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Objective: Risk factors related to residual cancer or lymph node metastasis after endoscopic non-curative resection of early colorectal cancer were analyzed to predict the risk of residual cancer or lymph node metastasis, optimize the indications of radical surgical surgery, and avoid excessive additional surgical operations. Methods: Clinical data of 81 patients who received endoscopic treatment for early colorectal cancer in the Department of Endoscopy, Cancer Hospital, Chinese Academy of Medical Sciences from 2009 to 2019 and received additional radical surgical surgery after endoscopic resection with pathological indication of non-curative resection were collected to analyze the relationship between various factors and the risk of residual cancer or lymph node metastasis after endoscopic resection. Results: Of the 81 patients, 17 (21.0%) were positive for residual cancer or lymph node metastasis, while 64 (79.0%) were negative. Among 17 patients with residual cancer or positive lymph node metastasis, 3 patients had only residual cancer (2 patients with positive vertical cutting edge). 11 patients had only lymph node metastasis, and 3 patients had both residual cancer and lymph node metastasis. Lesion location, poorly differentiated cancer, depth of submucosal invasion ≥2 000 μm, venous invasion were associated with residual cancer or lymph node metastasis after endoscopic (P<0.05). Logistic multivariate regression analysis showed that poorly differentiated cancer (OR=5.513, 95% CI: 1.423, 21.352, P=0.013) was an independent risk factor for residual cancer or lymph node metastasis after endoscopic non-curative resection of early colorectal cancer. Conclusions: For early colorectal cancer after endoscopic non-curable resection, residual cancer or lymph node metastasis is associated with poorly differentiated cancer, depth of submucosal invasion ≥2 000 μm, venous invasion and the lesions are located in the descending colon, transverse colon, ascending colon and cecum with the postoperative mucosal pathology result. For early colorectal cancer, poorly differentiated cancer is an independent risk factor for residual cancer or lymph node metastasis after endoscopic non-curative resection, which is suggested that radical surgery should be added after endoscopic treatment.
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Humans , Lymphatic Metastasis , Neoplasm, Residual , Retrospective Studies , Endoscopy , Risk Factors , Colorectal Neoplasms/pathology , Neoplasm InvasivenessABSTRACT
Objective:To evaluate the adjuvant role of the eCura scoring system in selecting appropriate treatment strategies after non-curative endoscopic submucosal dissection (ESD) of early gastric cancer (EGC) patients.Methods:The clinicopathological data of 110 EGC patients who underwent non-curative ESD at Fujian Provincial Hospital from January 2015 to June 2019 were retrospectively analyzed. According to the eCura score, patients were divided into three lymph node metastasis (LNM) risk groups: low-risk group (79 cases), middle-risk group (22 cases), and high-risk group (9 cases). The receiver operator characteristic (ROC) curve analysis was used to test the diagnostic efficacy of eCura scoring system in predicting LNM. Logistic regression analysis was used to explore the influence of risk stratification of eCura scoring system on LNM. Kaplan-Meier method was used to evaluate cancer survival rate, which was then compared with log-rank test.Results:Thirty-five patients underwent additional standard surgery after ESD, including 22 in the low-risk group, 8 in the middle-risk group, and 5 in the high-risk group. Among them, 5 cases had LNM, including 1 case in the low-risk group and the middle-risk group respectively and 3 cases in the high-risk group. The area under the ROC curve was 0.857 (95% CI: 0.697-0.952, P=0.001), and when the cut-off value of the eCura score was set at 3, the Yuden index reached the maximum value of 0.7, with the corresponding sensitivity and specificity of 80% and 90%, respectively. Logistic regression analysis showed that the probability of LNM in the middle-risk group was about 3.00 times (95% CI: 0.17-54.57, P=0.458) as high as that in the low-risk group, and the probability of LNM in the high-risk group was about 31.50 times (95% CI: 2.14-463.14, P=0.012) of that in the low-risk group. The follow-up time was 12 to 58 months, and the median follow-up time was 40 months. There were 10 cases of recurrence, including 4 cases in the low-risk group, 3 cases in the middle-risk group and 3 cases in the high-risk group, of which 2 cases in the low-risk group were from those of additional standard surgery after ESD, and the remaining 8 cases were from those who did not receive additional standard surgery after ESD. Kaplan-Meier survival curve analysis showed that the survival rate of patients with additional surgery in the low-risk group was similar to that of patients without ( P=0.319), and the survival rate of patients with additional surgery in the middle-risk group was also similar to that of patients without ( P=0.296). The survival rate of patients with additional surgery in the high-risk group was significantly higher than that of those without ( P=0.013). Conclusion:The eCura scoring system can assist the selection of treatment strategies after non-curative resection of EGC, and can accurately predict the risk of subsequent LNM and recurrence. Close follow-up may be an acceptable option for patients with low risk of LNM, and additional standard surgical treatment may be more conducive to improving the prognosis in patients with high risk of LNM.
