Endoscopic submucosal dissection in early gastric cancer: has the West caught up?

 

 Buy Article Permissions and Reprints

Gastric cancer is often deemed an Asian health maintenance issue and comprehensive screening is not recommended by US-based guidelines [1] [2]. Though the incidence of gastric cancer is relatively low in the USA, there will be an estimated 26 500 new cases and 11 130 deaths in 2023. At 35 %, the 5-year survival remains poor, largely attributed to the late stage at time of diagnosis [3] [4].

Endoscopic submucosal dissection (ESD) was developed in Japan and quickly disseminated in Asia as a first-line modality for therapy of dysplastic lesions and early gastric cancer. It offers the benefit of en bloc removal and provides the histological information needed to confirm curative resection. Widespread adoption of ESD in the West has encountered several obstacles including procedure complexity, availability of expertise, and lack of reimbursement models. In addition, concern has remained that the Japanese criteria for curative resection and estimation of risk for lymph node metastasis may not be applicable to Western populations [5] [6]. As such, the outcomes of gastric ESD in the West may not be comparable to those in Asia.

In this issue of Endoscopy, Bhandari et al. present new insights into the long-term outcomes of gastric ESD in a multicenter, European cohort [7]. In this study, 415 patients were included in a retrospective analysis of a prospectively collected ESD registry from 2009 to 2021. Median follow-up was 52 months, which is probably the longest follow-up available in a Western study to date. The study found that ESD was a safe and effective treatment, with rates of en bloc and R0 resection, and early and delayed recurrence of 94.7 %, 83.4 %, 2.7 %, and 3.2 %, respectively. Most complications were successfully managed endoscopically. These primary outcomes were comparable to a large North American multicenter study, as well as several Japanese multicenter studies [5] [6].

Knife-assisted resection, a precut technique analogous to hybrid ESD, was found to be predictive of recurrence and piecemeal resection in this study, and this finding is consistent with results of earlier Japanese and Korean studies [8] [9] [10] [11]. Despite the shorter procedure time and learning curve, the current evidence suggests that hybrid ESD should be avoided in gastric lesions.

“… this Western study provides very valuable information on long-term outcomes of ESD in early gastric cancer and suggests that expert endoscopists in tertiary care centers can produce results not dissimilar to our colleagues in the East.”

The authors also applied the most recent Japanese guidelines for management of gastric cancer to their study population and approximately one quarter of the resected lesions were outside the absolute indication criteria, indicating that Western centers have been endoscopically managing more advanced gastric lesions [12]. Possible explanations include issues with quality of upper endoscopy in the West, along with expertise to identify early gastric malignancy, and less accurate pre-procedure lesion staging. In the East, pre-procedure staging is heavily dependent on endoscopic observation of the lesion, whereas in the West, we are more reliant on pre-ESD tissue biopsy. Pre-ESD biopsy has been shown to have its limitations in the management of Barrett’s esophagus, and the current study reaffirms that the same is true in the stomach [13]. Indeed, when the investigators correlated pre-ESD biopsy results to post-resection surgical pathology, a significant number of lesions were upstaged to adenocarcinoma (90 lesions with high grade dysplasia and 12 with low grade dysplasia on biopsy). This finding raises the question of whether there may be a role for staging ESD in gastric adenocarcinoma to obtain the most accurate histopathology.

This study has a number of strengths including large sample size, multicenter representation, and long-term follow-up. The limitations are centered around the typical issues related to the retrospective design and the lack of endoscopic follow-up in approximately one quarter of the cohort. Nevertheless, this Western study provides very valuable information on long-term outcomes of ESD in early gastric cancer and suggests that expert endoscopists in tertiary care centers can produce results not dissimilar to our colleagues in the East, even in the setting of more advanced gastric lesions encountered in our practice. The investigators also identified hybrid ESD as a risk factor for suboptimal outcomes, which may help guide the future approach to endoscopic resection of gastric lesions.

Publication History

Article published online:
27 June 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

• References

• 1 Gupta S, Li D, El Serag HB. et al. AGA clinical practice guidelines on management of gastric intestinal metaplasia. Gastroenterology 2020; 158: 693-702
  CrossrefPubMedGoogle Scholar
• 2 Evans JA, Chandrasekhara V, Chathadi KV. et al. The role of endoscopy in the management of premalignant and malignant conditions of the stomach. Gastrointest Endosc 2015; 82: 1-8
  CrossrefPubMedGoogle Scholar
• 3 Morgan E, Arnold M, Camargo MC. et al. The current and future incidence and mortality of gastric cancer in 185 countries, 2020–40: a population-based modelling study. EClinicalMedicine 2022; 47: 101404
  CrossrefPubMedGoogle Scholar
• 4 SEER Database. Cancer of the Stomach – Cancer Stat Facts. Accessed: May 3, 2023. https://seer.cancer.gov/statfacts/html/stomach.html
  PubMedGoogle Scholar
• 5 Ngamruengphong S, Ferri L, Aihara H. et al. Efficacy of endoscopic submucosal dissection for superficial gastric neoplasia in a large cohort in North America. Clin Gastroenterol Hepatol 2021; 19: 1611-1619
  CrossrefPubMedGoogle Scholar
• 6 Draganov PV, Aihara H, Karasik MS. et al. Endoscopic submucosal dissection in North America: a large prospective multicenter study. Gastroenterology 2021; 160: 2317-2327
  CrossrefPubMedGoogle Scholar
• 7 Bhandari P, Abdelrahim M, Alkandari AA. et al. Predictors of long-term outcomes of endoscopic submucosal dissection of early gastric neoplasia in the West: a multicenter study. Endoscopy 2023; 55: 898-906
  Article in Thieme ConnectPubMedGoogle Scholar
• 8 Esaki M, Ihara E, Sumida Y. et al. Hybrid and conventional endoscopic submucosal dissection for early gastric neoplasms: a multi-center randomized controlled trial. Clin Gastroenterol Hepatol 2022; DOI: 10.1016/j.cgh.2022.10.030.
  CrossrefPubMedGoogle Scholar
• 9 Jang GH, Kim HH, Ahn SY. Feasibility of planned endoscopic submucosal dissection with snaring for gastric adenoma compared with standard endoscopic submucosal dissection. The Korean Journal of Helicobacter and Upper Gastrointestinal Research 2014; 14: 174-180
  CrossrefPubMedGoogle Scholar
• 10 Kim SJ, Choi CW, Kang DH. et al. Endoscopic submucosal dissection of gastric neoplasms using a snare tip. Scand J Gastroenterol 2018; 53: 238-242
  CrossrefPubMedGoogle Scholar
• 11 Goto O, Fujishiro M, Kodashima S. et al. Feasibility of electrocautery snaring as the final step of endoscopic submucosal dissection for stomach epithelial neoplasms. Dig Liver Dis 2009; 41: 26-30
  CrossrefPubMedGoogle Scholar
• 12 Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2018 (5th edition). Gastric Cancer 2021; 24: 1-21
  CrossrefPubMedGoogle Scholar
• 13 Yang D, King W, Aihara H. et al. Effect of endoscopic submucosal dissection on histologic diagnosis in Barrett’s esophagus visible neoplasia. Gastrointest Endosc 2022; 95: 626-633
  CrossrefPubMedGoogle Scholar