Clinical significance of additional gastrectomy after non-curative endoscopic submucosal dissection for early gastric cancer: a retrospective single-center study

Purpose: Additional surgery is recommended for patients after a non-curative endoscopic submucosal dissection (ESD) to prevent residual cancer (RC) or lymph node metastasis (LNM). We aimed to evaluate the clinicopathologic characteristics of patients who underwent an additional gastrectomy after a non-curative ESD procedure and identify the risk factors of RC and LNM.Methods: We retrospectively assessed the clinicopathological factors of 73 patients who underwent additional gastrectomy following a non-curative ESD between January 2009 and December 2019 at our center.Results: RC and LNM rates after additional gastrectomy were 9.6% and 8.2%, respectively. Invasion deeper than 500 μm (P = 0.045), positive horizontal resection margin (P < 0.001), and positive ESD margin (P = 0.001) were identified as statistically significant factors in univariate analysis for RC, but not in multivariate analysis. Lymphatic invasion was the only risk factor found to be significant in both univariate and multivariate analyses (P = 0.005 and P = 0.012).Conclusion: Additional gastrectomy is necessary to prevent RC or LNM after non-curative ESD. Lymphatic invasion was also associated with LNM in patients who underwent an additional gastrectomy after a non-curative ESD, and in such cases, active treatment is required.

Is Additional Gastrectomy Required for Elderly Patients after Endoscopic Submucosal Dissection with Endoscopic Curability C-2 for Early Gastric Cancer?

<b><i>Background:</i></b> With the ongoing growth of the aged population, the number of elderly patients suffering from gastric cancer has increased in Japan. Since the frequency of lymph node metastasis (LNM) in patients after endoscopic submucosal dissection (ESD) with endoscopic curability (eCura) C-2 for early gastric cancer (EGC) is relative low, the following question can be raised: “Is additional gastrectomy required for elderly patients with such criteria for ESD?” <b><i>Summary:</i></b> For therapeutic decision-making after ESD with eCura C-2, the risk of all-cause mortality and impaired quality of life (QoL) should thus be evaluated. Risk stratification of LNM and gastric cancer-specific mortality was established by the eCura system; however, it remains unclear how much these categories and treatment selection affect all-cause mortality. The contribution of prognostic tools for predicting all-cause mortality was noted to vary across the studies of patients with EGC; thus, further studies that investigate comprehensive geriatric assessment (CGA) may be required. Regarding the QoL, studies on elderly patients remain to be lacking. Furthermore, one of the issues with CGA and QoL tools is that they are time consuming. <b><i>Key Messages:</i></b> Combined evaluation of risk stratification of gastric cancer-specific mortality by the eCura system and risk of nongastric cancer-related mortality and impaired QoL may be the current optimal method to decide treatment strategy after ESD with eCura C-2 for EGC among elderly patients. A large-scale prospective study that investigates CGA domains is required to identify predictors of all-cause mortality and impaired QoL, and a more easily usable tool should be developed.

Robotic Sentinel Lymph Node Procedure After Endoscopic Submucosal Dissection of High Risk Early Gastric Cancer: A Case Report

Endoscopic resection (ER) is the treatment of choice for early gastric cancer (T1) without lymph node involvement. An additional gastrectomy with D2 lymphadenectomy is recommended if ER is considered as non-curative. Here, we present a case of a robot-assisted sentinel lymph node procedure performed with the use of duel-tracer, including ICG fluorescence and technetium-99, after a non-curative ESD for an early gastric tumor. Five “hot” lymph nodes were resected, one of which was positive for metastasis. A subtotal gastrectomy with D2 lymphadenectomy was performed additionally during the same procedure. This case presentation indicates the feasibility of a robot-assisted sentinel lymph node procedure in early gastric cancer.

A case report of a gastric neuroendocrine tumor arising from gastric adenoma

Background : Composite glandular/exocrine-endocrine neoplasms of the gastrointestinal tract are a special tumor type. There are only three reports in English on secondary gastric neuroendocrine tumor (G-NET) arising from gastric adenoma. Here, we describe a rare case of a G-NET arising from a gastric adenoma. Case presentation: A 69-year-old man underwent esophagogastroduodenoscopy as part of a general health check-up. An endoscopic examination revealed a 5-mm elevated tumor on the fornix of the stomach. Further, atrophic changes in the gastric mucosa were not noted. The tumor was diagnosed as a gastric adenoma; thus, endoscopic submucosal dissection (ESD) was performed. Histologically, the tumor was composed of two components, an epithelial component, which was diagnosed as an adenoma, and a depth component, which was diagnosed as a neuroendocrine tumor. The neuroendocrine tumor was diagnosed as a Grade 2 G-NET arising from the gastric adenoma. Histologically, the tumor invaded the submucosal layer (&gt;1000 μm), invading the lymph vessels, additional gastrectomy was performed. Pathologist revealed no remaining tumor or lymph node metastases in the resected specimen. Conclusions : We report this extremely rare case of a G-NET (Grade 2), initially diagnosed as a gastric adenoma, that is considered to have originated from the gastric adenoma. Pathologists, endoscopists and surgeons should be aware of the occurrence and association of NETs with adenomas in the stomach because small submucosal NETs of the stomach have relatively high metastatic rates.