to investigate the association between gastrectomy and endoscopic resection for gastric cancer and the subsequent tuberculosis incidence.

METHODS

We conducted a nationwide matched cohort study using data from the Korea National Health Insurance Service from 2013 to 2019. We created two cohorts: patients who underwent gastrectomy and those who had endoscopic resection. Each patient was matched 1:1 with an unexposed individual based on index year, age, sex, income, and various comorbidities. The primary outcome was the incidence of tuberculosis during the follow-up period.

RESULTS

Our study comprised 90,886 gastrectomy patients and 46,759 endoscopic resection patients. The tuberculosis incidence was significantly higher in the gastrectomy group compared to its matched non-gastrectomy group (IRR 1.69, 95% CI 1.43-1.99, p < .001). In contrast, there was no significant difference in tuberculosis incidence between the endoscopic resection group and its matched non-resection group (IRR 0.95, 95% CI 0.75-1.19, p = 0.627). The Kaplan-Meier cumulative incidence also did not differ between the two groups. However, tuberculosis incidence significantly increased in the first year after endoscopic resection.

CONCLUSION

Gastrectomy for gastric cancer is associated with a higher incidence of subsequent tuberculosis, while no significant association was observed for endoscopic resection. However, tuberculosis incidence increases significantly during the first year after endoscopic resection.

Molecular Classifications in Gastric Cancer: A Call for Interdisciplinary Collaboration

Gastric cancer (GC) is a heterogeneous disease, often diagnosed at advanced stages, with a 5-year survival rate of approximately 20%. Despite notable technological advancements in cancer research over the past decades, their impact on GC management and outcomes has been limited. Numerous molecular alterations have been identified in GC, leading to various molecular classifications, such as those developed by The Cancer Genome Atlas (TCGA) and the Asian Cancer Research Group (ACRG). Other authors have proposed alternative perspectives, including immune, proteomic, or epigenetic-based classifications. However, molecular stratification has not yet transitioned into clinical practice for GC, and little attention has been paid to alternative molecular classifications. In this review, we explore diverse molecular classifications in GC from a practical point of view, emphasizing their relationships with clinicopathological factors, prognosis, and therapeutic approaches. We have focused on classifications beyond those of TCGA and the ACRG, which have been less extensively reviewed previously. Additionally, we discuss the challenges that must be overcome to ensure their impact on patient treatment and prognosis. This review aims to serve as a practical framework to understand the molecular landscape of GC, facilitate the development of consensus molecular categories, and guide the design of innovative molecular studies in the field.

Comparison of endoscopic submucosal dissection outcomes between early gastric cardiac and non-cardiac cancers: a retrospective single-center study

OBJECTIVES

This study aims to compare the efficacy of endoscopic submucosal dissection (ESD) between early gastric cardiac cancer (EGCC) and early gastric non-cardiac cancer (EGNCC), and investigate associated risk factors for non-curative resection.

METHODS

Early gastric cancer (EGC) patients who underwent ESD from January 2015 to September 2020 in Beijing Friendship Hospital were consecutively enrolled. The clinical, histopathological and endoscopic data were retrospectively analyzed. The study was registered in Chinese Clinical Trial Registry (ChiCTR1800017117).

RESULTS

Among 500 patients with 534 EGC lesions, 117 patients with 118 lesions were allocated to the EGCC group, and 383 patients with 416 lesions to the EGNCC group. The rates of en bloc resection, complete resection and curative resection in the EGCC group were 97.5%, 78.8% and 71.2%, respectively, significantly lower than those in the EGNCC group (99.8%, 94.5% and 90.4%, p = .010, <.001 and <.001). Among non-curative resected lesions, EGCC had more cases in both endoscopic curability (eCura) C-1 and C-2 groups than EGNCC (10.2% and 18.6% vs. 2.4% and 7.2%, p < .001). Multivariate analysis showed that tumor size (OR 2.393, 95% CI 1.388-4.126) and submucosal invasion (OR 11.498, 95% CI 3.759-35.175) were risk factors for non-curative resection in the EGCC group. For EGCC larger than 3 cm, none achieved curative resection, 86.7% were classified as eCura C-2 and 46.7% exhibited deep submucosal infiltration.

