Analysis Of Clinical And Pathological Characteristics For Early Gastric Cancer With Endoscopic Treatment

Objective:Endoscopic resection(ER)procedures,including endoscopic mucosal resection(EMR)and endoscopic submucosal dissection(ESD),have been widely recommended and used for the treatment of early gastric cancer(EGC)without evidence of lymph node metastasis.According to“Guidelines for ESD and EMR for EGC”in 2014,we analyzed the clinicopathological characteristics of EGC patients with indications for ER and evaluated the short-term prognosis of ER for EGC(en bloc resection,complete resection,curative resection,post-operative complications,etc.).Meanwhile,we closely investigated the risk factors for non-curative resection and upgraded diagnosis for EGC lesions.The results and conclusions of our research may provide more insights for further EGC treatment.Methods:All EGC patients diagnosed and treated at the Sir Run Run Shaw Hospital between January 2011 and April 2019 have been retrospectively registered if the following criteria were simultaneously satisfied:(1)lesions with the ER indications in pre-operative evaluation;(2)lesions identified as Category 4-5 of Vienna classification on post-operative pathology examination.Medical history,endoscopy information and pathology data have been carefully reviewed,collected and then analyzed.Results:232 EGC patients with 236 EGC lesions are classified into absolute indication(AI)group and expanded indication(EI)group in the study.All lesions are resected by ESD.The mean age of EGC patients is 62.67 years old.The median diameter of EGC lesions is 19.5mm.Male patients account for 69.8%,while female patients account for 30.2%of all patients.There is no statistical difference between AI and EI group regarding patients'clinical characteristics(P>0.05).In contrast,there is significant statistical difference in lesion diameter(P<0.01),invasive depth(P<0.05)and differentiation(P<0.05)between AI and EI group.Post-operative hemorrhage is identified in 18(7.9%)patients,among which 72.2%patients experienced hemorrhage within the first 72 hours after ESD.For hemostasis,6 patients were treated with medicine,11 patients were treated with endoscopy,while 1 patient was treated with surgery.Perforation is identified in 4(1.8%)patients.Three patients with macro-perforation were noticed during ESD and treated with clamp,while one patient with micro-perforation wasn't given any further intervention except observation.13(5.8%)patients were treated with additional surgery.There is no statistical difference in post-operative bleeding rate or perforation rate between AI and EI group(P>0.05).However,significant statistical difference exists in additional surgery rate between AI and EI group(P<0.01).En bloc resection is achieved in 235(99.6%)EGC lesions,including 222(94.1%)complete resection lesions and 13(5.5%)R1 resection lesions,while piecemeal resection is identified in one(0.4%)EGC lesion.169(82.4%)EGC lesions are classified as curative or expanded curative resection,while 36(17.6%)EGC lesions are classified as non-curative resection.There is no statistical difference in complete resection rate,R1resection rate,piecemeal resection rate between AI and EI group(P>0.05).On the contrary,non-curative resection rate between AI and EI group shows significantdifference(P<0.01).Four independent risk factors concerning non-curative resection have been clarified:BMI?25kg/m~2(adjusted OR=5.087,95%CI 1.738-14.894);lesions located on cardia and fundus of stomach(adjusted OR=11.865,95%CI 3.600-39.101);undifferentiated cancer diagnosed by biopsy(adjusted OR=78.705,95%CI 7.193-861.214);ulcerative lesions identified during biopsy(adjusted OR=3.629,95%CI1.020-12.909).Two independent risk factors concerning upgraded diagnosis after ER have been clarified:lesions with pathological diameter between 20-29mm(adjusted OR=6.658,95%CI 2.040-21.724)or?30mm(adjusted OR=18.059,95%CI 3.629-89.882);lesions with invasion beyond mucosa layer(adjusted OR=62.243,95%CI2.817-1375.455).Two independent protective factors concerning upgraded diagnosis after ER have also been clarified:atrophic gastritis identified during biopsy(adjusted OR=0.310,95%CI 0.103-0.928);ulcerative lesions identified during biopsy(adjusted OR=0.072,95%CI 0.008-0.686).Conclusion:ESD is the mainstream treatment technique for EGC patients with ER indications in our hospital.The baseline clinical characteristics of EGC patients between AI and EI group are comparable.Compared with AI group,lesions in EI group have following features:larger diameter,deeper invasive depth and poorer differentiation.However,when it comes to Paris classification,lesion location,ulceration rate,lymphovascular invasion rate and positive margin rate,lesion characteristics between AI and EI group are similar.Hemorrhage and perforation are two major complications after ESD.Hemorrhage mostly begins within the first 72 hours after ESD.Medical therapy and endoscopic treatment prove to be effective for hemostasis in most cases.Perforation is mostly noticed and treated during endoscopic resection.Patients in AI group and EI group have similar post-operative complication rate,but additional surgery rate is higher in EI group.There is no significant difference in complete resection rate,R1resection rate and piecemeal resection rate in each group,but non-curative resection rateis much higher in EI group.BMI?25kg/m~2,lesions located on cardia and fundus of stomach,undifferentiated cancer diagnosed by biopsy and ulcerative lesions identified during biopsy are independent risk factors for non-curative resection.Lesions with pathological diameter between 20-29mm or?30mm,lesions with invasion beyond mucosa layer are associated with upgraded diagnosis after ER.In contrast,atrophic gastritis and ulcerative lesions identified during biopsy are independent protective factors for upgraded diagnosis after ER.