title: Endoscopic submucosal dissection for papillary adenocarcinoma of the stomach: is it really safe?
abstract: BACKGROUND
  Papillary adenocarcinoma of the stomach has been treated according to the same endoscopic submucosal dissection (ESD) indication criteria as other differentiated-type adenocarcinomas. We aimed to compare lymph node metastasis (LNM) in patients with early gastric cancer (EGC) with papillary adenocarcinoma (EGC-P) with that in patients with EGC with nonpapillary adenocarcinoma (EGC-NP) and to consider the potential limitation of current ESD indication criteria in the treatment of EGC-P.
  
  
  METHODS
  In total, 1583 patients who underwent gastrectomy for EGC from 2005 to 2014 were included. Clinicopathologic characteristics of 56 patients with EGC-P were compared with those of 1527 patients with EGC-NP. The safety of ESD was evaluated, by application of current ESD indication criteria to EGC-P.
  
  
  RESULTS
  The frequency of submucosal invasion was significantly higher in EGC-P than in both EGC-NP with differentiated-type histologic appearance and EGC-NP with undifferentiated-type histologic appearance (71.4% vs 50.8% and 37.6%, respectively). In addition, the frequency of LNM in EGC-P was 17.9%, higher than that in both EGC-NP with differentiated-type histologic appearance and EGC-NP with undifferentiated-type histologic appearance (9.7% and 11.1%, respectively). When the current ESD indication criteria were applied to the 56 patients with EGC-P, 17 patients met the current indications. Of these patients, two (11.8%) had LNM and three (17.6%) had lymphovascular invasion (LVI). When LNM and LVI were combined, one of seven patients (16.7%) meeting the absolute ESD indications and three of ten patients (30.0%) meeting the expanded ESD indications would not be cured after ESD.
  
  
  CONCLUSIONS
  The use of ESD should be more carefully applied in patients with EGC-P meeting the ESD indication criteria, especially the expanded indication criteria, after pretreatment workup compared with other differentiated-type adenocarcinomas, owing to the higher frequencies of submucosal invasion, LNM, and LVI in EGC-P.
authors.affiliation: Department of Internal Medicine, Pusan National University School of Medicine, and Biomedical Research Institute, Pusan National University Hospital, 179, Gudeok-ro, Seo-Gu, Busan, 49241, South Korea.
authors.forename: Hyun Jung
authors.initials: HJ
authors.lastname: Lee
authors.affiliation: Department of Internal Medicine, Pusan National University School of Medicine, and Biomedical Research Institute, Pusan National University Hospital, 179, Gudeok-ro, Seo-Gu, Busan, 49241, South Korea. doc0224@pusan.ac.kr.
authors.forename: Gwang Ha
authors.initials: GH
authors.lastname: Kim
authors.affiliation: Department of Pathology, Pusan National University School of Medicine, and Biomedical Research Institute, Pusan National University Hospital, 179, Gudeok-ro, Seo-Gu, Busan, 49241, South Korea.
authors.forename: Do Youn
authors.initials: DY
authors.lastname: Park
authors.affiliation: Department of Pathology, Pusan National University School of Medicine, and Biomedical Research Institute, Pusan National University Hospital, 179, Gudeok-ro, Seo-Gu, Busan, 49241, South Korea.
authors.forename: Young Keum
authors.initials: YK
authors.lastname: Kim
authors.affiliation: Department of Internal Medicine, Pusan National University School of Medicine, and Biomedical Research Institute, Pusan National University Hospital, 179, Gudeok-ro, Seo-Gu, Busan, 49241, South Korea.
authors.forename: Hye Kyung
authors.initials: HK
authors.lastname: Jeon
authors.affiliation: Department of Internal Medicine, Pusan National University School of Medicine, and Biomedical Research Institute, Pusan National University Hospital, 179, Gudeok-ro, Seo-Gu, Busan, 49241, South Korea.
authors.forename: Bong Eun
authors.initials: BE
authors.lastname: Lee
authors.affiliation: Department of Internal Medicine, Pusan National University School of Medicine, and Biomedical Research Institute, Pusan National University Hospital, 179, Gudeok-ro, Seo-Gu, Busan, 49241, South Korea.
authors.forename: Geun Am
authors.initials: GA
authors.lastname: Song
mesh_terms: D000230:Adenocarcinoma / Q000601:surgery; D000231:Adenocarcinoma, Papillary / Q000473:pathology / Q000601:surgery*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000069916:Endoscopic Mucosal Resection / Q000009:adverse effects / Q000379:methods*; D005260:Female; D005743:Gastrectomy / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D008207:Lymphatic Metastasis / Q000473:pathology; D008297:Male; D008875:Middle Aged; D013274:Stomach Neoplasms / Q000473:pathology / Q000601:surgery*; D055815:Young Adult
keywords: Early gastric cancer; Endoscopic submucosal dissection; Lymph node; Metastasis; Papillary adenocarcinoma