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M1578: Endoscopic Mucosal Resection in Gastric Epithelial Lesions: A North American Tertiary Centre's Experience
Abstracts argon plasma coagulation for an initial recurrence had recurred again. Conclusion: Despite the potential advantages in treatment of EGC with ESD, a risk for local recurrence remains. All patients treated with EMR, even with curative resection, and those with incomplete resection after ESD require conscientious surveillance for local recurrence. Furthermore, a large prospective study will be required to determine the best treatment modality for local recurrence.
M1578 Endoscopic Mucosal Resection in Gastric Epithelial Lesions: A North American Tertiary Centre’s Experience Kwang-an Kwon, Maria Cirocco, Naoki Muguruma, Issa Al-Quarshobi, Fergal Donnellan, Michael Swan, Streutker Catherine, Gary R. May, Gabor Kandel, Paul P. Kortan, Norman E. Marcon Background and Aims: Endoscopic mucosal resection (EMR) has evolved into an alternative to surgical resection of superficial gastric neoplastic lesions. This study retrospectively reviews a North American tertiary endoscopic center experience to evaluate: 1) the clinicopathological characteristics of patients with EMR; 2) the discrepancy between endoscopic forceps biopsies and EMR specimens; 3) to demonstrate how uncommon early gastric lesions are in a North American centre. Methods: Data was analyzed for 18 patients who had gastric EMR (mean age;73.7 yrs, M/F;12/6) between April 2002 and May 2009.The techniques of EMR were as follows: 14 with ligation (Duette, Cook Medical), and 4 injection, lift and cut method. All EMR were done on an outpatient basis. Endoscopic ultrasonography was also done if the lesion could not be lifted easily with submucosal saline injection, or if there was any other indication that the neoplasm had extended deep to the mucosa. Results: The mean endoscopic follow up period was 16.9 (2.1-69.9) months. The mean size of lesions was 2.2 (0.5-5.0) cm. The final diagnoses of lesions were: 3 inflammation, 4 low-grade dysplasia, 2 high-grade dysplasia, 7 intramucosal carcinoma, 1 submucosal carcinoma, and 1 carcinoid tumor. Locations of lesion were 8 antrum, 5 body, 1 fundus, and 4 cardia. Endoscopic morphologys of lesion were 4 polypoid, 9 sessile, and 5 flat. Sessions required for endoscopic eradication were as follows: 1 lesion - 3 sessions, 5 lesions - 2 sessions, and 12 lesions - 1 session. During the follow up period, 2 cases of neoplastic recurrences were noted and successfully eradicated by subsequent EMR (time to recurrence: 25.7months and 13.2months). In only 11 lesions (61.1%), was there agreement between the histological results on the forceps biopsy sample and on the EMR specimen. EMR resulted in upgrading of histopathologic staging to carcinoma in 5 patients (27.8%). EMR downgraded the histopathologic staging in 2 patients (11.1%). One patient was referred to surgery due to incomplete EMR. There were no complications such as perforation or bleeding requiring blood transfusion. No patients required admission after EMR. Conclusions: Endoscopic forceps biopsy is not reliable for the identification of gastric epithelial lesions. These lesions should be fully resected by EMR for final diagnosis and possibly definitive treatment. EMR with ligation, or lift and cut method is a safe and effective procedure for the outpatient treatment of gastric epithelial lesions.
M1579 Clinical Outcomes of Endoscopic Submucosal Dissection for Early Gastric Cancer With Expanded Criteria & Undifferentiated Cancer: Single Center Study Choong Heon Ryu, Sang Young Seol, Yeon Jae Lee, Jung Sik Choi, Sam Ryong Jee, Ji Hyun Kim, Sang Heon Lee, Kyung Sun Ok, Eun Uk Jung Introduction&aimEndoscopic submucosal dissection (ESD) has the advantage over conventional endoscopic mucosa resection,permitting removal of early gastric cancer (EGC) en bloc,in particular case with large,ulcerated and minute submucosal invasive lesion.But,long-term outcomes of ESD in early gastric cancer with expanded criteria proposed by Gotoda et al, remain unknown.The aim of this study was to evaluate the rate of tumor recurrence and disease free survival in early gastric cancer that categorized into expanded criteria after ESD&undifferentiated cancer.Method ESD was performed for patients with EGC that fulfilled the standard&expanded criteria and undifferentiated cancer. The expanded criteria defined as:1mucosal cancer without ulcer irrespective of tumor size2)mucosal cancer with ulcer ⱕ3 cm in diameter3)Minimal submucosal invasive cancer(SM1) with ⱕ3 cm in diameter.The intramucosal or SM1 invasive undifferentiated cancer (signet ring cell carcinoma and poorly differentiated adenocarcinoma)ⱕ3cm were also included for endoscopic treatment group.Cases with differentiated mucosal cancer without ulcerⱕ2cm were defined as standard criteria.The outcome measures were respectability and incidence of procedurerelated complications such as bleeding&perforation.The difference in disease free survival rate and local recurrence rate between three groups was estimated. Results Total 116 patients(71 patients in expanded criteria;33 patients in standard criteria;12 patients in undifferentiated cancer) underwent ESD and then received periodic endoscopic survey for 17-601 days (mean,91days). There was no significant difference in en bloc resection rates,curative resection rates and
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incidence of procedure-related complications between three groups.There was no case with metastasis to lymph node or distant organs during the study period in three groups.Conclusion Standard criteria and expanded criteria of ESD and undifferentiated cancer have similar clinical outcomes in en bloc resection rates, local recurrence and disease free survival rates. It is suggested that EGC that categorized into expanded criteria and undifferentiated cancer will be indication of endoscopic treatment.
