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  • 1. Aims and Scope

    Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE

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    Yong Chan Lee Professor of Medicine
    Director, Gastrointestinal Research Laboratory
    Veterans Affairs Medical Center, Univ. California San Francisco
    San Francisco, USA

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    Deputy Editor
    Jong Pil Im Seoul National University College of Medicine, Seoul, Korea
    Robert S. Bresalier University of Texas M. D. Anderson Cancer Center, Houston, USA
    Steven H. Itzkowitz Mount Sinai Medical Center, NY, USA
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Letter to the Editor

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Prediction of the Risk of Lymph Node Metastases in Early Gastric Cancer: Contrast-Enhanced Harmonic Endoscopic Ultrasonography May Help

Chiara Pierantoni , Andrea Lisotti , and Pietro Fusaroli

Gastroenterology Unit, Department of Medical and Surgical Sciences, Hospital of Imola, University of Bologna, Imola, Italy

Correspondence to:Chiara Pierantoni
ORCID https://orcid.org/0000-0003-2160-5685
E-mail chiarapierantoni@gmail.com

Received: March 17, 2021; Accepted: April 1, 2021

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gut and Liver 2021; 15(6): 940-941

Published online November 15, 2021 https://doi.org/10.5009/gnl210122

Copyright © Gut and Liver.

To the Editor:

We have read with interest the article by Shin et al.1 reporting their experience in the evaluation of clinicopathologic features associated with lymph node metastases (LNM) in submucosal papillary gastric cancer.

The authors found that the LNM rate tended to be higher in papillary early gastric cancer (P-EGC) than in other differentiated types of EGC and that the rate increased to 25.6% when there was invasion of the submucosal layer.

Lymphovascular invasion was the only factor significantly associated with LNM in submucosal P-EGC. Moreover, location in the lower third of the stomach and elevated gross appearance were independent factors associated with lymphovascular invasion in submucosal P-EGC. Conversely, the depth of submucosal invasion, which is a known predictive factor against LNM in classic EGC, was not significantly associated with LNM.

These findings raise concern about the appropriateness of the current European guidelines that recommend the use of the same criteria for endoscopic submucosal dissection (ESD) as a treatment or both P-EGC and other differentiated EGCs.2 The feasibility of ESD for P-EGC is still debatable, in particular when it meets the expanded criteria.

Accurate assessment of the depth of invasion of EGC is critical for selecting the appropriate treatment option. Although endoscopic ultrasonography (EUS) has become the preferred tool for the locoregional staging of gastric cancer,3 there is no consensus on the accuracy of EUS for the evaluation of the invasion depth of EGC.4-6

However, several studies have shown the optimal accuracy of contrast-enhanced harmonic EUS (CH-EUS) for the differential diagnosis of benign and malignant lesions.7-10 In particular, the diagnostic accuracy of CH-EUS in the differential diagnosis of lymph nodes was comparable to those of EUS elastography and EUS-guided fine needle aspiration.11 Therefore, the characterization of lymph nodes could represent the main target of EUS during EGC staging rather than the T parameter, especially for P-EGC.

Several studies performed on surgical specimens reported a worse prognosis associated with P-EGC than with other differentiated types.2,12 However, the treatment outcomes of ESD for P-EGC have not been precisely documented.12

A recent Korean study13 evaluated the short- and long-term outcomes after ESD in P-EGC; the curative resection rate of P-ECG was significantly lower than those of well differentiated and moderately differentiated EGC (49.4% vs 72.5% and 93.7%, respectively), although it increased to 72.5% for mucosal (T1a) cancer. Despite the poor short-term outcomes, the long-term outcomes of ESD for P-EGC were favorable once curative resection was achieved (no LNM, no extragastric recurrences and a low metachronous recurrence).

As discussed by the authors, qualitative endoscopic criteria evaluation and accurate staging should be adopted for the assessment of submucosal invasive P-EGC, although lymphovascular invasion is difficult to predict. Indeed, accurate staging, together with a radical endoscopic or surgical resection of gastric neoplasia can significantly improve patients’ clinical outcomes.14

In P-EGC accurate N staging is crucial due to the high rate of LNM even in the early stages. We think that EUS evaluation, together with CH-EUS, should therefore be included in the staging process for P-EGC. Further large-scale studies are needed to demonstrate whether the correct staging yield and prediction of lymphovascular invasion could be further improved.


No potential conflict of interest relevant to this article was reported.

