Department of Internal Medicine, Hallym University College of Medicine, Sakju-ro 77, Chuncheon, Gangwon-do, 24253, Korea.
Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, Korea.
Dig Dis Sci. 2020 Jan;65(1):276-291. doi: 10.1007/s10620-019-05761-w. Epub 2019 Jul 31.
Endoscopic submucosal dissection (ESD) criteria are histologically categorized by early gastric cancer (EGC) with differentiated- and undifferentiated-type histology. However, EGC is histologically heterogenous and there have been no separate criteria for EGC with mixed-type histology [EGC-MH; differentiated-type predominant EGC mixed with an undifferentiated component (EGC-MD) or undifferentiated-type predominant EGC mixed with a differentiated component (EGC-MU)]. Moreover, therapeutic outcomes of ESD for EGC-MH have not been clearly described.
This study aimed to evaluate the feasibility of ESD for EGC-MH.
We searched core databases for specific inclusion factors: patients with EGC-MH, intervention of ESD, and at least one of the following outcomes: rate of en bloc, complete, curative resection, recurrence, procedure-related adverse event, lymphovascular invasion (LVI), or lymph node metastasis (LNM) that enabled evaluation of feasibility of ESD.
A total of eight (systematic review) and four studies (meta-analysis) were included. There was no robustness in age, location, or morphology of EGC-MH. Moderately differentiated adenocarcinoma was frequent in pre-ESD biopsy. EGC-MH showed larger size, deeper invasion, and higher rates of LVI/LNM than pure-type EGC. Total en bloc, complete resection, and curative resection rates were 94.6% (95% confidence interval 86.6-97.9%), 77.8% (57.9-89.9%), and 55.1% (50.4-59.6%), respectively. There was no LNM or extra-gastric recurrence after ESD if the EGC-MD met the curative resection criteria. However, the EGC-MD itself was a risk factor for non-curative resection. (Margin positivity was the most common reason.) CONCLUSIONS: Although ESD seems to be technically feasible, inaccurate prediction of lateral or vertical margin leads to lower curative resection rate. Application of more strict indication is needed for EGC-MH.
内镜黏膜下剥离术（ESD）的适应证是根据早期胃癌（EGC）的组织学类型进行分类，包括分化型和未分化型。然而，EGC 在组织学上是异质的，并且对于混合组织学类型的 EGC（EGC-MH；分化型为主的 EGC 混合未分化成分[EGC-MD]或未分化型为主的 EGC 混合分化成分[EGC-MU]）尚未有单独的适应证。此外，ESD 治疗 EGC-MH 的疗效尚不清楚。
本研究旨在评估 ESD 治疗 EGC-MH 的可行性。
我们在核心数据库中搜索特定的纳入因素：EGC-MH 患者，ESD 干预，以及以下至少一种结局：整块切除率、完全切除率、治愈性切除率、复发率、与操作相关的不良事件、淋巴管浸润（LVI）或淋巴结转移（LNM），这些结局能够评估 ESD 的可行性。
共纳入 8 项（系统评价）和 4 项（荟萃分析）研究。EGC-MH 在年龄、部位或形态上没有明显的特征。ESD 术前活检中以中分化腺癌多见。与单纯型 EGC 相比，EGC-MH 具有更大的肿瘤直径、更深的浸润程度和更高的 LVI/LNM 发生率。整块切除率、完全切除率和治愈性切除率分别为 94.6%（95%可信区间 86.6-97.9%）、77.8%（57.9-89.9%）和 55.1%（50.4-59.6%）。如果 EGC-MD 符合治愈性切除标准，则 ESD 后无淋巴结转移或胃外复发。然而，EGC-MD 本身就是非治愈性切除的危险因素。（边缘阳性是最常见的原因。）
尽管 ESD 在技术上似乎是可行的，但对侧向或垂直边缘的预测不准确会导致治愈性切除率降低。对于 EGC-MH 需要应用更严格的适应证。