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Objective:To evaluate the clinical outcomes of additional surgery after non-curative endoscopic submucosal dissection (ESD) for early gastric cancer.Methods:Sixty-nine patients with early gastric cancer who underwent ESD and were diagnosed as having non-curative resection by postoperative pathology at Union Hospital, Tongji Medical College, Huazhong University of Science and Technology from January 2014 to December 2020 were included in the retrospective observation. Patients were divided into the additional surgery group ( n=12) and the follow-up group ( n=57). The differences in clinical and pathological data of the two groups, the surgical outcomes of the additional surgery group, three-year recurrence-free survival and tumor-specific survival of the two groups, and the independent risk factors affecting three-year recurrence-free survival in the follow-up group were analyzed. Results:Compared with the follow-up group, the rates of submucosal infiltration [66.7% (8/12) VS 21.1% (12/57), χ 2=7.927, P=0.005], vascular invasion [33.3% (4/12) VS 1.8% (1/57), P=0.003] and nerve invasion [16.7% (2/12) VS 0.0% (0/57), P=0.028] in the additional surgery group were significantly higher. In the additional surgery group, the interval between the additional surgery and ESD was 18.5 d (7-55 d), the surgical time was 286.4±85.9 min, and the number of dissected lymph nodes was 25.6±7.4. Four patients (33.3%) had residual tumor. Postoperative complications occurred in 4 patients (33.3%) (all were discharged after conservative treatment), and there was no perioperative death. One patient developed liver metastases 17 months after the surgery, and died 22 months after surgery due to liver metastases. One patient died 22 months after surgery due to non-tumor causes. The three-year recurrence-free survival and three-year tumor-specific survival in additional surgery group were 91.7% (11/12) and 91.7% (11/12), respectively, and those in the follow-up group were 87.7% (50/57) and 100.0% (57/57), respectively. Multivariate Cox regression analysis showed that tumor size ≥2 cm was an independent risk factor for three-year recurrence-free survival in the follow-up group ( P=0.037, HR=15.595, 95% CI: 1.181-205.952). Conclusion:Additional surgery and close follow-up are safe and feasible therapeutic strategies for early gastric cancer patients who underwent non-curative ESD. Clinicians should make reasonable choice based on the pathological results, patients' physical condition and surgery intention. But for patients with primary tumor size ≥2 cm, additional surgery is recommended.
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Objective:To explore the endoscopic features of early gastric cancer (EGC) related to non-curative endoscopic resection, and to construct an assessment model to quantify the risk of non-curative resection.Methods:From August 2006 to October 2019, 378 lesions that underwent endoscopic resection and were diagnosed pathological as EGC in the Department of Gastroenterology, Peking Union Medical College Hospital were included in this case-control study.Seventy-eight (20.6%) non-curative resection lesions were included in the observation group, and 234 lesions which selected from 300 lesions of curative resection were included in the control group according to the difference of operation year ±1 with the observation group, and the ratio of 1∶3 of the observation group to the control group. Univariate and multivariate logistic regression analysis were performed to explore the risk factors for non-curative resection. The independent risk factor with the minimum β coefficient was assigned 1 point, and the remaining factors were scored according to the ratio of their β coefficient to the minimum. A predictive model was established to analyze the 378 lesions.The non-curative resection rates of lesions of different scores were calculated. Results:Univariate analysis showed that the lesion diameter, the location, redness, ulcer or ulcer scar, fold interruption, fold entanglement, and invasion depth observed with endoscopic ultrasonography (EUS) were associated with non-curative resection of EGC lesions ( P<0.05), and contact or spontaneous bleeding may be associated with non-curative resection ( P=0.068). Multivariate logistic regression analysis showed that submucosal involvement (VS confined to the mucosa: β=0.901, P=0.011, OR=2.46, 95% CI: 1.23-4.92), lesion diameter of 