Clin Endosc.  2016 Jul;49(4):327-331. 10.5946/ce.2016.082.

How to Interpret the Pathological Report before and after Endoscopic Submucosal Dissection of Early Gastric Cancer

• Cheung DY
• Park SH

• KMID: 2348249
• DOI: http://doi.org/10.5946/ce.2016.082

Abstract

Possible lymph node metastasis (LNM) and residual cancer are major concerns in endoscopic submucosal dissection (ESD) for early gastric cancer. To reduce the risk of LNM and cancer recurrence, the proper indications for ESD should be considered. Histology, size, depth of invasion, and presence of ulceration should be thoroughly evaluated before proceeding with ESD. However, with incomplete information, discrepancies often arise between the pathological diagnosis based on the forceps biopsy and that based on the totally resected specimen. In addition, the presence of lymphovascular involvement and histological homogeneity can be clarified only after ESD. If the pathological diagnosis changes after ESD, we should reevaluate the curativeness and reformulate the goal of treatment. Additional surgery is a reasonable strategy for non-curative ESD, but a patient's other health conditions should also be considered. It is simple to read pathological reports before and after ESD, but it can be a complicated art to interpret the report and formulate an optimal approach. In this review, various considerations regarding the pathological diagnosis will be discussed.

Keyword

Endoscopic submucosal dissection; Early gastric cancer; Pathology

MeSH Terms

Biopsy
Diagnosis
Lymph Nodes
Neoplasm Metastasis
Neoplasm, Residual
Pathology
Recurrence
Stomach Neoplasms*
Surgical Instruments
Ulcer

Figure

• 

  Fig. 1. Suggested algorithm for treatment of early gastric cancer (EGC) under various histological conditions. EUS, endoscopic ultrasonography; CT, computed tomography; ESD, endoscopic submucosal dissection.

Reference

1. Pei Q, Wang L, Pan J, Ling T, Lv Y, Zou X. Endoscopic ultrasonography for staging depth of invasion in early gastric cancer: a meta-analysis. J Gastroenterol Hepatol. 2015; 30:1566–1573.

2. Lee JH, Nam BH, Ryu KW, et al. Comparison of outcomes after laparoscopy-assisted and open total gastrectomy for early gastric cancer. Br J Surg. 2015; 102:1500–1505.

3. Gotoda T, Iwasaki M, Kusano C, Seewald S, Oda I. Endoscopic resection of early gastric cancer treated by guideline and expanded National Cancer Centre criteria. Br J Surg. 2010; 97:868–871.

4. Ahn JY, Jung HY. Long-term outcome of extended endoscopic submucosal dissection for early gastric cancer with differentiated histology. Clin Endosc. 2013; 46:463–466.

5. Ahn JY, Jung HY, Choi KD, et al. Endoscopic and oncologic outcomes after endoscopic resection for early gastric cancer: 1370 cases of absolute and extended indications. Gastrointest Endosc. 2011; 74:485–493.

6. Lee JH, Min YW, Lee H, et al. Diagnostic group classifications of gastric neoplasms by endoscopic resection criteria before and after treatment: real-world experience. Surg Endosc. 2015; Dec. 22. [Epub]. http://dx.doi.org/10.1007/s00464-015-4710-z.

7. Kang MS, Hong SJ, Kim DY, et al. Long-term outcome after endoscopic submucosal dissection for early gastric cancer: focusing on a group beyond the expanded indication. J Dig Dis. 2015; 16:7–13.

8. Gotoda T, Yanagisawa A, Sasako M, et al. Incidence of lymph node metastasis from early gastric cancer: estimation with a large number of cases at two large centers. Gastric Cancer. 2000; 3:219–225.

9. Yoon HJ, Kim YH, Kim JH, et al. Are new criteria for mixed histology necessary for endoscopic resection in early gastric cancer? Pathol Res Pract. 2016; 212:410–414.

10. Ye BD, Kim SG, Lee JY, et al. Predictive factors for lymph node metastasis and endoscopic treatment strategies for undifferentiated early gastric cancer. J Gastroenterol Hepatol. 2008; 23:46–50.

11. Lee JH, Choi MG, Min BH, et al. Predictive factors for lymph node metastasis in patients with poorly differentiated early gastric cancer. Br J Surg. 2012; 99:1688–1692.

12. Park YD, Chung YJ, Chung HY, et al. Factors related to lymph node metastasis and the feasibility of endoscopic mucosal resection for treating poorly differentiated adenocarcinoma of the stomach. Endoscopy. 2008; 40:7–10.

13. Chung JW, Jung HY, Choi KD, et al. Extended indication of endoscopic resection for mucosal early gastric cancer: analysis of a single center experience. J Gastroenterol Hepatol. 2011; 26:884–887.

14. Kim HM, Pak KH, Chung MJ, et al. Early gastric cancer of signet ring cell carcinoma is more amenable to endoscopic treatment than is early gastric cancer of poorly differentiated tubular adenocarcinoma in select tumor conditions. Surg Endosc. 2011; 25:3087–3093.

15. Lee SH, Jee SR, Kim JH, Seol SY. Intramucosal gastric cancer: the rate of lymph node metastasis in signet ring cell carcinoma is as low as that in well-differentiated adenocarcinoma. Eur J Gastroenterol Hepatol. 2015; 27:170–174.

16. Oda I, Gotoda T, Sasako M, et al. Treatment strategy after non-curative endoscopic resection of early gastric cancer. Br J Surg. 2008; 95:1495–1500.

17. Pyo JH, Shin CM, Lee H, et al. A risk-prediction model based on lymph-node metastasis for incorporation into a treatment algorithm for signet ring cell-type intramucosal gastric cancer. Ann Surg. 2016; Jan. 7. [Epub]. http://dx.doi.org/10.1097/SLA.0000000000001602.

18. Hoteya S, Iizuka T, Kikuchi D, et al. Clinicopathological outcomes of patients with early gastric cancer after non-curative endoscopic submucosal dissection. Digestion. 2016; 93:53–58.

19. Kim ER, Lee H, Min BH, et al. Effect of rescue surgery after non-curative endoscopic resection of early gastric cancer. Br J Surg. 2015; 102:1394–1401.

20. Choi JM, Kim SG, Yang HJ, et al. Endoscopic predictors for undifferentiated histology in differentiated gastric neoplasms prior to endoscopic resection. Surg Endosc. 2016; 30:89–98.

21. Hanaoka N, Tanabe S, Mikami T, Okayasu I, Saigenji K. Mixed-histologic-type submucosal invasive gastric cancer as a risk factor for lymph node metastasis: feasibility of endoscopic submucosal dissection. Endoscopy. 2009; 41:427–432.

22. Choi JY, Jeon SW, Cho KB, et al. Non-curative endoscopic resection does not always lead to grave outcomes in submucosal invasive early gastric cancer. Surg Endosc. 2015; 29:1842–1849.