Does the discrepancy in histologic differentiation between a forceps biopsy and an endoscopic specimen necessitate additional surgery in early gastric cancer?

Nomogram for pre-procedural prediction of non-curative endoscopic resection in patients with early gastric cancer

BACKGROUND

Non-curative resection (non-CR) after endoscopic submucosal dissection (ESD) requires additional surgery due to the possibility of lymph node metastasis (LNM). Therefore, it is important to accurately predict the risk of non-CR to avoid unnecessary preoperative procedures. Thus, we aimed to develop and verify a nomogram to predict the risk of non-CR prior to ESD.

METHODS

Patients who underwent ESD for early gastric cancer (EGC) were divided into CR and non-CR groups based on the present ESD criteria. The pre-procedural factors, such as endoscopic features, radiologic findings, and pathology of the lesion, were compared between the groups to identify the risk factors associated with non-CR. A nomogram was developed using multivariate analysis, and its predictive value was assessed using an external validation group.

RESULTS

Among 824 patients, 682 were curative (82.7%) and 142 were non-curative (17.3%). By comparing two groups, endoscopic features including redness, whitish mucosal change, fold convergence, and large lesion size; histologic features such as moderately or poorly differentiated or signet ring cell carcinoma; and abnormal CT findings including non-specific lymph node enlargement and fold thickening were identified as significant predictors of non-CR. The nomogram was developed based on these predictors and showed good predictive performance in the external validation, with an area under the curve of 0.87.

CONCLUSIONS

We developed a nomogram to predict the risk of non-CR prior to ESD. These predictive factors in addition to the existing ESD criteria can help provide the best treatment option for patients with EGC.

A Prediction Model Based on the Risk Factors Associated with Pathological Upgrading in Patients with Early-Stage Gastric Neoplasms Diagnosed by Endoscopic Forceps Biopsy

Background/Aims

The discrepancies between the diagnosis of preoperative endoscopic forceps biopsy (EFB) and endoscopic submucosal dissection (ESD) in patients with early gastric neoplasm (EGN) exist objectively. Among them, pathological upgrading directly influences the accuracy and appropriateness of clinical decisions. The aims of this study were to investigate the risk factors for the discrepancies, with a particular focus on pathological upgrading and to establish a prediction model for estimating the risk of pathological upgrading after EFB.

Methods

We retrospectively collected the records of 978 patients who underwent ESD from December 1, 2017 to July 31, 2021 and who had a final histopathology determination of EGN. A nomogram to predict the risk of pathological upgrading was constructed after analyzing subgroup differences among the 901 lesions enrolled.

Results

The ratio of pathological upgrading was 510 of 953 (53.5%). Clinical, laboratorial and endoscopic characteristics were analyzed using univariable and binary multivariable logistic regression analyses. A nomogram was constructed by including age, history of chronic atrophic gastritis, symptoms of digestive system, blood high density lipoprotein concentration, macroscopic type, pathological diagnosis of EFB, uneven surface, remarkable redness, and lesion size. The C-statistics were 0.804 (95% confidence interval, 0.774 to 0.834) and 0.748 (95% confidence interval, 0.664 to 0.832) in the training and validation set, respectively. We also built an online webserver based on the proposed nomogram for convenient clinical use.

Conclusions

The clinical value of identifying the preoperative diagnosis of EGN lesions is limited when using EFB separately. We have developed a nomogram that can predict the probability of pathological upgrading with good calibration and discrimination value.

Construction of a nomogram for preoperative prediction of the risk of lymph node metastasis in early gastric cancer

Background

The status of lymph node metastasis (LNM) in patients with early gastric cancer (EGC) is particularly important for the formulation of clinical treatment. The purpose of this study was to construct a nomogram to predict the risk of LNM in EGC before operation.

Methods

Univariate analysis and logistic regression analysis were used to determine the independent risk factors for LNM. The independent risk factors were included in the nomogram, and the prediction accuracy, discriminant ability and clinical practicability of the nomogram were evaluated by the receiver operating characteristic curve (ROC), calibration curve and clinical decision curve (DCA), and 100 times ten-fold cross-validation was used for internal validation.

Results

33 (11.3%) cases of AGC were pathologically confirmed as LNM. In multivariate analysis, T stage, presence of enlarged lymph nodes on CT examination, carbohydrate antigen 199 (CA199), undifferentiated histological type and systemic inflammatory response index (SIRI) were risk factors for LNM. The area under the ROC curve of the nomogram was 0.86, the average area under the ROC curve of the 100-fold ten-fold cross-validation was 0.85, and the P value of the Hosmer-Lemeshow test was 0.60. In addition, the clinical decision curve, net reclassification index (NRI) and Integrated Discriminant Improvement Index (IDI) showed that the nomogram had good clinical utility.

Conclusions

We found that SIRI is a novel biomarker for preoperative prediction of LNM in EGC, and constructed a nomogram for preoperative prediction of the risk of LNM in EGC, which is helpful for the formulation of the clinical treatment strategies.

Histopathologic Diagnosis Discrepancies Between Preoperative Endoscopic Forceps Biopsies and Specimens Resected by Endoscopic Submucosal Dissection in Superficial Gastric Neoplasms

BACKGROUND

The standard of practice when a superficial lesion was identified during upper GI endoscopy is to take an endoscopic forceps biopsy (EFB) of the lesion. The histopathologic findings then will determine the management plan. Endoscopic submucosal dissection (ESD) enables en-bloc resection for early neoplasms of the gastrointestinal tract and provides an adequate specimen that permits a more reliable histopathologic assessment. The objective of this study was to determine the rate of histopathologic discrepancy between EFB and specimens resected by ESD, and to identify the predisposing risk factors for this discordance.