En bloc resection Curative resection Perforation Major Bleeding Local recurrence Median follow-up period(range) Disease free survival
Expanded criteria
Standard criteria
undifferentiated cancer
P value
87.3% 88.7% 2.9% 11.3% 1.9% 85 days (17-601) 97.4%
97.0% 97.0% 6.1% 0% 3.4% 73 days (34-373) 91.7%
83.3% 75.0% 0% 0% 14.3% 245 days (68-405)
0.242 0.093 0.564 0.066 0.232 0.349*
80%
0.648**
Data were analysed the chi-square test* One way ANOVA**Kaplan-Meier method and Log-rank
M1580 Is Presence of Endoscopic Ulcer or Ulcer Scar in EGC Associated With an Increased Risk of Submucosal Invasion?: Analysis With Endoscopically Resected Specimen Choong Heon Ryu, Sang Young Seol, Yeon Jae Lee, Jung Sik Choi, Sam Ryong Jee, Ji Hyun Kim, Sang Heon Lee, Kyung Sun Ok, Eun Uk Jung Introduction and AimSubmucosal invasion in EGC was a risk factor of lymph node metastasis.Lymph node metastasis was related to poor survival rate and needed subsequent gastrectomy with lymph node dissection.Cancer size,histologic type&presence of ulcer or ulcer scar have been reported as risk factors for submucosal invasion. Currently,⬉3cm differentiated mucosal cancer with ulcer was classified as expanded criteria for endoscopic resection according to Japanese guideline.However,EGCs accompanied by endoscopic ulcer is found not infrequently and,in our experiences,EGC with ulcer were not seemed to be more submucosal invasive compared to those without ulcer.The aim of this study was to evaluate the rate of submucosal invasion in EGC with/without ulcer with endoscopically resected specimen.MethodESD was performed for patients with EGC that fulfilled the standard and expanded criteria and undifferentiated mucosal cancer.(signet ring cell carcinoma&poorly differentiated adenocarcinoma) We divided patients into two groups :the ulcer group and the non ulcer group. Ulcer was defined as a endoscopic ulcer more than H2 stage. EGC with A1 or A2 staged ulcers were treated with proton pump inhibitor for 4 weeks and then ESD was performed. The outcome measures were respectability and incidence of procedure-related complications such as bleeding and perforation. The difference in submucosal invasion rate and local recurrence rate between two groups was estimated.ResultsTotal 116 patients (51 patients in Ulcer group;65 patients in Non ulcer group)underwent ESD.The undifferentiated cancer was significantly more frequent in ulcer group. (4.6%/17.6%) The submucosal invasion rates in two groups were 12.3% and 21.6%, respectively.(p⫽0.212) There was no case with metastasis to lymph node or distant organs during the study period in two groups.ConclusionEGCs accompanied by endoscopic ulcer have a similar clinical outcomes in submucosal invasion rate, en bloc resection rates, local recurrence and procedure-related complications (bleeding and perforation) compared to those without ulcer. It is suggested that early gastric cancer with ulcer will be indication of endoscopic treatment.
