title: A Scoring System to Stratify Curability after Endoscopic Submucosal Dissection for Early Gastric Cancer: "eCura system".
abstract: OBJECTIVE
  Although radical surgery is recommended for patients not meeting the curative criteria for endoscopic submucosal dissection (ESD) of early gastric cancer (EGC) because of the potential risk of lymph node metastasis (LNM), this recommendation may be overestimated and excessive. We aimed to establish a simple scoring system for decision making after ESD.
  
  
  METHODS
  This multicenter retrospective study consisted of two stages. First, the risk-scoring system for LNM was developed using multivariate logistic regression analysis in 1,101 patients who underwent radical surgery after having failed to meet the curative criteria for ESD of EGC. Next, the system was internally validated by survival analysis in another 905 patients who also did not meet the criteria and did not receive additional treatment after ESD.
  
  
  RESULTS
  In the development stage, based on accordant regression coefficients, five risk factors for LNM were weighted with point values: three points for lymphatic invasion and 1 point each for tumor size >30 mm, positive vertical margin, venous invasion, and submucosal invasion ≥500 μm. Then, the patients were categorized into three LNM risk groups: low (0-1 point: 2.5% risk), intermediate (2-4 points: 6.7%), and high (5-7 points: 22.7%). In the validation stage, cancer-specific survival differed significantly among these groups (99.6, 96.0, and 90.1%, respectively, at 5 years; P<0.001). The C statistic of the system for cancer-specific mortality was 0.78.
  
  
  CONCLUSIONS
  This scoring system predicted cancer-specific survival in patients who did not meet the curative criteria after ESD for EGC. ESD without additional treatment may be an acceptable option for patients at low risk.
authors.affiliation: Department of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan.
authors.forename: Waku
authors.initials: W
authors.lastname: Hatta
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan.
authors.forename: Takuji
authors.initials: T
authors.lastname: Gotoda
authors.affiliation: Division of Endoscopy, Saku Central Hospital Advanced Care Center, Saku, Japan.
authors.forename: Tsuneo
authors.initials: T
authors.lastname: Oyama
authors.affiliation: Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan.
authors.forename: Noboru
authors.initials: N
authors.lastname: Kawata
authors.affiliation: Division of Endoscopy, Saku Central Hospital Advanced Care Center, Saku, Japan.
authors.forename: Akiko
authors.initials: A
authors.lastname: Takahashi
authors.affiliation: Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan.
authors.forename: Yoshikazu
authors.initials: Y
authors.lastname: Yoshifuku
authors.affiliation: Department of Gastroenterology, Toranomon Hospital, Tokyo, Japan.
authors.forename: Shu
authors.initials: S
authors.lastname: Hoteya
authors.affiliation: Department of Endoscopy, Hiroshima City Hospital, Hiroshima, Japan.
authors.forename: Masahiro
authors.initials: M
authors.lastname: Nakagawa
authors.affiliation: Department of Internal Medicine, Niigata Prefectural Central Hospital, Joetsu, Japan.
authors.forename: Masaaki
authors.initials: M
authors.lastname: Hirano
authors.affiliation: Department of Gastroenterology, Kitakyushu Municipal Medical Center, Kitakyushu, Japan.
authors.forename: Mitsuru
authors.initials: M
authors.lastname: Esaki
authors.affiliation: Department of Internal Medicine, Toyama Prefectural Central Hospital, Toyama, Japan.
authors.forename: Mitsuru
authors.initials: M
authors.lastname: Matsuda
authors.affiliation: Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan.
authors.forename: Ken
authors.initials: K
authors.lastname: Ohnita
authors.affiliation: Department of Internal Medicine and Gastrointestinal Endoscopy, Saga Medical School, Saga, Japan.
authors.forename: Kohei
authors.initials: K
authors.lastname: Yamanouchi
authors.affiliation: Department of Gastroenterology and Endocrinology and Metabolism, Nara Medical University, Nara, Japan.
authors.forename: Motoyuki
authors.initials: M
authors.lastname: Yoshida
authors.affiliation: Department of Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Kyoto, Japan.
authors.forename: Osamu
authors.initials: O
authors.lastname: Dohi
authors.affiliation: Department of Gastroenterology, Gifu University Graduate School of Medicine, Gifu, Japan.
authors.forename: Jun
authors.initials: J
authors.lastname: Takada
authors.affiliation: Department of Gastroenterology, Shinshu University School of Medicine, Matsumoto, Japan.
authors.forename: Keiko
authors.initials: K
authors.lastname: Tanaka
authors.affiliation: Department of Gastroenterology and Hepatology, Japanese Red Cross Society Kyoto Daiichi Hospital, Kyoto, Japan.
authors.forename: Shinya
authors.initials: S
authors.lastname: Yamada
authors.affiliation: Department of Gastroenterology, Akita City Hospital, Akita, Japan.
authors.forename: Tsuyotoshi
authors.initials: T
authors.lastname: Tsuji
authors.affiliation: Department of Gastroenterology, Osaki Citizen Hospital, Osaki, Japan.
authors.forename: Hirotaka
authors.initials: H
authors.lastname: Ito
authors.affiliation: Division of Gastroenterology, Fukui Prefectural Hospital, Fukui, Japan.
authors.forename: Yoshiaki
authors.initials: Y
authors.lastname: Hayashi
authors.affiliation: Department of Preventive Medicine and Epidemiology, Tohoku Medical Megabank Organization, Sendai, Japan.
authors.forename: Naoki
authors.initials: N
authors.lastname: Nakaya
authors.affiliation: Department of Preventive Medicine and Epidemiology, Tohoku Medical Megabank Organization, Sendai, Japan.
authors.forename: Tomohiro
authors.initials: T
authors.lastname: Nakamura
authors.affiliation: Department of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan.
authors.forename: Tooru
authors.initials: T
authors.lastname: Shimosegawa
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001808:Blood Vessels / Q000473:pathology; D000066491:Clinical Decision-Making; D003661:Decision Support Techniques; D000069916:Endoscopic Mucosal Resection; D005260:Female; D006801:Humans; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D018365:Neoplasm, Residual; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods; D013274:Stomach Neoplasms / Q000473:pathology* / Q000601:surgery*; D015996:Survival Rate; D047368:Tumor Burden