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Endoscopic Submucosal Dissection for the Treatment of Superficial Epithelial Gastric Neoplasia in a Portuguese Centre

Costa R.S.a · Ferreira A.a · Leal T.a · Costa D.a,b,c · Rolanda C.a,b,c · Gonçalves R.a

Author affiliations

aDepartment of Gastroenterology, Braga Hospital, Braga, Portugal
bLife and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
cICVS/3B’s – PT Government Associate Laboratory, Guimarães/Braga, Portugal

Corresponding Author

Dr. Rita Seara Costa

Departamento de Gastrenterologia, Hospital de Braga

Sete Fontes – São Victor

PT–4710-243 Braga (Portugal)

E-Mail rita.seara.costa@gmail.com

Keywords: Endoscopic resectionSubmucosal dissectionUpper endoscopyGastric epithelial neoplasiaEarly gastric cancerLow-grade intraepithelial neoplasiaHigh-grade intraepithelial neoplasia

Related Articles for ""
GE Port J Gastroenterol 2019;26:90–98
https://doi.org/10.1159/000487820

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Abstract

Background: The emergence of endoscopic submucosal dissection (ESD) made possible en bloc resection of neoplastic gastric lesions, regardless of lesion size, with reduced rates of complications and recurrence. This technique has become the preferred method for curative resection, instead of conventional endoscopic mucosal resection and surgery, when distant metastases have negligible risk. In Western countries experience with this technique has evolved quickly, with an increasing number of case series reported in the literature. This study aims to report the short- and long-term outcomes of ESD in gastric epithelial neoplastic lesions by a single operator in a Portuguese centre. Methods: A retrospective analysis of all gastric ESDs in a tertiary specialised unit during a 5-year period, between May 2012 and September 2017, was performed. Results: A total of 114 ESDs of gastric epithelial lesions were performed during this period; 96.5% of them were removed en bloc and 87.6% with R0 resection. A curative treatment was achieved in 83.2% of the cases. Complications occurred in 13.2% of the procedures, including early and delayed bleeding in 12 patients (10.5%) and one perforation (0.9%). With a median follow-up period of 12 months (interquartile range [IQR] = 18), 6 cases of recurrence at the previous ESD site were diagnosed: 4 residual lesions and 2 local recurrences in previous R0 resections. Residual lesions occurred more often in patients with larger lesions (median = 40.0 mm, IQR = 26 vs. median = 20.0 mm, IQR = 15, p = 0.008) and with positive horizontal margins (HMs) after resection (50.0 vs. 0.0%, Fisher exact test, p < 0.001). The cumulative incidence of metachronous gastric lesions at 34 months was 16.1%. All new lesions were effectively treated using an endoscopic technique. The disease-specific survival at 12 months was 100%. Conclusion: This study showed that ESD is an effective resection technique for gastric lesions with a good safety profile, confirming other European series. Regardless, high en bloc resection positive HM is still a problem in some specimens resected by ESD. Endoscopic surveillance can detect local recurrence and new lesions during early stages, potentially treatable by endoscopy.

© 2018 Sociedade Portuguesa de Gastrenterologia Published by S. Karger AG, Basel

Disseção endoscópica da submucosa no tratamento da neoplasia epitelial gástrica num centro Português

Palavras Chave

Resseção endoscópica · Disseção submucosa · Endoscopia digestiva alta · Neoplasia epitelial gástrica · Cancro gástrico precoce · Neoplasia intraepitelial de baixo grau · Neoplasia intraepitelial de alto grau ·

Resumo

Introdução: O aparecimento da dissecção endoscópica da submucosa (ESD) tornou possível a resseção em bloco de lesões neoplásicas superficiais do estômago, independentemente da sua dimensão, com reduzidas taxas de complicações e recorrência. Esta técnica tem evoluído como método preferencial face à mucosectomia convencional e cirurgia, quando a metastização à distância tem risco negligenciável. No mundo ocidental a experiência nesta técnica tem evoluído de forma rápida surgindo um número crescente de séries na literatura. Este estudo tem como objetivo reportar os resultados a curto e longo prazo da ESD de lesões epiteliais gástricas realizadas por um único operador num centro Português. Metodologia: Análise retrospetiva unicêntrica dos casos de ESD de lesões epiteliais gástricas, realizadas durante um período de 5 anos, entre maio de 2012 e setembro de 2017. Resultados: Foram realizadas 114 ESDs de neoplasias epiteliais gástricas durante o período em estudo, com uma taxa de resseção em bloco de 96.5% e R0 de 87.6%. A resseção curativa confirmou-se em 83.2% dos casos. Ocorreram complicações em 13.2% dos procedimentos, incluindo hemorragia em 12 doentes (10.5%) e 1 perfuração (0.9%). Com uma mediana de follow-up de 12 meses (variação interquartil [IQR] 18), verificaram-se 6 casos de recorrência local: 4 lesões residuais e 2 recorrências em resseções R0 prévias. Observaram-se mais frequentemente lesões residuais de ESD de lesões de maiores dimensões (me­diana = 40.0 mm, IQR = 26 vs. mediana = 20.0 mm, IQR = 15, p = 0.008) e com margens horizontais (HM) positivas após a resseção (50.0% vs. 0.0%, Teste exato de Fisher, p c; 0.001). A incidência cumulativa de lesões gástricas metácronas aos 34 meses foi de 16.1%. Todas as novas lesões foram eficazmente tratadas por endoscopia. A sobrevivência específica aos 12 meses de follow-up foi de 100%. Conclusão: Este estudo mostra que a ESD gástrica é uma técnica eficaz e segura para o tratamento de lesões neoplásicas precoces confirmando a maioria das séries europeias. Embora a ESD permita geralmente uma resseção em bloco as HM positivas continuam a ser um problema em alguns doentes. A vigilância endoscópica pode detetar recorrência local e novas lesões, em estádios precoces, potencialmente tratáveis por endoscopia.



Related Articles:

References

  1. Uedo N, Takeuchi Y, Ishihara R: Endoscopic management of early gastric cancer: endoscopic mucosal resection or endoscopic sub-mucosal dissection: data from a Japanese high-volume center and literature review. Ann Gastroenterol 2012; 25: 281–290.
    External Resources
  2. Japanese Gastric Cancer Association: Japanese gastric cancer treatment guidelines 2014. Gastric Cancer 2017; 20: 1–19.
    External Resources
  3. Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T, Repici A, Vieth M, De Ceglie A, et al: Endoscopic submucosal dissection: Europe an Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: 829–854.
    External Resources
  4. Pimentel-Nunes P, Libânio D, Dinis-Ribeiro M: Evaluation and management of gastric superficial neoplastic lesions. GE Port J Gastroenterol 2017; 24: 8–21.
    External Resources
  5. Japanese Gastric Cancer Association: Japanese gastric cancer treatment guidelines 2010. Gastric Cancer 2011; 14: 113–123.
    External Resources
  6. Gotoda T, Yanagisawa A, Sasako M, Ono H, Nakanishi Y, Shimoda T, et al: Incidence of lymph node metastasis from early gastric cancer: estimation with a large number of cases at two large centers. Gastric Cancer 2000; 3: 219–225.
    External Resources
  7. Hirasawa T, Gotoda T, Miyata S, Kato Y, Shimoda T, Taniguchi H, et al: Incidence of lymph node metastasis and the feasibility of endoscopic resection for undifferentiated-type early gastric cancer. Gastric Cancer 2009; 12: 148–152.
    External Resources
  8. Gotoda T, Iwasaki M, Kusano C, Seewald S, Oda I: Endoscopic resection of early gastric cancer treated by guideline and expanded National Cancer Centre criteria. Br J Surg 2010; 97: 868–871.
    External Resources
  9. Suzuki H, Oda I, Abe S, Sekiguchi M, Mori G, Nonaka S, et al: High rate of 5-year survival among patients with early gastric cancer undergoing curative endoscopic submucosal dissection. Gastric Cancer 2016; 19: 198–205.
    External Resources
  10. Yakirevich E, Resnick MB: Pathology of gastric cancer and its precursor lesions. Gastroenterol Clin North Am 2013; 42: 261–284.
    External Resources
  11. Probst A, Pommer B, Golger D, Anthuber M, Arnholdt H, Messmann H: Endoscopic submucosal dissection in gastric neoplasia – experience from a European center. Endoscopy 2010; 42: 1037–1044.
    External Resources
  12. Dinis-Ribeiro M, Pimentel-Nunes P, Afonso M, Costa N, Lopes C, Moreira-Dias L: A European case series of endoscopic submucosal dissection for gastric superficial lesions. Gastrointest Endosc 2009; 69: 350–355.
    External Resources
  13. Rodrigues J, Carmo J, Carvalho L, Barreiro P, Chagas C: Endoscopic submucosal dissection for gastrointestinal superficial lesions: initial experience in a single Portuguese center. GE Port J Gastroenterol 2015; 22: 190–197.
    External Resources
  14. Pimentel-Nunes P, Mourão F, Veloso N, Afonso LP, Jácome M, Moreira-Dias L, et al: Long-term follow-up after endoscopic resection of gastric superficial neoplastic lesions in Portugal. Endoscopy 2014; 46: 933–940.
    External Resources
  15. Tanabe S, Hirabayashi S, Oda I, Ono H, Nashimoto A, Isobe Y, et al: Gastric cancer treated by endoscopic submucosal dissection or endoscopic mucosal resection in Japan from 2004 through 2006: JGCA nationwide registry conducted in 2013. Gastric Cancer 2017; 20: 834–842.
    External Resources
  16. Itoh T, Kusaka K, Kawaura K, Kashimura K, Yamakawa Y, Takahashi T, et al: Selective binding of sucralfate to endoscopic mucosal resection-induced gastric ulcer: evaluation of aluminium adherence. J Int Med Res 2004; 32: 520–529.
    External Resources
  17. Masuelli L, Tumino G, Turriziani M, Mo desti A, Bei R: Topical use of sucralfate in epithelial wound healing: clinical evidence and molecular mechanisms of action. Recent Pat Inflamm Allergy Drug Discov 2010; 4: 25–36.
    External Resources
  18. Ishii N, Omata F, Fujisaki J, Hirasawa T, Kaise M, Hoteya S, et al: Management of early gastric cancer with positive horizontal or indeterminable margins after endoscopic submucosal dissection: multicenter survey. Endosc Int Open 2017; 5:E354–E362.
    External Resources
  19. Sekiguchi M, Suzuki H, Oda I, Abe S, Nonaka S, Yoshinaga S, et al: Risk of recurrent gastric cancer after endoscopic resection with a positive lateral margin. Endoscopy 2014; 46: 273–278.
    External Resources
  20. Kakushima N, Ono H, Tanaka M, Takizawa K, Yamaguchi Y, Matsubayashi H: Factors related to lateral margin positivity for cancer in gastric specimens of endoscopic submucosal dissection. Dig Endosc 2011; 23: 227–232.
    External Resources
  21. Numata N, Oka S, Tanaka S, Kagemoto K, Sanomura Y, Yoshida S, et al: Risk factors and management of positive horizontal margin in early gastric cancer resected by en bloc endoscopic submucosal dissection. Gastric Cancer 2015; 18: 332–338.
    External Resources
  22. Yun GW, Kim JH, Lee YC, Lee SK, Shin SK, Park JC, et al: What are the risk factors for residual tumor cells after endoscopic complete resection in gastric epithelial neoplasia? Surg Endosc 2015; 29: 487–492.
    External Resources
  23. Hahn KY, Park JC, Kim EH, Shin S, Park CH, Chung H, et al: Incidence and impact of scheduled endoscopic surveillance on recurrence after curative endoscopic resection for early gastric cancer. Gastrointest Endosc 2016; 84: 628–638.
    External Resources
  24. Peng LJ, Tian SN, Lu L, Chen H, Ouyang YY, Wu YJ: Outcome of endoscopic submucosal dissection for early gastric cancer of conventional and expanded indications: systematic review and meta-analysis. J Dig Dis 2015; 16: 67–74.
    External Resources
  25. Yang HJ, Kim SG, Lim JH, Choi JM, Oh S, Park JY, et al: Novel risk stratification for metachronous recurrence after curative endoscopic submucosal dissection for early gastric cancer. Gastrointest Endosc 2018; 87: 419–428.e3.
    External Resources

