ESD for Gastric Cancer in the West: Are We There?

Vanessa M. Shami, MD, FASGE reviewing Tate DJ, et al. Gastrointest Endosc 2019 May 8.

Endoscopic submucosal dissection (ESD), a technique well established in Japan, is a potentially curative procedure for early gastric cancer. Data on the utility of ESD in the West have lagged partly due to the decreased incidence and prevalence of early gastric cancer and, consequently, the slower adaptation of the technique. This large, single-center trial studied the rates of en-bloc and R0 ESD resections of early gastric cancers (EGCs) and adenomatous precursor lesions (pEGCs), as well as the safety, rates for surgery, and rates of recurrence at 6- and 12-month surveillance using the Vienna classification of dysplasia. 

One hundred thirty-five lesions underwent ESD in a total of 121 patients. Before ESD, the pEGC and EGC lesions were divided according to the Japanese criteria for ESD resectability: those with absolute indication for resection (nonulcerated EGC up to 20 mm) or expanded criteria for resection (nonulcerated, differentiated EGCs of any size, ulcerated differentiated EGCs up to 30 mm, or undifferentiated EGCs up to 20 mm). Of the lesions, 54.1% satisfied the absolute clinical criteria for ESD while 45.9% met the expanded criteria. Bleeding occurred in 7/135 (5.2%) of cases, and there were no deaths. There were two perforations that were managed by endoscopic clipping. The overall en-bloc resection rate was 128/135 (94.8%): 72 (98.6%) in the absolute criteria group and 56 (90.3%) in the expanded clinical criteria group. The overall rate of R0 resection was 86.7%: 68/73 (93.2%) in the absolute criteria group and 49/62 (79%) in the expanded criteria group. Post-ESD, of the 107 (79.2%) pEGCs that met the absolute or expanded criteria for endoscopic cure, two recurred during follow-up.


Comment:
ESD is less invasive than surgery and potentially curative in the management of pEGCs and EGCs. While the West has been slower to adapt this technique, in high-volume centers, outcomes may be comparable to the East.
Note to readers:
At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

Vanessa M. Shami, MD, FASGE
Bio and Disclosures

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Citation(s):
Tate DJ, Klein A, Sidhu M, et al. Endoscopic submucosal dissection for suspected early gastric cancer: absolute versus expanded criteria in a large Western cohort (with video). Gastrointest Endosc 2019 May 8. (Epub ahead of print) (https://doi.org/10.1016/j.gie.2019.04.242)