CONCLUSIONS

The curative resection rate of ESD for EGCC was lower than that for EGNCC. ESD for EGCC larger than 3 cm should be cautiously considered.

Endoscopic advances in the management of gastric cancer and premalignant gastric conditions

Gastric cancer is the fifth most common cancer and in 2018, it was the third most common cause of cancer-related deaths worldwide. Endoscopic advances continue to be made for the diagnosis and management of both early gastric cancer and premalignant gastric conditions. In this review, we discuss the epidemiology and risk factors of gastric cancer and emphasize the differences in early vs late-stage gastric cancer outcomes. We then discuss endoscopic advances in the diagnosis of early gastric cancer and premalignant gastric lesions. This includes the implementation of different imaging modalities such as narrow-band imaging, chromoendoscopy, confocal laser endomicroscopy, and other experimental techniques. We also discuss the use of endoscopic ultrasound in the diagnosis and staging of early gastric cancer. We then discuss the endoscopic advances made in the treatment of these conditions, including endoscopic mucosal resection, endoscopic submucosal dissection, and hybrid techniques such as laparoscopic endoscopic cooperative surgery. Finally, we comment on the current suggested recommendations for surveillance of both gastric cancer and its premalignant conditions.

The Perioperative and Operative Management of Esophageal and Gastric Cancer

Optimal management of esophageal and gastric cancer during the perioperative period requires a coordinated multidisciplinary treatment effort. Accurate staging guides treatment strategy. Advances in minimally invasive surgery and endoscopy have reduced risks associated with resection while maintaining oncological standards. Although the standard perioperative chemo-and radiotherapy regimens have not yet been established, randomized control trials exploring this subject show promising results.

A retrospective analysis based on multiple machine learning models to predict lymph node metastasis in early gastric cancer

Background

Endoscopic submucosal dissection has become the primary option of treatment for early gastric cancer. However, lymph node metastasis may lead to poor prognosis. We analyzed factors related to lymph node metastasis in EGC patients, and we developed a construction prediction model with machine learning using data from a retrospective series.

Methods

Two independent cohorts’ series were evaluated including 305 patients with EGC from China as cohort I and 35 patients from Spain as cohort II. Five classifiers obtained from machine learning were selected to establish a robust prediction model for lymph node metastasis in EGC.

Results

The clinical variables such as invasion depth, histologic type, ulceration, tumor location, tumor size, Lauren classification, and age were selected to establish the five prediction models: linear support vector classifier (Linear SVC), logistic regression model, extreme gradient boosting model (XGBoost), light gradient boosting machine model (LightGBM), and Gaussian process classification model. Interestingly, all prediction models of cohort I showed accuracy between 70 and 81%. Furthermore, the prediction models of the cohort II exhibited accuracy between 48 and 82%. The areas under curve (AUC) of the five models between cohort I and cohort II were between 0.736 and 0.830.

Conclusions

Our results support that the machine learning method could be used to predict lymph node metastasis in early gastric cancer and perhaps provide another evaluation method to choose the suited treatment for patients.

Feasibility of same-day discharge following endoscopic submucosal dissection for esophageal or gastric early cancer

BACKGROUND

Endoscopic submucosal dissection (ESD) is an established technique for the treatment of early gastrointestinal neoplasia. Generally, multi-day (M-D) admission is required for patients undergoing ESD due to potential complications.

AIM

To evaluate the feasibility of a same-day (S-D) discharge strategy for ESD of the esophagus or stomach.

METHODS

The data of patients who underwent esophageal or gastric ESD were retrospectively collected from January 2018 to December 2021 at Peking University Cancer Hospital. The propensity score matching (PSM) method was applied to balance the unevenly distributed patient baseline characteristics between the S-D and M-D groups. Intraoperative and postoperative parameters were compared between the matched groups.

RESULTS

Among the 479 patients reviewed, 470 patients, including 91 in the S-D group and 379 in the M-D group, fulfilled the inclusion and exclusion criteria. Following PSM, 78 patients in each group were paired using the 1:1 nearest available score match algorithm. No significant difference was found between groups with respect to intraoperative and postprocedural major adverse events (AEs). Tumor size, complete resection rate, and procedural duration were comparable between the groups. The S-D group demonstrated a significantly shorter length of hospital stay (P < 0.001) and lower overall medical expenses (P < 0.001) compared with the M-D group.

