Exosomal LINC00853 promotes progression of gastric cancer via the MAP17/PDZK1/AKT signaling pathway

Although rare, there is ongoing research into biomarkers that predict the onset and recurrence of gastric cancer, particularly focusing on substances found in exosomes. Long non-coding RNAs (lncRNAs) have garnered attention for their potential in diagnosing gastric cancer. This study investigates the role of lncRNAs in gastric cancer, focusing on their presence in exosomes as potential biomarkers for the disease's onset and recurrence. We utilized the ArrayStar Human LncRNA array 2.0 to analyze lncRNA expression in tissues from early-stage gastric cancer patients. Our analysis highlighted LINC00853, which was significantly upregulated in cancer tissues and implicated in promoting epithelial-mesenchymal transition via the MAP17/PDZK1/AKT pathway. Functional studies on AGS and MKN74 gastric cancer cell lines demonstrated that LINC00853 facilitates cell proliferation, invasion, and migration. Additionally, RNA immunoprecipitation and electrophoretic mobility shift assays confirmed LINC00853 interaction with MAP17. Importantly, LINC00853 was also detected in exosomes from both patient samples and cell lines, and its downregulation led to decreased tumorigenicity in AGS cells. These findings suggest that both cellular and exosomal LINC00853 contribute to gastric cancer pathogenesis and may serve as valuable biomarkers for the disease.

Clip-and-snare method with a pre-looping technique versus conventional method in the treatment of precancerous lesion and early gastric cancer: a retrospective study

BACKGROUND

Low grade intraepithelial neoplasia (LGIN) and high grade intraepithelial neoplasia (HGIN) are potential precancerous lesion of gastric neoplasms. Endoscopic submucosal dissection (ESD) is the first option for the treatment of precancerous lesion and early gastric cancer (EGC). Traction is an effective method to improve efficiency, and reduce complications during ESD. In this study, we shared a useful traction method using the clip-and-snare method with a pre-looping technique (CSM-PLT) for precancerous lesion and EGC.

METHODS

We retrospectively analyzed patients received ESD combined with CSM-PLT or conventional ESD from June 2018 to December 2021 in Shenzhen People's hospital. The primary outcome was resection speed.

RESULTS

Forty-two patients were enrolled in ESD combined with CSM-PLT group and sixty-five patients in conventional ESD group respectively. Baseline characteristics were comparable among two groups (P>0.05). There were no significant differences in terms of R0 resection rate, en bloc resection rate (97.6% vs. 98.5%, P = 1.000 and 97.6% vs. 96.9%, P = 1.000, respectively), operation costs (933.7 (644.1-1102.4) dollars vs. 814.7 (614.6-988.3) dollars, P = 0.107), and hospital stays (8.0 ± 3.1 days vs. 7.3 ± 3.2 days, P = 0.236). In addition, no significant difference was observed with respect to complications (P>0.05). However, the resection speed of ESD combined with CSM-PLT was faster than that of conventional ESD (11.3 (9.4-14.9) mm2/min vs. 8.0 (5.8-10.9) mm2/min, P < 0.001), particularly lesions located in anterior wall and lesser curvature. In addition, the association between ESD combined with CSM-PLT and resection speed was still supported after propensity matching scores (PMS).

CONCLUSIONS

CSM-PLT can help to improve ESD efficiency without reducing the en bloc resection rate or increasing the incidence of complications.

Early gastric cancer with RhoGAP fusion is linked to frequent nodal metastasis and a part of microtubular-mucocellular histology

INTRODUCTION

Gastric cancer with fusion genes involving the Rho GTPase-activating protein domain (RhoGAP-GC) is mainly included in the genomically stable type of The Cancer Genome Atlas classification. Clinical implications and histological characteristics of RhoGAP-GC in the early phase remain unclear.

METHODS

We analyzed 878 consecutive pT1b GCs for RhoGAP and its partner genes using fluorescence in situ hybridization assay.

RESULTS

RhoGAP fusion was detected in 57 (6.5%) GCs. Univariate analysis revealed that female sex, middle-lower third tumor location, advanced macroscopic type, tumor diameter > 2 cm, pT1b2, lymphatic invasion, venous invasion, negative EBER-ISH, and RhoGAP fusion were significantly associated with lymph node metastasis (LNM). Multivariate analysis presented RhoGAP fusion, lymphatic invasion, tumor diameter > 2 cm, advanced macroscopic type, venous invasion, and middle-lower third tumor location as independent risk factors for LNM. Notably, RhoGAP fusion had the highest odds ratio (3.92) for LNM among analyzed parameters (95% CI 2.12-7.27; p < 0.001). Compared to non-RhoGAP-GCs, RhoGAP-GCs were significantly frequent in younger females and showed the highest incidence of lymphatic invasion (56.2%) and LNM (49.1%) (p < 0.001). Histologically, microtubular architecture with pseudo-trabecular interconnection and small aggregations of tumor cells with a varied amount of cytoplasmic mucin, named "microtubular-mucocellular (MTMC) histology," was found in 93.0% (53 of 57) of RhoGAP-GCs in the intramucosal area. MTMC histology showed high sensitivity and negative predictive value (93.0% and 99.4%, respectively) for RhoGAP fusion, albeit positive predictive value is low (34.9%).

CONCLUSION

RhoGAP-GC is linked to a characteristic MTMC histology and a high incidence of LNM.

A novel artificial intelligence-based endoscopic ultrasonography diagnostic system for diagnosing the invasion depth of early gastric cancer

BACKGROUND

We developed an artificial intelligence (AI)-based endoscopic ultrasonography (EUS) system for diagnosing the invasion depth of early gastric cancer (EGC), and we evaluated the performance of this system.

METHODS

A total of 8280 EUS images from 559 EGC cases were collected from 11 institutions. Within this dataset, 3451 images (285 cases) from one institution were used as a development dataset. The AI model consisted of segmentation and classification steps, followed by the CycleGAN method to bridge differences in EUS images captured by different equipment. AI model performance was evaluated using an internal validation dataset collected from the same institution as the development dataset (1726 images, 135 cases). External validation was conducted using images collected from the other 10 institutions (3103 images, 139 cases).

RESULTS

The area under the curve (AUC) of the AI model in the internal validation dataset was 0.870 (95% CI: 0.796-0.944). Regarding diagnostic performance, the accuracy/sensitivity/specificity values of the AI model, experts (n = 6), and nonexperts (n = 8) were 82.2/63.4/90.4%, 81.9/66.3/88.7%, and 68.3/60.9/71.5%, respectively. The AUC of the AI model in the external validation dataset was 0.815 (95% CI: 0.743-0.886). The accuracy/sensitivity/specificity values of the AI model (74.1/73.1/75.0%) and the real-time diagnoses of experts (75.5/79.1/72.2%) in the external validation dataset were comparable.

CONCLUSIONS

Our AI model demonstrated a diagnostic performance equivalent to that of experts.

Chronic active and atrophic gastritis as significant contributing factor to the development of gastric cystica profunda

Gastric cystica profunda (GCP) is an uncommon but underestimated gastric lesion. Its precancerous potential determines its significance. In addition to previous mucosa injury due to operations, biopsy or polypectomy, chronic active and atrophic gastritis may also lead to the development of GCPs. By carefully examining the stomach and taking biopsy samples from the susceptible regions, the stage of atrophy can be determined. Chronic atrophic gastritis is a risk factor for cancer evolvement and it can also contribute to GCPs formation. GCPs frequently occur close to early gastric cancers (EGCs) or EGC can arise from the cystic glands. Endoscopic resection is an effective and minimally invasive treatment in GCP.

Risk factors and a nomogram for predicting local recurrence in adult patients with early gastric cancer after endoscopic submucosal dissection

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is an effective treatment method for early gastric cancers. The aim of this study was to evaluate the risk factors of recurrence for patients with early gastric cancer after ESD and construct a nomogram for predicting recurrence.

METHODS

A retrospective observational study was conducted on patients with early gastric cancer who underwent ESD at Beijing Friendship Hospital between 2013 and 2018. The risk factors of gastric cancer recurrence after ESD were analyzed by univariate and multivariate Cox regression.

RESULTS

A total of 238 patients with a median follow-up period of 70.5-month were enrolled in the study. Risk factors for recurrence included diabetes (HR = 3.68), alcohol consumption history (HR = 5.73), complications (HR = 5.22), lymphatic invasion (HR = 13.09) and multiple lesions (HR = 4.34). The analysis of the receiver operating characteristic curve, calibration curve, and model consistency index demonstrates that the graphical representation exhibits a good predictive capability.

CONCLUSIONS

Based on identified risk factors, this study developed the first nomogram with high accuracy to predict the recurrence of early gastric cancer after ESD. This model offers valuable guidance to clinicians for identifying high-risk patient groups and planning more intensive follow-up strategies.

Feasibility of intraoperative pathologic examination for sentinel lymph nodes during sentinel node navigation surgery in early gastric cancer: results of pathologic protocol for SENORITA trial

BACKGROUND

During sentinel node navigation surgery in patients with gastric cancer, intraoperative pathologic examination of sentinel nodes is crucial in determining the extent of surgery. In this study, we evaluated the feasibility and accuracy of intraoperative pathologic protocols using data from a prospective, multicenter, randomized trial.