  1. Shin SY, Kim JH, Kook MC, et al. Clinicopathologic features of submucosal papillary gastric cancer differ from those of other differentiated-type histologies. Gut Liver 2021;15:44-52.
    Pubmed KoreaMed CrossRef
  2. Lee HJ, Kim GH, Park DY, et al. Endoscopic submucosal dissection for papillary adenocarcinoma of the stomach: is it really safe? Gastric Cancer 2017;20:978-986.
    Pubmed CrossRef
  3. Caletti G, Fusaroli P. The rediscovery of endoscopic ultrasound (EUS) in gastric cancer staging. Endoscopy 2012;44:553-555.
    Pubmed CrossRef
  4. Shi D, Xi XX. Factors affecting the accuracy of endoscopic ultrasonography in the diagnosis of early gastric cancer invasion depth: a meta-analysis. Gastroenterol Res Pract 2019;2019:8241381.
    Pubmed KoreaMed CrossRef
  5. Fusaroli P, Kypraios D, Eloubeidi MA, Caletti G. Levels of evidence in endoscopic ultrasonography: a systematic review. Dig Dis Sci 2012;57:602-609.
    Pubmed CrossRef
  6. 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.
    Pubmed CrossRef
  7. Fusaroli P, D'Ercole MC, De Giorgio R, Serrani M, Caletti G. Contrast harmonic endoscopic ultrasonography in the characterization of pancreatic metastases (with video). Pancreas 2014;43:584-587.
    Pubmed CrossRef
  8. Yamashita Y, Shimokawa T, Napoléon B, et al. Value of contrast-enhanced harmonic endoscopic ultrasonography with enhancement pattern for diagnosis of pancreatic cancer: a meta-analysis. Dig Endosc 2019;31:125-133.
    Pubmed CrossRef
  9. Kamata K, Takenaka M, Kitano M, et al. Contrast-enhanced harmonic endoscopic ultrasonography for differential diagnosis of localized gallbladder lesions. Dig Endosc 2018;30:98-106.
    Pubmed CrossRef
  10. Kamata K, Takenaka M, Kitano M, et al. Contrast-enhanced harmonic endoscopic ultrasonography for differential diagnosis of submucosal tumors of the upper gastrointestinal tract. J Gastroenterol Hepatol 2017;32:1686-1692.
    Pubmed CrossRef
  11. Lisotti A, Ricci C, Serrani M, et al. Contrast-enhanced endoscopic ultrasound for the differential diagnosis between benign and malignant lymph nodes: a meta-analysis. Endosc Int Open 2019;7:E504-E513.
    Pubmed KoreaMed CrossRef
  12. Bang CS, Lee JJ, Baik GH. Endoscopic submucosal dissection of papillary gastric adenocarcinoma; systematic review. J Clin Med 2020;9:1465.
    Pubmed KoreaMed CrossRef
  13. Kim TS, Min BH, Kim KM, Lee JH, Rhee PL, Kim JJ. Endoscopic submucosal dissection for papillary adenocarcinoma of the stomach: low curative resection rate but favorable long-term outcomes after curative resection. Gastric Cancer 2019;22:363-368.
    Pubmed CrossRef
  14. Catena F, Di Battista M, Ansaloni L, et al. Microscopic margins of resection influence primary gastrointestinal stromal tumor survival. Onkologie 2012;35:645-648.
    Pubmed CrossRef

Article

Letter to the Editor

Gut and Liver 2021; 15(6): 940-941

Published online November 15, 2021 https://doi.org/10.5009/gnl210122

Copyright © Gut and Liver.

Prediction of the Risk of Lymph Node Metastases in Early Gastric Cancer: Contrast-Enhanced Harmonic Endoscopic Ultrasonography May Help

Chiara Pierantoni , Andrea Lisotti , and Pietro Fusaroli

Gastroenterology Unit, Department of Medical and Surgical Sciences, Hospital of Imola, University of Bologna, Imola, Italy

Correspondence to:Chiara Pierantoni
ORCID https://orcid.org/0000-0003-2160-5685
E-mail chiarapierantoni@gmail.com

Received: March 17, 2021; Accepted: April 1, 2021

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Body

To the Editor:

We have read with interest the article by Shin et al.1 reporting their experience in the evaluation of clinicopathologic features associated with lymph node metastases (LNM) in submucosal papillary gastric cancer.

The authors found that the LNM rate tended to be higher in papillary early gastric cancer (P-EGC) than in other differentiated types of EGC and that the rate increased to 25.6% when there was invasion of the submucosal layer.

Lymphovascular invasion was the only factor significantly associated with LNM in submucosal P-EGC. Moreover, location in the lower third of the stomach and elevated gross appearance were independent factors associated with lymphovascular invasion in submucosal P-EGC. Conversely, the depth of submucosal invasion, which is a known predictive factor against LNM in classic EGC, was not significantly associated with LNM.

These findings raise concern about the appropriateness of the current European guidelines that recommend the use of the same criteria for endoscopic submucosal dissection (ESD) as a treatment or both P-EGC and other differentiated EGCs.2 The feasibility of ESD for P-EGC is still debatable, in particular when it meets the expanded criteria.

Accurate assessment of the depth of invasion of EGC is critical for selecting the appropriate treatment option. Although endoscopic ultrasonography (EUS) has become the preferred tool for the locoregional staging of gastric cancer,3 there is no consensus on the accuracy of EUS for the evaluation of the invasion depth of EGC.4-6

However, several studies have shown the optimal accuracy of contrast-enhanced harmonic EUS (CH-EUS) for the differential diagnosis of benign and malignant lesions.7-10 In particular, the diagnostic accuracy of CH-EUS in the differential diagnosis of lymph nodes was comparable to those of EUS elastography and EUS-guided fine needle aspiration.11 Therefore, the characterization of lymph nodes could represent the main target of EUS during EGC staging rather than the T parameter, especially for P-EGC.

