Risk factors and management of positive horizontal margin in early gastric cancer resected by en bloc endoscopic submucosal dissection

Abstract

Background Although endoscopic submucosal dissection (ESD) is a widely accepted treatment for early gastric cancer (EGC), there is no consensus regarding the management of positive horizontal margin (HM) despite en bloc ESD. The aim of the current study was to identify the risk factors and optimal management of positive HM in EGCs resected by en bloc ESD. Methods A total of 890 consecutive patients with 1,053 intramucosal EGCs resected by en bloc ESD between April 2005 and June 2011. Clinicopathological data were retrieved retrospectively to assess the positive HM rate, local recurrence rate, risk factors for positive HM, and outcomes of treatment for local recurrent tumor. Positive HM was defined as a margin with direct tumor invasion (type A), the presence of cancerous cells on either end of 2-mm-thick cut sections (type B), or an unclear tumor margin resulting from crush or burn damage (type C).Results The positive HM rate was 2.0 % (21/1,053). The local recurrence rate was 0.3 % (3/1,053). All local recurrent tumors were intramucosal carcinomas, and were resected curatively by re-ESD. Multivariate analysis with logistic regression showed tumor location in the upper third of the stomach and lesions not matching the absolute indication to be independent risk factors for positive HM. Conclusion The risk factors for HM positivity in cases of EGC resected by en bloc ESD are tumor location in the upper third of the stomach and dissatisfaction of the absolute indication for curative ESD.

Evaluation of the Expanded Criteria of Endoscopic Submucosal Dissection for Early Gastric Cancers: A Meta-Analysis

“…Numata et al [8] argued that the reason why some patients with a positive lateral margin never experienced recurrence was that these so-called positive margins were actually caused by crushing-or burn-related damages. As such, the positive margin often occurred in the upper-third portion of the stomach, where it is difficult to perform ESD.…”

“…There were 7,562 participants involved in total. Moreover, there were 34 patients and 22 patients who did not meet either the absolute or the expanded criteria in the studies conducted by Kosaka et al [6] and Numata et al [8] , respectively. Similarly, Oda et al [9] only observed 2,806 patients' long- term outcomes, so the present meta-analysis included a total of 6,687 patients.…”

“…The combined data analysis from the 3 included studies [6][7][8] showed that patients in the EG faced a higher risk of a positive lateral margin. Since there was heterogeneity (p = 0.13, I 2 = 51%), a random-effects model was applied (OR 7.13; 95% CI 1.91-26.63; fig.…”

Endoscopic Submucosal Dissection for the Treatment of Superficial Epithelial Gastric Neoplasia in a Portuguese Centre

“…Some retrospective studies have tried to identify risk factors to positive HMs [19-21]. Kakushima et al [20] reported three main reasons for positive HMs after resection: lesions with a flat spreading area not included in the marking, lesions with an unexpected nearby lesion, and lesions with lateral extension in the submucosa under a non-cancerous mucosa.…”

“…After that, Sekiguchi et al [19] identified a cancer-positive lateral margin length ≥6 mm as an independent risk factor for local recurrence after ESD (with a sensitivity and specificity for a 5-year risk of developing local recurrence of 66.7  and 95.6 %, respectively). Recently, Numata et al [21] recognised that location of the tumour in the upper third of the stomach and lesions not matching the absolute indication criteria were independent risk factors for positive HMs. In this study, expertise with digital chromoendoscopy improved along with the ESD learning curve, and the regular use of high-definition endoscopy in the last period can partially explain highly positive HMs in the beginning.…”