METHODS

A retrospective analysis was conducted using data from the SEntinel Node ORIented Tailored Approach trials from 2013 to 2016. All sentinel lymph nodes were evaluated during surgery with hematoxylin-eosin (HE) staining using a representative section at the largest plane for lymph nodes. For permanent histologic evaluation, sentinel basin nodes were stained with HE and cytokeratin immunohistochemistry in formalin-fixed, paraffin-embedded (FFPE) sections and examined with HE for three deeper-step sections at 200-μm intervals. The failure rate of identification by frozen section and the metastasis rate in non-sentinel basins were investigated.

RESULTS

Of the 237 patients who underwent sentinel node basin dissection, 30 had lymph node metastases on permanent pathology. Thirteen patients had macrometastasis confirmed in frozen sections as well as FFPE sections (failure rate: 0%). Patients with negative sentinel nodes in frozen sections but micrometastasis in FFPE sections had no lymph node recurrence during the follow-up period (0%, 0/6). However, in cases with tumor-positive nodes in frozen sections, metastases in non-sentinel basins were detected in the paraffin blocks (8.3%, 2/24).

CONCLUSIONS

The single-section HE staining method is sufficient for detecting macrometastasis via intraoperative pathological examination. If a negative frozen-section result is confirmed, sentinel basin dissection can be performed safely. Otherwise, standard surgery is required.

Endoscopic submucosal dissection (ESD) for gastritis cystica profunda (GCP) with early gastric cancer: A propensity score matching analysis

Background and aim

Cystic dilatation of the gastric glands within the mucosal layer is the hallmark of the rare condition known as gastritis cystica profunda (GCP). Although it has been proved that GCP is the precursor lesion for early gastric cancer (EGC), the management strategy of GCP-related EGC is not well established.The purpose of this research was to determine if ESD is effective and safe for GCP-related EGC.

Methods

Patients with EGC who had ESD at Beijing Friendship Hospital between January 2015 and May 2023 were retrospectively included. All patients were divided into two groups: those with GCP-related EGC, and those with EGC alone. The two groups were matched 1:1 using the propensity score matching (PSM) method. Curative resection rate, postoperative adverse outcome rate (bleeding, perforation, stricture), and recurrence rate were the primary measures used to evaluate the efficacy and safety of ESD.

Results

There were a total of 386 participants (44 with GCP and 342 with EGC alone). Following PSM, 44 patients were paired and analyzed separately. Except for the presence of cysts in EUS (multiple/single/none cyst: 12/2/5 versus 1/0/25, P < 0.0001), there was no change in baseline characteristics, EUS appearance, or histology results between groups. Overall, there was no significant difference in curative resection rates between the GCP group (70.5 %) and the control group (81.8 %) (P = 0.211). Postoperative complications were comparative (9/44 vs 5/44, P = 0.244), as were rates of local recurrence (1/44 vs 0/44, P = 1.0), metachronous gastric cancer (1/44 vs 0/44, P = 1.0), and mortality (0/44 vs 0/44, P = 1.0).

Conclusions

Existence of cysts in EUS is a characteristic presentation to distinguish GCP-related EGC from EGC-alone lesions. ESD might be a safe and effective therapy for patients with GCP-related EGC.

Present situation of minimally invasive surgical treatment for early gastric cancer

Minimally invasive surgery is a kind of surgical operation, which is performed by using professional surgical instruments and equipment to inactivate, resect, repair or reconstruct the pathological changes, deformities and wounds in human body through micro-trauma or micro-approach, in order to achieve the goal of treatment, its surgical effect is equivalent to the traditional open surgery, while avoiding the morbidity of conventional surgical wounds. In addition, it also has the advantages of less trauma, less blood loss during operation, less psychological burden and quick recovery on patients, and these minimally invasive techniques provide unique value for the examination and treatment of gastric cancer patients. Surgical minimally invasive surgical techniques have developed rapidly and offer numerous options for the treatment of early gastric cancer (EGC): endoscopic mucosal resection (EMR), underwater EMR (UEMR), endoscopic submucosal dissection (ESD), endoscopic full-thickness resection (EFTR), endoscopic submucosal excavation (ESE), submucosal tunnel endoscopic resection), laparoscopic and endoscopic cooperative surgery (LECS); Among them, EMR, EFTR and LECS technologies have a wide range of applications and different modifications have been derived from their respective surgical operations, such as band-assisted EMR (BA-EMR), conventional EMR (CEMR), over-the-scope clip-assisted EFTR, no-touch EFTR, the inverted LECS, closed LECS, and so on. These new and improved minimally invasive surgeries are more precise, specific and effective in treating different types of EGC.

Equal short-term outcomes of intracorporeal mechanical gastrogastrostomy in laparoscopic pylorus-preserving gastrectomy for cT1N0 gastric cancer in the middle stomach compared with the extracorporeal hand-sewing method

BACKGROUND

Intracorporeal mechanical gastrogastrostomy (IMG) techniques have recently been developed and their short-term safety was presented in their initial evaluation. However, whether they are comparable to extracorporeal hand-sewing gastrogastrostomy (EHG) remains unclear. The aim of the study is to establish the safety of IMG in totally laparoscopic pylorus-preserving gastrectomy (TLPPG) compared to EHG in laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG).

METHODS

We retrospectively analyzed the short-term outcomes of patients with middle-third early gastric cancer who underwent LAPPG or TLPPG between 2005 and 2022. The primary objective of this study was to evaluate the non-inferiority of IMG to EHG in terms of safety, with the primary endpoint being the risk difference in anastomosis-related complications (ARCs). The sample size required to achieve a statistical power of 80% for the non-inferiority test was 971 with a one-sided alpha level of 5% and non-inferiority of 5%.

RESULTS

The analysis included a total of 1,021 patients who underwent LAPPG or TLPPG during the study period. Among them, 488 patients underwent EHG, while 533 underwent IMG. The incidences of ARCs were 11.3% and 11.4% in EHG and IMG, respectively. The observed difference in incidence was 0.0017 (90% confidence interval - 0.0313 to 0.0345), which statistically demonstrated the non-inferiority of IMG to EHG in the incidence of ARCs. Among other complications, the incidence of wound infection in IMG was lower than that in EHG.

CONCLUSION

IMG is safe regarding ARCs compared with EHG. These results will encourage surgeons to introduce IMG for patients with early middle gastric cancer.

'Long-term outcomes after endoscopic submucosal dissection for relative indication early gastric cancer in non-surgical candidates'

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is effective in treating early gastric cancer (EGC). It's role in the comorbid with more advanced disease is unknown. We sought to evaluate this in a large Western cohort.

METHODS

Consecutive patients who underwent ESD for EGC in a single tertiary Western endoscopy centre over 10 years were prospectively analyzed. The primary outcomes were long term overall survival (OS) and disease-free survival (DFS) up to 5 years. Secondary outcomes were efficacy and serious adverse events (SAE).

RESULTS

ESD for 157 EGC in 149 patients were performed in an elderly and comorbid cohort with mean age 73.7 years and age-adjusted Charleson Comorbidity Index 4.2. Over a median follow-up period of 51.6 months, there was no significant difference in 5-year OS (88.9% vs 77.9%, P = 0.290) and DFS (83.2% vs 75.1%, P = 0.593) between absolute indication (AI) EGC and relative indication (RI) EGC. AI EGC cohort achieved higher en bloc (96.3% vs 87.5%, P = 0.069) and R0 resection rate (93.6% vs 62.5%, P <0.001) when compared to RI EGC. There were no significant differences in SAE (7.3% vs 12.5%, P = 0.363). No mortality or surgical resection ensued from ESD complications.

CONCLUSION

ESD safely confers DFS in poor surgical candidates with RI EGC in a large Western cohort. Patients who are elderly and comorbid or decline surgical resection may benefit from ESD and avoid the risks of surgery and its long-term sequelae.

Early gastric cancer detection and lesion segmentation based on deep learning and gastroscopic images

Gastric cancer is a highly prevalent disease that poses a serious threat to public health. In clinical practice, gastroscopy is frequently used by medical practitioners to screen for gastric cancer. However, the symptoms of gastric cancer at different stages of advancement vary significantly, particularly in the case of early gastric cancer (EGC). The manifestations of EGC are often indistinct, leading to a detection rate of less than 10%. In recent years, researchers have focused on leveraging deep learning algorithms to assist medical professionals in detecting EGC and thereby improve detection rates. To enhance the ability of deep learning to detect EGC and segment lesions in gastroscopic images, an Improved Mask R-CNN (IMR-CNN) model was proposed. This model incorporates a "Bi-directional feature extraction and fusion module" and a "Purification module for feature channel and space" based on the Mask R-CNN (MR-CNN). Our study includes a dataset of 1120 images of EGC for training and validation of the models. The experimental results indicate that the IMR-CNN model outperforms the original MR-CNN model, with Precision, Recall, Accuracy, Specificity and F1-Score values of 92.9%, 95.3%, 93.9%, 92.5% and 94.1%, respectively. Therefore, our proposed IMR-CNN model has superior detection and lesion segmentation capabilities and can effectively aid doctors in diagnosing EGC from gastroscopic images.

Da Vinci robot-assisted endoscopic full-thickness gastric resection with regional lymph node dissection using a 3D near-infrared video system: a single-center 5-year clinical outcome

BACKGROUND

Endoscopic full-thickness gastric resection (EFTGR) with regional lymph node dissection (LND) has been used for early gastric cancer (EGC) exceeding the indications for endoscopic submucosal dissection (ESD). The extent of the dissected lymph nodes is crucial. A 3D near-infrared (NIR) video robot system significantly enhances visualization of the lymphatic system. However, this system has not been used in EFTGR with LND. Thus, this study assessed the benefits of the 3D NIR video robot system in a clinical setting.

