Department of Surgery, Kishiwada Tokushukai Hospital, 4-27-1 Kamori-Cho, Kishiwada, Osaka, 596-8522, Japan.
BMC Surg. 2022 Oct 1;22(1):352. doi: 10.1186/s12893-022-01777-8.
Performing additional surgery after noncurative endoscopic submucosal dissection (ESD) for early gastric cancer is controversial. Our aims are to clarify the risk factors for lymph node metastasis (LNM) and local residual cancer (RC) after noncurative ESD and to determine recommendations for additional treatment.
Of the 1483 patients who underwent ESD for early gastric cancer between January 2012 and April 2020, we retrospectively analyzed 151 patients diagnosed as having a lesion not meeting the curative criteria after ESD. Of these patients, 100 underwent additional gastrectomy, and 51 were observed without surgery.
Surgical specimens showed LNM in 14 patients (14.0%) and local RC in 7 (7.0%). However, 81 patients (81.0%) had neither of these malignancies. Multivariate analysis revealed that a positive lymphatic invasion (P = 0.035) and an undifferentiated type (P = 0.047) were independent risk factors for LNM, whereas a positive horizontal margin (P = 0.010) was an independent risk factor for local RC. Furthermore, the prevalence of LNM was significantly higher in patients with both positive lymphatic and vascular invasions. In the additional gastrectomy group, 3 patients (3.0%) had recurrences, and 2 patients (2.0%) who had distant recurrences died of gastric cancer. In the observation group, recurrence was observed in 3 patients (5.9%). One patient (2.0%) who had liver metastasis died of gastric cancer. Of the 2 patients (3.9%) who had local recurrences, one underwent additional ESD, and the other without additional ESD died of other disease. The 5-year overall survival rates in the additional gastrectomy and observation groups were 87.4% and 73.8%, respectively (log-rank test, P = 0.008).
Following noncurative ESD for early gastric cancer, we recommend an additional gastrectomy with lymph node dissection for patients with lymphovascular invasion and/or undifferentiated type. Careful follow-ups without additional surgery may be acceptable for patients with advanced age, severe comorbidity, or no lymphovascular invasion.
对于早期胃癌，非治愈性内镜黏膜下剥离术（ESD）后进行额外手术存在争议。我们的目的是明确非治愈性 ESD 后发生淋巴结转移（LNM）和局部残留癌（RC）的危险因素，并确定进一步治疗的建议。
回顾性分析 2012 年 1 月至 2020 年 4 月期间因早期胃癌接受 ESD 的 1483 例患者，对术后诊断为非治愈性的 151 例患者进行分析。其中 100 例行追加胃切除术，51 例未行手术观察。
手术标本显示 LNM 患者 14 例（14.0%），局部 RC 患者 7 例（7.0%）。然而，81 例（81.0%）患者均无上述两种恶性肿瘤。多因素分析显示，淋巴管浸润阳性（P=0.035）和未分化型（P=0.047）是 LNM 的独立危险因素，而水平切缘阳性（P=0.010）是局部 RC 的独立危险因素。此外，淋巴管和血管侵犯阳性患者 LNM 的发生率明显更高。在追加胃切除术组中，3 例（3.0%）复发，2 例（2.0%）远处转移死亡。观察组中，3 例（5.9%）复发。1 例（2.0%）发生肝转移，死于胃癌。2 例（3.9%）局部复发患者中，1 例行追加 ESD，另 1 例未行 ESD 死于其他疾病。追加胃切除术组和观察组的 5 年总生存率分别为 87.4%和 73.8%（log-rank 检验，P=0.008）。
对于早期胃癌，非治愈性 ESD 后建议对淋巴管血管侵犯和/或未分化型患者进行追加胃切除术及淋巴结清扫。对于年龄较大、合并严重疾病或无淋巴管血管侵犯的患者，密切随访而不进行额外手术可能是可以接受的。
