Upper GI
John J Newland, MD
General Surgery Resident
University of Maryland Medical Center
Baltimore, Maryland, United States
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
The Japanese Gastric Cancer Association (JGCA) updated guidelines for endoscopic local excision (LE) of early-stage gastric cancer in 2018. While LE has expanded in the United States over recent years, appropriateness and national outcomes are unknown. The purpose of the study is to evaluate LE utilization and survival in the United States for early-stage gastric cancer.
Methods:
Patients with resectable gastric adenocarcinoma between 2010 to 2017 were extracted from the national cancer database. Patients were classified into eCuraA (strict criteria), eCuraB (expanded), and eCuraC (inappropriate) based on stage, margin, lymphovascular invasion, tumor size, and differentiation as per JGCA guidelines. We extracted demographics, clinical and provider descriptors, and perioperative and survival outcomes. Factors associated with overall survival were assessed using cox proportional hazards regression.
Results:
Patients (N = 46,334) were stratified into eCuraA (N = 1,405), eCuraB (N = 727), and eCuraC (N = 43,675) subgroups. Annual volume of LE increased by 76.9% between 2010 to 2017, while the volume for radical resection was constant. Among LE cases, 10.1% were eCuraA, 1.6% were eCuraB, and 84.8% were eCuraC. Patients with smaller tumors (OR 1.06, p < 0.001) and those treated at academic centers (OR 1.38-1.76, p< 0.001) were more likely to undergo LE. Among eCuraC patients, LE was associated with higher likelihood of positive margins (OR 2.00, p < 0.001). Postoperative 30-day mortality (0.7% vs 2.7%, p < 0.001) and readmission (2.8% vs 7.5%, p< 0.001) were lower among LE patients. Local excision was associated with worse overall survival among stage II patients (18.8 vs 53.8 mo, p=0.009), but not stage I patients (82.5 vs 95.6 mo, p=0.214) (Figure 1).
Conclusions:
The use of LE for definitive resection of EGC has nearly doubled in recent years. However, most cases do not satisfy eligibility criteria. Although early morbidity is lower for LE than radical resection, long-term survival is compromised for stage II patients. More stringent national oversight of this specialized technique is necessary during this early adoption phase.