METHODS

Between February 2015 and September 2018, 24 patients with EGC exceeding the indications for ESD were treated with EFTGR and LND using a 3D NIR video system with the da Vinci surgical robot. Indocyanine green (ICG) was injected endoscopically around the tumor, and basin node (BN) dissection around the nodes was examined using the 3D NIR video system of the da Vinci Si surgical robot. Subsequently, robot-assisted EFTGR was performed. The primary outcome was the 5-year survival rate.

RESULT

During a 5-year follow-up of all 24 patients, an 80-year-old patient with an ulcer and T2 invasion was lost to follow-up. Among the remaining 23 patients, no mortality or recurrence was observed.

CONCLUSION

No metastasis or mortality occurred using the da Vinci robot-assisted EFTGR with LLND and a 3D NIR video system for patients who required radical gastrectomy for EGC in over 5 years. Hence, this may be a safe and effective method for radical gastrectomy; further studies are required confirming its effectiveness.

DNA methylation profiling identifies epigenetic signatures of early gastric cancer

Research on the DNA methylation status of gastric cancer (GC) has primarily focused on identifying invasive GC to develop biomarkers for diagnostic. However, DNA methylation in noninvasive GC remains unclear. We conducted a comprehensive DNA methylation profiling study of differentiated-type intramucosal GCs (IMCs). Illumina 850K microarrays were utilized to assess the DNA methylation profiles of formalin-fixed paraffin-embedded tissues from eight patients who were Epstein-Barr virus-negative and DNA mismatch repair proficient, including IMCs and paired adjacent nontumor mucosa. Gene expression profiling microarray data from the GEO database were analyzed via bioinformatics to identify candidate methylation genes. The final validation was conducted using quantitative real-time PCR, the TCGA methylation database, and single-sample gene set enrichment analysis (GSEA). Genome-wide DNA methylation profiling revealed a global decrease in methylation in IMCs compared with nontumor tissues. Differential methylation analysis between IMCs and nontumor tissues identified 449 differentially methylated probes, with a majority of sites showing hypomethylation in IMCs compared with nontumor tissues (66.1% vs 33.9%). Integrating two RNA-seq microarray datasets, we found one hypomethylation-upregulated gene: eEF1A2, overlapped with our DNA methylation data. The mRNA expression of eEF1A2 was higher in twenty-four IMC tissues than in their paired adjacent nontumor tissues. GSEA indicated that the functions of eEF1A2 were associated with the development of IMCs. Furthermore, TCGA data indicated that eEF1A2 is hypomethylated in advanced GC. Our study illustrates the implications of DNA methylation alterations in IMCs and suggests that aberrant hypomethylation and high mRNA expression of eEF1A2 might play a role in IMCs development.

BEST-J Score: Validation of a Predicting Model for Delayed Bleeding After Gastric Endoscopic Submucosal Dissection on a European Sample

BACKGROUND

Delayed bleeding (DB) is a possible adverse event following gastric endoscopic submucosal dissection (ESD). The BEST-J score was created as a risk prediction model for DB following gastric ESD, but is yet to be validated in Western populations.

AIMS

We aimed to validate the BEST-J score on a European sample and to perform a subgroup analysis according to histological classification.

METHODS

Retrospective study of all consecutive patients undergoing gastric ESD on a European Endoscopic Unit. DB was defined as hemorrhage with clinical symptoms and confirmed by emergency endoscopy from the time of completion to 28 days after ESD. BEST-J score was calculated in each patient and confronted with the outcome (DB).

RESULTS

Final sample included 161 patients. From these, 10 (6.2%) presented DB following ESD, with a median time to bleeding of 7 days (IQR 6.8). BEST-J score presented an excellent accuracy predicting DB in our sample, with an AUC = 0.907 (95%CI 0.801-1.000; p < 0.001). Subgroup analysis by histological classification proved that the discriminative power was still excellent for each grade: low-grade dysplasia-AUC = 0.970 (p < 0.001); high-grade dysplasia-AUC = 0.874 (p < 0.001); early gastric cancer-AUC = 0.881 (p < 0.001). The optimal cut-off value to predict DB was a BEST-J score ≥ 3, which matches the cut-off value for high-risk of bleeding in the original investigation.

CONCLUSIONS

The BEST-J score still presents excellent accuracy in risk stratification for post-ESD bleeding in European individuals. Thus, this score may help to guide which patients benefit the most from prophylactic therapies following gastric ESD in this setting.

Risk Assessment of Metachronous Gastric Neoplasm after Endoscopic Resection for Early Gastric Cancer According to Age at Helicobacter pylori Eradication

Background/Aims

Helicobacter pylori eradication can reduce the incidence of metachronous gastric neoplasm (MGN) after endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). This study evaluated the risk of developing MGN after ESD for EGC based on age at H. pylori eradication.

Methods

Data of patients who underwent curative ESD for EGC with H. pylori infection between 2005 and 2018 were retrospectively analyzed. The patients were allocated to four groups according to age at H. pylori eradication: group 1 (<50 years), group 2 (50-59 years), group 3 (60-69 years), and group 4 (≥70 years).

Results

All patients were followed up for at least 5 years after ESD. The 5-year cumulative incidence of MGN was 2.1%, 7.0%, 8.7%, and 16.7% in groups 1, 2, 3, and 4, respectively (p<0.001), and groups 3 and 4 showed a significant increase in the risk of MGN (hazard ratio [HR], 4.66; 95% confidence interval [CI], 1.09 to 19.92 and HR, 10.75; 95% CI, 2.45 to 47.12). After adjustments for moderate to severe intestinal metaplasia based on the updated Sydney system, groups 3 and 4 remained significantly associated with MGN (HR, 4.40; 95% CI, 1.03 to 18.84 and HR, 10.14; 95% CI, 2.31 to 44.57).

Conclusions

The incidence of MGN after ESD for EGC increased with age at H. pylori eradication. Age at H. pylori eradication ≥60 years was an independent risk factor for MGN, even after adjusting for the presence of advanced intestinal metaplasia.

How-I-do-it: laparoscopic intragastric submucosal dissection (LISD) for gastric and gastro-oesophageal junction early lesions

PURPOSE

Laparoscopic intragastric submucosal dissection (LISD) is a novel approach to the resection of gastric lesion that are not amenable to conventional endoscopic approaches. The technique permits favourable access to lesions situated at the cardia and angular notch of the stomach, enables en-bloc resection of large areas of tissue, and can prevent the need of formal gastrectomy or oesophagectomy in selected patients.

METHODS

All cases were deemed suitable for LISD by a multidisciplinary team panel following endoscopic assessment (using white light enhancement, chromoendoscopy and magnification endoscopy) that was integrated when needed with EUS, CT scan or PET scan. The surgical technique consisted in a 3-port laparoscopic approach; after establishment of pneumoperitoneum, three gastrotomies were performed to enable port insertion into the stomach. Following establishment of stable pneumogastrium, the area of interest was identified, submucosal hyaluronic acid injection performed to provide a cushion in the plane of dissection, and the excision area was circumferentially marked with cautery. Resection was completed using cautery hook, along a plane parallel to the muscolaris propria. After the specimen was extracted in a retrieval bag, intracorporeal single layer running suture closure of gastrotomies was performed. The abdominal wall closed by layers and tap block performed along with local anaesthetic injection on skin incision. Measures were taken to ensure correct orientation of resected specimens prior to fixation.

RESULTS

During the study period that spans from 2014 and 2022, a total of 11 patients underwent LISD for limited lesions of the stomach, 10 were located at gastro-oesophageal junction and one at the angular incisura. Four patients were female, seven males. The median age was 74 (46-79) years. R0 resection rate was 54.5%. Mean operative time was 109 min with very low blood loss (10 ml). Mortality rate was 0%, no immediate major complications (Grade II-V Clavien Dindo), including haemorrhage or perforation, occurred in these cases. Two patients developed dysphagia later that was successfully treated with endoscopic balloon dilatations. Median hospital stay was 3 days and median oral intake was on day 1 post-procedural.

CONCLUSIONS

Laparoscopic intragastric submucosal dissection is shown to be a safe and effective intervention for the treatment of early gastric cancers in selected patients having undergone deemed not amenable for endoscopic submucosal resection for their technically challenging location. Its application can serve as route to avoid formal surgery and the associated morbidity.

Endoscopic resection and laparoscopic lymph node dissection for early gastric cancer beyond conventional endoscopic treatment indications: a 10-year outcome study

BACKGROUND

Endoscopic full-thickness gastric resection (EFTGR) with laparoscopic regional lymph node dissection (LLND) and endoscopic submucosal dissection (ESD) with LLND have been investigated as treatment options for early gastric cancer beyond the absolute indications for ESD. However, comparative studies on the long-term outcomes of these procedures are lacking. This study aimed to analyze and compare the 10-year outcomes of both procedures in a real clinical setting.

METHODS

Between January 2009 and December 2013, 28 and 37 patients diagnosed with EGC beyond the absolute indications for ESD were treated with EFTGR with LLND and ESD with LLND, respectively. In both procedures, the dye was injected into the tumor. However, after injection and LLND, EFTGR was performed immediately in the EFTGR with LLND group, whereas LLND was followed by ESD in the ESD with LLND group. The primary endpoint was the 10-year survival rate.

RESULTS

The EFTGR with LLND group had one case of local recurrence (3.6%) and mortality (3.6%) each, while the ESD with LLND group had none (0.0% for both); however, the differences were not statistically significant (P = 0.247 for each). Furthermore, there was no significant difference in complications such as ischemia and anastomosis leakage between the groups (P = 0.247).

CONCLUSIONS

When the procedures were properly applied, EFTGR with LLND and ESD with LLND did not increase the 10-year mortality in patients with EGC beyond the absolute ESD indications compared with conventional radical gastrectomy.

Exploring non-curative endoscopic submucosal dissection: Current treatment optimization and future indication expansion

The increasing popularity of endoscopic submucosal dissection (ESD) as a treatment for early gastric cancer has highlighted the importance of quality assessment in achieving curative resections. This article emphasizes the significance of evaluating ESD quality, not only for curative cases but also for non-curative ones. Postoperative assessment relies on the endoscopic curability (eCura) classification, but management strategies for eCuraC-1 tumour with a positive horizontal margin are unclear. Current research primarily focuses on comparing additional surgical procedures in high-risk patients, while studies specifically targeting eCuraC-1 patients are limited. Exploring management strategies and follow-up outcomes for such cases could provide valuable insights. Furthermore, the application of molecular imaging using near-infrared fluorescent tracers holds promise for precise tumour diagnosis and navigation, potentially impacting the management of early-stage gastric cancer patients. Advancing research in these areas is essential for improving the overall efficacy of endoscopic techniques and refining treatment indications.

Potential of Direct Oral Anticoagulant in Bleeding After Gastric Endoscopic Submucosal Dissection: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

An increasing number of patients are undergoing gastric endoscopic submucosal dissection (ESD) with active prescriptions of direct oral anticoagulants (DOACs). Only a few reports have described the effects of DOAC intake on postoperative bleeding. We aimed to investigate the bleeding risk associated with DOACs after gastric ESD.

METHODS

Clinical studies published up to April 2022 showing bleeding rates after gastric ESD in patients taking DOACs were identified using electronic searches. The primary outcome was the rate of bleeding after gastric ESD in patients receiving DOACs compared to those not receiving antithrombotic therapy. In this meta-analysis, odds ratios (ORs) were calculated and pooled using a random effects model. The secondary outcome was the difference in the bleeding rate between patients treated with DOACs and those treated with warfarin and antiplatelet drugs.

RESULTS

Seven studies were included in this meta-analysis. The pooled analysis showed that DOACs had a higher bleeding rate than non-thrombotic therapy (17.0% vs. 3.4%; OR 5.72; 95% confidence interval [CI], 4.33-7.54; I2 = 0%). The bleeding risk associated with DOAC administration was similar to that associated with warfarin (17.0% vs. 20.0%; OR 0.83; 95% CI 0.59-1.18; I2 = 0%), whereas it was higher than that associated with antiplatelet administration (16.9% vs. 11.0%; OR 1.63; 95% CI 1.14-2.34; I2 = 8%).

CONCLUSIONS

This meta-analysis reveals that the bleeding risk of DOACs is higher than that of non-antithrombotics and antiplatelets, whereas it is comparable to that of warfarin. Gastric ESD in patients on anticoagulants requires careful postoperative management.

Efficacy and safety of endoscopic submucosal dissection for early gastric cancer and precancerous lesions in elderly patients

BACKGROUND

With advancements in the development of endoscopic technologies, the endoscopic submucosal dissection (ESD) has been one of the gold-standard therapies for early gastric cancer.

AIM

To investigate the efficacy and safety ESD in the treatment of early gastric cancer and precancerous lesions in the elderly patients.

METHODS

Seventy-eight elderly patients with early gastric cancer and precancerous lesions admitted to the Third Affiliated Hospital of Qiqihar Medical University were selected and classified into two groups according to the different surgical therapies they received between January 2021 and June 2022. Among them, 39 patients treated with ESD were included in an experimental group, and 39 patients treated with endoscopic mucosal resection (EMR) were included in a control group. We compared the basic intraoperative conditions, postoperative short-term recovery, long-term recovery effects and functional status of gastric mucosa between the two groups; the basic intraoperative conditions included lesion resection, intraoperative bleeding and operation time; the postoperative short-term recovery assessment indexes were length of hospital stay and incidence of surgical complications; and the long-term recovery assessment indexes were the recurrence rate at 1 year postoperatively and the survival situation at 1 year and 3 years postoperatively; and we compared the preoperative and predischarge serum pepsinogen I (PG I) and PG II levels and PG I/PG II ratio in the two groups before surgery and discharge.

RESULTS

The curative resection rate and the rate of en bloc resection were higher in the experimental group than in the control group. The intraoperative bleeding volume was higher in the experimental group than in the control group. The operation time was longer in the experimental group than that in the control group, and the rate for base residual focus was lower in the experimental group than that of the control group, and the differences were all statistically significant (all P < 0.05). The length of hospital stay was longer in the experimental group than in the control group, and the incidence of surgical complications, 1-year postoperative recurrence rate and 3-year postoperative survival rate were lower in the experimental group than in the control group, and the differences were statistically significant (all P < 0.05). However, the difference in the 1-year postoperative survival rate was not statistically significant between the two groups (P > 0.05). Before discharge, PG I and PG I/PG II ratio were elevated in both groups compared with the preoperative period, and the above indexes were higher in the experimental group than those in the control group, and the differences were statistically significant (both P < 0.05). Moreover, before discharge, PG II level was lower in both groups compared with the preoperative period, and the level was lower in the experimental group than in the control group, and the differences were all statistically significant (all P < 0.05).

CONCLUSION

Compared with EMR, ESD surgery is more thorough. It reduces the rate of base residual focus, recurrence rate, surgical complications, and promotes the recovery of gastric cells and glandular function. It is safe and suitable for clinical application.

Endoscopic features and treatments of gastric cystica profunda

BACKGROUND

Gastric cystica profunda (GCP) represents a rare condition characterized by cystic dilation of gastric glands within the mucosal and/or submucosal layers. GCP is often linked to, or may progress into, early gastric cancer (EGC).

AIM

To provide a comprehensive evaluation of the endoscopic features of GCP while assessing the efficacy of endoscopic treatment, thereby offering guidance for diagnosis and treatment.

METHODS

This retrospective study involved 104 patients with GCP who underwent endoscopic resection. Alongside demographic and clinical data, regular patient follow-ups were conducted to assess local recurrence.

RESULTS

Among the 104 patients diagnosed with GCP who underwent endoscopic resection, 12.5% had a history of previous gastric procedures. The primary site predominantly affected was the cardia (38.5%, n = 40). GCP commonly exhibited intraluminal growth (99%), regular presentation (74.0%), and ulcerative mucosa (61.5%). The leading endoscopic feature was the mucosal lesion type (59.6%, n = 62). The average maximum diameter was 20.9 ± 15.3 mm, with mucosal involvement in 60.6% (n = 63). Procedures lasted 73.9 ± 57.5 min, achieving complete resection in 91.3% (n = 95). Recurrence (4.8%) was managed via either surgical intervention (n = 1) or through endoscopic resection (n = 4). Final pathology confirmed that 59.6% of GCP cases were associated with EGC. Univariate analysis indicated that elderly males were more susceptible to GCP associated with EGC. Conversely, multivariate analysis identified lesion morphology and endoscopic features as significant risk factors. Survival analysis demonstrated no statistically significant difference in recurrence between GCP with and without EGC (P = 0.72).

CONCLUSION

The findings suggested that endoscopic resection might serve as an effective and minimally invasive treatment for GCP with or without EGC.

Editorial article to: Animal experimental study on magnetic anchor technique-assisted endoscopic submucosal dissection of early gastric cancer

In this editorial we comment on the article published in the recent issue of the World Journal of Gastrointestinal Endoscopy 2023; 15 (11): 634-680. Gastric cancer (GC) remains the fifth most common malignancy and the fourth leading cause of cancer-related death worldwide. The overall prevalence of GC has declined, although that of proximal GC has increased over time. Thus, a significant proportion of GC cases and deaths can be avoided if preventive interventions are taken. Early GC (EGC) is defined as GC confined to the mucosa or submucosa. Endoscopic resection is considered the most appropriate treatment for precancerous gastrointestinal lesions improving patient quality of life, with reduced rates of complications, shorter hospitalization period, and lower costs when compared to surgical resection. Endoscopic mucosal resection (EMR) and endoscopic sub-mucosal dissection (ESD) are representative endoscopic treatments for EGC and precancerous gastric lesions. Standard EMR implies injection of a saline solution into the sub-mucosal space, followed by excision of the lesion using a snare. Complete resection rates vary depending on the size and severity of the lesion. When using conventional EMR methods for lesions less than 1 cm in size, the complete resection rate is approximately 60%, whereas for lesions larger than 2 cm, the complete resection rate is low (20%-30%). ESD can be used to remove tumors exceeding 2 cm in diameter and lesions associated with ulcers or submucosal fibrosis. Compared with EMR, ESD has higher en bloc resection rates (90.2% vs 51.7%), higher complete resection rates (82.1 vs 42.2%), and lower recurrence rates (0.65% vs 6.05%). Thus, innovative techniques have been introduced.

The role of the multidisciplinary tumor board after endoscopic resection of malignant tumors: is it worth it?

OBJECTIVES

The value of multidisciplinary tumor boards (MTBs) in the treatment of gastrointestinal cancer patients is well known. Most of the current evidence focuses on advanced cancer cases, whereas little is known about the effect of MTBs on early tumors, especially after endoscopic resection. The aim of our study is to evaluate the value of the MTB after endoscopic resection of malignant tumors of the gastrointestinal tract.

METHODS

We retrospectively analyzed all endoscopically resected malignant tumors in our department between 2011 and 2019, focusing on the existence of an MDT recommendation after endoscopic resection, the MDT adherence to the current guidelines, and the implementation of the recommendation by the patients.

RESULTS

We identified 198 patients fulfilling our inclusion criteria, of whom 168 (85%) were discussed in the MDT after endoscopic resection. In total, 155 of the recommendations (92%) were in accordance with the current guidelines, and 147 (88%) of them were implemented by the patients. The MDT discussion itself did not influence the overall survival, whereas the implementation of the MTB recommendation was associated with a significantly better prognosis. Deviations of the MDT recommendation from the guidelines had no effect on the overall survival.

CONCLUSIONS

The discussion of endoscopically resected malignant tumors in the MTB is crucial for the treatment of patients with this type of cancer, since the implementation of the MTB recommendation, even if it deviates from the current guidelines, improves the prognosis.

An umbrella-inspired snap-on robotic 3D photoacoustic endoscopic probe for augmented intragastric sensing: Proof of concept study

In this paper, we present a novel on-demand modular robotic photoacoustic tomography (PAT) probe integrated into an endoscopic device, potentially for deep intragastric sensing. The proposed solution offers a plug-and-play approach through the use of meso-scale steerable endoscopy and a new 'snap-on' 3D robotic PAT probe that can reconfigure the geometry of the intracorporeal light delivery, inspired by an umbrella structure. Specifically, using the limited esophageal access, steerable endoscopy allows navigation and advancement of a distally mounted robotic add-on for PAT that is folded until it reaches the deep-seated gastric lesion. Once the tip is positioned near the lesion site in the gastric cavity, there is ample working space for the robotic probe to adjust its umbrella-like unfolded shape. This allows fine-tuning of the laser delivery orientation of the fiber bundles to achieve the lesion-specific light delivery scheme. This design allows volumetric imaging of the intragastric PAT with enhanced sensitivity. To evaluate the performance of the modular robotic PAT probe, we performed a simulation analysis of the light intensity and ultrasound field distribution. The simulation results show that the robotic probe is feasible for intracorporeal PAT imaging. In addition, we printed a 3D model of a human stomach containing a simulated gastric tumour. Both the phantom and ex vivo experimental results validate the feasibility of the proposed robotic PAT probe.

Management of high risk T1 gastric adenocarcinoma following endoscopic resection

Endoscopic submucosal dissection has revolutionized the treatment of early gastric cancer. However, cases that do not meet the curability criteria have a higher risk of lymph node metastasis and salvage surgery is still considered the next treatment approach to increase the chance of cure. Nevertheless, not all high-risk resections entail the same level of risk, emphasizing the utmost importance of individualized stratification for further treatment. In this review, we aim to examine the current evidence concerning the management following a high-risk non-curative resection, highlighting the existing approaches, while also presenting upcoming strategies that attempt to improve patient outcomes, minimize adverse events, and provide a tailored management.

Potential for expanding indications and curability criteria of endoscopic resection for early gastric cancer in elderly patients: results from a Japanese multicenter prospective cohort study

BACKGROUND AND AIMS

Evidence for endoscopic resection (ER) in elderly patients with early gastric cancer (EGC) is limited. We assessed its clinical outcomes, and explored new indications and curability criteria.

METHODS

We analyzed data from a Japanese multicenter prospective cohort study. Patients aged ≥75 years with EGC treated with ER were included. We classified "eCuraC-2 (corresponding to noncurative ER, defined in the Japanese gastric cancer treatment guidelines)" into "elderly-high (EL-H)" (>10% estimated metastatic risk) and "elderly-low (EL-L)" (≤10%).

RESULTS

In total, 3,371 patients with 3,821 EGCs were included; endoscopic submucosal dissection (ESD) was the prominent treatment choice. Among them, 3,586 lesions met the guidelines' ER indications and 235 did not. The proportions of en bloc and R0 resections and perforations were 98.9%, 94.4%, and 0.8%, respectively, in EGCs within the indications. In EGCs beyond the indications, they were 99.5%, 85.4%, and 5.9%, respectively, for lesions diagnosed as ≤3 cm, and 96.0%, 64.0%, and 18.0% for those >3 cm. Curative ER ("eCuraA/B") and EL-L were observed in 83.6% and 6.2% of lesions within the indications, respectively, and in 44.2% and 16.8% of lesions <3 cm beyond the indications, respectively. The 5-year cumulative gastric cancer death rates following eCuraA/B and EL-H were 0.3% (95% CI, 0.2-0.6) and 3.5% (2.0-5.7), respectively. Following EL-L, the rate was 0.9% (0.2-3.5) even without subsequent treatment.

CONCLUSIONS

Usefulness of ESD for elderly EGC patients was confirmed by their clinical outcomes. Lesions ≤3 cm and EL-L emerged as new ER indication and curability criterion, respectively.

Early gastric cancer recurrence after endoscopic submucosal dissection: Not to be ignored!

This editorial comments on the article "Efficacy of multi-slice spiral computed tomography in evaluating gastric cancer recurrence after endoscopic submucosal dissection". We focus on the importance of paying more attention to post-endoscopic submucosal dissection (ESD) gastric cancer recurrence in patients with early gastric cancer (EGC) and how to manage it effectively. ESD has been a well-known treatment and the mainstay for EGC, with the advantages of less invasion and fewer complications when compared with traditional surgical procedures. Despite a lower local recurrence rate after ESD, the problem of postoperative recurrence in patients with EGC has become increasingly non-ignorable with the global popularization of ESD technology and the increasing number of post-ESD patients.

Risk Factors for a Narrow Safety Margin after Endoscopic Submucosal Dissection for Early Gastric Cancer

INTRODUCTION

A narrow safety margin (NSM) after endoscopic submucosal dissection (ESD) is a well-recognized risk factor for local recurrence in early gastric cancer (EGC). However, only a few studies have investigated the risk factors for the development of NSM.

METHODS

The medical records and pathologic specimens of patients with EGC who underwent ESD from January 2020 to December 2020 at a single tertiary hospital (Daejeon, South Korea) were reviewed.

RESULTS

A total of 218 patients were enrolled and 29 had NSM (<3 mm). When comparing the NSM and the control groups, the size of the lesion, the depth of invasion, and the operating endoscopist were found to be risk factors for the development of NSM. The increased length of the subepithelial spread of the lesion was associated with a narrower safety margin. Logistic regression analysis revealed that lesion size was a risk factor for NSM, and a marginally significant difference between endoscopists was found.

CONCLUSIONS

Multiple factors may need to be considered during ESD, including lesion size, invasion depth, operating endoscopist, and subepithelial spread.

Characteristics of Gastric Mucosa-Associated Microbiota in Patients with Early Gastric Cancer After Successful Helicobacter pylori Eradication

BACKGROUND

Helicobacter pylori (H. pylori) is widely recognized as a definite carcinogen in gastric cancer (GC). Although H. pylori eradication reduces the risk of GC, GC recurrence has been detected even after successful H. pylori eradication. Recently, the analysis of gut microbiota was reported.

AIMS

This study aimed to evaluate the correlation between gastric mucosa-associated microbiota (G-MAM) and early gastric cancer (EGC) after successful H. pylori eradication.

METHODS

In this pilot study, G-MAM were collected during the esophagogastroduodenoscopy of 17 patients, receiving H. pylori eradication therapy at least 5 years ago. The patients were divided into those with EGC (the EGC group, 8 patients) and those without EGC (the NGC group, 9 patients). Microbial samples in the greater curvature of the pyloric site were obtained using an endoscopic cytology brush, and the G-MAM profiles of each sample were analyzed using 16S rRNA V3-V4 gene sequencing.

RESULTS

Between the two groups, there was no significant difference in the median age, sex, median period after successful eradication of H. pylori, the α diversity, and the average abundance at the phylum level. At the genus level, the average abundance of Unclassified Oxalobacteraceae, Capnocytophaga, and Haemophilus was significantly lower in the EGC group than in the NGC group (0.89 vs. 0.14%, P < 0.01, 0.28 vs. 0.00%, P < 0.01 and 5.84 vs. 2.16%, P = 0.034, respectively).

CONCLUSIONS

We demonstrated alternations in the profiles of G-MAM between the two groups. Our results suggest that G-MAM may influence carcinogenesis after successful H. pylori eradication.

A web-based prediction model for long-term cancer-specific survival of middle-aged patients with early-stage gastric cancer: a multi-institutional retrospective study

BACKGROUND

This study constructed and validated a prognostic model to evaluate long-term cancer-specific survival (CSS) in middle-aged patients with early gastric cancer (EGC).

METHODS

We extracted clinicopathological data from relevant patients between 2004 and 2015 from Surveillance, Epidemiology, and End Results (SEER) database, and randomly divided the patients into a training group (N = 688) and a validation group (N = 292). In addition, 102 Chinese patients were enrolled for external validation. Univariate and multivariate Cox regression models were used to screen for independent prognostic factors, and a nomogram was constructed to predict CSS. We used the concordance index (C-index), calibration curve, receiver operating characteristic (ROC) curve, and decision curve analysis (DCA) to evaluate the predictive performance of the model.