Several studies performed on surgical specimens reported a worse prognosis associated with P-EGC than with other differentiated types.2,12 However, the treatment outcomes of ESD for P-EGC have not been precisely documented.12

A recent Korean study13 evaluated the short- and long-term outcomes after ESD in P-EGC; the curative resection rate of P-ECG was significantly lower than those of well differentiated and moderately differentiated EGC (49.4% vs 72.5% and 93.7%, respectively), although it increased to 72.5% for mucosal (T1a) cancer. Despite the poor short-term outcomes, the long-term outcomes of ESD for P-EGC were favorable once curative resection was achieved (no LNM, no extragastric recurrences and a low metachronous recurrence).

As discussed by the authors, qualitative endoscopic criteria evaluation and accurate staging should be adopted for the assessment of submucosal invasive P-EGC, although lymphovascular invasion is difficult to predict. Indeed, accurate staging, together with a radical endoscopic or surgical resection of gastric neoplasia can significantly improve patients’ clinical outcomes.14

In P-EGC accurate N staging is crucial due to the high rate of LNM even in the early stages. We think that EUS evaluation, together with CH-EUS, should therefore be included in the staging process for P-EGC. Further large-scale studies are needed to demonstrate whether the correct staging yield and prediction of lymphovascular invasion could be further improved.

CONFLICTS OF INTEREST


No potential conflict of interest relevant to this article was reported.

References

  1. Shin SY, Kim JH, Kook MC, et al. Clinicopathologic features of submucosal papillary gastric cancer differ from those of other differentiated-type histologies. Gut Liver 2021;15:44-52.
    Pubmed KoreaMed CrossRef
  2. Lee HJ, Kim GH, Park DY, et al. Endoscopic submucosal dissection for papillary adenocarcinoma of the stomach: is it really safe? Gastric Cancer 2017;20:978-986.
    Pubmed CrossRef
  3. Caletti G, Fusaroli P. The rediscovery of endoscopic ultrasound (EUS) in gastric cancer staging. Endoscopy 2012;44:553-555.
    Pubmed CrossRef
  4. Shi D, Xi XX. Factors affecting the accuracy of endoscopic ultrasonography in the diagnosis of early gastric cancer invasion depth: a meta-analysis. Gastroenterol Res Pract 2019;2019:8241381.
    Pubmed KoreaMed CrossRef
  5. Fusaroli P, Kypraios D, Eloubeidi MA, Caletti G. Levels of evidence in endoscopic ultrasonography: a systematic review. Dig Dis Sci 2012;57:602-609.
    Pubmed CrossRef
  6. 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.
    Pubmed CrossRef
  7. Fusaroli P, D'Ercole MC, De Giorgio R, Serrani M, Caletti G. Contrast harmonic endoscopic ultrasonography in the characterization of pancreatic metastases (with video). Pancreas 2014;43:584-587.
    Pubmed CrossRef
  8. Yamashita Y, Shimokawa T, Napoléon B, et al. Value of contrast-enhanced harmonic endoscopic ultrasonography with enhancement pattern for diagnosis of pancreatic cancer: a meta-analysis. Dig Endosc 2019;31:125-133.
    Pubmed CrossRef
  9. Kamata K, Takenaka M, Kitano M, et al. Contrast-enhanced harmonic endoscopic ultrasonography for differential diagnosis of localized gallbladder lesions. Dig Endosc 2018;30:98-106.
    Pubmed CrossRef
  10. Kamata K, Takenaka M, Kitano M, et al. Contrast-enhanced harmonic endoscopic ultrasonography for differential diagnosis of submucosal tumors of the upper gastrointestinal tract. J Gastroenterol Hepatol 2017;32:1686-1692.
    Pubmed CrossRef
  11. Lisotti A, Ricci C, Serrani M, et al. Contrast-enhanced endoscopic ultrasound for the differential diagnosis between benign and malignant lymph nodes: a meta-analysis. Endosc Int Open 2019;7:E504-E513.
    Pubmed KoreaMed CrossRef
  12. Bang CS, Lee JJ, Baik GH. Endoscopic submucosal dissection of papillary gastric adenocarcinoma; systematic review. J Clin Med 2020;9:1465.
    Pubmed KoreaMed CrossRef
  13. Kim TS, Min BH, Kim KM, Lee JH, Rhee PL, Kim JJ. Endoscopic submucosal dissection for papillary adenocarcinoma of the stomach: low curative resection rate but favorable long-term outcomes after curative resection. Gastric Cancer 2019;22:363-368.
    Pubmed CrossRef
  14. Catena F, Di Battista M, Ansaloni L, et al. Microscopic margins of resection influence primary gastrointestinal stromal tumor survival. Onkologie 2012;35:645-648.
    Pubmed CrossRef
Gut and Liver

Vol.15 No.6
November, 2021

pISSN 1976-2283
eISSN 2005-1212

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