The Combined Use Of Endoscopy,Endoscopic Ultrasonography And Multidetector Computed Tomography In Preoperative Evaluation Of The Absolute Indication Criteria For Endoscopic Submucosal Dissection

Objective: The prognosis of early gastric cancer is as high as 90%.Endoscopic Submucosal Dissection is seen as a safe mode of treatment in selected EGC patients with differentiated non-ulcerated mucosal cancers of size ≤2cm,with similar survival outcomes to that of surgery and lesser postoperative complications,shorter hospital stay and better postoperative quality of life.However,the absolute indications for ESD have been proposed after review of a large sample of post surgical pathology samples,and the preoperative patient selection is not an easy task due to the lack of accuracy of existing diagnostic and staging tools.This study aims to determine the accuracy of preoperative imaging information by combined use of endoscopy,endoscopic ultrasonography and multidetector computed tomography with regards to the absolute indication criteria of ESD,by comparison with postoperative pathology,and by extension determine the accuracy of patient selection for ESD treatment in EGC in our hospital setting.Methods: In 794 cases of EGC that received surgical treatment in Ruijin Hospital between 2012-2016,the risks of lymph node metastasis were studied according to the clinicopathological features that have been accepted as the absolute indications for ESD using univariate and multivariate Logistic regression analysis.In the second segment,43 patients suspected as having EGC in initial endoscopy were preoperatively staged with both EUS and MDCT,and the imaging information compared with postoperative pathology to determine the accuracy in preoperative diagnosis of tumor depth,lymph node involvement,tumor size and the presence of ulcerations.Combining the four clinicopathological features,the accuracy of patient selection for ESD treatment was also studied using Receiver Operating Characteristic.Results: Tumor size > 2cm(P=0.0071),T1 b stage(P<0.0001),undifferentiated histology(P<0.0001)and vascular invasion(P=0.0007)were identified as individual risk factors for lymph node metastasis in EGC.The diagnostic efficacy of the combined use of endoscopy,EUS and MDCT in identifying node positive status,T1 a disease,tumor size ≤2cm,and ulceration was found to be moderate with AUC of ROC 0.71,0.64,0.72 and 0.68 respectively.Diagnosis of overall indication criteria for ESD had a similarly moderate utility value with an AUC of 0.71,but with highly desirable specificity of 100%.Conclusion: The absolute indications for endoscopic management of early gastric cancer are safe with no risks of lymph node metastasis.However preoperative patient selection for ESD management is a difficult task because the efficacy of diagnostic and staging tools in identifying the individual indications before treatment is less than ideal.However,by the combined use of endoscopy,EUS and Ultrasound,a high specificity of patient selection for ESD treatment can be achieved,as in our case none of the patients would have been falsely indicated for ESD management.There is scope for improvement in the sensitivity factor because a large percentage of patients actually eligible for ESD lose the opportunity due to preoperative overestimation in one or more of the indication criteria.