RESULTS

Univariate and multivariate COX regression analyses showed that tumor location, differentiation grade, N stage, chemotherapy, and number of regional nodes examined were independent risk factors for prognosis, and these factors were used to construct the nomogram. The C-index of the model in the training cohort, internal validation cohort, and external validation cohort was 0.749 (95% CI 0.699-0.798), 0.744 (95% CI 0.671-0.818), and 0.807 (95% CI 0.721-0.893), respectively. The calibration curve showed that the model had an excellent fit. The DCA curve showed that the model had good predictive performance and practical clinical value.

CONCLUSION

This study developed and validated a new nomogram to predict CSS in middle-aged patients with EGC. The prediction model has unique and practical value and can help doctors carry out individualized treatment and judge prognosis.

Feasibility and safety of pure single-incision laparoscopic total and proximal gastrectomy for early gastric cancer: propensity score-matched comparison to multiport totally laparoscopic approach

BACKGROUND

There have been few studies regarding the feasibility and safety of pure single-incision laparoscopic total gastrectomy (SITG) or proximal gastrectomy (SIPG) for early gastric cancer (EGC). The purpose of this study was to analyze the surgical outcome of all consecutive SITG or SIPG cases compared with multiport laparoscopic total gastrectomy (MLTG) or proximal gastrectomy (MLPG) for EGC.

METHODS

We analyzed all consecutive SITG or SIPG cases with double-tract reconstruction for ECG, including the initial case, between March 2013 and December 2021. SITG/SIPG was performed on patients without significant systemic comorbidities through a 3-4 cm vertical transumbilical incision. SITG/SIPG was matched to multiport laparoscopic total or proximal gastrectomy (MLTG/MLPG) cases performed in the same period using a 1:3 propensity score matching, including sex, body mass index (BMI), age and type of resection, year of operation, and institution as covariates. We compared perioperative clinicopathological characteristics and early postoperative morbidity within 1 month after surgery between the SITG/SIPG and MLTG/MLPG groups.

RESULTS

In total, 21 patients with SITG and 15 patients with SIPG were compared with those with MLTG (n = 264) and MLPG (n = 220). No conversion to an open or multiport approach occurred in the SITG/SIPG group. After matching, operation time was similar between SITG/SIPG and MLTG/MLPG (223.9 ± 63.5 min vs 234.8 ± 68.7 min, P = 0.402). Length of stay was not significantly different between SITG/SIPG and MLTG/MLPG (11.9 ± 15.4 days vs 8.4 ± 5.0 days, P = 0.210). The average number of retrieved lymph nodes was not significantly different between SITG and MLTG (53.1 ± 16.3 vs 63.2 ± 27.5, P = 0.115), but it was significantly higher in SIPG than MLPG (59.6 ± 27.2 vs 46.0 ± 19.7, P = 0.040). The overall complication rate (30.6% vs 25.9%, P = 0.666) and Clavien-Dindo grade III or higher complication rates (13.9% vs 6.5%, P = 0.175) were not significantly different between the SITG/SIPG and MLTG/MLPG groups.

CONCLUSION

Cautious adoption of SITG/SIPG procedures for EGC is feasible and safe.

Coexistence of early gastric cancer and benign submucosal lesions mimic invasive cancer: a retrospective multicenter experience

OBJECTIVE

To present a study to identify the characteristics of coexisting early gastric cancer (EGC) and benign submucosal lesions, with the aim of reducing the adverse consequences of overdiagnosis and overtreatment.

METHODS

In this retrospective study, we searched the endoscopic databases of three tertiary centers. We screened of patients suspected of early gastric cancer submucosal infiltration by conventional endoscopy and ultimately selected for endoscopic submucosal dissection treatment after endoscopic ultrasonography and magnifying endoscopy with narrow-band imaging examination. Patients with coexisting EGC and benign submucosal lesions in histological sections were included. Clinical data and endoscopic images were reviewed. To evaluate the precision of endoscopists' diagnoses for this type of lesion, eight endoscopists with different experiences were recruited to judge the infiltration depth of these lesions and analyze the accuracy rate.

RESULTS

We screened 520 patients and retrospectively identified 18 EGC patients with an invasive cancer-like morphology. The most common lesion site was the cardia (12/18, 66.67%). The coexisting submucosal lesions could be divided into solid (5/18, 27.78%) and cystic (13/18, 72.22%). The most common type of submucosal lesion was gastritis cystica profunda (12/18, 66.67%), whereas leiomyoma was the predominant submucosal solid lesion (3/18, 16.67%). Ten (55.56%) patients < underwent endoscopic ultrasonography; submucosal lesions were definitively diagnosed in 6 patients (60.00%). The accuracy of judgement of the infiltration depth was significantly lower in cases of coexistence of EGC with benign submucosal lesions (EGC-SML) than in EGC (38.50% versus 65.60%, P = 0.0167). The rate of over-diagnosis was significantly higher within the EGC-SML group compared to the EGC group (59.17% versus 10.83%, P < 0.0001).

CONCLUSIONS

We should be aware of the coexistence of EGC and benign submucosal lesions, the most common of which is early cardiac-differentiated cancer with gastritis cystica profunda.

Endoscopic submucosal dissection for early gastric cancer: It is time to consider the quality of its outcomes

Endoscopic resection, particularly endoscopic submucosal dissection (ESD), is widely used as a standard treatment modality for early gastric cancer (EGC) when the risk of lymph node metastasis is negligible. Compared with surgical gastrectomy, ESD is a minimally invasive procedure with additional advantages, such as preservation of the entire stomach and maintenance of the patient's quality of life. However, not all patients achieve curative resection after ESD of EGC. Several patients require surgical gastrectomy after ESD to achieve a curative treatment. Additional surgery after ESD, owing to non-curative resection, places considerable emotional and financial burdens on patients. Recently, as the number of endoscopists performing ESD has increased, the rate of non-curative resection after ESD has increased correspondingly. In order to decrease the non-curative resection rate, as well as determine the ideal rate of non-curative resection after ESD, it is time to consider quality indicators for the outcomes of ESD for EGC.

Risk factors of additional surgery after non-curative endoscopic submucosal dissection for early gastric cancer

BACKGROUND

The criteria for surgical intervention after non-curative endoscopic submucosal dissection (ESD) of early gastric cancer are unclear. We aimed to clarify the risk factors for residual cancer and lymph node metastasis after non-curative ESD and to identify recommendations for additional surgery.

METHODS

We collected data on 133 consecutive patients who underwent additional surgery after non-curative ESD of early gastric cancer at Nanjing Drum Tower Hospital from January 2013 to July 2022. Univariate and multivariate analyses were performed to seek risk factors of residual cancer and lymph node metastasis.

RESULTS

The incidence rates of residual cancer and lymph node metastasis were 13.5% (18/133) and 10.5% (14/133), respectively. There was neither residual tumor nor lymph node metastasis in 104 (78.2%) cases. Multivariate analyses elucidated that horizontal margin was an independent risk factor for local residual cancer, whereas lymphatic infiltration was an independent risk factor for lymph node metastasis. Patients with mixed histological types were more likely to suffer lymph node metastasis and further undergo additional surgery after non-curative ESD than pure histological type.

CONCLUSIONS

Additional gastrectomy with lymph node dissection was strongly recommended in patients with lymphatic infiltration after non-curative ESD of early gastric cancer. Patients with mixed histological type have a high propensity for lymph node metastasis and should be treated as a separate subtype.

Recent Progress of Image-Enhanced Endoscopy for Upper Gastrointestinal Neoplasia and Associated Lesions

BACKGROUND

The main therapeutic modality of early upper gastrointestinal neoplasms has shifted from surgery to endoscopic therapy. The role of endoscopy has also expanded not only for more accurate diagnosis of neoplasms but also for the determination of extent and depth of neoplasms with a combination of multiple electronically modified images acquired with image-enhanced endoscopy (IEE) for assessing the feasibility of endoscopic treatment.

SUMMARY

These IEE with or without magnifying endoscopy including narrow-band imaging, blue laser imaging, and linked color imaging (LCI) using narrow-band light have greatly changed the diagnosis for upper gastrointestinal neoplasms. These modalities produce high color contrast between cancer and surrounding mucosa at distant views and clear visualization of surface and vessels at close-up observations. LCI shows purple color of intestinal metaplasia (IM) distinct from other inflammatory gastric mucosae and facilitates the recognition of early gastric cancers often surrounded by IM. Recently, ultrathin endoscopy has provided high-resolution images similar to standard-caliber endoscopy. In addition, these advanced IEEs that integrate computer-assisted artificial intelligence systems are marked and will improve our diagnostic performance for neoplasia in the future.

KEY MESSAGE

New IEE with sufficient brightness and color contrast has increasingly been used based on accumulated evidence for early and accurate detection of neoplastic lesions. We provide recent articles relevant to endoscopic diagnosis with IEE on esophageal, gastric, and duodenal neoplasms. Endoscopic equipment that integrates artificial intelligence support system is now being introduced into routine clinical use and is expected to enhance early detection of neoplastic lesions.

pylori Infection

INTRODUCTION

Early gastric cancer with current Helicobacter pylori infection (HpC-EGC) is common, but it is still unclear whether H. pylori eradication therapy (Hp-ET) or endoscopic submucosal dissection (ESD) should be performed first. We evaluated Hp-ETs short-term effects on horizontal boundary delineations of HpC-EGC in ESD.

