Indications for gastrectomy after incomplete EMR for early gastric cancer

Hideki Nagano1, 4, Shigekazu Ohyama1 , Tetsu Fukunaga1, Yasuyuki Seto1, Junko Fujisaki2, Toshiharu Yamaguchi1, Noriko Yamamoto3, Yo Kato3 and Akio Yamaguchi4

(1) Department of Surgery, Cancer Institute Hospital, 3-10-6 Ariake, Koto-ku, Tokyo 135-8550, Japan
(2) Department of Internal Medicine, Cancer Institute Hospital, Tokyo, Japan
(3) Department of Pathology, Cancer Institute Hospital, Tokyo, Japan
(4) First Department of Surgery, Faculty of Medicine, University of Fukui, Fukui, Japan

Received: 01 November 2004 Accepted: 25 February 2005

Abstract
Background Although the number of patients with early gastric cancer (EGC) treated by endoscopic mucosal resection (EMR) has increased, the appropriate strategy for treating those with incomplete resection has not been established.
Methods This study analyzed 726 cases of EGC in patients treated by EMR between 1991 and 2000, in order to clarify the en-bloc and complete resection rates. We classified patients with incomplete resection into four groups according to the estimated risk of residual cancer or lymph node (LN) metastasis, determined from pathological findings of EMR specimens. We then analyzed 45 patients with EGC treated surgically after incomplete EMR, with the aim of eliciting the risk of residual cancer and LN metastasis.
Results Of the 726 patients, 529 (72.9%) had an en-bloc resection, while 378 (52.1%) had a complete resection. Three hundred and nine patients were found to have mucosal cancer and lateral cut-end-positive status with no LN metastasis (group A). In this group, 18 patients (5.8%) had residual cancer, with the lesions in the majority of patients being limited to the mucosal layer. Group B consisted of 14 patients with differentiated and submucosal (sm1) depth cancers, with 1 patient having residual cancer and 2 patients having LN metastasis. Fifteen patients were classified as group C, with sm2 or greater and vertical cut end-negative status, with 2 showing residual cancer and 1 showing LN metastasis. Group D included 10 patients with vertical cut end-positive status. Four of these patients had residual cancer while 1 had LN metastasis.
Conclusion We recommend that patients in group A should have close follow-up or endoscopic treatment, while those in groups B, C, or D should be treated by gastrectomy associated with LN dissection.
Key words Gastric cancer - Endoscopic mucosal resection - Residual cancer - Lymph node metastasis