MATERIALS AND METHODS

This is a retrospective study, enrolling patients with superficial gastric neoplasms that underwent EFB followed by ESD. We divided cases to concordant or discordant group according to the histopathologic diagnosis of EFB and ESD specimens. We also analyzed the features that may have influenced the occurrence of histopathologic discordance and the association between discordant samples of adenocarcinoma and neoplastic invasion to deeper layers.

RESULTS

A total of 115 gastric ESD procedures were performed with 84 patients meeting the inclusion criteria. Histopathologic discordance between EFB and ESD specimens were observed in 35.8% of cases (30/84 lesions). The univariant-bivariant analysis and multivariate logistic regression analysis showed that histologic discordance was closely related to the size of the lesions ( P =0.028).

CONCLUSION

Histopathologic discrepancy between EFB and ESD specimens may occur in approximately one-third of cases, particularly for lesions over 20 mm, which may lead to crucial delays in gastric cancer precise diagnosis and treatment.

Mixed histology poses a greater risk for noncurative endoscopic resection in early gastric cancers regardless of the predominant histologic types

OBJECTIVES

Clinicopathologic characteristics and treatment outcomes of mixed-histological-type (MT) early gastric cancers (EGCs) treated with endoscopic submucosal dissection (ESD) have not been sufficiently elucidated. We aimed to clarify them in comparison with pure-histological-type EGCs.

METHODS

We used 3022 consecutive EGCs in 2281 patients treated with ESD from our prospectively maintained database. Cases were stratified into four groups according to the final diagnosis of the resected specimen are as follows: 2780 pure differentiated-type (DT), 127 DT-predominant MT (D-MT), 87 pure undifferentiated-type (UDT), and 28 UDT-predominant MT (U-MT). Clinicopathologic characteristics and treatment outcome were compared between pure DT and D-MT, and between pure UDT and U-MT separately. Risk factors for deep submucosal invasion, lymphovascular invasion, and a final diagnosis of MT were identified using multivariate analysis.

RESULTS

Both D-MT (41.7 vs. 92.0%; P < 0.0001) and U-MT (35.7 vs. 75.9%; P = 0.0002) showed a significantly lower curative resection rate than their pure histologic counterparts. Multivariate analysis revealed that MT was an independent risk factor for deep submucosal (OR 6.55; 95% CI, 4.18-10.14) and lymphovascular (OR 4.74; 95% CI, 2.72-8.29) invasion. Preoperative biopsy results that did not show well-differentiated tubular adenocarcinoma (OR 28.2; 95% CI, 18.9-42.9) were an independent risk factor for a final diagnosis of MT.

CONCLUSIONS

MT poses a greater risk for noncurative resection regardless of the predominant histologic types, reflecting more aggressive malignant potential. Although a biopsy examination rarely shows MT, clinicians should consider the possibility of MT when a biopsy examination does not show well-differentiated tubular adenocarcinoma.

Development and validation of a nomogram for preoperative prediction of lymph node metastasis in early gastric cancer

Background

The status of lymph nodes in early gastric cancer is critical to make further clinical treatment decision, but the prediction of lymph node metastasis remains difficult before operation. This study aimed to develop a nomogram that contained preoperative factors to predict lymph node metastasis in early gastric cancer patients.

Methods

This study analyzed the clinicopathologic features of 823 early gastric cancer patients who underwent gastrectomy retrospectively, among which 596 patients were recruited in the training cohort and 227 patients in the independent validation cohort. Significant risk factors in univariate analysis were further identified to be independent variables in multivariable logistic regression analysis, which were then incorporated in and presented with a nomogram. And internal and external validation curves were plotted to evaluate the discrimination of the nomogram.

Results

Totally, six independent predictors, including the tumor size, macroscopic features, histology differentiation, P53, carbohydrate antigen 19-9, and computed tomography-reported lymph node status, were enrolled in the nomogram. Both the internal validation in the training cohort and the external validation in the validation cohort showed the nomogram had good discriminations, with a C-index of 0.82 (95%CI, 0.78 to 0.86) and 0.77 (95%CI, 0.60 to 0.94) respectively.

Conclusions

Our study developed a new nomogram which contained the most common and significant preoperative risk factors for lymph node metastasis in patients with early gastric cancer. The nomogram can identify early gastric cancer patients with the high probability of lymph node metastasis and help clinicians make more appropriate decisions in clinical practice.

Mixed Histology Is a Risk Factor for Lymph Node Metastasis in Early Gastric Cancer

BACKGROUND

The risk factors of lymph node (LN) metastasis are important factors to consider in endoscopic submucosal dissection in early gastric cancer (EGC). The aim of the study was to identify the correlation between mixed histology and LN metastasis in EGC.

METHODS

A total of 1645 patients who underwent curative radical gastrectomy for EGC were divided into three groups (pure differentiated [pure D], mixed, and pure undifferentiated [pure UD]) according to histologic type. They were subsequently analyzed retrospectively for LN metastasis. The patients who had mixed histology between differentiated and undifferentiated tubular adenocarcinoma were defined as mixed group.

RESULTS

The pure UD group was significantly younger than the other groups. Tumor size was larger in the mixed group. LN metastasis occurred more frequently in the mixed group and the pure UD group than in the pure D group (pure D, mixed, and pure UD, 7.7%, 23.2%, and 10.8%, respectively; P < 0.001). A logistic regression analysis revealed that the independent risk factors for LN metastasis were large tumor size (odd ratio [OR], 1.308), submucosal invasion (OR, 3.565), lymphovascular invasion (OR, 9.755), and histologic types of mixed (OR, 2.360) and pure UD (OR, 1.657).

CONCLUSIONS

Mixed histology is an important risk factor for LN metastasis in EGC. Thus, radical gastrectomy should be considered in the cases of mixed-type histology after endoscopic resection.