En bloc resection Curative resection Perforation Major Bleeding Local recurrence Undifferentiated cancer SM invasion rate (SM1 /SM2 invasion rate)
Non Ulcer group
Ulcer group
P value
89.2% 90.8% 4.8% 6.2% 4.1% 4.6% 12.3% (6.2%/ 6.2%)
90.2% 88.2% 2.0% 7.8% 2.5% 17.6% 21.6% (17.6%/ 3.9%)
1.0 0.762 0.627 0.729 1.0 0.031 0.212 (0.319)
Data were analysed the chi-square test
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB259
M1578 Endoscopic Mucosal Resection in Gastric Epithelial Lesions: A North American Tertiary Centre’s Experience Kwang-an Kwon, Maria Cirocco, Naoki Muguruma, Issa Al-Quarshobi, Fergal Donnellan, Michael Swan, Streutker Catherine, Gary R. May, Gabor Kandel, Paul P. Kortan, Norman E. Marcon Background and Aims: Endoscopic mucosal resection (EMR) has evolved into an alternative to surgical resection of superficial gastric neoplastic lesions. This study retrospectively reviews a North American tertiary endoscopic center experience to evaluate: 1) the clinicopathological characteristics of patients with EMR; 2) the discrepancy between endoscopic forceps biopsies and EMR specimens; 3) to demonstrate how uncommon early gastric lesions are in a North American centre. Methods: Data was analyzed for 18 patients who had gastric EMR (mean age;73.7 yrs, M/F;12/6) between April 2002 and May 2009.The techniques of EMR were as follows: 14 with ligation (Duette, Cook Medical), and 4 injection, lift and cut method. All EMR were done on an outpatient basis. Endoscopic ultrasonography was also done if the lesion could not be lifted easily with submucosal saline injection, or if there was any other indication that the neoplasm had extended deep to the mucosa. Results: The mean endoscopic follow up period was 16.9 (2.1-69.9) months. The mean size of lesions was 2.2 (0.5-5.0) cm. The final diagnoses of lesions were: 3 inflammation, 4 low-grade dysplasia, 2 high-grade dysplasia, 7 intramucosal carcinoma, 1 submucosal carcinoma, and 1 carcinoid tumor. Locations of lesion were 8 antrum, 5 body, 1 fundus, and 4 cardia. Endoscopic morphologys of lesion were 4 polypoid, 9 sessile, and 5 flat. Sessions required for endoscopic eradication were as follows: 1 lesion - 3 sessions, 5 lesions - 2 sessions, and 12 lesions - 1 session. During the follow up period, 2 cases of neoplastic recurrences were noted and successfully eradicated by subsequent EMR (time to recurrence: 25.7months and 13.2months). In only 11 lesions (61.1%), was there agreement between the histological results on the forceps biopsy sample and on the EMR specimen. EMR resulted in upgrading of histopathologic staging to carcinoma in 5 patients (27.8%). EMR downgraded the histopathologic staging in 2 patients (11.1%). One patient was referred to surgery due to incomplete EMR. There were no complications such as perforation or bleeding requiring blood transfusion. No patients required admission after EMR. Conclusions: Endoscopic forceps biopsy is not reliable for the identification of gastric epithelial lesions. These lesions should be fully resected by EMR for final diagnosis and possibly definitive treatment. EMR with ligation, or lift and cut method is a safe and effective procedure for the outpatient treatment of gastric epithelial lesions.
M1579 Clinical Outcomes of Endoscopic Submucosal Dissection for Early Gastric Cancer With Expanded Criteria & Undifferentiated Cancer: Single Center Study Choong Heon Ryu, Sang Young Seol, Yeon Jae Lee, Jung Sik Choi, Sam Ryong Jee, Ji Hyun Kim, Sang Heon Lee, Kyung Sun Ok, Eun Uk Jung Introduction&aimEndoscopic submucosal dissection (ESD) has the advantage over conventional endoscopic mucosa resection,permitting removal of early gastric cancer (EGC) en bloc,in particular case with large,ulcerated and minute submucosal invasive lesion.But,long-term outcomes of ESD in early gastric cancer with expanded criteria proposed by Gotoda et al, remain unknown.The aim of this study was to evaluate the rate of tumor recurrence and disease free survival in early gastric cancer that categorized into expanded criteria after ESD&undifferentiated cancer.Method ESD was performed for patients with EGC that fulfilled the standard&expanded criteria and undifferentiated cancer. The expanded criteria defined as:1mucosal cancer without ulcer irrespective of tumor size2)mucosal cancer with ulcer ⱕ3 cm in diameter3)Minimal submucosal invasive cancer(SM1) with ⱕ3 cm in diameter.The intramucosal or SM1 invasive undifferentiated cancer (signet ring cell carcinoma and poorly differentiated adenocarcinoma)ⱕ3cm were also included for endoscopic treatment group.Cases with differentiated mucosal cancer without ulcerⱕ2cm were defined as standard criteria.The outcome measures were respectability and incidence of procedurerelated complications such as bleeding&perforation.The difference in disease free survival rate and local recurrence rate between three groups was estimated. Results Total 116 patients(71 patients in expanded criteria;33 patients in standard criteria;12 patients in undifferentiated cancer) underwent ESD and then received periodic endoscopic survey for 17-601 days (mean,91days). There was no significant difference in en bloc resection rates,curative resection rates and
www.giejournal.org
incidence of procedure-related complications between three groups.There was no case with metastasis to lymph node or distant organs during the study period in three groups.Conclusion Standard criteria and expanded criteria of ESD and undifferentiated cancer have similar clinical outcomes in en bloc resection rates, local recurrence and disease free survival rates. It is suggested that EGC that categorized into expanded criteria and undifferentiated cancer will be indication of endoscopic treatment.