CONCLUSION

The S-D discharge strategy may be feasible and effective for esophagogastric ESD, and the procedural-related AEs can be managed successfully.

Construction and analysis of an ulcer risk prediction model after endoscopic submucosal dissection for early gastric cancer

BACKGROUND

Endoscopic submucosal dissection (ESD) has been widely used in the treatment of early gastric cancer (EGC). A personalized and effective prediction method for ESD with EGC is urgently needed.

AIM

To construct a risk prediction model for ulcers after ESD for EGC based on LASSO regression.

METHODS

A total of 196 patients with EGC who received ESD treatment were prospectively selected as the research subjects and followed up for one month. They were divided into an ulcer group and a non-ulcer group according to whether ulcers occurred. The general data, pathology, and endoscopic characteristics of the groups were compared, and the best risk predictor subsets were screened by LASSO regression and tenfold cross-validation. Multivariate logistic regression was applied to analyze the risk factors for ulcers after ESD in patients with EGC. A receiver operating characteristic (ROC) curve was used to estimate the predictive model performance.

RESULTS

One month after the operation, no patient was lost to follow-up. The incidence of ulcers was 20.41% (40/196) (ulcer group), and the incidence of no ulcers was 79.59% (156/196) (non-ulcer group). There were statistically significant differences in the course of disease, Helicobacter pylori infection history, smoking history, tumor number, clopidogrel medication history, lesion diameter, infiltration depth, convergent folds, and mucosal discoloration between the groups. Gray's medication history, lesion diameter, convergent folds, and mucosal discoloration, which were the 4 nonzero regression coefficients, were screened by LASSO regression analysis. Further multivariate logistic analysis showed that lesion diameter [Odds ratios (OR) = 30.490, 95%CI: 8.584-108.294], convergent folds (OR = 3.860, 95%CI: 1.060-14.055), mucosal discoloration (OR = 3.191, 95%CI: 1.016-10.021), and history of clopidogrel (OR = 3.554, 95%CI: 1.009-12.515) were independent risk factors for ulcers after ESD in patients with EGC (P < 0.05). The ROC curve showed that the area under the curve of the risk prediction model for ulcers after ESD in patients with EGC was 0.944 (95%CI: 0.902-0.972).

CONCLUSION

Clopidogrel medication history, lesion diameter, convergent folds, and mucosal discoloration can predict the occurrence of ulcers after ESD in patients with EGC.

Increasing utilization of endoscopic local excision for early-stage gastric cancers in the United States

BACKGROUND

The Japanese Gastric Cancer Association provided updated criteria for endoscopic local excision of early-stage gastric cancer in 2018. The purpose of this study was to evaluate utilization patterns for endoscopic local excision in the United States for resectable gastric adenocarcinoma.

METHODS

Patients with resectable gastric adenocarcinoma were identified from the National Cancer Database between 2010 and 2017. Patients were classified into strict appropriate criteria, expanded criteria, and inappropriate based on the Japanese Gastric Cancer Association guidelines. Factors associated with endoscopic local excision were identified using univariate and logistic multivariate regression.

RESULTS

Within the National Cancer Database, 46,334 patients were stratified into strict appropriate criteria (n = 1,405), expanded criteria (n = 727), and inappropriate (n = 43,675). Annual cases of local excision increased by 76.9% over the study period, from 273 in 2010 to 483 in 2017. Among patients who underwent local excision, 10.1% were classified as strict appropriate criteria, 1.6% were classified as expanded criteria, and 84.5% were classified as inappropriate. Among inappropriate patients, factors associated with endoscopic local excision were: more recent year of diagnosis, increasing age, female sex, tumor located in the cardia, smaller size, low-grade, absence of lymphovascular invasion, and treatment at an academic facility.

CONCLUSION

The use of endoscopic local excision for gastric cancer has nearly doubled since 2010. However, most patients do not satisfy consensus criteria for endoscopic therapy.