3-<5 cm (VS <3 cm: β=0.723, P=0.038, OR=2.06, 95% CI: 1.04-4.09), lesion diameter of ≥5 cm (VS <3 cm: β=2.078, P=0.003, OR=7.99, 95% CI: 2.02-31.66), location in the upper 1/3 of the stomach (VS lower 1/3: β=1.540, P<0.001, OR=4.66, 95% CI: 2.30-9.45), and fold interruption ( β=2.287, P=0.008, OR=1.93, 95% CI: 0.95-3.93) were independent risk factors for non-curative resection of EGC lesions. The factor of lesion diameter of 3-<5 cm and submucosal involvement were assigned 1 point respectively, location in the upper 1/3 of the stomach was assigned 2 points, diameter of ≥5 cm and fold interruption were assigned 3 points respectively, and other factors were assigned 0 point. Then the analysis of 378 lesions showed that the probability of non-curative resection at ≥2 points was 41.9% (37/93), 4 times as much as that at 0 [11.5% (25/217)]. Conclusion:EGC lesions with diameter ≥3 cm, located in the upper 1/3 of the stomach, interrupted folds or submucosal involvement are highly related to non-curative resection. The predictive model based on these factors achieves satisfactory efficacy, but it still needs further validation in larger cohorts.
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Endoscopic resection(ER) is playing an increasingly important role in treatment of gastric cancer. However,many patients received endoscopic resection turned out to be non-curative. Thus, the following treatment after ER is worthy of discussion. Reviewing the recomandations of guidelines published by European Society for Medical Oncology(ESMO), National Comprehensive Cancer Network(NCCN) and Japanese Gastric Cancer Association(JGCA) and relevant articles, and also retrospectively analysis of cases in our center. In conclusion, for patients of eCura-C, surgery is recommended after considering relevant risks. Gastrectomy type and lymph node dissection range may refer to those for early gastric cancer.Further research is needed to predict lymph node metastasis more accurately. With the development of minimal invasive surgery, sentinel node navigation surgery and laparoscopic and endoscopic cooperative surgery will gain more and more attention.
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Objective To investigate the risk factors for non-curative resection after endoscopic submucosal dissection ( ESD ) for early esophageal cancer and high-grade intraepithelial neoplasia .Methods The clinicopathological data of 427 cases of early esophageal cancer and high-grade intraepithelial neoplasia who underwent ESD was performed from January 2013 to December 2016 in the Department of Gastroenterology , First Affiliated Hospital of Nanjing Medical University were retrospectively analyzed .According to the results of postoperative pathology and immunohistochemistry ,339 patients were defined as curative resection group and 88 patients were defined as non-curative resection group .Chi-square test , univariate analysis and multivariate logistic regression analysis were used for statistical analysis .Results A total of 427 patients were enrolled in this study, with an average age of (63.2 ±7.7) years, including 96 cases of early esophageal cancer and 331 cases of high-grade intraepithelial neoplasia .The enbloc resection rate of ESD was 94.8％(405/427), 88 of them were non-curative resected, and the non-curative resection rate was 20.6％.Univariate analysis showed that early esophageal cancer (odds ratio (OR)=3.682, 95％confidence interval (CI) 2.216 to 6.118, P<0.01), submucosal infiltration (OR=10.220, 95％CI 4.861 to 21.481, P<0.01), ESD indications (OR=6.005, 95％CI 3.545 to 10.172, P<0.01) and lifting sign after injecting at the base of lesions (OR=2.508, 95％CI 1.005 to 6.255, P=0.042) were statistically significant between non-curative resection group and curative resection group . Multivariate unconditional logistic regression analysis revealed that submucosal infiltration (OR =4.329, 95％CI 1.758 to 10.661,P =0.001), not absolute indications of ESD (OR =6.484, 95％CI 2.205 to 19.068, P=0.001) and negative lifting sign (OR=3.182, 95％CI 1.171 to 8.651, P=0.023) were independent risk factors for non-curative resection.Conclusions Patients with early esophageal cancer , submucosal infiltration , not absolute indications for ESD and negative lifting signs are prone to non-curative resection .Moreover , submucosal infiltration , not absolute indications for ESD , and negative lifting signs are the independent risk factors for non-curative resection .