En bloc resection Curative resection Perforation Major Bleeding Local recurrence Median follow-up period(range) Disease free survival
Expanded criteria
Standard criteria
undifferentiated cancer
P value
87.3% 88.7% 2.9% 11.3% 1.9% 85 days (17-601) 97.4%
97.0% 97.0% 6.1% 0% 3.4% 73 days (34-373) 91.7%
83.3% 75.0% 0% 0% 14.3% 245 days (68-405)
0.242 0.093 0.564 0.066 0.232 0.349*
80%
0.648**
Data were analysed the chi-square test* One way ANOVA**Kaplan-Meier method and Log-rank
M1580 Is Presence of Endoscopic Ulcer or Ulcer Scar in EGC Associated With an Increased Risk of Submucosal Invasion?: Analysis With Endoscopically Resected Specimen Choong Heon Ryu, Sang Young Seol, Yeon Jae Lee, Jung Sik Choi, Sam Ryong Jee, Ji Hyun Kim, Sang Heon Lee, Kyung Sun Ok, Eun Uk Jung Introduction and AimSubmucosal invasion in EGC was a risk factor of lymph node metastasis.Lymph node metastasis was related to poor survival rate and needed subsequent gastrectomy with lymph node dissection.Cancer size,histologic type&presence of ulcer or ulcer scar have been reported as risk factors for submucosal invasion. Currently,⬉3cm differentiated mucosal cancer with ulcer was classified as expanded criteria for endoscopic resection according to Japanese guideline.However,EGCs accompanied by endoscopic ulcer is found not infrequently and,in our experiences,EGC with ulcer were not seemed to be more submucosal invasive compared to those without ulcer.The aim of this study was to evaluate the rate of submucosal invasion in EGC with/without ulcer with endoscopically resected specimen.MethodESD was performed for patients with EGC that fulfilled the standard and expanded criteria and undifferentiated mucosal cancer.(signet ring cell carcinoma&poorly differentiated adenocarcinoma) We divided patients into two groups :the ulcer group and the non ulcer group. Ulcer was defined as a endoscopic ulcer more than H2 stage. EGC with A1 or A2 staged ulcers were treated with proton pump inhibitor for 4 weeks and then ESD was performed. The outcome measures were respectability and incidence of procedure-related complications such as bleeding and perforation. The difference in submucosal invasion rate and local recurrence rate between two groups was estimated.ResultsTotal 116 patients (51 patients in Ulcer group;65 patients in Non ulcer group)underwent ESD.The undifferentiated cancer was significantly more frequent in ulcer group. (4.6%/17.6%) The submucosal invasion rates in two groups were 12.3% and 21.6%, respectively.(p⫽0.212) There was no case with metastasis to lymph node or distant organs during the study period in two groups.ConclusionEGCs accompanied by endoscopic ulcer have a similar clinical outcomes in submucosal invasion rate, en bloc resection rates, local recurrence and procedure-related complications (bleeding and perforation) compared to those without ulcer. It is suggested that early gastric cancer with ulcer will be indication of endoscopic treatment.
En bloc resection Curative resection Perforation Major Bleeding Local recurrence Undifferentiated cancer SM invasion rate (SM1 /SM2 invasion rate)
Non Ulcer group
Ulcer group
P value
89.2% 90.8% 4.8% 6.2% 4.1% 4.6% 12.3% (6.2%/ 6.2%)
90.2% 88.2% 2.0% 7.8% 2.5% 17.6% 21.6% (17.6%/ 3.9%)
1.0 0.762 0.627 0.729 1.0 0.031 0.212 (0.319)
Data were analysed the chi-square test
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB259