Post written by Mohamed O. Othman, MD, from the Gastroenterology and Hepatology Section, Baylor College of Medicine, Houston, Texas, United States.
Endoscopic submucosal dissection (ESD) has been used successfully for treating early gastric cancer. The Japanese Gastric Cancer association had previously published the standard criteria for ESD in early gastric cancer, which included non-ulcerated differentiated lesions less than 2 cm in size without deep invasion. These standard criteria ensured a very low rate of lymph node metastasis (LNM), which translated into low recurrence rate of gastric cancer after ESD. Further publications showed that ESD can be safely extended into gastric lesions, which does not fit the standard. The Japanese Gastric Cancer Association published the extended criteria for ESD of gastric lesions to include differentiated lesions larger than 2 cm, ulcerated lesions less than 3 cm, poorly differentiated lesions less than 2 cm, and well-differentiated lesions invading into the superficial submucosa.
The risk of lymph node metastasis (LNM) in patients who met the expanded criteria was variable among published studies. We performed this meta-analysis to better estimate the benefits of applying the expanded ESD criteria in comparison to the risks of lymph node metastasis, which lead to non-curative endoscopic resection with lesion recurrence.
Figure 2. Forest plot of studies evaluating the incidence of lymph node metastasis in patients who met the absolute and expanded criteria. M-H, Mzantel-haenszel; CI, confidence interval.
Data of 12 published trials with more than 9700 patients who underwent gastrectomy and lymph node dissection for early gastric cancer were included in this analysis. LNM was very low in patients who met both the standard resection criteria (0.2%) and the expanded criteria ( 0.7%). However, upon estimating the LNM for each component of the expanded criteria, it was found that undifferentiated lesions and lesions with submucosal invasion had a higher LNM (2.5%.). We recommend discussing this slightly higher increase in LNM and subsequent tumor recurrence with patients with undifferentiated or submucosal gastric lesions.
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