• Journal of Digestive Cancer Research
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• v.11 no.1
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• pp.15-20
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• 2023

Endoscopic submucosal dissection (ESD) is a minimally invasive and effective treatment for early gastric cancer. The criteria for determining the suitability and success of ESD have expanded, with changes in the histopathological classification of gastric carcinoma, including results from molecular research. Treatment methods have also diversified to include targeted therapies and immuno-oncology agents. To improve communication between clinicians and pathologists, it is crucial to understand the standardized diagnostic forms of gastric cancer. This study aims to examine the handling method of ESD specimens and describe the pathological findings of gastric tumors.

• Journal of Gastric Cancer
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• v.10 no.3
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• pp.87-90
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• 2010

Early gastric cancer (EGC) is defined as tumor invasion confined to the mucosa or submucosa, regardless of the presence of regional lymph node metastasis. Lymph node metastasis is the most powerful and important prognostic factor for gastric cancer. Based on the risk of lymph node metastasis in EGC obtained from a large number of surgical cases in Japan, it was suggested that the criteria for endoscopic mucosal resection (EMR) and endoscopic submucosal resection (ESD) as local treatment for EGC might be extended. However, extending the indications for EMR and ESD remains controversial because the long-term outcomes of these procedures have not been fully documented, and there is a risk for lymph node metastasis. Furthermore, current diagnostic imaging techniques are unsatisfactory for accurately predicting metastasis to lymph nodes. Moreover, the long-term results of standard radical gastrectomy including minimally invasive procedures for stage IA have been increasing and have reached 99 to 100%. To determine the true efficacy of endoscopic resection of EGC, we need more evidence of long-term follow-up, standardization of techniques, and pathological interpretation.

• Journal of Gastric Cancer
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• v.11 no.3
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• pp.155-161
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• 2011

Purpose: To determine the diagnostic utility of a frozen section biopsy in patients undergoing endoscopic submucosal dissection (ESD) for early gastric neoplasms with obscure margins even with chromoendoscopy using acetic acid and indigo carmine (AI chromoendoscopy). Materials and Methods: The lateral spread of early gastric neoplasms was unclear even following AI chromoendoscopy in 38 patients who underwent ESD between June 2007 and May 2011. Frozen section biopsies were obtained by agreement of the degree of lateral spread between two endoscopists. Thus, frozen section biopsies were obtained from 23 patients (FBx group) and not in the other 15 patients (AI group). Results: No significant differences were observed for size, histology, invasive depth, and location of lesions between the AI and FBx groups. No false positive or false negative results were observed in the frozen section diagnoses. Adenocarcinoma was revealed in three patients and tubular adenoma in one, thereby changing the delineation of lesion extent and achieving free lateral margins. The rates of free lateral resection margins and curative resection were significantly higher in the FBx group than those in the AI group. Conclusions: Frozen section biopsy can help endoscopists perform more safe and accurate ESD in patients with early gastric neoplasm.

• Journal of Digestive Cancer Research
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• v.5 no.1
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• pp.44-49
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• 2017

Background: Recently, endoscopic submucosal dissection (ESD) with laparoscopic sentinel lymph node dissection, named ESN or endoscopic full-thickness gastric resection with laparoscopic sentinel lymph node dissection, named Hybrid-natural orifice transluminal endoscopic surgery (NOTES) was suggested the possibility of minimally invasive treatment for patients with early gastric cancer (EGC) who were beyond the indication of ESD. This study aimed to evaluate the outcomes of ESN or Hybrid-NOTES. Methods: We retrospectively analyzed patients treated with these therapies from January 2009 to May 2013 in terms of short- and long-term outcomes. Each patient was diagnosed with EGC but was not included in ESD indications and had the high risk of lymph node metastasis (LNM). Results: A total of 42 patients with EGC treated by ESN or Hybrid-NOTES. Of the 21 patients who underwent ESN, a total of 4 patients underwent additional gastrectomy, 1 with LNM, 1 with surgical complication, and 2 with noncurative resection. Of the 21 patients who underwent Hybrid-NOTES, a total of 5 patients underwent additional surgery, 1 with LNM, 2 with surgical complication, and 2 with noncurative resection. Overall survival was 100% over a mean follow-up of 75 months, but 3 patients underwent ESD or gastrectomy with metachronous lesion. And 1 patient who had received ESN was found to have a metastatic lymph node and undergo palliative chemotherapy. Conclusion: ESN or Hybrid-NOTES showed favorable short-and long-term outcomes. These methods may be utilized as a bridge between ESD and gastrectomy in the case of EGC which is more likely to have LNM beyond the ESD indications.

• Journal of Gastric Cancer
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• v.20 no.3
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• pp.245-255
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• 2020

Purpose: Recently, non-exposure simple suturing endoscopic full-thickness resection (NESS-EFTR) was developed to prevent tumor exposure to the peritoneal cavity. This study aimed to evaluate the feasibility of NESS-EFTR with sentinel basin dissection for early gastric cancer (EGC). Materials and Methods: This was the prospective SENORITA 3 pilot. From July 2017 to January 2018, 20 patients with EGC smaller than 3 cm without an absolute indication for endoscopic submucosal dissection were enrolled. The sentinel basin was detected using Tc^99m-phytate and indocyanine green, and the NESS-EFTR procedure was performed when all sentinel basin nodes were tumor-free on frozen pathologic examination. We evaluated the complete resection and intraoperative perforation rates as well as the incidence of postoperative complications. Results: Among the 20 enrolled patients, one dropped out due to large tumor size, while another underwent conventional laparoscopic gastrectomy due to metastatic sentinel lymph nodes. All NESS-EFTR procedures were performed in 17 of the 18 other patients (94.4%) without conversion, and the complete resection rate was 83.3% (15/18). The intraoperative perforation rate was 27.8% (5/18), and endoscopic clipping or laparoscopic suturing or stapling was performed at the perforation site. There was one case of postoperative complications treated with endoscopic clipping; the others were discharged without any event. Conclusions: NESS-EFTR with sentinel basin dissection is a technically challenging procedure that obtains safe margins, prevents intraoperative perforation, and may be a treatment option for EGC after additional experience.

• Journal of Gastric Cancer
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• v.6 no.2
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• pp.109-113
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• 2006

Purpose: Various minimally invasive surgical techniques, such as an endoscopic mucosal resection and a laparoscopic gastrectomy, are becoming common practice for some cases of early gastric cancer (EGC) defined in terms of the depth of invasion being limited to the mucosa or submucosa. However, there are rare cases of early gastric cancer with massive lymph-node metastasis. Materials and Methods: From 6 university hospitals of Korea, 2,772 EGC cases were resected during the various period of analysis (1,432 cases of mucosal cancer and 1,340 of submucosal cancer). Results: As control data, we used the data from a single institute, CHA University Hospital. There were nine cases of early gastric cancer (9/2,772, 0.32%) with N3 lymph node metastasis defined by more than 15 lymph nodes being metastasized according to the UICC-TNM classification (pT1N3, stage IV). Two cases were mucosal cancer (2/1,432, 0.1 4%), and seven cases were submucosal cancer (7/1,340, 0.52%). Metastasized lymph nodes varied in number from 18 to 52. There were three male and six female patients with a mean age of 57. This is a totally reversed sex ratio compared to the usual gastric cancer or EGC. Among the total of 9 EGC patients, there were 5 who had superficial spreading carcinomas with surface areas larger than $25\;cm^2$. This is a significantly higher proportion compared to the general EGC population. When we compared the tumor size according to the LN status, the N3 group was definitely larger than the other groups. 78% of the pT1N3 cases showed lymphatic invasion, which is very high compared to the 4.7% in general EGC cases. Among the 9 cases, 6 patients had too short a follow-up period to evaluate the correct prognosis, but there was one patient with a non-curative resection and two patients with early recurrence. Although the sample size is small and the follow-up period is short, we can expect a very poor prognosis when we consider the common prognosis of EGC that is widely known and accepted. Conclusion: From these results, we can a conclude that the risk factors for pT1N3 gastric cancer are female patients, submucosal invasion, larger tumor size, and lymphatic invasion. However rare, the existence of pT1N3 gastric cancer needs to be taken into consideration, especially during the diagnosis. Furthermore, minimally invasive treatment for EGC needs to be chosen with great precaution. Since the prognosis of pT1N3 gastric cancer is expected to be poor, aggressive adjuvant chemotherapy may be necessary. (J Korean Gastric Cancer Assoc 2006;6:109-113)

• Journal of Gastric Cancer
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• v.11 no.3
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• pp.162-166
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• 2011

Purpose: Endoscopic resection is widely accepted as standard treatment for early gastric cancer (EGC) without lymph node metastasis. The procedure is minimally invasive, safe, and convenient. However, surgery is sometimes needed after endoscopic mucosal resection (EMR)/endoscopic submucosal dissection (ESD) due to perforation, bleeding, or incomplete resection. We evaluated the role of surgery after incomplete resection. Materials and Methods: We retrospectively studied 29 patients with gastric cancer who underwent a gastrectomy after incomplete EMR/ESD from 2006 to 2010 at Korea University Hospital. Results: There were 13 incomplete resection cases, seven bleeding cases, three metachronous lesion cases, three recurrence cases, two perforation cases, and one lymphatic invasion case. Among the incomplete resection cases, a positive vertical margin was found in 10, a positive lateral margin in two, and a positive vertical and lateral margin in one case. Most cases (9/13) were diagnosed as mucosal tumors by endoscopic ultrasonography, but only three cases were confirmed as mucosal tumors on final pathology. The positive residual tumor rate was two of 13. The lymph node metastasis rate was three of 13. All lymph node metastasis cases were submucosal tumors with positive lymphatic invasion and no residual tumor in the gastrectomy specimen. No cases of recurrence were observed after curative resection. Conclusions: A gastrectomy is required for patients with incomplete resection following EMR/ESD due to the risk of residual tumor and lymph node metastasis.

• Journal of Gastric Cancer
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• v.4 no.4
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• pp.213-218
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• 2004

Purpose: The superficial spreading type of early gastric cancer has different clinicopathologic features from other types of early gastric cancer in terms of its invasiveness and lymph-node metastases. Therefore, we attempted to elucidate the pathological features, surgical procedures and patients prognoses. Materials and Methods: Clinical information was reviewed for patients who had undergone a gastrectomy for gastric cancer during an 8-year period ($1995\~2002$) at Dankook University Hospital and Ulsan University, with an average follow-up of 48 months. Three hundred (300) superficial spreading lesions were analyzed with respect to macroscopic type, lymph-node (LN) metastasis, recurrent pattern, survival rate and method of surgical operation. In addition, the clinicopathological features of the superficial spreading type were compared with those of 739 other patients with small-sized cancer. Results: In both groups, the IIc-type macroscopic lesion, the elevated subtype to be more specific, occurred most frequently. There was no significant difference in the method of surgery between the groups. The submucosal invasion was $39.8\%$ in small-sized cancer, and $61.7\%$ in superficial spreading cancer (P=0.005). The incidence of LN metastasis was $11.3\%$ in early gastric cancer, $7.8\%$ in small-sized cancer and $20.0\%$ in superficial spreading cancer (P=0.005). The incidence of lymphatic invasion was $4.6\%$ in small-sized cancer and $13.0\%$ in superficial spreading cancer (P=0.009). The incidence of recurrence was $1.4\%$ in small-sized cancer and $3.6\%$ in superficial spreading cancer. The overall 5-year survival rate was $84.8\%$ in superficial spreading cancer and $93.0\%$ in small-sized cancer (P=0.052). The 5-year diseasefree survival rate was $94.7\%$ in superficial spreading cancer and $87.5\%$ in small-sized cancer (P=0.053). Conclusion: The superficial spreading type of early gastric cancer tends to be more invasive and to show a higher incidence of lymph-node metastasis than small-sized early gastric cancer. A wide resection with extensive lymph-node dissection seems to be an appropriate treatment for a superficial spreading type of early gastric cancer.

• Journal of Gastric Cancer
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• v.14 no.2
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• pp.129-134
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• 2014

Purpose: This study aimed to analyze the effect of screening by using endoscopy on the diagnosis and treatment of gastric cancer. Materials and Methods: The clinicopathologic characteristics of gastric cancer were compared in individuals who underwent an endoscopy because of symptoms (non-screening group) or for screening purposes (screening group). The distributions of gastric cancer stages and treatment modalities in 2006 and 2011 were compared. Results: The proportion of patients in the screening group increased from 45.1% in 2006 to 65.4% in 2011 (P<0.001). The proportion of stage I cancers in the entire patient sample also increased (from 60.5% in 2006 to 70.6% in 2011; P=0.029). In 2011, the percentages of patients with cancer stages I, II, III, and IV were 79.9%, 8.2%, 10.9%, and 1.1%, respectively, in the screening group, and 47.9%, 10.8%, 29.8%, and 11.5%, respectively, in the non-screening group. The proportion of laparoscopic and robotic surgeries increased from 9.6% in 2006 to 48.3% in 2011 (P<0.001), and endoscopic submucosal dissection increased from 9.8% in 2006 to 19.1% 2011 (P<0.001). Conclusions: The proportion of patients diagnosed with gastric cancer by using the screening program increased between 2006 and 2011. This increase was associated with a high proportion of early-stage cancer diagnoses and increased use of minimally invasive treatments.

• Journal of Gastric Cancer
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• v.8 no.2
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• pp.70-78
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• 2008

Purpose: VEGF-C and VEGF-D are angiogenetic factors, and abnormal expression of E-cadherin hasa role in the progression of gastric carcinoma. The aim of this study was to evaluate the relationship between the expression of E-cadherin, VEGF-C and VEGF-D with the presence of lymph node metastases (LNM) using cytokeratin 18 in early gastric cancer (EGC). Materials and Methods: Immunohistochemical staining for E-cadherin, VEGF-C and VEGF-D was performed in 49 EGC patients from March 1997 to December 2002. To evaluate the real extent of LNM, 1,562 lymph nodes from 49 patients were re-examined with the use of cytokeratin 18. Results: Eleven (0.7%) LNM were newly found in 12.2% (n=6) of patients. The real LNM rate was 3.6% in mucosal invasive (m) cancer and 38.1% in submucosal invasive (sm). Stage migration was seen in three patients (6.1%). Abnormal expression of E-cadherin was detected in 36.7% of the patients and expression of VEGF-C and VEGF-D was detected in 16.3% and 36.7% of the patients, respectively. Abnormal expression of E-cadherin was significantly correlated with tumor differentiation (P=0.0103) and Lauren classification (P<0.0001). There was no positive relationship of VEGF-C and VEGF-D expression with the clinicopathological findings for EGC including LNM. However, the frequency of lymph node metastases was significantly higher in patients that demonstrated abnormal expression of E-cadherin with positive immunoreactivity of VEGF-C or VEGF-D (P=0.031). Conclusion: In present study, we could not demonstrate a relationship between the presence of LNM and expression of VEGF-C and VEGF-D in EGC. However, VEGF-C or VEGF-D expression, in addition to the abnormal expression of E-cadherin, was correlated with the real extent of LNM in EGC.