Article / Publication Details

First-Page Preview
Abstract of Original Article

Received: November 23, 2017
Accepted: February 12, 2018
Published online: April 11, 2018
Issue release date: March - April

Number of Print Pages: 9
Number of Figures: 3
Number of Tables: 2

ISSN: 2341-4545 (Print)
eISSN: 2387-1954 (Online)

For additional information: https://www.karger.com/PJG

References

  1. Uedo N, Takeuchi Y, Ishihara R: Endoscopic management of early gastric cancer: endoscopic mucosal resection or endoscopic sub-mucosal dissection: data from a Japanese high-volume center and literature review. Ann Gastroenterol 2012; 25: 281–290.
    External Resources
  2. Japanese Gastric Cancer Association: Japanese gastric cancer treatment guidelines 2014. Gastric Cancer 2017; 20: 1–19.
    External Resources
  3. Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T, Repici A, Vieth M, De Ceglie A, et al: Endoscopic submucosal dissection: Europe an Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: 829–854.
    External Resources
  4. Pimentel-Nunes P, Libânio D, Dinis-Ribeiro M: Evaluation and management of gastric superficial neoplastic lesions. GE Port J Gastroenterol 2017; 24: 8–21.
    External Resources
  5. Japanese Gastric Cancer Association: Japanese gastric cancer treatment guidelines 2010. Gastric Cancer 2011; 14: 113–123.
    External Resources
  6. Gotoda T, Yanagisawa A, Sasako M, Ono H, Nakanishi Y, Shimoda T, et al: Incidence of lymph node metastasis from early gastric cancer: estimation with a large number of cases at two large centers. Gastric Cancer 2000; 3: 219–225.
    External Resources
  7. Hirasawa T, Gotoda T, Miyata S, Kato Y, Shimoda T, Taniguchi H, et al: Incidence of lymph node metastasis and the feasibility of endoscopic resection for undifferentiated-type early gastric cancer. Gastric Cancer 2009; 12: 148–152.
    External Resources
  8. Gotoda T, Iwasaki M, Kusano C, Seewald S, Oda I: Endoscopic resection of early gastric cancer treated by guideline and expanded National Cancer Centre criteria. Br J Surg 2010; 97: 868–871.
    External Resources
  9. Suzuki H, Oda I, Abe S, Sekiguchi M, Mori G, Nonaka S, et al: High rate of 5-year survival among patients with early gastric cancer undergoing curative endoscopic submucosal dissection. Gastric Cancer 2016; 19: 198–205.
    External Resources
  10. Yakirevich E, Resnick MB: Pathology of gastric cancer and its precursor lesions. Gastroenterol Clin North Am 2013; 42: 261–284.
    External Resources
  11. Probst A, Pommer B, Golger D, Anthuber M, Arnholdt H, Messmann H: Endoscopic submucosal dissection in gastric neoplasia – experience from a European center. Endoscopy 2010; 42: 1037–1044.
    External Resources
  12. Dinis-Ribeiro M, Pimentel-Nunes P, Afonso M, Costa N, Lopes C, Moreira-Dias L: A European case series of endoscopic submucosal dissection for gastric superficial lesions. Gastrointest Endosc 2009; 69: 350–355.
    External Resources
  13. Rodrigues J, Carmo J, Carvalho L, Barreiro P, Chagas C: Endoscopic submucosal dissection for gastrointestinal superficial lesions: initial experience in a single Portuguese center. GE Port J Gastroenterol 2015; 22: 190–197.
