Mohamed M Abdelfatah1, Mohamed Barakat2, Hyuk Lee3, Jae J Kim3, Noriya Uedo4, Ian Grimm5, Mohamed O Othman6. 1. Division of Gastroenterology, Department of Internal Medicine, East Carolina University, Greenville, North Carolina. 2. Department of Internal Medicine, Icahn School of Medicine at Mt. Sinai-Queens Hospital Center, Jamaica, New York. 3. Division of Gastroenterology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. 4. Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan. 5. Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina. 6. Gastroenterology and Hepatology Section, Baylor College of Medicine, Houston, Texas, United States.
Abstract
BACKGROUND AND AIMS: Japanese criteria for curative endoscopic resection of early gastric cancer initially included nonulcerated, well-differentiated mucosal lesions ≤2 cm in diameter, known as the absolute criteria. Subsequently, these indications were expanded to include larger, ulcerated, and undifferentiated mucosal lesions as well as differentiated lesions with slight submucosal invasion. Whether patients meeting the expanded criteria can be managed safely without gastrectomy and lymph node dissection has been controversial. The risk of lymph node metastasis (LNM) in patients who met the expanded criteria is a critical factor in determining the best course of management for these patients. METHODS: We comprehensively searched main reference databases for studies that included patients who underwent gastrectomy and lymph node dissection for early gastric cancer. A meta-analysis was conducted by using the random effects model. Relative risk reduction was used to compare the incidence of LNM in patients meeting the absolute criteria as compared with those meeting the expanded criteria. RESULTS: Twelve studies met the inclusion criteria, providing a total of 9798 patients. The incidence of LNM was 0.2% for patients who met the absolute criteria as compared with 0.7% for patients who met the expanded criteria. Analysis of the various components of the expanded criteria was conducted, revealing that the incidence of LNM for differentiated mucosal lesions ≤3 cm with ulceration and for differentiated mucosal lesions without ulceration, irrespective of size, was 16 of 2814 (0.57%), reference range (RR) 3.01; P = .02 and 8 of 3004 (0.27%), RR 1.69; P = .37, respectively, only marginally higher than the risk of LNM associated with the absolute criteria. In contrast, undifferentiated mucosal lesions ≤2 cm and differentiated lesions <3 cm with slight submucosal invasion had a significantly higher incidence of LNM in comparison with the absolute criteria (25/972 [2.6%], RR 6.79; P = .0004 and 8/315 [2.5%], RR 6.30; P = .004, respectively). CONCLUSION: Overall, expanding the indication for endoscopic resection to include mucosal nonulcerated differentiated lesions irrespective of size and differentiated mucosal ulcerated lesions <3 cm is justified with minimal increased risk in comparison to the absolute criteria. However, expanding the indication for undifferentiated lesions ≤2 cm and differentiated lesions with slight submucosal invasion (T1b) should be balanced with the risks of surgery, given the increased risk of LNM in these patients.
BACKGROUND AND AIMS: Japanese criteria for curative endoscopic resection of early gastric cancer initially included nonulcerated, well-differentiated mucosal lesions ≤2 cm in diameter, known as the absolute criteria. Subsequently, these indications were expanded to include larger, ulcerated, and undifferentiated mucosal lesions as well as differentiated lesions with slight submucosal invasion. Whether patients meeting the expanded criteria can be managed safely without gastrectomy and lymph node dissection has been controversial. The risk of lymph node metastasis (LNM) in patients who met the expanded criteria is a critical factor in determining the best course of management for these patients. METHODS: We comprehensively searched main reference databases for studies that included patients who underwent gastrectomy and lymph node dissection for early gastric cancer. A meta-analysis was conducted by using the random effects model. Relative risk reduction was used to compare the incidence of LNM in patients meeting the absolute criteria as compared with those meeting the expanded criteria. RESULTS: Twelve studies met the inclusion criteria, providing a total of 9798 patients. The incidence of LNM was 0.2% for patients who met the absolute criteria as compared with 0.7% for patients who met the expanded criteria. Analysis of the various components of the expanded criteria was conducted, revealing that the incidence of LNM for differentiated mucosal lesions ≤3 cm with ulceration and for differentiated mucosal lesions without ulceration, irrespective of size, was 16 of 2814 (0.57%), reference range (RR) 3.01; P = .02 and 8 of 3004 (0.27%), RR 1.69; P = .37, respectively, only marginally higher than the risk of LNM associated with the absolute criteria. In contrast, undifferentiated mucosal lesions ≤2 cm and differentiated lesions <3 cm with slight submucosal invasion had a significantly higher incidence of LNM in comparison with the absolute criteria (25/972 [2.6%], RR 6.79; P = .0004 and 8/315 [2.5%], RR 6.30; P = .004, respectively). CONCLUSION: Overall, expanding the indication for endoscopic resection to include mucosal nonulcerated differentiated lesions irrespective of size and differentiated mucosal ulcerated lesions <3 cm is justified with minimal increased risk in comparison to the absolute criteria. However, expanding the indication for undifferentiated lesions ≤2 cm and differentiated lesions with slight submucosal invasion (T1b) should be balanced with the risks of surgery, given the increased risk of LNM in these patients.
Authors: Chan Hyuk Park; Dong-Hoon Yang; Jong Wook Kim; Jie-Hyun Kim; Ji Hyun Kim; Yang Won Min; Si Hyung Lee; Jung Ho Bae; Hyunsoo Chung; Kee Don Choi; Jun Chul Park; Hyuk Lee; Min-Seob Kwak; Bun Kim; Hyun Jung Lee; Hye Seung Lee; Miyoung Choi; Dong-Ah Park; Jong Yeul Lee; Jeong-Sik Byeon; Chan Guk Park; Joo Young Cho; Soo Teik Lee; Hoon Jai Chun Journal: Intest Res Date: 2020-10-13