Elsevier

Gastrointestinal Endoscopy

Volume 90, Issue 3, September 2019, Pages 467-479.e4
Gastrointestinal Endoscopy

Original article
Clinical endoscopy
Endoscopic submucosal dissection for suspected early gastric cancer: absolute versus expanded criteria in a large Western cohort (with video)

https://doi.org/10.1016/j.gie.2019.04.242Get rights and content

Background and Aims

Endoscopic submucosal dissection (ESD) is an effective, minimally invasive, surgery-sparing technique for the treatment of early gastric cancer (EGC). It is not well established whether EGC within the Japanese expanded criteria can be safely and effectively treated using ESD in the West. We describe the outcomes of ESD for endoscopically suspected, biopsy specimen–confirmed EGC and its adenomatous precursor lesions (pEGC) using the Vienna classification of dysplasia in a Western cohort.

Methods

Prospective data were collected on all pEGCs undergoing ESD at a single expert endoscopy center. Outcomes were compared among pEGC, satisfying the Japanese absolute and expanded criteria, those outside criteria, and those specimens that contained low-grade dysplasia (LGD) only. Specialist GI pathologists reviewed and classified all ESD specimens. Patients were followed up at 6 and 12 months.

Results

Over 71 months, 135 pEGCs in 121 patients (mean age, 72.0 years; 61.2% men) underwent ESD. Median pEGC size was 20 mm (interquartile range, 15-30), and 62 (45.9%) satisfied the expanded clinical criteria. Perforation occurred in 1.5% and postprocedural bleeding in 5.2%. Forty-two pEGCs (31.1%) contained LGD only. Rates of en bloc and R0 resection were 94.8% and 86.7%, respectively. One hundred seven pEGCs (79.2%) met the absolute or expanded criteria for endoscopic cure. Two pEGCs recurred during follow-up. Ten of 26 patients with pEGC (38.5%) outside criteria for cure underwent surgery after ESD with residual tumor detected in 3 specimens. Fifteen patients with outside criteria for pEGCs did not undergo surgery because of frailty or their expressed wish. Eleven of 15 patients have so far undergone first surveillance with 1 of 11 experiencing endoscopic and histologic recurrence.

Conclusions

ESD is a safe and effective treatment for pEGCs in a Western context. Patients who either decline or are too frail for surgery, with outside criteria resections, may benefit from ESD for local disease control. Large Western studies of ESD for pEGCs are required to define long-term patient outcomes and surveillance guidelines, particularly where pathology shows LGD or high-grade dysplasia only. (Clinical trial registration number: NCT02306707.)

Abbreviations

EGC
early gastric cancer
ESD
endoscopic submucosal dissection
HGD
high-grade dysplasia
IMC
intramucosal carcinoma
IQR
interquartile range
LGD
low-grade dysplasia
pEGC
precursor to early gastric cancer
SE
surveillance endoscopy
SMIC
submucosal invasive cancer

Cited by (0)

DISCLOSURE: Dr David Tate received a scholarship from the “Westmead Medical Research Foundation.” These funds were not used for this study. All authors disclosed no financial relationships relevant to this publication. The Cancer Institute New South Wales provided funding for a research nurse and data manager to assist with the administration of the study. There was no influence from the Institution regarding study design or conduct, data collection, management, analysis or interpretation, or preparation, review, or approval of the manuscript.

If you would like to chat with an author of this article, you may contact Dr Bourke at [email protected].

View Abstract