title: Endoscopic submucosal dissection for foregut neuroendocrine tumors: an initial study.
abstract: OBJECTIVE
  To evaluate the feasibility and efficacy of endoscopic submucosal dissection (ESD) for foregut neuroendocrine tumors (NETs).
  
  
  METHODS
  From April 2008 to December 2010, patients with confirmed histological diagnosis of foregut NETs were included. None had regional lymph node enlargement or distant metastases to the liver or lung on preoperative computerized tomography scanning or endoscopic ultrasonography (EUS). ESD was attempted under general anesthesia. After making several marking dots around the lesion, a mixture solution was injected into the submucosa. The mucosa was incised outside the marking dots. Dissection of the submucosal layer beneath the tumor was performed under direct vision to achieve complete en bloc resection of the specimen. Tumor features, clinicopathological characteristics, complete resection rate, and complications were evaluated. Foregut NETs were graded as G1, G2, or G3 on the basis of proliferative activity by mitotic count or Ki-67 index. All patients underwent regular follow-up to evaluate for any local recurrence or distant metastasis.
  
  
  RESULTS
  Those treated by ESD included 24 patients with 29 foregut NETs. The locations of the 29 lesions are as follows: esophagus (n = 1), cardia (n = 1), stomach (n = 23), and duodenal bulb (n = 4). All lesions were found incidentally during routine upper gastrointestinal endoscopy for other indications, and none had symptoms of carcinoid syndrome. Preoperative EUS showed that all tumors were confined to the submucosa. Among the 24 gastric lesions, 16 lesions in 11 patients were type I gastric NETs arising in chronic atrophic gastritis with hypergastrinemia, while the other 8 solitary lesions were type III because of absence of atrophic gastritis in these cases. All of the tumors were removed in an en bloc fashion. The average maximum diameter of the lesions was 9.4 mm (range: 2-30 mm), and the procedure time was 20.3 min (range: 10-45 min). According to the World Health Organization 2010 classification, histological evaluation determined that 26 lesions were NET-G1, 2 gastric lesions were NET-G2, and 1 esophageal lesion was neuroendocrine carcinoma (NEC). Complete resection was achieved in 28 lesions (28/29, 96.6%), and all of them were confined to the submucosa in histopathologic assessment with no lymphovascular invasion. The remaining patient with NEC underwent additional surgery because the resected specimens revealed angiolymphatic and muscularis invasion, as well as incomplete resection. Delayed bleeding occurred in 1 case 3 d after ESD, which was managed by endoscopic treatment. There were no procedure-related perforations. During a mean follow-up period of 24.4 mo (range: 12-48 mo), local recurrence occurred in only 1 patient 7 mo after initial ESD. This patient successfully underwent repeat ESD. Metastasis to lymph nodes or distal organs was not observed in any patient. No patients died during the study period.
  
  
  CONCLUSIONS
  ESD appears to be a safe, feasible, and effective procedure for providing accurate histopathological evaluations and curative treatment for eligible foregut NETs.
authors.affiliation: Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China.
authors.forename: Quan-Lin
authors.initials: QL
authors.lastname: Li
authors.forename: Yi-Qun
authors.initials: YQ
authors.lastname: Zhang
authors.forename: Wei-Feng
authors.initials: WF
authors.lastname: Chen
authors.forename: Mei-Dong
authors.initials: MD
authors.lastname: Xu
authors.forename: Yun-Shi
authors.initials: YS
authors.lastname: Zhong
authors.forename: Li-Li
authors.initials: LL
authors.lastname: Ma
authors.forename: Wen-Zheng
authors.initials: WZ
authors.lastname: Qin
authors.forename: Jian-Wei
authors.initials: JW
authors.lastname: Hu
authors.forename: Ming-Yan
authors.initials: MY
authors.lastname: Cai
authors.forename: Li-Qing
authors.initials: LQ
authors.lastname: Yao
authors.forename: Ping-Hong
authors.initials: PH
authors.lastname: Zhou
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001706:Biopsy; D004210:Dissection; D004379:Duodenal Neoplasms / Q000473:pathology / Q000601:surgery*; D016099:Endoscopy, Gastrointestinal / Q000379:methods*; D019160:Endosonography; D004938:Esophageal Neoplasms / Q000473:pathology / Q000601:surgery*; D005240:Feasibility Studies; D005260:Female; D005753:Gastric Mucosa / Q000473:pathology / Q000601:surgery; D006801:Humans; D007413:Intestinal Mucosa / Q000473:pathology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D060787:Neoplasm Grading; D018358:Neuroendocrine Tumors / Q000601:surgery*; D013274:Stomach Neoplasms / Q000473:pathology / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome