Challenges and advancing strategies of endoscopic submucosal dissection for early gastric cancer:The puzzle of eCura C1

In this editorial,we explore the challenges of managing noncurative resections in early gastric cancer after endoscopic submucosal dissection(ESD),starting from the consideration recently made by Zhu et al.Specifically,we evaluate the management of eCura C1 lesions,where decisions regarding further interventions are pivotal yet contentious.Collaboration among endoscopists,surgeons,and pathologists is underscored to refine risk assessment and personalize therapeutic management.Recent advancements in ESD techniques and interdisciplinary collaboration offer opportunities for outcome optimization in managing eCura C1 lesions.Moreover,despite needing further clinical validation,molecular biomarkers have emerged as promising tools for enhancing prognostication.This manuscript highlights the ongoing research attempts to define treatment paradigms effectively and evaluates the potential of emerging options,ultimately aiming to improve patient care and outcomes in this complex clinical scenario.

Bone metastasis from early gastric cancer following non-curative endoscopic submucosal dissection

A 67-year-old male underwent endoscopic submucosal dissection(ESD)to treat early gastric cancer(EGC)in 2001.The lesion(50 mm × 25 mm diameter)was histologically diagnosed as poorly differentiated adenocarcinoma,with an ulcer finding.Although the tumor was confined to the mucosa with no evidence of lymphovascular involvement,the ESD was regarded as a noncurative resection due to the histological type,tumor size,and existence of an ulcer finding(as indicated by the 2010 Japanese gastric cancer treatment guidelines,ver.3).Despite strong recommendation for subsequent gastrectomy,the patient refused surgery.An alternative follow-up routine was designed,which included five years of biannual clinical examinations to detect and measure serum tumor markers and perform visual assessment of recurrence by endoscopy and computed tomography scan after which the examinations were performed annually.The patient's condition remained stable for eight years,until a complaint of back pain in 2010 prompted further clinical investigation.Bone scintigraphy indicated increased uptake.Histological examination of biopsy specimens taken from the lumbar spine revealed adenocarcinoma resembling the carcinoma cells from the EGC that had been treated previously by ESD,and which was consistent with immunohistochemical findings of gastrointestinal tract cancer.Thus,the diagnosis of bone metastasis from EGC was made.The reported rates of EGC recurrence in surgically resected cases range 1.4%-3.4%,but among these bone metastasis is very rare.To our knowledge,this is the first reported case of bone metastasis from EGC following a non-curative ESD and occurring after an eight-year disease-free interval.

Long-term outcomes of additional surgery versus non-gastrectomy treatment for early gastric cancer after non-curative endoscopic submucosal dissection: a meta-analysis

Background:Endoscopic resection is increasingly used in the treatment for early gastric cancer(EGC);however,about 15%of endoscopic submucosal dissection(ESD)cases report non-curative resection.The efficacy of different remedial interventions after non-curative ESD for EGC remains controversial.This meta-analysis aimed to compare the long-term outcomes of additional surgery and non-gastrectomy treatment for EGC patients who underwent non-curative ESD.Methods:All relevant studies published up to October 2021 were systematically searched in the PubMed,Web of Science,and Embase databases.The medical subject headings terms"early gastric cancer,""gastrectomy,""endoscopic submucosal dissection,"and their related free keywords were used to search relevant articles without restrictions on regions,publication types,or languages.The Newcastle–Ottawa Quality Assessment Scale was used to evaluate the quality of the included studies.Odds ratios(ORs)with 95%confidence intervals(CIs)of 5-year overall survival(OS),disease-specific survival(DSS),disease-free survival(DFS)and hazard ratios(HRs)with 95%CIs of OS were calculated using a random-or fixed-effects model.Results:This meta-analysis included 17 retrospective cohort studies with 5880 patients,of whom 3167 underwent additional surgery and 2713 underwent non-gastrectomy.We found that patients receiving additional gastrectomy had better 5-year OS(OR=3.63,95%CI=3.05–4.31),DSS(OR=3.22,95%CI=2.22–4.66),and DFS(OR=4.39,95%CI=1.78–10.82)outcomes than those receiving non-gastrectomy treatments.The pooled HR also showed that gastrectomy following non-curative ESD significantly improved OS(HR=0.40,95%CI=0.33–0.48).In addition,elderly patients benefited from additional surgery in consideration of the 5-year OS(HR=0.54,95%CI=0.41–0.72).Conclusions:Compared with non-gastrectomy treatments,additional surgery offered better long-term survival outcomes for patients with EGC who underwent non-curative ESD.

Additional gastrectomy in early-stage gastric cancer after non-curative endoscopic resection:a meta-analysis

Background and objective:The role of additional gastrectomy after non-curative endoscopic resection remains uncertain.The present meta-analysis aimed to explore the risk factors for early-stage gastric-cancer patients after non-curative endoscopic resection and evaluate the efficacy of additional gastrectomy.Methods:Relevant studies that reported additional gastrectomy after non-curative endoscopic resection were comprehensively searched in MedLine,Web of Science and EMBASE.We first investigated the risk factors for residual tumor and lymph-node metastasis after non-curative endoscopic resection and then analysed the survival outcome,including 5-year overall survival(OS)and 5-year disease-free survival,of additional gastrectomy.Results:Twenty-one studies comprising 4870 cases were included in the present study.We found that residual tumor was associated with larger tumor size(>3 cm)(odds ratio[OR]=2.81,P<0.001),undifferentiated tumor type(OR=1.78,P=0.011)and positive horizontal margin(OR=9.78,P<0.001).Lymph-node metastasis was associated with larger tumor size(>3 cm)(OR=1.73,P<0.001),elevated tumor type(OR=1.60,P=0.035),deeper tumor invasion(>SM1)(OR=2.68,P<0.001),lymphatic invasion(OR=4.65,P<0.001)and positive vertical margin(OR=2.30,P<0.001).Patients who underwent additional gastrectomy had longer 5-year OS(hazard ratio[HR]=0.34,P<0.001),5-year disease-free survival(HR=0.52,P=0.001)and 5-year disease-specific survival(HR=0.50,P<0.001)than those who did not.Moreover,elderly patients also benefited from additional gastrectomy regarding 5-year OS(HR=0.41,P=0.001).Conclusions:Additional gastrectomy with lymph-node dissectionmight improve the survival of early-stage gastric-cancer patients after non-curative endoscopic resection.However,risk stratification should be performed to avoid excessive treatment.