METHODS

Prospectively enrolled HpC-EGC patients were randomly assigned to eradication or control groups. Operation scopes of HpC-EGC lesions were delineated with marking dots at 5 mm out of the endoscopic demarcation line by an independent endoscopist, unaware of eradication status, before formal circumferential incision. As representatives, precise delineation rate, the shortest distance of all marking dots to the pathological demarcation line in all slices of one intact resected specimen (Dmin), and negative marking dot specimen rate were examined.

RESULTS

Twenty-three HpC-EGC patients (25 lesions) were allocated to eradication group and 26 patients (27 lesions) were allocated to the control group with similar eradication success rates and all were differentiated type. With improving background mucosa inflammation after Hp-ET and similar gastritis-like epithelium rates, 10 lesions (40.0%) in the eradication group were of precise delineation compared to control group with 2 lesions (7.4%) (relative risk = 5.40, 95% CI 1.31-22.28). Dmin of eradication and control groups were 4.17 ± 2.52 mm and 2.67 ± 2.30 mm (p = 0.029), accompanied by 4 (14.8%) and none (0.0%) specimens that exhibited positive marking dots (p = 0.11), respectively.

CONCLUSION

For HpC-EGC patients, administrating eradication medication before ESD is beneficial for the precise delineation of lesions and reducing the risk of positive horizontal resection margins.

Endoscopic resection of early gastric cancer

Endoscopic resection (ER) is an effective treatment for early gastric cancer (EGC) without metastases. Existing endoscopic mucosal resection (EMR) is easy to perform, has few complications, and can be applied when the lesion size is small. However, en bloc and complete resection rates vary depending on the size and severity of the lesion. EMR using the cap-mounted panendoscopic method and EMR after circumferential preamputation of the lesion are useful in the treatment of EGC. However, completely oversized lesions (≥2 cm) and lesions associated with ulcers or submucosal fibrosis are more likely to fail resection. Endoscopic submucosal dissection has been widely used to resect tumors larger than 2 cm in diameter and has a higher acceptable complication rate and en bloc and complete resection rates than EMR. ER for EGC is superior to surgical resection in terms of improving patient quality of life. Additionally, compared to surgery, emergency rooms have a lower rate of treatment-related complications, shorter hospital stays, and lower costs. Accordingly, the indications for ER are expanding in the field of therapeutic endoscopy. Long-term outcomes regarding recurrence are excellent in both absolute and extended criteria for ER in EGC. Close surveillance should be performed after ER to detect early metachronous gastric cancer and precancerous lesions that can be treated with ER. Follow-up gastroscopy and abdominopelvic computed tomography scans every 6 to 12 months are recommended for patients who undergo curative ER for EGC on absolute or extended criteria.

Decision to perform additional surgery after non-curative endoscopic submucosal dissection for gastric cancer based on the risk of lymph node metastasis: a long-term follow-up study

BACKGROUND

Radical surgery after non-curative endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) may be excessive, since only 5-10% of patients have lymph node metastasis (LNM). This study investigated the suitability of the eCura system for determining the need for radical surgery after non-curative ESD.

METHODS

We retrospectively investigated 343 patients who underwent non-curative ESD for EGC from 2006 to 2021 at a tertiary hospital in Korea. These patients were divided into surgery (n = 191) and observation (n = 152) groups based on whether they underwent additional surgery post-ESD. Each group was further classified into low-risk (eCura score 0-1), intermediate-risk (eCura score 2-4) and high-risk (eCura score 5-7). All patients were regularly followed-up at least annually after the initial treatment. The cumulative overall and recurrence-free survival rates were calculated for each category and compared between the surgery and observation groups.

RESULTS

No significant differences in overall survival were found between the surgery and observation groups in low-risk (p = 0.168) and intermediate-risk patients (p = 0.306); however, high-risk patients had better 5-year overall survival rate in the surgery group than in the follow-up group (95.2% vs. 71.4%, p < 0.001). The 5-year recurrence-free survival rate was higher in the surgery group than in the observation group for low-risk (100% vs. 84.3%; p = 0.034), intermediate-risk (96.1% vs. 88.4%; p = 0.081) and high-risk patients (100% vs. 83.3%; p = 0.023).

CONCLUSIONS

Follow-up without additional surgery after non-curative ESD can be a reasonable option for low-risk and even intermediate-risk patients according to the eCura system. However, surgery is warranted for eCura high-risk patients.

Exploring the challenge of early gastric cancer diagnostic AI system face in multiple centers and its potential solutions

BACKGROUND

Artificial intelligence (AI) performed variously among test sets with different diversity due to sample selection bias, which can be stumbling block for AI applications. We previously tested AI named ENDOANGEL, diagnosing early gastric cancer (EGC) on single-center videos in man-machine competition. We aimed to re-test ENDOANGEL on multi-center videos to explore challenges applying AI in multiple centers, then upgrade ENDOANGEL and explore solutions to the challenge.

METHODS

ENDOANGEL was re-tested on multi-center videos retrospectively collected from 12 institutions and compared with performance in previously reported single-center videos. We then upgraded ENDOANGEL to ENDOANGEL-2022 with more training samples and novel algorithms and conducted competition between ENDOANGEL-2022 and endoscopists. ENDOANGEL-2022 was then tested on single-center videos and compared with performance in multi-center videos; the two AI systems were also compared with each other and endoscopists.

RESULTS

Forty-six EGCs and 54 non-cancers were included in multi-center video cohort. On diagnosing EGCs, compared with single-center videos, ENDOANGEL showed stable sensitivity (97.83% vs. 100.00%) while sharply decreased specificity (61.11% vs. 82.54%); ENDOANGEL-2022 showed similar tendency while achieving significantly higher specificity (79.63%, p < 0.01) making fewer mistakes on typical lesions than ENDOANGEL. On detecting gastric neoplasms, both AI showed stable sensitivity while sharply decreased specificity. Nevertheless, both AI outperformed endoscopists in the two competitions.

CONCLUSIONS

Great increase of false positives is a prominent challenge for applying EGC diagnostic AI in multiple centers due to high heterogeneity of negative cases. Optimizing AI by adding samples and using novel algorithms is promising to overcome this challenge.

Development and Validation of Models to Predict Lymph Node Metastasis in Early Gastric Cancer Using Logistic Regression and Gradient Boosting Machine Methods

PURPOSE

To identify important features of lymph node metastasis (LNM) and develop a prediction model for early gastric cancer (EGC) using a gradient boosting machine (GBM) method.

MATERIALS AND METHODS

The clinicopathologic data of 2556 patients with EGC who underwent gastrectomy were used as training set and the internal validation set (set 1) at a ratio of 8:2. Additionally, 548 patients with EGC who underwent endoscopic submucosal dissection (ESD) as the initial treatment were included in the external validation set (set 2). The GBM model was constructed, and its performance was compared with that of the Japanese guidelines.

RESULTS

LNM was identified in 12.6% (321/2556) of the gastrectomy group (training set & set 1) and 4.3% (24/548) of the ESD group (set 2). In the GBM analysis, the top five features that most affected LNM were lymphovascular invasion, depth, differentiation, size, and location. The accuracy, sensitivity, specificity, and the area under the receiver operating characteristics of set 1 were 0.566, 0.922, 0.516, and 0.867, while those of set 2 were 0.810, 0.958, 0.803, and 0.944, respectively. When the sensitivity of GBM was adjusted to that of Japanese guidelines (beyond the expanded criteria in set 1 [0.922] and eCuraC-2 in set 2 [0.958]), the specificities of GBM in sets 1 and 2 were 0.516 (95% confidence interval, 0.502-0.523) and 0.803 (0.795-0.805), while those of the Japanese guidelines were 0.502 (0.488-0.509) and 0.788 (0.780-0.790), respectively.

CONCLUSION

The GBM model showed good performance comparable with the eCura system in predicting LNM risk in EGCs.

Factors associated with heterochronic gastric cancer development post-endoscopic mucosal dissection in early gastric cancer patients

BACKGROUND

Endoscopic mucosal resection is an innovative method for treating early gastric cancer and has been widely used in clinical practice.

AIM

To analyze the factors associated with the development of heterochronic gastric cancer in patients with early gastric cancer who had undergone endoscopic mucosal dissection (EMD).

METHODS

A cohort of patients with early gastric cancer treated using EMD was retrospectively analyzed, and patients who developed heterochronic gastric cancer after the surgery were compared with those who did not. The effects of patient age, sex, tumor size, pathological type, and surgical technique on the development of heterochronic gastric cancer were assessed using statistical analysis.

RESULTS

Of the 300 patients with early gastric cancer, 150 patients developed heterochronic gastric cancer after EMD. Statistical analysis revealed that patient age (P value = XX), sex (P value = XX), tumor size (P value = XX), pathological type (P value = XX), and surgical technique (P value = XX) were significantly associated with the occurrence of heterochronic gastric cancer.

CONCLUSION

Age, sex, tumor size, pathological type, and surgical technique are key factors influencing the occurrence of heterochronic gastric cancer after EMD in patients with early gastric cancer. To address these factors, postoperative follow-up and management should be strengthened to improve the prognosis and survival rate of patients.

