Is radical surgery necessary in all patients who do not meet the curative criteria for endoscopic submucosal dissection in early gastric cancer? A multi-center retrospective study in Japan.
BACKGROUND
Although radical surgery is routinely performed for patients who do not meet the curative criteria for endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) due to the risk of lymph node metastasis (LNM), this standard therapeutic option may be excessive given the lower number of patients with LNM. Therefore, we aimed to investigate long-term outcomes and validate risk factors predicting recurrence after ESD.


METHODS
Of 15,785 patients who underwent ESD for EGC at 19 institutions between 2000 and 2011, 1969 patients not meeting the curative criteria were included in this multi-center study. Based on the treatment strategy after ESD, patients were divided into radical surgery (n = 1064) and follow-up (no additional treatment, n = 905) groups.


RESULTS
Overall survival (OS) and disease-specific survival (DSS) were significantly higher in the radical surgery group than in the follow-up group (p < 0.001 and p = 0.012, respectively). However, the difference in 3-year DSS between the groups (99.4 vs. 98.7 %) was rather small compared with the difference in 3-year OS (96.7 vs. 84.0 %). LNM was found in 89 patients (8.4 %) in the radical surgery group. Lymphatic invasion was found to be an independent risk factor for recurrence in the follow-up group (hazard ratio 5.23; 95 % confidence interval 2.01-13.6; p = 0.001).


CONCLUSIONS
This multi-center study, representing the largest cohort to date, revealed a large discrepancy between OS and DSS in the two groups. Since follow-up with no additional treatment after ESD may be an acceptable option for patients at low risk, further risk stratification is needed for appropriate individualized treatment strategies.
Department of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan. waku-style@festa.ocn.ne.jp.
Waku
W
Hatta
Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, 1-6 Kanda-Surugadai, Chiyoda-ku, Tokyo, 101-8309, Japan.
Takuji
T
Gotoda
Division of Endoscopy, Saku Central Hospital Advanced Care Center, 3400-28 Nakagomi, Saku, Nagano, 385-0051, Japan.
Tsuneo
T
Oyama
Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan.
Noboru
N
Kawata
Division of Endoscopy, Saku Central Hospital Advanced Care Center, 3400-28 Nakagomi, Saku, Nagano, 385-0051, Japan.
Akiko
A
Takahashi
Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, Hiroshima, 734-8551, Japan.
Yoshikazu
Y
Yoshifuku
Department of Gastroenterology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan.
Shu
S
Hoteya
Department of Internal Medicine, Hiroshima City Hospital, 7-33 Motomachi, Naka-ku, Hiroshima, Hiroshima, 730-8518, Japan.
Koki
K
Nakamura
Department of Internal Medicine, Niigata Prefectural Central Hospital, 205 Shinnancho, Joetsu, Niigata, 943-0192, Japan.
Masaaki
M
Hirano
Department of Gastroenterology, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-ku, Kitakyushu, Fukuoka, 802-0077, Japan.
Mitsuru
M
Esaki
Department of Internal Medicine, Toyama Prefectural Central Hospital, 2-2-78 Nisinagae, Toyama, Toyama, 930-8550, Japan.
Mitsuru
M
Matsuda
Department of Gastroenterology and Hepatology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, Nagasaki, 952-8501, Japan.
Ken
K
Ohnita
Department of Internal Medicine and Gastrointestinal Endoscopy, Saga Medical School, 5-1-1 Nabeshima, Saga, Saga, 849-8501, Japan.
Ryo
R
Shimoda
Department of Gastroenterology and Endocrinology and Metabolism, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan.
Motoyuki
M
Yoshida
Department of Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, Kyoto, 602-8566, Japan.
Osamu
O
Dohi
Department of Gastroenterology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, Gifu, 501-1194, Japan.
Jun
J
Takada
Department of Gastroenterology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan.
Keiko
K
Tanaka
Department of Gastroenterology and Hepatology, Japanese Red Cross Society Kyoto Daiichi Hospital, 15-749 Hon-machi, Higashiyama-ku, Kyoto, Kyoto, 605-0981, Japan.
Shinya
S
Yamada
Department of Gastroenterology, Akita City Hospital, 4-30 Matsuoka-machi, Kawamoto, Akita, Akita, 010-0933, Japan.
Tsuyotoshi
T
Tsuji
Department of Gastroenterology, Osaki Citizen Hospital, 3-8-1 Honami, Furukawa, Osaki, Miyagi, 989-6183, Japan.
Hirotaka
H
Ito
Division of Gastroenterology, Fukui Prefectural Hospital, 2-8-1 Yotsui, Fukui, Fukui, 910-8526, Japan.
Yoshiaki
Y
Hayashi
Department of Preventive Medicine and Epidemiology, Tohoku Medical Megabank Organization, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8573, Japan.
Tomohiro
T
Nakamura
Department of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
Tooru
T
Shimosegawa
D000368:Aged; D000369:Aged, 80 and over; D000069916:Endoscopic Mucosal Resection / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007564:Japan; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local; D012189:Retrospective Studies; D012307:Risk Factors; D013274:Stomach Neoplasms / Q000473:pathology / Q000601:surgery*; D015996:Survival Rate; D016896:Treatment Outcome
Early gastric cancer; Endoscopic submucosal dissection; Follow-up; Lymphatic invasion; Radical surgery