Endoscopic gastric mucosectomy as the first line of treatment of early gastric neoplasia

In a study done in IPO-Porto, that represented the first European series of long-term follow-up after endoscopic resection for gastric lesions, involving 162 patients and 195 lesions, it was shown that 90% of early gastric neoplasias could be cured by gastric mucosectomy without the need for surgery. More importantly this technique did not compromise the global survival of the patients since in more than 10 years of follow-up no patient died because of gastric cancer. Concerning the safety profile, this technique proved very safe with adverse events occurring in only 10% of the cases, with only 1% being serious justifying surgery, even though most of the patients presented serious comorbidities.

These results strengthen the idea that when facing the diagnosis of early gastric neoplasia a precise endoscopic evaluation of the lesion in a reference centre should be the first step before sending the patient to surgery. Moreover, it allow us to say that gastric mucosectomy should be considered the first line of treatment of early gastric neoplasias also in western countries, as long as it is performed in reference centers with experts gastroenterologists in the performance of this technique. 

Authors and Affiliations:

Pedro Pimentel-Nunes ^{1,2, 3}, Francisco Mourão ³, Nuno Veloso ^1,3, Luís Pedro Afonso ⁴, Manuel Jácome ⁴, Luís Moreira-Dias¹, Mário Dinis-Ribeiro ^1,3

¹ Department of Gastroenterology, Portuguese Oncology Institute – Porto, PORTUGAL;

² Department of Physiology, Porto Faculty of Medicine, PORTUGAL;

³ CINTESIS/ Biostatistics and Medical Informatics, Porto Faculty of Medicine, PORTUGAL;

⁴ Department of Pathology, Portuguese Oncology Institute – Porto, PORTUGAL;

Abstract:

Background: Even though endoscopic resection for the treatment of gastric superficial neoplastic lesions is an established first line of treatment in Eastern countries, its role is yet to be considered in current Western guidelines mostly due to lack of long-term studies.

Objective: To describe long-term outcomes for endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) in the treatment of gastric neoplasias in a Western country.

Design: Single centre retrospective cohort of 162 consecutive patients (195 gastric superficial neoplasias, 54 EMR, 141 ESD) followed up during 3.2 years (median) from March 2003 to April 2013.

Results: Resection was feasible in 97% with en bloc and R0 resection rates of 85% (94% ESD vs 61% EMR, p=0.001) and 81% (91% ESD vs 54% EMR,p=0.001), respectively. Recurrence rate was 7% associated with Rx/R1 resection after EMR/ESD (OR=5.8; 3.9-8.8). Curative resection was possible in 86% after one and in 91% after two procedures. Adverse events were observed in 13% of cases: 8% bleeding and 2% of perforations (EMR=ESD). Surgery was performed in 6%: 5% after non-curative endoscopic resection and 1% due to complications. Metachronous lesion detection rate was 1-1.5% per patient year. Cancer specific survival rate was 100% at follow-up.

Conclusions: For the first time in a Western country results are described to be similar to those in East. Endoscopic resection, particularly ESD, is a highly effective treatment for gastric superficial lesions, without compromising cancer survival. Endoscopic resection should be considered a first line of treatment for gastric neoplasias also in Western countries.

Journal: Endoscopy

Link: https://www.thieme-connect.com/DOI/DOI?10.1055/s-0034-1377348