Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan.
Research and Development Center for New Frontier, Kitasato University School of Medicine, Sagamihara, Japan.
Surg Endosc. 2018 Mar;32(3):1314-1323. doi: 10.1007/s00464-017-5809-1. Epub 2017 Aug 24.
Gastric cancer treatment guidelines recommend additional surgery as the standard treatment for lesions for which endoscopic submucosal dissection (ESD) is not indicated. However, the incidence of lymph-node metastasis is low in most patients.
The study comprised 231 patients (231 lesions) who underwent ESD for early gastric cancer (EGC) in our hospital from September 2002 through March 2015 and were found to have lesions for which endoscopic treatment is not indicated on histopathological evaluation after ESD. The patients were divided into the additional operation group and the follow-up group, and long-term outcomes were studied retrospectively. Risk factors for metastasis and recurrence were also studied (capture rate, 98.7%).
The median follow-up was 48 months. There were 174 men and 57 women with a median age of 72 years. The additional operation group comprised 118 patients, and the follow-up group comprised 113 patients. The rates of 5-year cause-specific survival and 5-year overall survival were significantly higher in the additional operation group (100 and 96.0%, respectively) than in the follow-up group (92.6 and 73.3%, respectively; p = 0.010, p < 0.001). In the follow-up group, 5 patients (4.4%) died of gastric cancer (p = 0.021). Among elderly patients 75 years or older, long-term outcomes did not differ significantly between the groups. Sixteen patients had metastasis or recurrence, and the presence of lymphatic involvement was an independent risk factor for metastasis, recurrence, or both (p = 0.003; odds ratio 10.594; 95% confidence interval 2.294-48.927).
In patients with EGC who are confirmed to have lesions for which endoscopic treatment is not indicated on histopathological evaluation after ESD, additional surgery should be aggressively performed if the patient can tolerate such treatment. In elderly patients aged 75 years or older and patients with serious underlying diseases, follow-up observation was suggested to be one option in patients who give informed consent after receiving an explanation of the risk of recurrence.
胃癌治疗指南建议对内镜黏膜下剥离术（ESD）不适用的病变进行额外手术作为标准治疗。然而，大多数患者的淋巴结转移发生率较低。
本研究纳入了 231 例（231 处病灶）于 2002 年 9 月至 2015 年 3 月在我院接受 ESD 治疗的早期胃癌（EGC）患者，这些患者在 ESD 后病理评估发现病灶不适合内镜治疗。患者被分为追加手术组和随访组，回顾性研究长期结果。还研究了转移和复发的危险因素（捕获率 98.7%）。
中位随访时间为 48 个月。男性 174 例，女性 57 例，中位年龄为 72 岁。追加手术组 118 例，随访组 113 例。追加手术组的 5 年疾病特异性生存率和总生存率明显高于随访组（分别为 100%和 96.0%）（p=0.010，p<0.001）。随访组中有 5 例（4.4%）患者死于胃癌（p=0.021）。在 75 岁或以上的老年患者中，两组的长期结果无显著差异。16 例患者发生转移或复发，淋巴管浸润是转移、复发或两者的独立危险因素（p=0.003；优势比 10.594；95%置信区间 2.294-48.927）。
对于 ESD 后病理评估发现病灶不适合内镜治疗的 EGC 患者，如果患者能够耐受这种治疗，应积极进行追加手术。对于 75 岁或以上的老年患者和患有严重基础疾病的患者，如果患者在知情同意后接受了复发风险的解释，建议选择随访观察作为一种选择。