    External Resources
  14. Pimentel-Nunes P, Mourão F, Veloso N, Afonso LP, Jácome M, Moreira-Dias L, et al: Long-term follow-up after endoscopic resection of gastric superficial neoplastic lesions in Portugal. Endoscopy 2014; 46: 933–940.
    External Resources
  15. Tanabe S, Hirabayashi S, Oda I, Ono H, Nashimoto A, Isobe Y, et al: Gastric cancer treated by endoscopic submucosal dissection or endoscopic mucosal resection in Japan from 2004 through 2006: JGCA nationwide registry conducted in 2013. Gastric Cancer 2017; 20: 834–842.
    External Resources
  16. Itoh T, Kusaka K, Kawaura K, Kashimura K, Yamakawa Y, Takahashi T, et al: Selective binding of sucralfate to endoscopic mucosal resection-induced gastric ulcer: evaluation of aluminium adherence. J Int Med Res 2004; 32: 520–529.
    External Resources
  17. Masuelli L, Tumino G, Turriziani M, Mo desti A, Bei R: Topical use of sucralfate in epithelial wound healing: clinical evidence and molecular mechanisms of action. Recent Pat Inflamm Allergy Drug Discov 2010; 4: 25–36.
    External Resources
  18. Ishii N, Omata F, Fujisaki J, Hirasawa T, Kaise M, Hoteya S, et al: Management of early gastric cancer with positive horizontal or indeterminable margins after endoscopic submucosal dissection: multicenter survey. Endosc Int Open 2017; 5:E354–E362.
    External Resources
  19. Sekiguchi M, Suzuki H, Oda I, Abe S, Nonaka S, Yoshinaga S, et al: Risk of recurrent gastric cancer after endoscopic resection with a positive lateral margin. Endoscopy 2014; 46: 273–278.
    External Resources
  20. Kakushima N, Ono H, Tanaka M, Takizawa K, Yamaguchi Y, Matsubayashi H: Factors related to lateral margin positivity for cancer in gastric specimens of endoscopic submucosal dissection. Dig Endosc 2011; 23: 227–232.
    External Resources
  21. Numata N, Oka S, Tanaka S, Kagemoto K, Sanomura Y, Yoshida S, et al: Risk factors and management of positive horizontal margin in early gastric cancer resected by en bloc endoscopic submucosal dissection. Gastric Cancer 2015; 18: 332–338.
    External Resources
  22. Yun GW, Kim JH, Lee YC, Lee SK, Shin SK, Park JC, et al: What are the risk factors for residual tumor cells after endoscopic complete resection in gastric epithelial neoplasia? Surg Endosc 2015; 29: 487–492.
    External Resources
  23. Hahn KY, Park JC, Kim EH, Shin S, Park CH, Chung H, et al: Incidence and impact of scheduled endoscopic surveillance on recurrence after curative endoscopic resection for early gastric cancer. Gastrointest Endosc 2016; 84: 628–638.
    External Resources
  24. Peng LJ, Tian SN, Lu L, Chen H, Ouyang YY, Wu YJ: Outcome of endoscopic submucosal dissection for early gastric cancer of conventional and expanded indications: systematic review and meta-analysis. J Dig Dis 2015; 16: 67–74.
    External Resources
  25. Yang HJ, Kim SG, Lim JH, Choi JM, Oh S, Park JY, et al: Novel risk stratification for metachronous recurrence after curative endoscopic submucosal dissection for early gastric cancer. Gastrointest Endosc 2018; 87: 419–428.e3.
    External Resources
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