Efficacy of multi-slice spiral computed tomography in evaluating gastric cancer recurrence after endoscopic submucosal dissection

BACKGROUND

Recurrence is the major challenge facing endoscopic submucosal dissection (ESD)-based treatment therapies for early gastric cancer (EGC). Urgent development of simple and easy surveillance approaches will enhance clinical treatment of the disease.

AIM

To explore the role of computed tomography (CT) recurrence in evaluating EGC after ESD treatment.

METHODS

We retrospectively recruited patients from our endoscopy department, between January 2002 and December 2015, and analyzed their basic characteristics, including symptoms, CT results, and results of endoscopy with biopsy, among others.

RESULTS

Among a total of 2150 patients EGC patients surveyed, 1362 met our inclusion and exclusion criteria and were therefore enrolled in our study. The cohort's sensitivity of CT for recurrent GC and specificity were 44.22% and 43.86%, respectively, with negative and positive predictive values of 40.15% (275/685) and 48.01% (325/677), respectively. The area under the curve of arterial and venous CT values for recurrent EGC were 0.545, and 0.604, respectively. Receiver operating characteristic curve revealed no statistically significant differences between arterial and venous CT values for recurrent EGC.

CONCLUSION

Enhanced CT has superior diagnostic efficacy, but less accuracy, compared to gold standard techniques in patients with recurrent EGC.

Short-term efficacy of additional laparoscopic-assisted radical gastrectomy after non-curative endoscopic submucosal dissection for early gastric cancer

OBJECTIVE

To investigate short-term efficacy of direct laparoscopic-assisted radical gastrectomy (LAG) versus non-curative endoscopic submucosal dissection (ESD) plus additional LAG for early gastric cancer.

MATERIALS AND METHODS

286 patients were retrospectively assigned into two groups: direct LAG group (n = 255) and additional LAG (ESD plus LAG, n = 31) group. A 1:2 propensity score matching was performed to equalize relevant confounding factors between two groups for analysis.

RESULTS

Ninety-three patients were successfully matched, including 62 in the direct LAG group and 31 in the additional LAG group. A significant (P = 0.013) difference existed in the drainage removal time between the additional LAG and direct LAG group (7 d vs. 6 d). Age, sex, tumor location and surgical approach were significantly (P < 0.05) associated with complications, with age ≥ 60 years (P = 0.002) and total gastrectomy (P = 0.011) as significant independent risk factors. A significant (P = 0.023) difference existed in the surgical time between the early and late groups (193.3 ± 37.6 min vs. 165.5 ± 25.1 min).

CONCLUSION

Additional LAG (D1 + lymphadenectomy) after ESD may be safe and effective even though non-curative ESD may prolong the drainage removal time and increase the difficulty of surgery.

Comparison of endoscopic submucosal dissection versus surgery for early gastric cancer in the elderly: a pooled analysis

PURPOSE

The aim of this study was to investigate whether there was a difference in overall survival (OS) between elderly patients with early gastric cancer (EGC) who underwent endoscopic submucosal dissection (ESD) and those who underwent surgery.

METHODS

Four databases including PubMed, Embase, the Cochrane Library and CKNI were searched on March 20, 2023. The characteristics of the studies and the baseline information of the patients, including their medical histories, postoperative data, and prognoses, were recorded. Odds ratios (ORs) or mean differences (MDs), and 95% confidence intervals (CIs) were pooled up to calculate baseline information and postoperative information. Hazard ratios (HRs) and 95% CIs were used to calculate the prognosis of the patients. Stata V16.0 software was used for the data analysis.

RESULTS

A total of eight studies involving 2334 patients were included for the data analysis in this study. After pooling up the data, we found that the ESD group had lower Eastern Cooperative Oncology Groupprevious (ECOG) scores (OR = 0.33, 95% CI = 0.17 to 0.65, I2 = 59.69%, P = 0.00 < 0.05) than the surgery group. There were significant differences in the operation time (MD = -3.38, 95% CI = -5.19 to -1.57, I2 = 98.31%, P = 0.00 < 0.05), length of hospital stay (MD = -3.01, 95% CI = -4.81 to -1.20, I2 = 98.83%, P = 0.00 < 0.05) and hospitalization expenses (MD = -2.67, 95% CI = -3.59 to -1.75, I2 = 93.21%, P = 0.00 < 0.05) between the two groups. The ESD group had a lower OS rate (HR = 2.81, 95% CI = 2.20 to 3.58, I2 = 12.28%, P = 0.00 < 0.05).

CONCLUSION

Elderly patients with EGC who underwent ESD had a significantly worse OS rate than those who underwent surgery. If the patient's condition was suitable, surgery was still recommended for these patients.

Evaluation of the widths of the mucosal strips in pathological examination of specimens of endoscopic submucosal dissection for early gastric cancer

BACKGROUND

Endoscopic submucosal dissection (ESD) is the standard treatment for early gastric cancer in Japan. Pathological evaluation of ESD specimens is considered essential to determine if additional gastrectomy is necessary. Usually, specimens resected by ESD are sliced into 2-3 mm wide sections, and each section is examined for depth of tumor and lymphovascular invasion. Nevertheless, in most cases of additional gastrectomy, lymph node metastasis is not present. Given that there are few-studies on how clinical-decisions based on the pathologic-evaluation-method, in particular the specimen cut-width, influence patient outcomes, we retrospectively evaluated whether reducing the number of cuts to one-half or one-third would result in underestimation of the real need for additional surgery. The effect of the actual cut-width on recommended treatment (referral to operation) and patient-outcomes was also assessed.

METHODS

Pathological records of 498 lesions from 439 patients were reviewed and re-evaluated. All pathological descriptions are based on the gastric cancer classification system of the Japanese Gastric Cancer Association, 15th edition.

RESULTS

In 5.8% and 8.5% of the total specimens, underdiagnosis of tumor-depth and lymphovascular invasion occurred when the number of sections was reduced to one-half and one-third, respectively. Significantly more submucosal invasions were found in the group in which the cut-with was between 3 and 4 mm than in the group in which the cut width was less than 3 mm.

CONCLUSION

Evaluation of the appropriate cut-width is important and should be discussed from the standpoint of labor costs and lost opportunities to search for molecular markers in ESD materials.

Feasibility for the application of expanded endoscopic resection criteria in mucosal undifferentiated gastric cancer

BACKGROUND & AIM

The indication of endoscopic submucosal dissection (ESD) for mucosal undifferentiated early gastric cancer (EGC) remains controversial because of risk of lymph node metastasis (LNM). The aim of this study was to identify risk factors for lymph node metastasis (LNM) in mucosal undifferentiated EGC, and further to confirm feasibility of the ESD for the treatment of mucosal undifferentiated EGC.

METHODS

We retrospectively reviewed data of patients who underwent surgical resection with lymph node dissection of T1a stage primary gastric adenocarcinoma at three medical centers between 2012 and 2022. We evaluated the frequency of lymph node metastasis and the associated risk factors, as well as the lymph node metastasis rate in the expanded indication of mucosal undifferentiated EGC.

RESULTS

A total of 100 surgically treated patients with mucosal undifferentiated EGC were enrolled. LNM was irrelevant to the age, tumor size, location, and macroscopic type (all P > 0.05), while it was significantly associated with lymphovascular invasion (LVI, P ＜0.001). And logistic regression analysis showed that the LVI was the only significant risk factors for LNM (OR: 0.34, 95%CI: 0.06-0.204; P ＜0.001). Of 44 mucosal undifferentiated EGC patients satisfying the expanded indication of ESD, 3 patients (6.8%) showed LN metastasis, all of them with undifferentiated cancer without ulceration, less than 2.0 cm in size.

CONCLUSIONS

Because LNM is present in mucosal undifferentiated EGC patients who satisfied the expanded indication of ESD, ESD cannot be considered a better choice than surgery for all undifferentiated EGC patients. LVI was significant risk factors for LNM in patients with mucosal undifferentiated EGC.

Diagnostic accuracy of frozen section biopsy for early gastric cancer extent during endoscopic submucosal dissection: a prospective study

BACKGROUND

Accurate diagnosis of the lateral extent of early gastric cancer during endoscopic submucosal dissection (ESD) is crucial to achieve negative resection margins. Similar to intraoperative consultation with a frozen section in surgery, rapid frozen section diagnosis with endoscopic forceps biopsy may be useful in assessing tumor margins during ESD. This study aimed to evaluate the diagnostic accuracy of frozen section biopsy.

METHODS

We prospectively enrolled 32 patients undergoing ESD for early gastric cancer. Biopsy samples for the frozen sections were randomly collected from fresh resected ESD specimens before formalin fixation. Two different pathologists independently diagnosed 130 frozen sections as "neoplasia," "negative for neoplasia," or "indefinite for neoplasia," and the frozen section diagnosis was compared with the final pathological results of the ESD specimens.

RESULTS

Among the 130 frozen sections, 35 were from cancerous areas, and 95 were from non-cancerous areas. The diagnostic accuracies of the frozen section biopsies by the two pathologists were 98.5 and 94.6%, respectively. Cohen's kappa coefficient of diagnoses by the two pathologists was 0.851 (95% confidence interval: 0.837-0.864). Incorrect diagnoses resulted from freezing artifacts, a small volume of tissue, inflammation, the presence of well-differentiated adenocarcinoma with mild nuclear atypia, and/or tissue damage during ESD.

CONCLUSIONS

Pathological diagnosis of frozen section biopsy is reliable and can be applied as a rapid frozen section diagnosis for evaluating the lateral margins of early gastric cancer during ESD.